The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|GRACE COTTAGE HOSPITAL||PO BOX 216 TOWNSHEND, VT 05353||March 5, 2015|
|VIOLATION: QA - QUALITY OF PATIENT CARE||Tag No: C0336|
|Based on staff interview and record review, the hospital failed to conduct a thorough investigation and Quality Review of a patient's allegation of abuse by hospital staff for 1 applicable patient in the targeted sample. (Patient #1) Findings include:
Per review of the hospital's mandatory report of Patient #1's allegation of abuse by a nurse, Patient #1 stated to a Social worker on 1/20/15 "I don't want him abusing me". The patient stated that a nurse hurt him/her 'while poking me with needles' and 'put the catheter in the wrong place....hurt me so much'.
Based on surveyor interviews (via telephone on 3/5/15) with 2 nurses present during the insertion of a Foley catheter on 1/17/15, the nurses contradicted each other when asked who inserted the catheter and who assisted with the task. During interview with the Director of Quality on 3/5/15 at 1:10 PM, he/she confirmed that they had not interviewed both of the nurses present when the catheter was changed on 1/17/15; thus, they did not obtain all of the information available regarding the allegation(s). The lack of a thorough investigation contributed to the hospital's failure to analyze the data obtained during the investigation and to identify and implement improvement plans regarding care provision for the patient. Although the facts obtained did not substantiate that any abuse occurred, the lack of a thorough investigation impeded the hospital's efforts to promote an effective quality review and subsequent areas for improvement. The failure to interview all applicable nurses who provided the type of care alleged to be abusive by Patient #1 and to use the investigative data obtained to analyze and implement corrective action was confirmed during interview with the Director of Quality at 1:20 PM on 3/5/15.