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.

SAINT THOMAS HIGHLANDS HOSPITAL 401 SEWELL DR SPARTA, TN 38583 May 1, 2017
VIOLATION: COMPLIANCE WITH LAWS Tag No: A0021
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical record reviews, and interviews, the facility failed to report allegations of abuse for two patients (#5 and #9) of 11 patients reviewed.

The findings included:

Review of facility policy Abuse and Neglect of Patients, dated 11/2015, revealed "...Other agencies and organizations may also have obligations to investigate allegations of abuse or neglect. These included various hospital accreditation agencies, as well as local, state, and federal governmental agencies...The Hospital will cooperate and coordinate with these or other agencies as requested and as required by laws and regulations..."

Medical record review revealed Patient #5 was admitted to the facility's geriatric behavioral unit on 7/9/16 with diagnosis of Chronic Obstructive Pulmonary Disease with Acute Exacerbation (a desease of the lung which has worsened suddenly), Alzheimer's Dementia (a disease of the brain), and Chronic Hypertension (elevated blood pressure). Continued review revealed the patient was discharged to a skilled nursing facility on 7/25/16.

Medical record review of a Case Management Assessment note dated 7/13/16 at 9:46 AM revealed "...Pt's son admitted to SW [Social Worker] that he hit the pt [patient] across the face to keep her from pulling out IV [intravenous line] recently..."

Interview with Registered Nurse (RN) #2 on 4/24/17 at 10:10 AM, in the Chief Nursing Officer's (CNO) office, revealed she received a telephone call on 7/11/16 from Patient #5's granddaughter and she stated Patient #5 was slapped by the patient's son while in the Emergency Department (ED). Continued interview revealed the incident was not witnessed by any of the ED staff nor was it reported to the facility by the patient. Further interview revealed the incident was reported to Adult Protective Services (APS) and the local police. Continued interview revealed the allegation was not reported to federal or state agencies.

Interview with Licensed Medical Social Worker (LMSW) #1 on 4/24/17 at 9L43 AM, in the CNO's office, revealed she remembered the case incident. Continued interview revealed she interviewed the patient's son after the patient's granddaughter reported the alleged abuse and the patient's son admitted he hit the patient (his mother). Further interview revealed the incident was not witnessed by staff and was not reported by the patient to any of the staff. Continued interview confirmed the incident was reported to APS and the local police, but the facility failed to report the incident to federal or state agencies.

Interview with the CNO on 4/19/17 at 2:30 PM, in her office, confirmed the facility reported the incident to APS and the local police, but failed to report the allegation to federal and state agencies and the failed to comply with applicable laws.

Medical record review revealed Patient #9 was admitted on [DATE] to the Senior Care Unit with diagnosis of Major Neurocognitive Impairment with Psychosis and Behavioral Disturbances. Further review revealed the patient was discharged home in stable condition with her family on 8/31/16.

Interview with Social Worker (SW) #2 on 4/24/17 at 9:10 AM, in the CNO's office, revealed Nurse Aide (NA) #2 reported to SW #2 an incident of verbal abuse by NA #1 to Patient #9. Continued interview revealed NA #2 was in the process of termination from employment at the facility for poor job performance when she made the allegation against NA #1, and NA #1 and NA #2 had developed an enmity relationship. Further interview confirmed the allegation of abuse was not reported to federal and state agencies.

Interview with RN/Charge Nurse #1 on 4/24/17 at 9:45 AM, in the CNO's office, confirmed the facility failed to report the incident to applicable authorities.

Interview with the CNO on 4/24/17 at 11:30 PM, in her office, confirmed the allegation of abuse incident was not reported to federal and state agencies and the facility failed to follow applicable laws.



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VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on review of facility policy, review of facility documentation, and interview, the facility failed to protect the rights of 1patient (#11) of 11 patients reviewed.

The findings included:

Review of facility policy Patient Rights and Responsibilities, dated 4/2013, revealed "...You have the right to private and confidential treatment/personal care, communications..."

Review of a facility document "Conversations with [named Nurse Aid]" completed by Registered Nurse (RN) #1, not dated, revealed "...Week of August 15 [2016]...allegation that [Nurse Aid #1] had videotaped a patient screaming in the ICU. [Nurse Aide #1] was called in and said she had audio taped it and this was verified by [RN #3]. There was no video..."

Telephone interview with Nurse Aide (NA) #1 on 4/24/17 at 12:05 PM confirmed revealed NA #1 made an audio recording of a confused patient who was screaming.

Interview with RN #1 on 4/24/17 at 9:45 AM, in the CNO's office, revealed NA #2 told her NA #1 recorded a video of a confused patient who was screaming. Continued interview revealed RN #1 interviewed NA #1 and NA #1 admitted to the incident. Further interview confirmed the facility failed to follow facility policy and failed to ensure a patient's right to personal privacy.

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