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 staff interview and review of the facility's investigation, staffing schedules, timecards, and personnel file; the facility was not aware of the discrepancy in the schedule hours and actual hours worked by the nurse named in the complaint of abuse. This had the potential to affect all patients at this facility. The facility census was 107 at the time of the survey.

Findings include:

The facility's investigation of a complaint of abuse was reviewed on 08/14/12. The complaint was received on 08/09/12. The complaint contained allegations of abuse against a nurse (Staff O) during the night of 08/09/12. The nurse continued to work night shift on 08/11 and 12 before being suspended on 08/14/12 until the investigation was complete. The facility's investigation is on going at this time.

At 1:21 PM on 08/14/12, Staff A, the Director of Nursing, was interviewed regarding the facility's investigation of the alleged abuse. Staff A stated Staff O had come in on 08/14/12 to discuss the alleged incident and was suspended until the investigation was complete. Staff O was asked if the nurse had worked since the reported incident on 08/09/12. Staff A stated no, because Staff O was scheduled to be off. Staff A placed a call to the scheduling department and learned that Staff O had worked the night shift on Saturday and Sunday. Staff A did not know why Staff O worked those shifts as he/she should not have.

Staff A stated the expectation is that with any allegation of abuse of any kind, the employee accused would be suspended immediately until the investigation was complete in order to ensure the safety of all patients. Staff A stated the policy guides disciplinary action once an allegation is substantiated, but not during the investigation.

Staff A stated the reason the meeting and suspension of Staff O was scheduled for 08/14/12 when the incident happened on 08/09/12 was the schedule that was looked at on 08/09/12 revelaed Staff O was scheduled to be off and would not return until 08/14/12. At 1:44 PM Staff E, telemetry manager, joined the interview. Staff E did not know that Staff O had worked over the weekend and could not explain how that happened. Staff E also stated that if they had realized that Staff O was working on the weekend, they would have called him/her in on Friday and suspended him/her at that time.

The personnel file for Staff O was reviewed on 08/14/12. The file contained the written counseling and suspension of the employee on 08/14/12 for the alleged abuse and stated the duration of the suspension was until the investigation was completed.

On 08/15/12 at 9:30 AM, Staff A was interviewed. Staff A stated the reason Staff O worked over the weekend was that Staff E and A looked at the wrong staffing schedule on 08/09/12. The schedule was looked at on 08/09/12 and revealed Staff O had scheduled leave until 08/14/12 when he/she was scheduled to work evening shift. The decision was made not to call Staff O in while on leave but to wait until 08/14/12 and meet with him/her and human resources to discuss the issue in person and initiate the suspension. Had Staff A and E looked at the correct schedule, they would have noted Staff O was scheduled as the charge nurse on Saturday and Sunday night and called him/her in on 08/10/12 and suspended him/her at that time.

Staff A stated it was never the intention of administration to allow Staff O to work before the investigation was completed.

The Corrective Action policy was reviewed on 08/15/12. The policy revealed depending on the severity of the incident, immediate suspension or termination could result. The policy also contained a table of Code of Conduct violations and appropriate corrective actions to be taken once the violation is proven or substantiated. For physical abuse, the employee would be terminated. For verbal abuse, the employee would be suspended for the first offense and terminated for the second. The policy lacked direction on suspending employees while investigating the alleged violations.

On 08/16/12 the staffing schedule and time card for Staff O was reviewed. The staffing schedule and time card noted that Staff O worked 12 hour shifts on the night shift as the charge nurse on 08/11/12 and 08/12/12.