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 record review the facility failed to make a timely report to the appropriate SA (State Agency), of a potentially abusive staff to patient incident. Findings include:
Per record review Patient #2, was admitted to the facility on [DATE] for treatment of acute kidney failure, requiring IV (Intravenous) antibiotics and fluid replacement. The record noted a history of cognitive impairment (Alzheimer's) and indicated the patient had ongoing confusion with his/her mental status changes and, at times exhibited behaviors that included; resistance to care, aggressiveness and combativeness.
During interview, on the morning of 6/17/13, the DNS (Director of Nursing) for the unit on which Patient #2 had resided, stated s/he had been away from work for a period of time during Patient #2's admission, and when s/he returned to work s/he had been made aware on 6/4/13, that an incident had occurred on 5/29/13 in which LNA #1 had written inappropriate comments on the communication white board in Patient #1's room. The DNS stated an investigation was conducted and the incident was reported to the SA on 6/10/13. The DNS stated that LNA #1 had been providing 1:1 observation for Patient #2 during the 11 PM - 7 AM shift on 5/29/13. The LNA confirmed during interview with the DNS that s/he had written the following comments on the communication board, which is used as a tool to identify, for patients/family, the name of the doctor, nurse and LNA (Licensed Nursing Assistant) providing care, and is visible to anyone entering the room; 'patient is mean spirited, combative and resistive to care'. The DNS further stated that LNA #1 had admitted that s/he had asked the patient if s/he could see the comments on the whiteboard and asked the patient why s/he was so nasty.
RN #1 stated during interview, at 9:17 AM on the morning of 6/18/13 that s/he had noticed the inappropriate comments on the whiteboard in Patient #2's room upon entering the room to assess the patient at the beginning of his/her shift at approximately 7:00 AM on 5/29/13. RN #1 stated s/he had erased the comment and asked who wrote it and LNA #1 confirmed s/he had written it. The RN stated s/he told the LNA the comments had not been appropriate and should not be written on patient whiteboards. RN #1 stated s/he then reported the incident to the RN Unit Manager who had been working the same shift as LNA #1.
The RN Unit Manager confirmed during interview, at 2:44 PM on 6/18/13, that s/he had been informed of the incident with Patient #2 and LNA #1 and had not reported it until the Unit DNS returned to work because s/he did not consider it abusive behavior at the time.
The facility policy titled Mandatory Reporting of Abuse, Neglect and Exploitation of Vulnerable Adults, approved 1/2011 and identified by staff as the currently used policy which stated: "C. Reporting....1. Staff or the Department/Unit Leader shall immediately report to the Director of Risk Management or the Compliance Officer, or if they are not immediately available, the Administrator On-Call whenever there is reason to suspect that a Vulnerable Adult has been Abused, Neglected, or Exploited while at the Hospital. In no event shall this internal reporting prevent a mandatory report from being submitted to [SA] within 48 hours."
Despite the facility policy regarding mandated reporting to the SA within 48 hours and despite the definition of Abuse, identified in the policy as: "....Intentionally subjecting a vulnerable adult to behavior which should reasonably be expected to result in intimidation, fear, humiliation, degradation, agitation, disorientation, or other forms of serious emotional distress.." the incident was not reported to the appropriate SA until 12 days after the incident occurred. This was confirmed by the Unit DNS during interview at 11:34 AM on 6/17/13. The DNS also confirmed that LNA #1 continued to provide care to patients on the unit during the period of time between 5/29/13 and 6/7/13, at which point action was taken to remove the LNA from providing patient care.