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.
| BAPTIST HEALTH CORBIN | ONE TRILLIUM WAY CORBIN, KY 40701 | July 25, 2013 |
| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** AMENDED -- Based on interview, record review, and review of the facility's policies and documents, it was determined the facility failed to ensure patient rights were protected and promoted for two of ten patients (Patient #2 and Patient #8). The facility failed to protect Patient #2 from abuse. The facility failed to identify RN #3 had a history of abusive behavior. In addition, the facility further failed to ensure allegations of abuse were reported immediately, failed to protect patients from further potential abuse, and failed to conduct a timely, thorough investigation of an abuse allegation. Patient #2 was admitted on [DATE] with diagnoses that included term birth living child and neonatal withdrawal syndrome. On 07/10/13, Patient #2 was a Level II Nursery Patient. Registered Nurse (RN) #2 witnessed RN #3 jerk Patient #2 up by the left arm and throw the patient over her shoulder. RN #2 also heard RN #3 screaming at Patient #2 to "shut the fuck up." However, RN #2 did not report the incident immediately to the House Supervisor or to the appropriate state agency. On 07/12/13, RN #1 was conducting a full assessment of Patient #2 and observed Patient #2's left upper arm to be very swollen and red and the patient's arm appeared to be malformed because of the swelling. An x-ray of Patient #2's left arm revealed the patient's arm (humerus bone in the upper arm) was broken. There was no documented evidence the allegation of abuse was reported until RN #2 informed RN #6 of the abuse of Patient #2. RN #6 reported the verbal and physical abuse on 07/13/13 to the Unit Manager. RN #3 was suspended from employment pending the completion of the investigation on 07/15/13, two days later. There was no evidence the facility initiated an investigation of the allegations until 07/16/13 (six days after the abuse occurred). The facility also failed to ensure their abuse policy addressed reporting allegations of abuse immediately in accordance with state law and the policy did not address protection of patients from further potential abuse when a staff member was named as the perpetrator. The facility further failed to ensure abuse prevention plans required by the Department for Community Based Services (DCBS) were implemented. DCBS required supervision of Patient #2 when the patient's mother was present with Patient #2; however, there was no evidence that supervision occurred. The facility admitted Patient #8 on 07/05/13 with diagnoses that included term birth living child, and positive for amphetamine and opiates. On 07/05/13 DCBS, who became involved because the newborn was drug addicted, stated Patient #8 had to be discharged home with the patient's grandmother. On 07/08/13, Patient #8 was discharged home with the patient's mother by facility staff. No evidence was found that DCBS was contacted to verify the change in discharge plan. The failure of the facility to identify and protect patients from abuse; failure to provide a safe environment; failure to ensure the abuse policy addressed timely reporting of allegations of abuse and protection of patients during abuse investigations; and failure to ensure allegations of abuse were immediately reported, thoroughly and timely investigated, and patients were protected from further potential abuse placed patients at risk for serious injury, harm, impairment or death. It was determined Immediate Jeopardy existed on 07/10/13 and is ongoing. Refer to A0144 and A0145. |
||
| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy it was determined the facility failed to ensure newborn patients received care in a safe setting for two of ten sampled patients (Patient #2 and Patient #8). Patient #2 and Patient #8 had a diagnosis of [DIAGNOSES REDACTED]. The facility failed to ensure Patient #2 was supervised at all times when the patient's mother was present as required by DCBS. On 07/12/13, Patient #2 was assessed to have a humerus fracture that interviews with staff revealed was the result of abuse. In addition, the facility failed to ensure Patient #8's safety when the patient was discharged home with the patient's mother, instead of the patient's grandmother as required by DCBS. The failure to ensure newborn patients were supervised and discharged to appropriate individuals placed patients at risk for serious injury, harm, impairment, or death. It was determined Immediate Jeopardy existed on 07/10/13 and is ongoing. The findings include: A review of the facility's policy entitled "Your Rights and Responsibilities as a Hospital Patient," dated 03/28/11, revealed, "You have the right to receive care in a safe setting." However, the facility had no evidence of a policy or procedure related to the care and treatment of patients involved with DCBS. 1. Record review revealed the facility admitted Patient #2 on 07/06/13 at 12:47 PM with diagnoses that included [DIAGNOSES REDACTED]. Because of the positive drug screen, the facility social worker was contacted and a referral was made to involve DCBS. On 07/09/13, Patient#2's mother was discharged home; however, the patient remained under the care of the facility to continue medical drug detoxification. Interview with a DCBS supervisor on 07/22/13 at 12:30 PM revealed the abuse prevention plan for Patient #2 was for the mother to be supervised at all times while visiting with the patient. The plan did specify that the father could supervise the mother during the visitation. Interview with RN #4 on 07/22/13 at 12:40 PM revealed the visitation with Patient #2 took place in the visitation room beside the nursery. The interview further revealed that staff opened the door to the room and could see in while the parents visited, but other than noting the time of the visitation in the nursing notes, the facility did not continuously monitor or document the visitation. A review of Patient #2's medical record and interview with RN #1 on 07/23/13 at 12:10 PM revealed the RN identified the injury to Patient #2's left arm on 07/12/13. RN #1 stated Patient #2's upper left arm was red, swollen, and firm. "I've never seen anything like it," the RN stated. The patient's physician was notified and an x-ray was ordered that was positive for a humerus fracture in Patient #2's left arm. 2. The facility admitted Patient #8 on 07/05/13 with diagnoses that included [DIAGNOSES REDACTED]#8 had to be discharged home with the patient's grandmother, not the patient's mother. However, on 07/08/13, Patient #8 was discharged home with the mother by facility staff. No evidence was found in Patient #8's or the patient's mother's medical record that DCBS had changed the discharge plan. Interview with RN #7 on 07/24/13 at 4:30 PM revealed that she discharged Patient #8 home with the patient's mother. She stated she knew Patient #8 was involved with DCBS and had read the note from the social worker that Patient #8 had to discharge home with the grandmother, but she thought that issue had been resolved. RN #7 could not provide any evidence that DCBS had changed the discharge plan for Patient #8. Interview with the Unit Manager (UM) on 07/22/13 at 10:10 AM and on 07/24/13 at 1:20 PM revealed staff notified the facility social worker when infants were delivered at the facility and identified to have a positive drug screen. According to the UM, the facility social worker reported positive drug screens to DCBS and documented instructions received from DCBS in the medical record. The UM stated Patient #2's positive drug screen was reported to DCBS and Patient #2's injury of unknown cause (fractured arm) was reported to DCBS. The UM stated the injury of unknown cause was not reported immediately because she and the Risk Manager initially assumed the fracture was the result of [DIAGNOSES REDACTED] (genetic bone disease). The UM stated the facility did not have a policy for the supervision of newborns under the direction of the Department for Community Based Service (DCBS). The UM gave no explanation why Patient #8 was discharged home with the mother after the facility received instructions from DCBS to discharge the infant home with the grandmother. The interview further revealed that visitation with babies took place in a room off of the nursery and the facility did not have a procedure in place to monitor or document those visits. |
||
| VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT | Tag No: A0145 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policies and documents, it was determined the facility failed to protect one of ten sampled patients from abuse (Patient #2). The facility failed to identify the history of abusive behavior exhibited by RN #3. The facility failed to ensure their abuse policy addressed reporting allegations of abuse immediately in accordance with state law and the policy did not address protection of patients from further potential abuse when a staff member was named as the perpetrator. In addition, the policy failed to address an investigation was to be conducted in a timely and thorough manner. On 07/10/13, RN #2 observed RN #3 jerk Patient #2, a six-day old baby, up out of a crib by the left arm and throw the patient over her shoulder. RN #2 also heard RN #3 screaming at Patient #2 to "shut the fuck up." However, RN #2 did not report the incident until 07/14/13, after an x-ray of Patient #2's left arm on 07/12/13 revealed the patient's arm (humerus bone in the upper arm) was broken. The facility suspended RN #3 on 07/15/13, four days after the observation of the RN jerking the baby up by the left arm, and initiated an investigation of the allegation on 07/16/13 (six days after the abuse occurred). The failure of the facility to identify and protect patients from abuse and failure to ensure effective methods and mechanisms were in place to address timely reporting of allegations of abuse, to ensure a timely and thorough investigation of abuse allegations and protection of patients during abuse investigations, placed patients at risk for serious injury, harm, impairment, or death. It was determined Immediate Jeopardy existed on 07/10/13 and is ongoing. The findings include: A review of the facility's policy entitled "Your Rights and Responsibilities as a Hospital Patient," dated 03/28/11, revealed, "You have the right to receive care in a safe setting, and to be free from abuse and harassment." A review of the facility policy entitled "Suspected Child/Adult Neglect/Abuse," dated 01/18/13, revealed all staff witnessing abuse had the duty to cause an oral or written report to be made to the Department for Social Services [Department for Community Based Services (DCBS)] or if a child is involved by calling the Child Protection Hotline (also DCBS). The policy further stated that any employee suspected of abuse would receive appropriate work assignments to protect patients, which may include suspension from work, or different work area assignments. Further review of the policy revealed that when abuse was suspected the Vice President of Nursing/designee would appoint a representative to investigate the incident. The policy failed to define timeframes or the nature of a thorough investigation. A review of the medical record for Patient #2 revealed the patient was admitted on [DATE] with diagnoses including term birth living child and neonatal withdrawal syndrome. Further review of the record revealed the patient was transferred from a Level I nursery patient to Level II nursery patient and received Morphine 0.01 mg every 4 hours for withdrawal symptoms. A review of the nurse's notes dated 07/12/13 at 12:30 AM revealed a muscular assessment was conducted on Patient #2 and the patient's left arm was found to be swollen, red, firm, warm to touch, capillary refill was less than 3 seconds, and a radial pulse was present. The patient had limited mobility and the patient's physician was notified. The record further revealed an x-ray was ordered for Patient #2 and the impression was an angulated displaced fracture involving the distal third of the left humerus. An orthopedic consultation was ordered. On 07/12/13, a Physician Assistant for the orthopedic group evaluated and treated Patient #2 with a splint. The record further revealed the pediatrician consulted with a neonatal facility and the patient was transferred on 07/12/13 for further care and treatment. Interview with the Radiologist on 07/22/13 at 4:50 PM revealed that he conducted a follow-up reading of Patient #2's left arm x-ray on 07/15/13. He stated he agreed with the impression of the on-call radiologist that the patient had an angulated displaced fracture involving the distal third of the left humerus. The interview further revealed that the fracture was a "leverage type injury of a long bone" consistent with an abuse-type injury. He further stated that there was no way to appropriately age the fracture because there was no new growth present. According to the Radiologist, he had not been interviewed by facility staff related to the fracture and had not participated in an investigation of the fracture in any way. A review of the facility incident report dated 07/12/13 at 3:07 AM, revealed RN #1 assessed Patient #2, and found Patient #2 to have an upper left arm that was swollen, reddened, and firm to the touch. The report further stated capillary refill was less than 3 seconds and a radial pulse was present. The incident report also stated the patient had limited mobility, the doctor was notified, and an x-ray was ordered. The x-ray report revealed a fracture was noted to Patient #2's left arm. According to the incident report, the physician was aware of the findings. Further review of the incident report revealed the Unit Manager reviewed the report and documented that the pediatrician for Patient #2 had examined the patient and had contacted another facility to transfer care. The facility was advised that Patient #2 was having symptoms of [DIAGNOSES REDACTED]. Interview with RN #2 on 07/22/13, at 2:50 PM, revealed RN #2 was working in the newborn nursery the night of 07/10/13 and saw RN #3 "jerk" Patient #2 up out of the crib and throw the patient over her shoulder. RN #3 held Patient #2 there while RN #3 changed the bedding in the patient's crib. RN #2 also stated that she had heard RN #3 shouting "shut the fuck up" to Patient #2 that evening. RN #2 stated she told RN #3 that she had "seen nurses get fired for less than that kind of behavior." RN #2 stated that she had been trained on abuse and neglect, but that she did not know what to do when she witnessed the incident. RN #2 stated she told the Unit Manager about the incident on 07/14/13 after she found out the baby's arm was broken and because the behavior of RN #3 was "weighing on" her "mind." Interview with RN #3 on 07/22/13 at 4:20 PM revealed she was working on the night of 07/10/13 in the newborn nursery. RN #3 stated that when she got off work the morning of 07/11/13 nothing was wrong with Patient #2. The interview further stated that she did not know why she was being targeted in this manner and that she had never been abusive toward any patients, especially the newborns. Interview with RN #1 on 07/23/13 at 12:10 PM revealed she was conducting a full assessment of Patient #2 around midnight on 07/12/13 and assessed Patient #2 to have a red, swollen to the point of being firm, upper left arm. RN #1 called the House Supervisor and the pediatrician on call. RN #1 stated that the on-call pediatrician ordered an x-ray and the x-ray was positive for a fracture. RN #1 further stated she notified the on-call physician of the fracture and completed an incident report. According to RN #1, she had witnessed RN #3 pick up another baby by one arm. RN #1 stated she did not think that RN #3's actions were abusive at that time, but she did think it was inappropriate. RN #1 stated she did not report the incident to the Unit Manager. Interview with RN #6 on 07/24/13 at 12:45 PM revealed she was working in the newborn nursery on 07/12/13 the night Patient #2 was assessed to have a red and swollen left arm. She further stated that Patient #2 cried when the left arm was moved. RN #6 further stated that three years ago she had witnessed RN #3 screaming curse words at a patient. She stated she intervened and told RN #3 to stop and to never act that way toward a newborn again. RN #6 stated that in making the schedule she made it clear that she did not want to work with RN #3 again. Interview with the Unit Manager (UM) on 07/22/13 at 10:10 AM and on 07/24/13 at 1:20 PM revealed staff reported Patient #2's fracture to her when she came to work at approximately 7:30 AM on 07/12/13. The interview further revealed she received the incident report initiated by RN #1 and forwarded the report to Risk Management. The UM stated she was on the unit when Pediatrician #2 assessed the patient. At that time, she stated she was not aware of any allegations of abuse, nor did she even assume that there might be a problem. The interview further revealed RN #6 contacted her at home on 07/13/13 with a concern and she went to the facility to discuss the concerns verbalized by RN #6. The UM stated at that time RN #6 informed her of the allegations of abuse against RN #3; RN #2 had told RN #6 that she had witnessed RN #3 jerk Patient #2 up by the arm and throw the patient over her shoulder. The UM stated at that time she checked the schedule to ensure RN #3 was not on the schedule for the night of 07/13/13. The UM stated on 07/14/13 she received a call from RN #2 informing her of the incident she witnessed on the night of 07/10/13. The UM stated she met with the Chief Nursing Officer on the morning of 07/15/13 (two days later) and informed him of the allegations made against RN #3. The UM stated she had "assumed" up until that point that Patient #2 had a genetic disorder that caused the fracture. On 07/16/13, the UM stated she assisted the Risk Manager in the beginning of the investigation of the injury of unknown origin. In addition, the UM stated three years ago an emergency room tech had made an allegation regarding RN #3 screaming and cursing at the babies in the nursery. Interview with the Risk Manager on 07/24/13 at 2:30 PM stated she began an investigation into the incident involving Patient #2 on 07/16/13. She stated the facility up until then had assumed that Patient #2 had a diagnosis of [DIAGNOSES REDACTED]. Interview with Pediatrician #2 (Medical Director of OB/GYN Unit) on 07/22/13 at 1:00 PM revealed he assessed Patient #2 at around 8:00 AM on 07/12/13. He also stated he consulted with an orthopedist in the facility and contacted a transferring neonatal unit and advised them to obtain an ophthalmology workup for a non-accidental trauma. He stated he was not called at the birth of Patient #2 and was not aware of any complications with the patient's delivery. The interview further revealed at the time of the interview that he had not been asked to participate in or be a part of any facility investigation. Interview with the orthopedic surgeon on 07/24/13 at 4:50 PM revealed he had reviewed the x-ray of Patient #2 and had spoken with his Physician Assistant and educated her on the proper way to splint the patient's arm. He stated that he was consulted by Pediatrician #2 and before he could assess the patient, the patient was transferred to a Neonatal Unit. He stated if this injury had occurred at birth you would expect signs and symptoms to show up before six days. According to the orthopedic surgeon, Patient #2's injury could have been the result of RN #3 jerking the baby out of the crib by the arm. The orthopedic surgeon stated that when a fracture occurred in a newborn, swelling and redness may not be visible for 24-48 hours after the injury. Interview with the delivering Obstetrician was attempted but he was unavailable due to being out of the country. Interview with the Chief Nursing Officer on 07/22/13 at 11:30 AM revealed he had been told of the incident involving Patient #2 on 07/15/13 when the UM brought the allegations made against RN #3 to his attention. He stated he spoke with RN #3 on that day and suspended her until the facility investigation was completed. He stated he could not provide any of the evidence collected during his interview with RN #3 because he had been advised by legal counsel not to do so. |
||
| VIOLATION: NURSING SERVICES | Tag No: A0385 | |
| Based on interview, record review, review of the facility's policies and documents, it was determined the facility failed to ensure that each patient's rights were protected and promoted through nursing supervision. Based on the survey findings it was determined the Conditions of Participation at 42 CFR 482.23 Nursing Services was not met. The facility failed to provide written guidance to nurses to monitor and supervise visits in conjunction with Department for Community Based Services (DCBS) parenting/abuse prevention plans. In addition, the facility failed to provide written guidance to nursing supervisors for the appropriate investigation of allegations of abuse and failed to ensure each patient was free from all forms of abuse for two of ten sampled patients (Patients #2 and #8). Patient #2 was identified to have an injury of unknown cause (fractured upper left arm) on the morning of 07/12/13 while under the care of Nursing Services with no explanation how or why the injury occurred. As of 07/25/13 there was no evidence provided during the investigation that the facility completed a formal investigation and no evidence that any procedure was put in place to ensure the safety of other newborns. Further review revealed a second infant (Patient #8) was found positive for opiates and amphetamines at birth on 07/05/13 and then discharged home with the mother on 07/08/13. However, it was noted by Social Services on 07/05/13 that the facility had received instruction from the Department for Community Based Services (DCBS) that stated the grandmother was to be present and the grandmother was to provide transportation at discharge. There was no evidence found that the facility had ever developed a policy for the supervision of patients involved with DCBS. The failure to ensure newborn patients were supervised and discharged to appropriate individuals placed patients at risk for serious injury, harm, impairment, or death. It was determined Immediate Jeopardy existed on 07/10/13 and is ongoing. Refer to A0395. |
||
| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policies and documents, it was determined the facility failed to ensure that each patient's rights were protected and promoted through nursing supervision. The facility failed to provide written guidance to nursing supervisors for appropriate investigation of allegations of abuse and failed to ensure each patient was free from all forms of abuse. In addition, the facility failed to provide written guidance to nurses to monitor and supervise visits in conjunction with Department for Community Based Services (DCBS) parenting/abuse prevention plans for two of ten sampled patients (Patients #2 and #8). The facility failed to ensure Patient #2 was supervised at all times when the patient's parents were present, as required by DCBS. On 07/12/13, Patient #2 was assessed to have a humerus fracture, which interviews with staff revealed was the result of abuse. In addition, the facility failed to ensure Patient #8's safety when the patient was discharged home with the patient's mother, instead of the patient's grandmother as required by DCBS. The failure to ensure newborn patients were supervised and discharged to appropriate individuals placed patients at risk for serious injury, harm, impairment, or death. It was determined Immediate Jeopardy existed on 07/10/13 and is ongoing. The findings include: 1. Review of facility policies revealed the facility failed to develop a policy for the supervision of newborns and/or patients under the supervision of DCBS. A review of the facility policy entitled "Suspected Child/Adult Neglect/Abuse," dated 01/18/13, revealed all staff witnessing abuse had the duty to cause an oral or written report to be made to the Department for Social Services [Department for Community Based Services (DCBS)] or if a child is involved by calling the Child Protection Hotline (also DCBS). The policy further stated that any employee suspected of abuse would receive appropriate work assignments to protect patients, which may include suspension from work or different work area assignments. Further review of the policy revealed that when abuse was suspected the Vice President of Nursing/designee would appoint a representative to investigate the incident. The policy failed to define timeframes or the nature of a thorough investigation. Medical record review revealed Patient #2 was born at the facility on 07/06/13 at 12:47 PM with diagnoses including term birth living child and neonatal withdrawal syndrome. Further review revealed the infant's (Patient #2's) drug screen showed positive for Suboxone (classified narcotic) and THC (marijuana). As a result of the positive drug screen the facility Social Worker was contacted and a phone call was made to involve DCBS. On 07/09/13 the infant's (Patient#2's) mother was discharged home; however, the infant remained at the facility under nursing supervision to continue medical detoxification. Continued review of the record revealed the parenting/abuse prevention plan for the patient was supervised visits for the mother (due to the positive drug screen of the patient) and that the father of the patient could supervise the visits. There was no evidence in the medical record that verified the nursing staff monitored the visits of the patient. A telephone interview was conducted on 07/22/13 at 4:25 PM with Patient #1 (mother of newborn Patient #2). Patient #1 stated both the mother and father were in shock when they heard their baby's arm was broken. Patient #1 stated there were no problems with the delivery/C-section. Patient #1 was discharged home on 07/09/13. However, the baby remained at the hospital. Patient #1 stated she and dad both visited Patient #2 at the hospital nursery under the supervision of Nursing, however, Nursing staff did not continuously monitor the visit. Interview with the DCBS supervisor on 07/22/13 at 12:30 PM revealed the abuse prevention plan for Patient #2 was for the mother to be supervised at all times while visiting with the patient. The plan did specify that the father could supervise the mother during the visitation. Interview with RN #4 on 07/22/13 at 12:40 PM revealed the visitation of Patient #2 took place in the visitation room beside the nursery. The interview further revealed staff opened the door to the room and could see in while the parents visited, but other than noting the time of the visit in the nursing notes, the facility did not continuously monitor or document the visitation. On 07/12/13 at approximately 12:30 AM during a routine full body nursing assessment the infant (Patient #2) was identified to have an injury to the upper left arm. The physician was notified and an x-ray was ordered which showed the infant's left upper arm bone to be fractured. Review of Patient #2's x-ray report dated 07/12/13 revealed views of the left upper arm showed an angulated displaced fracture involving the distal shaft of the humerus (left upper arm). Interview with the Radiologist on 07/22/13 at 4:50 PM revealed that he conducted a follow-up reading of the Night Hawk (the on-call radiologist at night) interpretation for the x-ray of Patient #2 on 07/15/13. He stated he agreed with the impression of the Night Hawk radiologist of an angulated displaced fracture involving the distal third of the left humerus. The interview further revealed the Radiologist stated this was a "leverage type injury of a long bone consistent with an abuse type injury." He further stated that there was no way to appropriately age the fracture because there was no new bone growth present. The Radiologist stated that he had not participated in an investigation of the fracture in any way. Interview with the neonatal physician at the receiving hospital on [DATE] at 2:40 PM revealed Patient #2 remained hospitalized and continued to receive morphine for pain. The neonatal physician stated Patient #2's lab results and CT scan were normal. It was the neonatal physician's personal opinion that the injury was the result of "suspicious trauma." Interview with RN #1 on 07/23/13 at 12:10 PM who found the injury on 07/12/13 revealed no explanation why or how the injury occurred. According to RN #1, the injury was identified during a routine full body assessment. RN #1 stated Patient #2's upper left arm was red and swollen, "I've never seen anything like it." RN #1 stated since she was a new nurse she consulted with two other RNs (RN #2 and RN #6) who also assessed Patient #2's arm and all agreed something was wrong. RN #1 notified the on-call physician and the House Patient Care Manager. RN #1 stated an incident report was filed. When RN #1 was questioned, she stated that she had witnessed, on a different occasion with a different patient, RN #3 pick up another baby (name unknown) by one arm. RN #1 stated she didn't think it was abuse but did think it was inappropriate. RN #1 did not report the incident. RN #2 stated in interview on 07/22/13 at 2:50 PM that she was working on 07/12/13 when RN #1 found Patient #2's left upper arm injury. RN #2 stated she worked with RN #3 on the night of 07/10/13 and witnessed RN #3 "jerk" Patient #2 out of the crib and throw the patient over her (RN #3's) shoulder. RN #2 stated she confronted RN #3 and told her (RN #3) that she (RN #2) had "seen nurses get fired for less than that kind of behavior." RN #2 also reported having witnessed RN #3 curse babies, telling the babies to "shut the fuck up." RN #2 reported the abuse to the Unit Manger on 07/14/13 four days after the incident occurred because the behavior of RN #3 was "weighing on" her "mind." RN #6 stated in interview on 07/24/13 at 12:45 PM that she was working on 07/12/13 when RN #1 found Patient #2's left upper arm injury. RN #6 stated the arm was swollen, firm, and deformed looking. According to RN #6 there was nothing done on her shift to cause harm to the infant (Patient #2). RN #6 went on to say that she had witnessed RN #3 curse the babies but had never observed RN #3 physically harm a baby. RN #6 further stated that three years ago she had witnessed RN #3 scream curse words at an infant. RN #6 stated she intervened and told RN #3 to stop and to never act that way toward a newborn again. RN #6 did not report the incident to the Unit Manager until 07/13/13 (three years later). A telephone interview was conducted on 07/22/13 at 4:20 PM with RN #3 who stated she was "targeted" by the facility. RN #3 stated she had done nothing wrong and was afraid to talk to anyone. According to RN #3, the infant's (Patient #2's) injury was found 24 hours after she cared for the infant. RN #3 requested that her lawyer be present for any further questions. The interview was stopped. Interview with the Social Worker on 07/22/13 at 5:10 PM revealed that when DCBS is involved with a family she documents the parenting/abuse prevention plan in the social work notes and it becomes part of the social work care plan. However, the facility does not have a procedure or protocol for the nursing staff to monitor visits or verify they are aware of the limitations of the parenting/abuse prevention plan for discharge. In addition, the interview revealed that she became aware of Patient #2's injury and she contacted appropriate authorities but the investigation of the incident was under Risk Management. The Unit Manager on 07/24/13 at 1:20 PM stated Patient #2's positive drug screen was reported to DCBS and Patient #2's injury of unknown cause (fractured arm) was also reported to DCBS. The Unit Manager stated the injury of unknown cause was not reported timely because staff initially assumed the fracture was the result of [DIAGNOSES REDACTED] (genetic bone disease). The Unit Manager stated the Nursery had a system in place to use a "card system" initialed by nursing staff and parents when transferring infants to/from the nursery to room in with mom. An interview was conducted on 07/24/13 at 2:30 PM with the Risk Manager who stated a facility investigation was initiated on 07/16/13 regarding Patient #2 (injury of unknown cause, fractured upper arm). The Risk Manager stated all information related to the investigation was "part of legal and could not be released." There was no information provided during the investigation to show the facility had conducted a timely investigation and no evidence found that nursing staff provided appropriate care for Patient #2. Interview with the Chief Nursing Officer on 07/22/13 at 11:30 AM revealed that he had been told of the incident involving Patient #2 on 07/15/13 when the UM brought the allegations made against RN #3 to his attention. He stated he spoke with RN #3 on that day and suspended her until the facility investigation was completed. He stated he could not provide any of the evidence collected during his interview with RN #3 because he had been advised by legal counsel not to do so. He presented no evidence during the investigation that verified the facility had taken any actions to further protect the patients receiving care in the facility. 2. Medical record review revealed Patient #8 was admitted to the facility on [DATE] with diagnoses that included [DIAGNOSES REDACTED]#8 had to be discharged home with the patient's grandmother, not the patient's mother. However, on 07/08/13, Patient #8 was discharged home with the mother by facility staff. No evidence was found in Patient #8's or the patient's mother's medical record that DCBS had changed the discharge plan. Interview with RN #7 on 07/24/13 at 4:30 PM revealed RN #7 discharged Patient #8 home with the patient's mother. RN #7 stated she knew that Patient #8 was involved with DCBS and had read the note from the social worker that Patient #8 had to discharge home with the grandmother, but she thought that issue had been resolved. RN #7 could not provide any evidence that DCBS had changed the discharge plan for Patient #8. Interview with the Social Worker on 07/22/13 at 5:10 PM revealed the Social Worker was not aware that Patient #8 had been sent home with the mother rather than the grandmother and could offer no explanation for the oversight. Interview with the Unit Manager on 07/24/13 at 1:20 PM revealed staff notified the facility social worker when infants were delivered at the facility and identified to have a positive drug screen. The Unit Manger stated it was the facility social worker who reported to the proper authorities. According to the Unit Manager, the facility social worker reported positive drug screens to DCBS and documented instructions received from DCBS in the medical record. The facility did not have a policy for the supervision of newborns under the direction of the Department for Community Based Service (DCBS). The Unit Manager gave no explanation why Patient #8 was discharged home with the mother after the facility received instructions from DCBS to discharge the infant home with the grandmother. The Unit Manager and staff found no evidence in Patient #8's or the patient's mother's medical record that DCBS had changed the discharge plan. The Unit Manager referred the surveyors to the Risk Manager. An interview was conducted on 07/24/13 at 2:30 PM with the Risk Manager who stated she was not aware nursing staff failed to follow DCBS discharge instructions for Patient #8. Interview with the Chief Nursing Officer on 07/22/13 at 11:30 AM revealed that he was not aware of the incident involving Patient #8. |
||