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MEMORIAL HERMANN HOSPITAL SYSTEM 1635 NORTH LOOP WEST HOUSTON, TX 77008 March 19, 2015
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to fully investigate per policy, an allegation of physical abuse concerning one of four (4) discharged sampled patients ( Patient # 6).

Findings include:

TX # 1735

Record review of nursing progress note / physician communication, dated 01-09-15 (time 2000) read: "hematoma on right forearm measuring 10.5 x 10.5 centimeter (cm) which per report from day shift Registered Nurse(RN) patient came back with after being transported downstairs for test."

Record review of facility form titled "Wound Evaluation,"dated 01-13-15 read:" Patient # 6 has an extensive ecchymotic area to her right forearm extending onto her upper arm with an apparent hematoma within the area on the anterior forearm.."

Record review of complaint intake TX # 735 revealed allegations that Patient # 6 was taken to Radiology for a test by a tech on or about 01-10-15. When Patient # 6 returned from radiology, a family member noticed a "large bruise on her arm and claw marks in her upper arms."

Record review of Patient # 6's clinical record revealed she was a [AGE] year old female admitted to the facility on on [DATE] who presented with nausea, vomiting, and cough with low grade fever.

Record review of facility "Patient Relations Worksheet" documentation for Patient # 6 revealed the following documentation by Operations Administrator # 15 on 01-10-15: "Patient # 6's granddaughter called today to complain about the big bruise, swollen arm, and big bump on the patient's right lower arm sustained after she came back from radiology yesterday...granddaughter said she observed the radiology transport person who is a big guy, grabbed the patient's right arm...an x-ray was done and is negative for fracture..."

Further record review of facility VRS (Variance Reporting System) documentation forms revealed two different VRS forms were completed. There was conflicting details regarding exactly when and how the injury to Patient # 6 occurred:

One of the VRS forms (01-09-15; time 12:00) said it happened during transport from the bed to a stretcher (indicated it occurred in Patient #6's room) & that her forearm was bumped on the side rail.

The 2nd VRS form ( 01-09-15 ; time 15:35): contained documentation the incident occurred in Radiology when the patient was transferred from her bed to neuro chair. On this form it was documented that granddaughter reported "they were rough."

Further review of both the VRS Forms revealed two sections titled " Witnesses/ Involved Parties" and " Follow-Up Actions/ Involved Parties." Both of these sections were left blank with no attachments on either VRS form.

Interview on 03-19-15 at 1:00 p.m. with facility Risk Manager # 8 she stated that she became aware of the incident when Patient Relations Coordinator # 4 called her. The Risk Manager stated Patient # 6's granddaughter was very upset and asked to speak with the involved employees. Risk Manager # 8 went on to say she met with the granddaughter who told her Patient # 6's arm had been bumped and had evidence of finger print marks.

Risk Manager # 8 said there were four (4) radiology patient transporters working that day ( 01-09-15). She said two ( 2) of the transporters witnessed the incident. One of them was Transporter # 16; she was unsure of the other transporter's name. Transporter # 16 said Patient # 6 was picked up 2 arm" carry style" because she was so small. [ Later interview with Radiology Manager : she reported Transporter # 16 was not working the day of the incident].

Risk Manager #8 stated she did not obtain witness statements or have documented notes from these interviews. None of the transporters involved were suspended during the investigation. Risk Manager # 8 said she was torn whether to investigate the incident as abuse or not. She decided not investigate as possible abuse because she determined the granddaughter was not in the room when it happened and she had the two (2) transporters as witnesses to what happened. The Risk Manager went on to say she did not interview any other staff in the Radiology department present during Patient # 6's diagnostic test.

Interview on 03-19-15 at 1:40 p.m. with Radiology/Imaging Manager # 19 she stated she heard about the incident the day after it happened. She stated they were unable to determine who transported Patient # 6 from her room to Radiology. Transporter # 17 transported Patient # 6 from Radiology back to the room after the test was complete. He was the staff member to whom the daughter mentioned the big bruise on the patient's arm. Radiology Manager # 19 said three transporters fit the description of the staff who was rough: Transporters # 16, 17, and 18. Radiology Manager stated that Transporter # 16 was not on duty the day it occurred. Transporter # 18 "could not remember if he took Patient # 6 to radiology or not."

Review of facility policy titled " Investigation of Alleged Abuse ( of a patient during an encounter)" , dated 02-27-13, read: "..: Response Team Representative: 6..interview patient regarding the alleged abuse...7. Develops detailed investigation plan...8. Interviews employee (alleged abuser) and witnesses. Employee will be suspended pending investigation results ( mandatory)..9. If allegations are credible...notify system risk manager and HR Legal.. System Risk Manager : 10. Reviews documents and re-interviews employee ( alleged abuser) & witnesses as necessary...11. If allegations are not credible & the investigation is complete, HR and the Director will follow-up with the employee was appropriate and will offer Employee Assistance Program..."