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 interview, record review and review of the facility's abuse policy and procedure, and incident report, it was determined the facility failed to follow their abuse policy in regards to reporting an alleged physical abuse against a patient in the facility's emergency department (ED) and failed to conduct an investigation into the alleged abuse for one (1) of ten (10) patients reviewed. The ED staff observed the alleged physical abuse against Patient #1. The patient was separated from the alleged perpetrator; however, the hospital staff did not report the alleged abuse to the state agency according to KRS 209.

The findings include:

Review of the facility's Suspected Abuse, Harassment, Neglect or Exploitation of an Adult: Identification and Reporting policy, review date of 03/12/12, revealed the facility would identify adult victims of mental, physical, or sexual abuse, neglect or exploitation thorough the assessment process and will report such cases when identified. Suspected abuse of any nature will be reported to the Department of Community Based Services (DCBS) in accordance with KRS 209.030. The policy stated each employee has the responsibility to report related to the identification of abuse of any nature. The responsibilities of the Nurses are to notify DCBS of the suspected abuse and perform clinical and psychosocial assessments and document findings.

Review of the ED clinical record for Patient #1 revealed the patient presented to the ED, on 07/10/12 at 7:33 PM, via ambulance for evaluation of a head wound. The patient was transferred from a local Psychiatric hospital with an employee (sitter) accompanying the patient. The patient received a medical examination screen which documented an abrasion to the back of the head. In addition, findings of a concussion without loss of conscious (LOC) and a hematoma to face-scalp-neck was noted. Review of the nurses' notes revealed at 9:19 PM, the patient was observed to be walking in the ED hallway with the sitter. The patient was swinging at the sitter and the sitter was swinging back at the patient and shoved the patient. The hospital staff had to separate the patient and the sitter. The patient was placed in a wheelchair and the sitter said, the patient wanted to go home with mom and dad. They are probable dead. The patient was placed onto a bed in exam Room #3. The patient and sitter continued to argue. The patient attempted to stand, the sitter shoved the patient back onto the bed. The patient was swinging at the sitter. The sitter placed one hand on the patient's shoulder and the other around the patient's neck to hold her down on the bed. The hospital security came into the room and sent the sitter to the waiting room and calmed the patient.

Interview with Risk Management, on 07/16/12 at 9:43 AM, revealed she thought the ED manager had notified the state agency of the incident. She stated she became aware of the incident when she received a report generated by security and a phone call from the Psychiatric hospital requesting statements from the two nurses who witnessed the incident. She was told the other hospital had reported the incident to DCBS. She said she forward the request to the ED manager and recommended she review the hospital's current abuse policy and procedures regarding reporting abuse to DCBS. The Risk Manager stated any employee can report an allegation of abuse; however, could not say at the time of the interview if any facility staff had reported this allegation.

Interview with the ED Nurse Manager, on 07/16/12 at 10:00 AM, revealed the risk manager had spoken to her regarding the incident. She obtained the requested written statements from the nurses that witnessed the incident. She had not reported to DCBS because when she spoke with the nurses, they had considered the incident to be an assault not abuse. In addition, the Psychiatric hospital had reported the alleged abuse.

Interview with RN #1, on 07/16/12 at 11:05 AM, revealed the patient came to the ED accompanied by the sitter. The patient was placed in exam Room #3 and was cooperative during the medical exam, lab draw, and other procedures. The nurse stated she left the patient and was checking on another patient in another ED exam room. When she came out of the other room, she saw the patient and sitter in the ED hallway close to the nurses' station. She said the patient and sitter were yelling at each other (loud) and the patient attempted to hit the sitter. Both the patient and sitter was swinging their arms at each other and with the help from emergency medical service (EMS), the patient was placed in a wheelchair and taken back to exam Room #3. The sitter followed. The patient was cooperative and sitting on the side of the bed when the patient said to the sitter, you will be in your place soon, bitch. The sitter replied, no, I will be at home and you will be at the Psychiatric hospital. The nurse stated the patient then stood up and the sitter pushed the patient back onto the bed and placed one hand on the patient's chest and one hand around the patient's neck. The sitter placed her legs across the patient's legs to prevent movement. The nurse said she felt uncomfortable with the sitter's actions and reported what she observed to the charge nurse. (RN#2). The charge nurse came into the exam room and asked the sitter to leave and go to the waiting room. RN #1 stated the security officer was in the room at the time of the incident. The nurse stated RN #2 had called the Psychiatric hospital and they sent another employee to transfer the patient back to the hospital after discharge. The nurse further stated she did not like the way the sitter had placed her hand around the patient's neck and tried to hold the patient down. She felt it was excessive force and would consider the sitter's actions to be abusive. However, the nurse revealed she only reported the sitter's actions to the charge nurse and did not call the abuse hotline or state agency. She stated the charge nurse had called the Psychiatric hospital and they had reported the incident.

Interview with RN #2, on 07/16/12 at 11:30 AM, revealed she was sitting at the nurses' station the day of the incident. She saw the patient walking down the ED hallway toward the ambulance entrance. She saw the sitter grab the patient by the shoulders and tried to turn the patient around. The patient became irritated and was slapping at the sitter. The sitter slapped the resident back and arms were swinging between the two. The local police was in the ED at the time of the incident and assisted the staff in getting the patient back into the exam room. When RN #2 walked into the exam room, the sitter and patient was again arguing. The sitter had the patient held to the bed. The RN told the sitter to leave the room. RN #2 and the security officer stayed with the patient until discharge. The charge nurse said RN #1 told her the sitter had pushed the patient back onto the bed. The charge nurse stated she had reported the incident to the Psychiatric hospital and they reported the incident to the state agency. However, she had not reported what she had observed to the abuse hotline, state agency, or risk management.

Interview with the sitter (Patient Aide) from the Psychiatric hospital, on 07/17/12 at 3:45 PM, revealed she had escorted Patient #1 to the ED on 07/10/12. She stated the patient kept saying he/she wanted to go home and to take him/her out of here. After the nurse had completed an assessment of the patient's injuries and removed the blood pressure cuff, she left the room. The patient picked up his/her purse and walked out of the exam room toward the ambulance entrance. The Patient Aide said she could not get the patient to stop and go back to the exam room. She said she attempted to do a one-man hold with one hand on the abdomen and another on the patient's shoulder, lean the patient forward, with her legs in front of the patient's legs. She said this was not successful. She could only hold the patient's hands. The Patient Aide stated she was afraid the patient would leave the ED and get onto the streets. The hospital staff did not help her. She stated the EMS and Police helped get the patient into a wheelchair, then hospital staff was there. She was trying to keep the patient from hitting Her. She held the patient back onto the bed by her shoulders. The Patient Aide changed her story and then said, the patient was sitting on the side of the bed. Security surrounded the patient while she hid her face from the patient. She denied she shoved the patient onto the bed. The sitter said she laid the patient down with both hands. When the nurse came into the exam room, she had her hands on the patient's shoulders. The nurse misunderstood her actions. The aide denied placing her hand around the patient's neck. She stated the only thing on her mind was to protect the patient and prevent the patient from going outside of the hospital. The aide revealed she had taken care of Patient #1 before and the patient exhibits behaviors.

Another interview with the ED Manager, on 07/17/12 at 4:30 PM, revealed she had not been informed of the need to educate the ED staff regarding identification of abuse and reporting to DCBS. When she interviewed the nurses (RN #1 & #2) they had considered the incident to be assault, not abuse and did not report. Anyone can fill out an incident report online but the nurses had not. The nurses felt they had protected the patient and the police were involved (present in the ED at the time of the incident, however, were not there for that purpose). The nurses did not go the extra step to notify the state agency because they did not understand the definition of an vulnerable adult. Refer to 209.020 that states a person eighteen (18) years or older who, because of mental or physical dysfunctioning, is unable to protect himself from neglect, exploitation, or a hazardous or abusive situation without assistance from others, and who may be in need of protective services.

Interview with the Risk Manager, on 07/17/12 at approximately 5:00 PM, revealed the staff had failed to identify that the patient needed protection under the law and considered the incident as assault not abuse. She stated there was a need to educate the staff regarding the law.