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 | Feb. 14, 2017 |
| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility policies, and review of the facility investigation outline it was determined the facility failed to ensure patients received care in a safe setting for one (1) of ten (10) sampled patients (Patient #1). Interviews with nursing staff revealed on 02/02/17 at approximately 3:40 AM Certified Nursing Assistant (CNA) #1 and CNA #2 reported to Registered Nurse (RN) #2 that Patient #1 stated that CNA #1 was "rough" with him/her and he/she did not want CNA #1 providing care to him/her anymore because CNA #1 had hurt his/her leg. During report, RN #2 stated she informed RN #1 of the incident but she did not inform the House Supervisor or Nurse Manager #1 of the incident. On 02/02/17 Patient #1 reported to Physician #1 that CNA #1 was "rough with [him/her] this morning" and the patient did not want CNA #1 providing care to him/her anymore. Physician #1 did not report this allegation as per facility policy. RN #1 documented on 02/03/17 at 8:33 AM that Patient #1 had a bruised ecchymotic (a hematoma of the skin larger than 10 millimeters) left leg. The facility discharged Patient #1 to home on 02/03/17. Patient #1 reported to the facility on [DATE] during a follow-up call that CNA #1 was "rough" with the patient and had "hurt" his/her leg during the patient's hospitalization and had caused a hematoma (a localized collection of blood outside the blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillaries) on the patient's left leg. Nurse Manager #1 was notified of these allegations of abuse via email on 02/05/17. Nurse Manager #1 attempted contact with Patient #1 on 02/06/17. Nurse Manager #1 reported the allegations to Risk Management and the Chief Nursing Officer (CNO) on 02/07/17 and an investigation was initiated. Patient #1 was readmitted to the facility on [DATE] with a diagnosis of a lower extremity intramuscular hematoma. CNA #1 continued to work after the allegations of abuse were reported to nursing staff on 02/02/17, and worked with patients on 02/05/17 and 02/06/17. |
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| 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, review of the facility policies, and review of the facility investigation outline, it was determined the facility failed to ensure patients received care in a safe setting for one (1) of ten (10) sampled patients (Patient #1). Interviews with nursing staff revealed on 02/02/17 at approximately 3:40 AM Certified Nursing Assistant (CNA) #1 and CNA #2 reported to Registered Nurse (RN) #2 that Patient #1 alleged that CNA #1 was "rough" with the patient and had "hurt" the patient's leg. Patient #1 also reported he/she did not want CNA #1 providing care to him/her anymore because CNA #1 had "hit the patient's leg" on the bed rail when being turned. During report RN #2 stated she informed RN #1 of the incident but did not report the incident to the House Supervisor or Nurse Manager as required by the facility's policy. On 02/02/17 Patient #1 reported to Physician #1 that CNA #1 was "rough with him/her early this morning" and the patient did not want CNA #1 providing care to him/her anymore. According to interviews Physician #1 did not report this allegation as per facility policy. RN #1 documented on 02/03/17 at 8:33 AM that Patient #1 had a bruised ecchymotic (a hematoma of the skin larger than 10 millimeters) area on his/her left leg. The facility discharged Patient #1 to home on 02/03/17. Patient #1 reported to the facility on [DATE] during a follow-up call that CNA #1 was "rough" with the patient during the patient's hospitalization and had caused a hematoma (a localized collection of blood outside the blood vessels, due to either disease or trauma including injury or surgery, and may involve blood continuing to seep from broken capillaries) on the patient's left leg. Nurse Manager #1 was notified of these allegations of abuse via email on 02/05/17. Nurse Manager #1 attempted contact with Patient #1 on 02/06/17. Nurse Manger #1 reported the allegations to Risk Management and the Chief Nursing Officer (CNO) on 02/07/17 and an investigation was started. Patient #1 was readmitted to the facility on [DATE] with a diagnosis of a lower extremity intramuscular hematoma. CNA #1 continued to work with patients after the allegations of abuse were reported to facility staff on 02/02/17. The findings include: Review of the facility policy titled "Patient Rights and Responsibilities," revised 07/18/16, revealed patients have the right to retain personal dignity and privacy, receive care sensitive to personal feelings and need for bodily privacy, receive care in a safe setting, and to be free from abuse and harassment. Review of the facility policy titled "Suspected Child/Adult Neglect/Abuse," revised 07/30/13, revealed the purpose of the policy was to identify and assess victims of alleged or suspected abuse or neglect. Continued review of the facility policy revealed it was the responsibility of any staff member, including physicians, having reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation to initiate reporting immediately. All staff members were to immediately notify the House Supervisor, Department Supervisor, and the Protection Hotline if neglect/abuse was suspected. In addition, the policy defined abuse as the infliction of physical pain, injury, or mental injury, or the deprivation of services by a caretaker that were necessary to maintain the health and welfare of an adult. Further review of the policy revealed that any employee suspected of abuse would receive appropriate work assignments to protect patients, staff, and visitors. This would include but not be limited to suspension from work, a different work area assignment, or work assignments that do not involve patient contact. Record review revealed the facility admitted Patient #1 on 01/24/17 with a diagnosis of acute bronchitis and possible pneumonia. Interview with Patient #1 and Patient #1's family member on 02/14/17 at 7:30 AM revealed that on 02/02/17 in the early morning hours, CNA #1 was "rough" and hit his/her leg on the bed rail when turning and repositioning him/her. Patient #1 stated that he/she told RN #2 immediately after the incident that CNA #1 was "rough" with him/her and that she had "hurt" his/her leg. Patient #1 also stated he/she informed RN #2 that he/she did not want CNA #1 back in his/her room anymore. Further interview with Patient #1 revealed he/she also reported the incident to RN #1 and Physician #1 on 02/02/17 concerning the "rough" treatment and of CNA #1 "hurting" his/her leg. Patient #1 stated he/she felt like the facility did nothing with the allegations. Patient #1's family member stated that because the patient was "hurt" by CNA #1 she hired a caregiver to sit with the patient on 02/03/17. The medical record further revealed "generalized bruising" had been documented for Patient #1 on 02/01/17 at 3:00 PM and on 02/02/17 at 8:30 AM. On 02/03/17 at 8:33 AM the patient's skin assessment revealed the patient's left leg was bruised; however, the patient's medical record contained no measurements or detailed description of the bruising. Further review of the medical record revealed RN #2 documented on 02/02/17 at 3:43 AM that Patient #1 expressed concerns about being turned and was afraid that he/she would be injured. The facility discharged Patient #1 on 02/03/17. Record review revealed the facility readmitted Patient #1 on 02/06/17, for treatment of a lower extremity intramuscular hematoma. Review of "Photographic Wound Documentation," dated 02/06/17, revealed the lower extremity bruising extended from Patient #1's upper thigh to the mid-calf. However, the medical record contained no measurements of the bruise. Further interview with Patient #1 and his/her family member 02/14/17 at 7:30 AM revealed because CNA #1 hit his/her leg on the bed rail on 02/02/17 during the previous admission to the facility, Patient #1 had to be returned to the Emergency Department and was readmitted to the facility. Patient #1's family member reported that Patient #1 became upset, anxious, and fearful upon arrival to the patient's room on 02/06/17 after observing CNA #1's name on the board in his/her room indicating CNA #1 would be providing care. The family member stated they notified RN #3 that CNA #1 had hurt him/her during a previous admission. RN #3 stated to Patient #1 and the family member that she would reassign CNA #1 to care for another patient, and assured him/her that CNA #1 would not care for him/her that night. Patient #1's family member stated that even though nursing staff reassigned CNA #1 to other patient rooms, the patient was still upset because he/she felt like CNA #1 would be "rough" with other patients if nothing was done. Interview with Nurse Manager #1 on 02/13/17 at 3:05 PM revealed that she became aware of the allegations of "rough" treatment on 02/06/17 when a nurse from the "quality line" (patient satisfaction telephone survey) emailed her and made her aware of the allegations. Nurse Manager #1 stated that she then attempted to contact Patient #1 via phone. Nurse Manager #1 stated that on 02/07/17 she became aware that Patient #1 had been readmitted to the facility. She informed Administration of the allegations and an investigation was started. Review of the facility investigation outline dated 02/07/17 revealed on 02/07/17 at 11:00 AM Nurse Manager #1 contacted Risk Management and informed them of the allegations of CNA #1 being "rough" with Patient #1. Risk Management informed facility Administration and Human Resources. Continued review of the facility investigation outline revealed Risk Management interviewed Patient #1, two (2) other patients CNA #1 provided care to, and "several" nursing staff members. The facility determined that CNA #1 could not provide care to Patient #1; however, CNA #1 would continue to work. Interview with RN #2 on 02/13/17 at 7:20 PM revealed that she was Patient #1's nurse on 02/01/17 from 7:00 PM to 7:00 AM on 02/02/17. RN #2 stated at approximately 3:43 AM she went into Patient #1's room after CNAs #1 and #2 had informed her that Patient #1 had complained that CNA #1 was "rough" with him/her. RN #2 recalled that Patient #1 stated that he/she did not want CNA #1 in his/her room anymore because CNA #1 was too "rough" with the patient and that CNA #1 had "hurt" his/her leg. Further interview with RN #2 revealed that she understood Patient #1 to further request no one turn or reposition him/her anymore because the patient was in pain, and the patient had a fear of injuring his/her spleen. RN #2 stated that she did not report the allegations to the Protection Hotline as per facility policy nor did she report to the House Supervisor or Nurse Manager #1. During report RN #2 stated that she did notify RN #1 of the allegations. RN #2 stated she did not think Patient #1 was reporting abuse when the patient reported CNA #1 being "rough" with him/her. Interview with RN #1 on 02/13/17 at 2:45 PM revealed that she was Patient #1's assigned nurse on 02/02/17 and 02/03/17 from 7:00 AM to 7:00 PM. RN #1 stated that RN #2 informed her in report at approximately 7:00 AM on 02/02/17 that Patient #1 had alleged that CNA #1 had been "rough" with the patient. RN #1 stated she went into Patient #1's room on 02/02/17 to assess him/her. RN #1 stated that Patient #1 told her that CNA #1 had been "rough" with him/her in the night and hurt his/her legs and the patient did not want CNA #1 in his/her room anymore. RN #1 stated she contacted the unit clerk while in Patient #1's room and requested that CNA #1 not be assigned to Patient #1 on 02/02/17 during the night shift. RN #1 stated that she did not make a report to the House Supervisor, Nurse Manger #1, or the Protection Hotline as per facility policy. RN #1 stated she did not think "rough" treatment was abuse. RN #1 stated she noted that Patient #1 had generalized bruising on his/her legs but did not notice anything unusual. RN #1 stated that on 02/03/17 at approximately at 8:30 AM she conducted a skin assessment on saw a large bruise on Patient #1's left leg. RN #1 stated that she did not associate the bruise with Patient #1's allegations of "rough" treatment and again failed to report to Nurse Manger #1, the House Supervisor, or the Protection Hotline. RN #1 stated she did not understand that by reassigning CNA #1 to other rooms she placed other patients at risk for potential abuse. Interview with Physician #1 on 02/14/17 at 8:25 AM revealed that he was Patient #1's physician and when making rounds he recalled Patient #1 making allegations about a CNA being "rough" with the patient and hurting the patient's leg. Physician #1 stated he did not report the allegations to any facility staff member. Physician #1 stated he did not feel Patient #1 was reporting allegations of abuse and he received complaints of "rough" treatment from his patients all the time. Interview with CNA #1 on 02/13/17 at 2:25 PM revealed she was a CNA working on the floor on 02/01/17 from 7:00 PM to 7:00 AM on 02/02/17. CNA #1 stated that Patient #1 was assigned to CNA #2 on that shift, but Patient #1 required two (2) staff persons to assist with care and she would assist CNA #2 with turning and repositioning Patient #1. CNA #1 stated that the last time they went into Patient #1's room and were turning and repositioning Patient #1, the patient stated that she was too rough with him/her and that he/she did not want her to provide care to him/her anymore. CNA #1 stated when they exited the room they immediately informed RN #2 of Patient #1's statements. Continued interview revealed CNA #1 stated that she was not "rough" with Patient #1 and she did not recall hitting Patient #1's leg on the bed rail. Interview with CNA #2 on 02/13/17 at 2:10 PM revealed that Patient #1 was her patient on 02/01/17 during the night shift. CNA #2 stated that CNA #1 assisted her with the patient's care that night. CNA #2 stated the last time they were in the patient's room, Patient #1 complained that CNA #1 was too "rough" with him/her and hurt the patient's leg. CNA #2 stated that she never observed CNA #1 do anything that she thought was "rough" or inappropriate. CNA #2 stated that she did not recall CNA #1 hitting Patient #1's leg on the bed rail. CNA #2 stated when they left the patient's room they immediately reported Patient #1's allegations to RN #2. Continued interview with Nurse Manager #1 on 02/13/17 at 3:05 PM revealed nursing staff should have made her aware of Patient #1's allegations of "rough" treatment on 02/02/17 when the patient first made the allegations in order to report the allegation so it could be properly investigated. Review of the CNA schedule for 01/08/17-02/14/17 revealed CNA #1 worked 01/24/17-01/26/17, 01/31/17-02/02/17, and 02/05/17-02/07/17. CNA #1 worked three (3) days after nursing staff and Physician #1 were made aware of the allegations of "rough" treatment by Patient #1. |
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| VIOLATION: NURSING SERVICES | Tag No: A0385 | |
| Based on interview, record review, and review of the facility job description and facility policy it was determined the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as outlined in the facility policy for one (1) of ten (10) sampled patients (Patient #1) by failing to ensure nursing staff protected and reported abuse as per facility policy. Interview and record review revealed Registered Nurse (RN) #2 was Patient #1's nurse from 7:00 PM on 02/01/17 until 7:00 AM on 02/02/17. The RN stated that on 02/02/17 Certified Nursing Assistant (CNA) #1 and CNA #2 made her aware of allegations made by Patient #1 that CNA #1 was "rough" and hurt the patient's legs during care. RN #2 stated that Patient #1 stated he/she did not want CNA #1 back in his/her room anymore. On 02/02/17 Patient #1 reported to RN #1 that CNA #1 had been "rough" and hurt his/her legs while turning and repositioning the patient. Patient #1 also requested that CNA #1 not be allowed back into his/her room to provide treatment anymore. The facility failed to ensure nursing staff protected patients and reported allegations of suspected abuse as per facility policy. | ||
| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| Based on interview, record review, review of the facility job description, and review of facility policy it was determined the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as outlined in the facility policy for one (1) of ten (10) sampled patients (Patient #1) by failing to ensure nursing staff protected and reported abuse as per facility policy. Interview and record review revealed Registered Nurse (RN) #2 was Patient #1's nurse from 7:00 PM on 02/01/17 until 7:00 AM on 02/02/17. The RN stated on 02/02/17 Certified Nursing Assistant (CNA) #1 and CNA #2 made her aware that Patient #1 alleged that CNA #1 had "hurt" the patient's leg and was "rough" during care. RN #2 stated that Patient #1 informed her also that CNA #1 had been "rough" and injured his/her leg, and he/she did not want CNA #1 back in his/her room anymore. On 02/02/17 Patient #1 reported to RN #1 that CNA #1 had been "rough" and hurt his/her legs while turning and repositioning the patient. Patient #1 also requested that CNA #1 not to be allowed back into his/her room to provide treatment anymore. Neither RN #1 nor RN #2 reported the patient's complaints of injury and "rough" treatment according to facility policy. The facility failed to ensure nursing staff protected and reported abuse as per facility policy. The findings include: Review of the facility's policy titled "Suspected Child/Adult Neglect/Abuse," revised 07/30/13, revealed the purpose of the policy was to identify and assess victims of alleged or suspected abuse or neglect. Continued review of the facility policy revealed it was the responsibility of any staff member, including physicians, having reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation to initiate reporting immediately. All staff members were to immediately notify the House Supervisor, Department Supervisor, and the Protection Hotline if neglect/abuse was suspected. In addition, the policy defined abuse as the infliction of physical pain, injury, or mental injury, or the deprivation of services by a caretaker that were necessary to maintain the health and welfare of an adult. Further review of the policy revealed that any employee suspected of abuse would receive appropriate work assignments to protect patients, staff, and visitors. This would include but not be limited to suspension from work, different work area assignments, or work assignments that do not involve patient contact. Review of the Registered Nurse (RN) Job Description, undated, revealed the RN would perform care requiring substantial specialized knowledge, judgement, and nursing skills based upon the principles of psychological, biological, physical, and social sciences in the application of the nursing process. This job description stated that the RN utilized high-level assessment skills to design and ensure multidisciplinary patient care to meet holistic needs, incorporating established practice guidelines and regulatory standards. The job description further stated that the RN must possess the ability to supervise CNAs, LPNs, and students and that all employees will continually monitor and adhere to safety responsibilities and initiatives. Record review revealed the facility admitted Patient #1 on 01/24/17 with a diagnosis of acute bronchitis and possible pneumonia. Interview with Patient #1 and Patient #1's family member on 02/14/17 at 7:30 AM revealed that on 02/02/17 in the early morning hours, CNA #1 was "rough" and hit his/her leg on the bed rail when turning and repositioning him/her. Patient #1 stated that he/she told RN #2 immediately after the incident that CNA #1 was "rough" with him/her and that she had "hurt" his/her leg. Patient #1 also stated he informed RN #2 that he/she did not want CNA #1 back in his/her room anymore. Further interview with Patient #1 revealed he also reported the incident to RN #1 on 02/02/17 concerning the "rough" treatment and of CNA #1 "hurting" his/her leg. The medical record further revealed "generalized bruising" had been documented for Patient #1 on 02/01/17 at 3:00 PM and on 02/02/17 at 8:30 AM. On 02/03/17 at 8:33 AM the patient's skin assessment revealed the patient's left leg was bruised; however, the patient's medical record contained no measurements or detailed description of the bruising. Further review of the medical record revealed RN #2 documented on 02/02/17 at 3:43 AM that Patient #1 expressed concerns about being turned and was afraid that he/she would be injured. However, there was no evidence that RN #2 took action to follow the facility's policy related to abuse. Interview with Nurse Manager #1 on 02/13/17 at 3:05 PM revealed that she became aware of the allegations of "rough" treatment on 02/06/17 when a nurse from the "quality line" (patient satisfaction telephone survey) emailed her and made her aware of the allegations. Continued interview with Nurse Manager #1 revealed nursing staff should have made her aware of Patient #1's allegations of "rough" treatment on 02/02/17 when the patient first made the allegations in order to report the allegation so it could be properly investigated. Interview with CNA #1 on 02/13/17 at 2:25 PM and with CNA #2 on 02/13/17 at 2:10 PM revealed CNA #2 was Patient #1's assigned nursing assistant beginning at 7:00 PM on 02/01/17 through 7:00 AM on 02/02/17. CNA #2 stated CNA #1 assisted her in turning and repositioning Patient #1. They stated that at approximately 3:30 AM after turning Patient #1, the patient made allegations that CNA #1 was "rough" with the patient. Continued interviews revealed that as soon as Patient #1 made the allegations, they reported them to RN #2. Interview with RN #2 on 02/13/17 at 7:20 PM revealed that she was Patient #1's nurse on 02/01/17 from 7:00 PM to 7:00 AM on 02/02/17. RN #2 stated at approximately 3:43 AM she went into Patient #1's room after CNAs #1 and #2 had informed her that Patient #1 had complained that CNA #1 was "rough" with him/her. RN #2 recalled that Patient #1 stated that he/she did not want CNA #1 in his/her room anymore because CNA #1 was too "rough" with the patient and that CNA #1 had "hurt" his/her leg. Further interview with RN #2 revealed that she understood Patient #1 to further request that no one turn or reposition him/her anymore because the patient was in pain, and the patient had a fear of injuring his/her spleen. RN #2 stated that she did not report the allegations to the Protection Hotline as per facility policy nor did she report to the House Supervisor or Nurse Manager #1. During report RN #2 stated that she did notify RN #1 of the allegations. RN #2 stated she did not think Patient #1 was reporting abuse when the patient reported CNA #1 being "rough" with him/her. Interview with RN #1 on 02/13/17 at 2:45 PM revealed that she was Patient #1's assigned nurse on 02/02/17 and 02/03/17 from 7:00 AM to 7:00 PM. RN #1 stated that RN #2 informed her in report at approximately 7:00 AM on 02/02/17 that Patient #1 had alleged that CNA #1 had been "rough" with the patient. RN #1 stated she went into Patient #1's room on 02/02/17 to assess him/her. RN #1 stated that Patient #1 told her that CNA #1 had been "rough" with him/her in the night and hurt his/her legs and the patient did not want CNA #1 in his/her room anymore. RN #1 stated she contacted the unit clerk while in Patient #1's room and requested that CNA #1 not be assigned to Patient #1 on 02/02/17 during the night shift. RN #1 stated that she did not make a report to the House Supervisor, Nurse Manger #1, or the Protection Hotline as per facility policy. RN #1 stated she did not think "rough" treatment was abuse. RN #1 stated she noted that Patient #1 had generalized bruising on his/her legs but did not notice anything unusual. RN #1 stated that on 02/03/17 at approximately at 8:30 AM she conducted a skin assessment and saw a large bruise on Patient #1's left leg. RN #1 stated that she did not associate the bruise with Patient #1's allegations of "rough" treatment and again failed to report to Nurse Manger #1, the House Supervisor, or the Protection Hotline. RN #1 stated she did not understand that by reassigning CNA #1 to other rooms she placed other patients at risk for potential abuse. Interview with the Chief Nursing Officer (CNO) on 02/14/17 at 11:30 AM revealed the facility trained nursing staff on the definition of abuse and reporting of abuse. Although the CNO stated that nursing staff had not considered complaints of "rough" treatment as an allegation of abuse, they should have reported the incident as specified in the facility's policy and initiated an investigation. |
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| VIOLATION: GOVERNING BODY | Tag No: A0043 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, it was determined the facility failed to have an effective Governing Body responsible for the conduct of the facility. The facility's Governing Body and Chief Executive Officer (CEO) failed to ensure the facility's policies and procedures prohibiting abuse and potential abuse were implemented. The Governing Body failed to ensure nursing staff and medical staff was trained and knowledgeable of the facility's policy/procedure related to abuse/neglect and reporting. On 02/02/17 Patient #1 alleged Certified Nursing Assistant (CNA) #1 had been "rough" and hit the patient's leg on the bed rail when providing care to the patient. Patient #1 reported the allegations of "rough" treatment and his/her leg injury to Registered Nurse (RN) #1, RN #2, and Physician #1, and facility staff failed to report the allegations to the House Supervisor or the Protection Hotline as per facility policy. The facility discharged Patient #1 on 02/03/17 without the incident being investigated. Patient #1 returned to the facility on [DATE] and was readmitted to the facility and treated for an intramuscular lower extremity hematoma. CNA #1 continued to provide direct care to patients (for six days) until the facility's Administration was notified of the allegations on 02/07/17. |
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| VIOLATION: CHIEF EXECUTIVE OFFICER | Tag No: A0057 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, it was determined the facility failed to have an effective Governing Body responsible for the conduct of the facility. The facility's Governing Body and Chief Executive Officer (CEO) failed to ensure the facility's policies and procedures prohibiting abuse and potential abuse were implemented. The Governing Body failed to ensure nursing staff and medical staff was trained and knowledgeable of the facility's policy/procedure related to abuse/neglect and reporting. On 02/02/17 Patient #1 alleged Certified Nursing Assistant (CNA) #1 had been "rough" when providing care and injured the patient's leg. Patient #1 reported the allegations of "rough" treatment and the injury to Registered Nurse (RN) #1, RN #2, and Physician #1, and facility staff failed to report the allegations to the House Supervisor or the Protection Hotline as per facility policy. The facility took no action related to the allegation of abuse and discharged Patient #1 on 02/03/17. Patient #1 returned to the facility on [DATE] and was readmitted to the facility and treated for an intramuscular lower extremity hematoma. CNA #1 continued to provide direct care to patients until the facility Administration was notified of the allegations on 02/07/17. The findings include: Review of the policy titled "Hospital Plan for the Provision of Care," dated 09/04/15, revealed the President of the facility shall have necessary authority and responsibility to operate the hospital in all its activities and departments, subject to such policies as may be adopted and such orders that may be issued by the Governing Board. The President shall act as the duly authorized representative of the Governing Board in all matters in which they have not designated some other person to act. The President shall be an ex officio member of all committees of the Medical Staff. Review of the facility's policy titled, "Patient Rights and Responsibilities," revised 07/18/16, revealed patients have the right to retain personal dignity and privacy, receive care sensitive to personal feelings, and need for bodily privacy, receive care in a safe setting, and to be free from abuse and harassment. Review of the facility's policy titled "Suspected Child/Adult Neglect/Abuse," revised 07/30/13, revealed the purpose of the policy was to identify and assess victims of alleged or suspected abuse or neglect. Continued review of the facility policy revealed it was the responsibility of any staff member, including physicians, having reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation to initiate reporting immediately. Staff members were to immediately notify the House Supervisor, Department Supervisor, and the Protection Hotline if neglect/abuse was suspected. Further review of the policy revealed that when an incident of abuse or neglect, or injury of unknown origin, was reported, the Administrator on call was to be notified. In addition, the policy defined abuse as the infliction of physical pain, injury, or mental injury, or the deprivation of services by a caretaker that were necessary to maintain the health and welfare of an adult. Interview with Patient #1 and Patient #1's family member on 02/14/17 at 7:30 AM revealed that on 02/02/17 in the early morning hours, CNA #1 was "rough" and hit his/her leg on the bed rail when turning and repositioning him/her. Patient #1 stated that he/she told RN #2 immediately after the incident that CNA #1 was "rough" with him/her and that she had "hurt" his/her leg. Patient #1 also stated he informed RN #2 that he/she did not want CNA #1 back in his/her room anymore. Further interview with Patient #1 revealed he also reported the incident to RN #1 and Physician #1 on 02/02/17 concerning the "rough" treatment and of CNA #1 "hurting" his/her leg. However, none of the facility staff that Patient #1 reported the allegation to took any action to protect Patient #1 or other facility patients from further potential abuse. Record review revealed the facility readmitted Patient #1 on 02/06/17, for treatment of a lower extremity intramuscular hematoma. Review of "Photographic Wound Documentation," dated 02/06/17, revealed the lower extremity bruising extended from Patient #1's upper thigh to the mid-calf. However, the medical record contained no measurements of the bruise. Interview with Nurse Manager #1 on 02/13/17 at 3:05 PM, revealed that she became aware of the allegations of "rough" treatment on 02/06/17 when a nurse from the "quality line" (patient satisfaction telephone survey) emailed her after speaking with Patient #1, and made her aware of the allegations of suspected abuse. Nurse Manager #1 stated that she then attempted to contact Patient #1 but was unsuccessful, and took no further action to investigate or further report the concerns. She stated that on 02/07/17 she became aware that Patient #1 had been readmitted to the facility and she informed Administration of the allegations of abuse. Continued interview revealed the facility initiated an investigation at that time. Nurse Manager #1 stated that nursing staff should have made her aware on 02/02/17 when the patient first made the allegations of "rough" treatment against CNA #1. Interview with the President of the facility on 02/14/17 at 11:45 AM revealed he was responsible to oversee that all policies and procedures were implemented for the facility. Continued interview with the President of the facility revealed that he was unaware nursing staff and medical staff was not following the facility's policies and procedures related to abuse/neglect and reporting. Further interview revealed the President of the facility stated the incident should have been reported and investigated on 02/02/17. |
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