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STEPHENS MEMORIAL HOSPITAL 200 SOUTH GENEVA STREET BRECKENRIDGE, TX 76424 Feb. 1, 2012
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of documentation and interviews with facility staff, the facility failed to ensure that the patient has the right to be free from all forms of abuse or harassment as the facility policy entitled "Abuse Identification and Care of Suspected Child, Domestic or Elderly" was not completely followed in the case of patient #1.

The findings were:
The medical record of patient #1 was reviewed on the afternoon of 1/30/12 which reflected that on 12/31/11 at 0015, an entry was made to the nurses notes by the licensed vocational nurse, staff #3, "Pt (patient) started screaming while being changed and repositioned. Staff observed daughter placing her hand over her mother's mouth, telling her to hush. Staff moved daughter's hand and requested that she stop. Will continue to monitor. Reported to RN Charge Nurse."

An entry to the nurses notes was also made at 12/31/11 at 0015 by the licensed vocational nurse, staff #4, which reflected "While assisting to change pt with other nurse, this nurse witnessed pt daughter popping pt in mouth while covering pt mouth to silence patient who was confused and yelling. Staff asked family member to remove hand. Four more times daughter placed hand over pt mouth. Staff witnessed daughter to use elbow to dig into pt mouth to make pt stop yelling out in confusion. Staff gently intervened by stepping in between pt and family member when this nurse went to opposite side of bed to assist in turning patient to cleanse buttocks. The daughter roughly grabbed patient's arms and aggressively held patient arms down while harshly saying 'shush mother, think of the other pts, you are so loud.' Staff intervened by gently taking pts arms and gently turning her. Daughter was witnessed talking harshly multiple times as well as smacking at pts mouth or firmly placing her hand over pts mouth. Staff intervened whenever possible. Continue to monitor."

On 12/31/11 at 0500, an entry to the nurses notes was made by the licensed vocational nurse, staff #2 which reflected "In bed with eyes closed, no distress noted. Moans out in sleep. Daughter at bedside. Will continue to monitor."

On 12/31/11 at 1030, an entry to the nurses notes was made by the registered nurse, staff #6, which reflected "the physician, staff #5, notified of staff concern re: daughter's tx (treatment) of patient. He requested APS (Adult Protective Services) be notified. At 1430, the registered nurse, staff #6, charted "Report made by phone to APS hotline, case # 620 to staff ID# 1175. Daughter has not been observed with any with any abusive activity today, but report filed based on charted behavior of previous shift."

The facility policy entitled "Abuse, Identification and Care of Suspected Child, Domestic or Elderly" with a revision date of 11/11 was reviewed on the afternoon of 1/30/12 and reflected that "3.2.20.3 Notify Utilization Review nurse if need for information and/or referrals to community agencies during hospitalization or in the implementation of a discharge plan. 3.3.21 Whenever a report is made to Adult Protective Services, refer patient to Social Services and/or the Nurse Manager/Relief Charge Nurse to function as a liaison with Adult Protective Services regarding safe disposition of the patient. 3.2.22 Nurse Manager/Relief Charge nurse will collaborate with physician, nursing staff and Adult Protective Services regarding safe disposition of the patient. 3.3.23 CNO/ACNO, in collaboration with the Legal Department, will coordinate guardianship process if indicated."

In an interview with the facility utilization review nurse, personnel #2, on 1/30/12 at 2:30 pm, she stated that it was not reported to her that the nursing staff had made a report to adult protective services.

In an interview with the facility chief nursing officer, personnel #1, on 1/30/12 at 4:30 pm she stated that the nurses did not report the incident to the nurse manager or to the chief nursing officer. She stated that she would have expected the nursing staff to report to the nurse manager in a timely manner and complete an unusual event report.

In an interview with the facility medical-surgical nursing supervisor, staff #7, on 1/31/12 at 10:25 am she stated that she did not hear about the incident until 1/2/12 or 1/3/12. She stated did not receive a written report regarding the incident, nor did she initiate one. She stated she told the nursing staff to continue to watch the patient closely. She stated she did not report it to the utilization review nurse or chief nursing officer because she felt the patient was in no further danger.