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 hospital policy review, online review of "...Reporting Allegations to N.C. Health Care Personnel Investigations Branch", closed Medical Record review, hospital document review and staff interview, the hospital staff failed to report an allegation of staff to patient abuse for 1 of 1 sampled patients that alleged abuse (Pt # 7 ).

The findings include:

Review of hospital policy "Title: Abuse and/or Neglect - Adult", dated 04/12/2016, revealed Policy: (Hospital Name)....staff is expected to report cases in which there is a reasonable cause to believe that an adult patient has been or is being abused and/or neglected....The Director of Corporate Risk Management or the Office of the General Counsel should be consulted prior to making any report to DSS (Department of Social Services) or any other governmental or regulatory agency where the suspected abuse/neglect involves the actions of an employee or agent of (Hospital Initials)....Additional reporting requirements may exist for instances involving the suspected actions of licensed and unlicensed health care personnel that are employees or agents of (Hospital initials)."

Review of an online document "Reporting Allegations to N.C. Health Care Personnel Investigations Branch", last modified November 20, 2015, revealed "...Purpose: this procedure describes the requirements for health care providers to report allegations to the N.C. Health Care Personnel Registry (HCPR)....Health care facilities are required to report the following allegations to the HCPR:...Abuse of a resident....A 'Health Care Facility' required to report allegations to the HCPR are....Hospitals....'Health Care Personnel' includes any unlicensed staff of a health care facility that has direct access to residents, clients, or their property....Procedure: ....2. 24-Hour Report - Health care facilities are required to report all allegations against health care personnel, and injuries of unknown source, to the HCPR Investigations Branch within 24-hours of becoming aware of the allegation....3. 5-Working Day Report - The results of all investigations are required to be submitted within 5-working days of the initial 24-hour report whether the allegation was substantiated or not. The report should include the documentation and results of a thorough investigation. ..."

Closed medical record review of Patient # 7 (Pt #7), on 05/05/2016, revealed the patient arrived to the Emergency Department (ED) at 1006 on 04/11/2016. Review of ED Physician Note, dated 04/11/2016 at 1025, revealed the patient was having suicidal thoughts and auditory and visual hallucinations (seeing or hearing voices that do not exist except in a person's head). Review of ED Physician Assistant (PA) documentation revealed "...@ (at) 1105 Pt became agitated and hard to control. Pt was restrained. Pt sustained head laceration above R (right) eyebrow. Bleeding controlled. ..." Review of a PA note revealed at 1158 "Pt in restraints. Remains agitated and states that he is scared for his life. Will re-evaluate pt for injury when more cooperative."

Review of a Patient Relations Worksheet, date received 04/13/2016, revealed "(Employee # 6) spoke with (Pt # 7) who stated he was 'brutally assaulted' by staff in the ED. (Pt # 7) stated it was a staff member named (first name) and another staff member 'helping him' while he was restrained. (Pt # 7) states he was strangled, and punched in the face and head. ..."

Review of hospital documents did not reveal documentation of a 24 hour report of an allegation of assault to the HCPR.

Interview on 05/06/2016 at 0845 with Administrative Staff (AS) # 1 revealed the patient claimed he was assaulted and "punched in the face 20 times". Interview revealed that this was a very unusual circumstance and the facility realized there needed to be immediate and thorough action taken to determine if there was any validity to the allegation. Although the full investigation with response letter had not been finalized, interview revealed the hospital had completed the investigation related to abuse and decision to report to the HCPR within 5 days. Interview revealed they did not uncover any objective information that led them to believe this happened as reported. Further interview revealed the hospital takes its responsibility to investigate very seriously and had reported employees to the HCPR in the past. Interview revealed the hospital makes its decision on reporting based on whether there was any likelihood of abuse or neglect. They did not report this time because there was "no evidence this was (abuse)."

NC 257, NC 844