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.

Based on review of records, reports and interviews; the facility failed to develop and implement appropriate measures to ensure the right to be free from all forms of abuse. The members of the risk management program failed to report suspected abuse to the Department of Children and Families (DCF) until 16 days after the incident. Delays in reporting incidents interferes with the prescribed abuse investigation process. Such delays have the potential to leave vulnerable adults at risk.

The findings include:

In an interview on 11/7/13 at 10:30 a.m., System Investigator Staff M stated he had completed the investigation of the incident which had occurred on 9/8/13. He stated the allegation of abuse occurred on 9/8/13 and was reported to him on 9/9/13 and he immediately started an investigation.

In an interview on 11/7/13 at 10:32 a.m., Staff K and Staff L stated risk management was given notice by Staff I verbally on the morning of 9/9/13 of possible abuse. They stated the incident occurred on 9/8/13 around 8:00 p.m. Patient #6 was being restrained by staff and the son alleged that one of the staff members was observed bending the fingers of his hand back in an attempt to restrain him.

Review of records revealed an X-Ray was taken of Patient #6's left hand that had allegedly been injured by a staff member on 9/9/13. The X-Ray showed the hand had a fracture.

Review of the hospital policy titled "Identification and Reporting Alleged or Suspected Abuse, Neglect, or Exploitation of Vulnerable Adults" was done. The policy directs, "Any person who has reasonable cause to suspect that a child or vulnerable adult is being abused, neglected, or exploited shall immediately report such knowledge or suspicion to the Central Abuse Registry and Tracking System for the State of Florida."

Review of completed DCF Adult Protective Services (APS) investigation revealed Patient #6's family member complained at the time of the incident. An X-Ray some 20 hours later the following day showed a comminuted oblique fracture to the left hand. The DCF report documented that 2 persons admitted witnessing Staff H bend Patient #6's left hand backwards on 9/8/13 while in restraints. The incident was not reported to DCF until 9/24/13.