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, medical record review, and review of facility's documents, it was determined the facility failed to report and investigate a possible case of abuse in a timely manner for one (1) of eleven (11) patients, Patient #3.

The findings include:

Review of facility's document titled, "Documentation Guidelines," no date or reference number, stated when the Social Worker (SW) reviewed the daily census for new admissions, there were certain categories which would indicate case management's attention was required. One (1) of these categories was "red flags". Interview with the Social Work Supervisor (SWS), on 05/13/15 at 11:50 AM, revealed an abuse allegation would fall within this category. However, there was no mention of prioritizing existing patients on the unit for visits.

Review of Patient #3's closed medical record revealed he/she was admitted on [DATE] and discharged home on 05/11/15 in stable condition. His/her diagnoses included Viral Encephalitis, Acute Hepatitis B Viral Infection, Seizures, and Dysphagia. The record further revealed there was a stat social services consult ordered on [DATE] at 1:10 AM, but Case Management Notes from 04/22/15 at 4:53 PM revealed SW #1 learned from the RN staff on 8th Floor that an incident occurred on 04/20/15 regarding Patient #3 and the patient's son involving inappropriate physical contact. The Case Management Notes further revealed SW#1 was not notified of the incident by the 6th Floor staff. The record further showed Patient #3 was transferred from 6th Floor to 8th Floor on 04/21/15; and then from 8th Floor to 5th Floor in the PM of 04/22/15. The record also showed that Patient #3 had an altered mental status and was nonverbal for much of this hospitalization . In addition, Patient #3's medical record revealed an Adult Protective Services (APS) referral about the 04/20/15 incident was made by SW #2 on 04/22/15 at 8:33 PM.

Interview with SW #1, on 05/12/15 at 3:19 PM, revealed she was made aware of an incident concerning Patient #3 by nursing staff on 04/22/15 between 3:00 PM and 4:00 PM concerning inappropriate touching of Patient #3 by the son. She further revealed she was not made aware of the incident by a social services consult. SW #1 then stated she had seen the patient forty-eight (48) hours after admission but not about this incident. She then revealed the process for a social services consult was that after it was ordered in the computer, it was printed in the main Patient/Family Services office. Then, it was picked up by the SW. SW #1 revealed the social services consult on Patient #3 was entered as a stat order.

Interview with SW #2, on 05/12/15 at 3:45 PM, revealed she worked from 3:00 PM to 11:30 PM, and she had been notified by SW #1 about the incident with Patient #3 on 04/22/15 when she came to work. She further revealed she wanted to talk with the nurses that might have witnessed the event(s), and after she did this, she notified APS by hotline because it was after regular office hours. SW #2 further revealed she received a call from the on-call APS worker and informed her that Patient #3's son was no longer in the facility and would not be returning that evening.

Interview with the SWS, on 05/13/15 at 11:28 AM, revealed there were three (3) ways for social services to be notified after a consult had been ordered. The first was for the order to go to the main office and be printed and disseminated. The second, which she revealed was the fastest and easiest, was for the nursing staff to call the social worker directly. The third, was for the social worker when rounding in his/her area, to scan the order directly. The SWS then stated with the first way, by the time the SW got the paper notification, in most cases, the situation had already been addressed by the SW. She further revealed it was her expectation the SW be at the patients' bedsides and nursing stations daily to find out the patients' needs, and with the Patient #3 social services consult, the information was not passed along the morning of 04/21/15 and should have been.

Interview with the Manager of Patient/Family Services, on 05/13/15 at 11:38 AM, revealed even though the consult was made, it should have been discussed at morning rounds on 04/21/15, and Patient #3 should have been seen by SW #1 early in the morning of 04/21/15 because it was a high priority case. She also stated this case was dropped because nursing assumed since the consult had been ordered, SW #1 had been notified. Therefore, the nursing staff did not make a phone call to SW #1. She also revealed this process of notification needed to be improved so that other consults would not be delayed.