HospitalInspections.org

Based on review of the medical record, policy and procedures, staff interviews, and the incident log, it was determined that the facility failed ensure that nursing staff filed incident reports when one Patient (P) (P#1) of three (P#2 and P#3) patients alleged that an act of physical abuse occurred where a staff member struck the patient (P#1) in the face. As a result, the facility failed to ensure an effective assessment, tracking, and investigation of the incident occurred.


Findings include:


A review of a "Hospital Medicine Progress Note" by Medical Doctor (MD) AA dated 3/16/24 at 11:25 a.m., revealed that P#1 had swelling above her left eye and per nursing staff no mention of falls or trauma. P#1 reported that someone did something to her, refused medications, and displayed signs of confusion and increased agitation.


A review of a "Hospital Medicine Progress Note" by MD AA dated 3/18/24 at 10:54 a.m., revealed that P#1 was more cooperative and calmer. MD AA noted swelling along the left upper eye lid with improving bruising. The results of the CT head revealed no fracture or bleed with nonspecific minimal left periorbital soft tissue swelling in thought to cellulitis versus trauma.


A review of the facility policy titled, "Adverse Patient-Visitor Safety Events, Response and Investigation", effective 2/19/24, revealed that the purpose of the policy was to detail that the facility facilitates timely and complete investigation and reporting of events that pose an actual or potential safety risk to patients, families, visitors, and staff.
Procedure:
" A patient safety event includes occurrences or conditions associated with care or services that result (or could potentially) result in harm due to acts of commission or omission.
" Adverse events include events that may cause loss to the organization and may also meet the definition of a patient safety event.
" As an integrated part of monitoring and promoting patient safety, all patient safety events (unsafe conditions, near miss, no harm-precursor, serious safety, never/sentinel, and DCH/externally reportable events) and adverse events are to be entered as soon as they are observed.
" Event reporting should be initiated by the first staff person/employee, (including physicians, residents, students, volunteers, ect.) having knowledge of the event as immediately as possible.


During an interview on 4/19/24 at 12:49 p.m. in the conference room, Patient Care Technician (PCT) GG said that she has been employed for three years at the facility. PCT GG said that if a patient told her that someone hit the patient, PCT GG would report it to the Charge Nurse (CN). PCT GG recalled that she visited P#1 after returning to work from having a few days off and noticed that P#1 had bruising around their eye. PCT GG recalled that P#1 was pleasant and that PCT GG did not ask her about the bruise because it has been a couple of days since she last saw P#1 and thought that other staff members addressed it. PCT GG recalled that P#1 also wore thick glasses and was unsure whether the glasses caused the bruising or not. PCT GG does not recall P#1 telling her that any staff member hit her and if P#1 did, PCT GG said she would report it.


During a telephone interview on 4/19/24 at 1:21 p.m., Registered Nurse (RN) EE said that she has been an RN for four years and employed at the facility for almost six months. RN EE recalled that P#1 had a bruise around her eye and slight swelling but when RN EE spoke to P#1 about it, P#1 would not talk about it. RN EE recalled that she reported the situation to Medical Doctor (MD) AA, who came to assess P#1. RN EE recalled that she and MD AA were trying to assess if the injury was sustained from the patient's eyeglasses and her sleeping in them. RN EE recalled that P#1 often slept in her glasses and usually favored her left side. RN EE recalled that the eyeglasses were thick and had a bulky frame. RN EE recalled that MD AA did order imaging to further assess P#1's allegation of injury. RN EE said that she did not file an incident report because she was unsure whether the injury was related to the glasses or not.


During a telephone interview on 4/19/24 at 1:36 p.m., MD AA recalled that she was informed that P#1 had swelling on the left eye and reported that someone did it to her. MD AA recalled that when she assessed P#1 and attempted to gather more details, P#1 would not elaborate and initially refused treatment for it such as imaging. MD AA recalled following up with nursing staff to see if any mention of this was reported by the nightshift staff but was told there was no mention of it. MD AA recalled that she was concerned if P#1 hit her face against the bed rail. MD AA recalled that eventually P#1 agreed to a scan of her face and head. MD AA recalled that the imaging of P#1's face and head revealed no fractures and that the swelling did get better. MD AA recalled speaking to P#1's family member about the incident and follow-up treatment and that P#1's family member expressed no concerns or questions.


During a telephone interview on 4/19/24 at 2:18 p.m., Charge Nurse (CN) HH said that she assists the unit and staff with any support for nursing guidance, admission/discharge issues, and navigation of any patient concerns. CN HH said that she does not recall P#1. CN HH said that if a patient, whether confused or not, reported that they were hit by staff and CN HH saw the bruise, she would alert the medical care team. CN HH said that she was not informed of a patient who was hit by a staff member this year. CN HH said that she would also file an incident report of the allegation.
During a telephone interview on 4/19/24 at 1:51 p.m., Registered Nurse (RN) FF recalled P#1. RN FF recalled that she was told in nursing shift report that P#1 said someone attacked her but P#1, herself, never said it to RN FF. RN FF recalled seeing P#1's left eye and noted that it was slightly bruised and had some swelling. RN FF recalled that when she inquired about the eye incident to P#1, P#1 would not engage in conversation about it. RN FF said that she did not file an incident report on it because she was told that a previous RN and a physician were already investigating it.


During an interview on 4/23/24 at 12:21 p.m. in the conference room, Charge Nurse (CN) JJ said that she has been employed at the facility for eight years and a CN for two years. CN JJ said that if a staff member reported that a patient was hit by staff, then she would tell them to first assess the patient for any injuries, obtain a set of vital signs, contact the physician, and then complete an incident report. CN JJ said that the family would also need to be notified either by the nurse or physician. CN JJ said that she would tell the reporting staff member to perform these actions regardless of whether the patient was oriented or confused, especially if there was noted bruising or swelling. CN JJ said that the CN or the assistant nurse manager would follow up to make sure an incident report was filed.


During an interview on 4/23/24 at 12:26 p.m. in the conference room, Unit Manager (UM) KK said that she has been with the facility for three months. UM KK said that if a staff reported that a patient alleged that a staff member injured them, she would expect that staff would first assess the patient, notify the physician so that further assessment and treatment may be rendered, alert management, and file an incident report so that an investigation may occur. UM KK said that family should also be notified by either nursing or the medical care team. UM KK said that the charge nurse or the assistant nurse manager would usually follow up to ensure an incident report was filed. UM KK said that every allegation of physical abuse or assault must be investigated, and it does not matter whether the patient has a history of mental illness or not.


A review of the facility's Incident Log dated 11/23/23 through 4/18/24 revealed no entries related to P#1.