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 document review and interview, it was determined for 2 of 2 policies regarding patient abuse, the Hospital failed to ensure the policy included the reporting of abuse allegations in accordance with State regulations.

Findings include:

1. Per PART 250 HOSPITAL LICENSING REQUIREMENTS TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES PART 250 HOSPITAL LICENSING REQUIREMENTS, Any hospital administrator, agent, employee, or medical staff member who has reasonable cause to believe that any patient with whom he or she has direct contact has been subjected to abuse in the hospital shall promptly report or cause a report to be made to a designated hospital administrator responsible for providing such reports to the Department as required by this subsection (c)...(5) Upon receiving a report under subsection (c)(3), the hospital shall submit a report to the Department within 24 hours after obtaining such report.

2. The Hospital's Human Resources' policy entitled "Suspected Neglect or Patient Abuse" (revised 03/1998) was reviewed on 11/14/16 at approximately 12:00 PM and required, "Abuse shall include but not be limited to...Striking a patient...Any person witnessing neglect or abuse of any patient will notify his direct Supervisor or the Nursing Supervisor immediately...All cases will be reported to the apropriate state authorities when required by law." The policy did not include reporting of abuse allegations to the Department.

3. The Hospital's policy entitled "Sentinel Event" (revised 11/2016) was reviewed on 11/15/16 at approximately 12:10 PM and required, "...A sentinel event: Potentially involves a continuing threat to patient care or safety; Has significant potential for being reflective of serious underlying systems problems within an organization; Potentially undermines public confidence in the organization...Sentinel events will be reviewed by the administrative team and the Performance Improvement Director within 24 hours of incident identification...All sentinel events are reported to the [Department] within three business days..." This policy did not require reporting to the Department within 24 hours of awareness of the event.

4. On 11/17/16 at approximately 9:30 AM, an interview was conducted with the Director of Performance Improvement (E #5). E #5 stated the Hospital reports allegations of abuse to the Department within three business days of the occurrence of abuse.