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CENTRAL VERMONT MEDICAL CENTER BOX 547 BARRE, VT 05641 June 25, 2014
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and confirmed through staff interview the facility failed to report allegations, by 2 applicable patients, of abuse to the appropriate State Agency (SA) in accordance with Vermont State Statute Title 33 Chapter 69. (Patients #1 and #3). Findings include:

Per V.S.A. Title 33, Chapter 69, ? 6903. Reporting suspected abuse, neglect, and exploitation of vulnerable adults
(a) Any of the following, other than a crisis worker acting pursuant to 12 V.S.A. ? 1614, who knows of or has received information of abuse, neglect, or exploitation of a vulnerable adult or who has reason to suspect that any vulnerable adult has been abused, neglected, or exploited shall report or cause a report to be made in accordance with the provisions of section 6904 of this title within 48 hours:
Per review, the hospital policy, "Title: Assessment of Abuse and Neglect Reporting for Children and Vulnerable Adults" (Policy A-220, effective date 5/19/14) states on page 4 that "Abuse should be reported by mandated reporters when any mandated reporter has any reason to suspect that a vulnerable adult has been abused, neglected, or exploited. It is not up to the healthcare professional making the report to make the assessment of whether or not abuse has occurred. When unsure or in doubt, the report should be made....."

1. Per record review, on 6/23/14, Patient #1, who was admitted on an involuntary basis on 4/15/14, and whose diagnoses included schizoaffective disorder, bipolar type, currently manic, had a Discharge Planning Note, dated 5/22/14, that stated "....Pt makes numerous claims of staff physically abusing [him/her]; shows bruises s/he reports were caused by staff. SW (Social Worker) informed pt [s/he] can file complaint if this is the case. Pt requested paperwork & assistance. SW will follow up..." Subsequent Discharge Planning Notes, dated 5/26/14 and 5/27/14, respectively, revealed the following: "....Pt reports [s/he] is writing up complaints against staff [s/he] claims physically harmed [him/her]. This activity appears to be agitating pt to some degree. Pt reports [s/he] is struggling to write things down but that an RN (Registered Nurse) agreed to help [him/her] this eve." and, "...Pt provided papers [s/he] has been working on, complaints re staff members pt believes physically harmed [him/her]. Papers were barely decipherable...." Despite the documentation, there was no evidence the allegations, by the patient, of abuse by staff had been reported to the SA.
During interview, at 11:33 AM on 6/25/14, the staff member responsible for writing all three notes, confirmed that s/he had not reported the patient's allegations to the SA. The Nurse Manager for the unit on which Patient #1 resided stated, during the same interview, that generally, if there are complaints from patients, the patient's care team looks at how credible the complaint is, then makes the decision about whether or not to report.
The Quality Improvement Consultant, also confirmed, during interview on the morning of 6/25/14, that there was no evidence a report had been made to the SA.
2. Per 6/23/14 medical record review, Patient #3 was voluntarily admitted on [DATE] with diagnoses that included schizoaffective disorder with worsening psychosis. A unit SW documented in his/her Discharge Planning Note (dated 4/17/14 at 1323) that Patient #3 "did not want any further contact with [the care facility where s/he had resided] and did not want to go back there on discharge ..." S/he reported wanting to stay "here" [the hospital]. The note further documented that the "Pt was vague re reasons for not wanting to return ...., became anxious, sighing heavily and putting [his/her] head down ..." The next Discharge Planning Note, dated 4/17/14 at 1641 documented that, "Pt spoke at some length re [his/her] conviction that [s/he] had been 'verbally abused' by two staff at the [care facility where s/he had resided]. Pt stated [s/he] did not want to return to that residence on dc." The staff member who documented the above allegations was not available for interview during the survey.

The facility was not able to provide evidence that the allegations made by Patient #3 were reported to the SA. On 6/24/14, the SA confirmed that no report had been received.