HospitalInspections.org

Based on observation, interview and record review the facility failed to protect patient's rights to be free from abuse and physical harm.

A-144
Based on observation, interview and record review the facility failed to prevent disease transmission and treat two of two current inpatients (patients #3 and #6), admitted with a diagnosis of scabies infestation and failed to protect one of one discharged patients (patient #7) from injury from fall resulting in the risk for physical harm for all patients who are at risk for fall.

A-145
Based on observation, interview and record review the facility failed to protect and investigate one of one (patient #3) allegation of sexual abuse among current patients and failed to act to prevent patient to patient abuse for one of one discharged patients (patient #2) increasing the risk for lack of protection from abuse for all patients.

Based on observation, record review and interview, the facility failed to:
1. Respond to scabies infestations for two current patients (#3 and #6), increasing the risk of disease transmission for all patients,
2. Accurately document on the Fall Risk Assessment tool for 1 of 1 discharged patients who sustained a fall injury (patient #7),
-increasing the risk of scabies infestation and injuries from falls for all patients.
Findings include:

On 1/29/14 between 11 am and 3 pm a review of policy revealed:
Policy Review (#1):
"Treatment of Head, Body Lice & Scabies," dated 7/1/10, states:
"Patients identified to have lice or scabies will be promptly placed in contact isolation and treated to prevent the spread to other patients and staff."
Procedures:
4a. "Contact isolation will continue while patient is hospitalized and actively infective....(the)Medical care plan to include any body coverings patient may need while out of patient's room (i.e.., long sleeves, gloves, etc.)."
4b. "Private room is required."
4c. "Gowns (long sleeve) and gloves are indicated for staff in contact with patient."
4d. "Hands must be washed after removing gloves and before taking care of other patients."

Record Review (#1):
On 1/29/14 from 9 am-3:30 pm record review revealed:
1. Patient #3 was admitted 1/22/14 and discharged 1/28/14.
2. A physician's order for patient #3 for "Permethrin cream 5% to skin," dated 1/24/14.
3. A 1/25/14 note by physician G stating: "(Patient #3) was noted to have scabies on his arrival."
4. A 1/28/14 note in patient #6's record, by Nurse Practitioner K, listing "scabies" as a diagnosis.

Interview:
1. On 1/29/14 at approximately 10:55 am physician G was asked if precautions were ordered for patient #3, to prevent the spread scabies. Physician G stated that he informed the Director of Nursing (DON) of patient #3's scabies diagnosis and expected "the hospital would follow their procedures."
2. On 1/29/14 at approximately 3 pm the DON confirmed the findings noted above in patient #3's clinical record.
3. On 1/29/14 at approximately 3:05 pm the DON verified census data showing that patient #3 had roommates on: 1/22/14, 1/24/14, 1/26/14, 1/27/14 and 1/28/14..
4. On 1/29/14 at approximately 10 am the DON stated that another patient (#6) had also been diagnosed with scabies.
5. On 1/29/14 at approximately 3 pm the DON stated that he is not aware of the facility's definition of "contact precautions."

Observation:
Patient #6's room was toured on 1/29/14 at approximately 3:10 pm. Patient #6 was in a double bed-room but the other bed was not currently assigned. There were no gowns or gloves in the vicinity nor postings directing staff to observe contact precautions, apply personal protective equipment or see a nurse before entering the room. These observations were verified by the Director of Nursing (DON) on 1/29/14 at approximately 3:20 pm. The DON stated that contact precautions were not in being implemented for this patient.

On 1/29/14 between 11 am and 3 pm a review of policy revealed:
Policy Review (#2):
"Fall Policy," dated 9/23/13, states:
Procedures:
1A. "Assess risk score...daily at time of RN (registered nurse) assessment."
Interventions:
3Q. "Assistance to bathroom at mealtime, at bedtime and upon waking."
3R. "Patients identified as a fall risk will be assessed for toileting every 2 hours while awake and PRN overnight."
3S. "Patients identified as a High Fall Risk will be supervised while on the toilet."

Record Review (#2):
On 1/29/14 from 12 noon- 3 pm a review of patient #7's clinical record revealed:
1. A Nurse Practitioner's (NP's) note dated 11/14/13 stated: "Patient (#7) was seen following recent ER (Emergency Room) visit. Patient status post two recent falls. (Patient #7's) first fall occurred when she slipped on some water in the shower late yesterday. Today, she was scooting her chair up to the table and missed the chair...Patient is very high risk for complications due to two recent falls." The note stated that "(patient #7) sustained a laceration to the scalp" that was closed with staples on 11/14/13 in the ER.
2. The Fall Risk Assessments completed on 11/15/14, 11/18/13 and 11/21/13 scored patient #7 in the "minimal risk" range due to failure to score points for the patient's recent two falls.
3. The "Fall Policy" does not specify staff supervision of toileting unless a patient scores in the "high risk" range on the "Fall Risk Assessment" form.

Interview:
On 1/29/14 at approximately 3 pm the Director or Nursing (DON) verified the above fall assessment scores and stated that they were "not correct."

Based on interview and record review the facility failed to protect and investigate 1 of 1 current patient's (patient #3) allegation of sexual abuse in a timely manner and act to prevent and investigate patient to patient abuse for 1 of 1 discharged patients (patient #2), increasing the risk of physical abuse for all patients. Findings include:

On 1/29/14 between 11 am and 3 pm a review of policy revealed:
Policy Review:
"Identifying Abuse and Neglect," 10/1/13, states: "All employees are expected to report any suspected patient abuse or neglect to their immediate supervisor and the hospital's Recipient Rights Advisor."
Procedures:
Employee:
1. "Who receives notice of or witnesses an incident of patient abuse or neglect while the patient is in the hospital must report the incident to their 'immediate supervisor' and the Recipient Rights Advisor and Risk Management, as soon as possible."
2. "Documents all information concerning the incident in a Incident Report Form...and a Recipient Rights Complaint Form, being as descriptive as possible."
Charge Nurse:
1. "Assesses the patient, and takes whatever action is necessary to provide for the patient's immediate medical needs, and other safety measures."
3. "Sends the patient to the nearest Emergency Room if rape is suspected/or alleged, for a complete examination."

Record Review, Patient #3:
1. On 1/28/14 at approximately 11 am staff A was asked for all investigation documents for patient #3's allegation of sexual abuse, documented as opened on 1/23/14 on the Complaint Log.
2. On 1/28/14 at 1:20 pm review of patient #3's complaint investigation file (above) revealed a report titled "The Office of Recipient Rights Investigative Report." The report states: "On 1/23/2014 (staff A) asked (patient #3) if he would feel more comfortable being closer to the nurses' station. (Patient #3) stated he would feel more comfortable with this change." This report did not include a statement by patient #3 concerning the abuse allegation or a "Patient Rights Complaint Form."
3. On 1/28/14 at 2:25 pm staff A provided 2 pages of handwritten notes that were not included in patient #3's abuse investigation file. Staff A stated that this was the rest of the investigation documentation to date. The first note, dated 1/23/13, states: "(staff H) came to tell (writer/staff A). Pt. (patient #3) stated another Pt. was performing oral sex on him." The note does not document a detailed statement of what allegedly occurred, including identification of the other patient involved, and asking about possible witnesses.
4. On 1/28/14 at 3 pm record review revealed that there was no documentation of the above allegation in an Incident Report or noted in patient #3's clinical record until 1/25/14.
5. On 1/29/14 at 10:45 am census review revealed that on:
--1/22/14, patient #3 was in room 362 and patient #10 was in room 363, without a roommate.
--1/23/14 patient #3 was moved to room 357, a single room. Both patient remained on Unit B.
--1/24/14 patient #3 was moved out of the single room, to a double room down the hall from the nurse's station and patient #10's single room.
--1/25/14 patient #3 was moved to the room next to patient #10's room.
--1/26/13 patient #3 was moved to Unit A and patient #10 was not moved to this unit.
6. On 1/29/14 at approximately 10 am. record review revealed a 1/25/14 note by physician G stating: "(Patient #3) reports to me for the first time today that he allegedly was assaulted by another patient (patient #10). There is certainly no documentation or verification of this." This note contains documentation of a rectal examination, stating (patient #3) is "somewhat inflamed and erythematous."
7. On 1/29/14 at approximately 3:15 pm an Emergency Department (ED) Report for patient #3, dated 1/25/14, revealed the following statement: "Pt (patient #3) states he was sexually assaulted 3 days ago by another pt." No significant findings were noted at that time.

Interviews:
1. On 1/28/14 from 1:20 pm-3 pm, during record review, staff A confirmed findings noted in items 1-4 , above. Staff A was asked whether anybody completed a "Recipient Rights Complaint" form. Staff A stated that it had not been done and that it is part of the abuse complaint procedure.
2. On 1/29/14 at 3:20 pm staff A verified census data noted in #5 (above). Staff A stated: "I asked the nurse to move (patient #3) on 1/23...I didn't know that (patient #3) got moved from this room the next day." Staff A was asked whether patient #3 was offered a complaint form or asked to provide a full statement of what occurred, including a timeline and opportunity to name possible witnesses. Staff A stated that this had not been done yet and that video evidence of the hallway at the time of the alleged incident had not yet been reviewed yet.
3. On 1/29/14 at approximately 3 pm the Director of Nursing (DON) was asked if the nurse who was informed of patient #3's sexual abuse allegation (staff H) on 1/23/14 should have completed an Incident Report form. The DON responded "yes." The DON also confirmed that documentation of the 1/23/14 allegation was not noted in the patient #3's clinical record until 1/25/14.
4. On 1/29/14 at 11:30 am physician G stated that he was not informed of the sexual abuse allegation until 1/25/14.
5. On 1/29/14 at 11 am physician F stated that he was not informed of patient #3's sexual abuse allegation until 1/25/14. Physician F stated that he immediately met with all nurses on patient #3's unit. Physician F was asked if the nurses on duty (on 1/25/14) were aware of patient #3's allegation prior to 1/25/14. Physician F stated that some nurses stated that they had heard the allegation prior to 1/25/14.
6. On 1/29/14 at approximately 2:45 pm .Social Worker E stated that she was informed of patient #3's sexual abuse allegation on 1/23/14 but did not document it.

Record Review, patient #2:
1. On 1/28/14 from 11 am- 2 pm review of patient #2's clinical record revealed an Incident Report dated 12/16/13 at 3:25 pm stating: "Patient (#2) was observed being physically struck by peer 3-4 times in the face at 1525."
2. On 1/28/14 from 11:30-11:45 am review of video of the above incident revealed that 4 staff members were standing a few feet from patients #1 and #2 at the time of the above incident. Patients #1 and #2 were observed raising and lowering their arms and making angry facial expressions just prior to the incident. Staff J walked by the two patients seconds prior to the incident.
3. On 1/28/14 from 11 am-2 pm record review revealed that on 12/16/14, following the above incident, patient #2 was transferred to a Hospital Emergency Department (ED) for evaluation with instructions to discharge from the (psychiatric) hospital rather than return to the facility (where he was assaulted). The facility did not have results of the hospital's ED assessment of patient #2's injuries available on the medical record.

Interview:
1. On 1/28/14 at 11:45 am staff A confirmed that video evidence showed that staff J walked past patients 1 and #2 seconds before patient #1 hit patient #2 on 12/16/13. Staff A stated that staff J told her: "they (patients #1 and #2) were arguing when she walked by." Staff A confirmed that her investigation report, dated 12/17/13, concluded: "there is not a preponderance of evidence that the environment was unsafe or any employee acted ina manner that would constitute an unsafe environment for the patients."
2. On 1/28/14 at approximately 11:50 am staff A was asked if staff J should have intervened when she heard patients #1 and #2 arguing, rather than just walking past them, on 12/16/13. Staff A responded: "it might have helped."