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BRYNN MARR HOSP 192 VILLAGE DRIVE JACKSONVILLE, NC March 23, 2017
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on North Carolina Administrative Code (NCAC) and General Statue (GS) reviews, facility policy review, medical record review, grievance log/file reviews, facility staff and Department (Complaint Intake and Health Care Personnel Investigations Section) staff interviews, the facility's staff failed to report an allegation of staff to patient abuse to the State's Health Care Personnel Registry (HCPR) for 1 of 1 sampled patients (Patient #4) that alleged staff to patient abuse.

Findings included:

Review on 03/22/2017 of current North Carolina Administrative Code revealed, "10A NCAC 13O .0102 INVESTIGATING AND REPORTING HEALTH CARE PERSONNEL. The reporting by health care facilities to the Department of all allegations against health care personnel as defined in G.S. 131E-256 (a)(1), including injuries of unknown source, shall be done within 24 hours of the health care facility becoming aware of the allegation. The results of the health care facility's investigation shall be submitted to the Department in accordance with G.S. 131E-256(g)." Retrieved from https://www2.ncdhhs.gov/dhsr/hcpr/flohcinv.html (n.d.).

Review on 03/22/2017 of current North Carolina General Statues revealed, "131E-256. Health Care Personnel Registry. (a) The Department shall establish and maintain a health care personnel registry containing the names of all health care personnel working in health care facilities in North Carolina who have: (1) Been subject to findings by the Department of: a. Neglect or abuse of a resident in a health care facility....(c) For the purpose of this section, the term "health care personnel" means any unlicensed staff of a health care facility that has direct access to residents, clients, or their property. Direct access includes any health care facility unlicensed staff that during the course of employment has the opportunity for direct contact with an individual or an individual's property, when that individual is a resident or person to whom services are provided. ...(g) Health care facilities shall ensure that the Department is notified of all allegations against health care personnel, including injuries of unknown source, which appear to be related to any act listed in subdivision (a)(1) of this section. Facilities must have evidence that all alleged acts are investigated and must make every effort to protect residents from harm while the investigation is in progress. The results of all investigations must be reported to the Department within five working days of the initial notification to the Department. ..." Retrieved from https://www2.ncdhhs.gov/dhsr/hcpr/flohcinv.html (n.d.).

Review on 03/22/2017 of facility policy, "Patient Abuse, Neglect, And Exploitation - Reporting & Investigating", Policy No.: ADM-1-009, revised, 01/17/2017, revealed "POLICY STATEMENT: It is the policy of (Facility Name) to prohibit the abuse, neglect or exploitation of patients in any manner from staff, patient or visitors. ...DEFINITIONS: Abuse, neglect or exploitation is defined as any act of commission or act of omission by any employee or agent which may result in physical or psychological harm to the patient, whether due to deliberate intent, error in judgment, or negligence. 1. Abuse a. Any physical violence or threat thereof which may result in injury that may cause, death, disfigurement, impairment of physical health or loss or impairment of body organ. Examples include striking a patient, or causing a patient to be struck, with or without the use of an object held or thrown. ...b. Engaging in unprofessional behavior (verbal or physical) that is degrading to the patient. ...2. Neglect a. Failure to provide care or services necessary to maintain the mental health, physical health and well-being of a patient. ...6. Response ...d. Report substantiated allegations involving unlicensed healthcare personnel to the Health Care Personnel Registry at the Division of Facility Services within five (5) business days. Complete the five (5) day working report (Form DFS4500) and attach witnesses' statements. The report is to be mailed to Health Care Personnel Registry (Address). ..." Review of the policy failed to require the facility to report ALL allegations of abuse against health care personnel whether the allegations were substantiated or unsubstantiated by the facility to the HCPR within 24 hours of the health care facility becoming aware of the allegation.

Closed medical record review on 03/21/2017 for Patient #4 revealed a [AGE] year-old female who was admitted on [DATE] under petition for involuntary commitment (IVC) and discharged on [DATE] with a diagnosis of Disruptive Mood Dysregulation Disorder. Review of nursing progress notes dated 12/28/2016 at 1513 documented by a nurse revealed "Pt (patient) got into altercation w/peer (with peer) then altercation w/staff (with staff). Pt alleged that staff 'Hit me'. Pt admitted to hitting staff and threatening verbally. After altercation pt went to room for quiet. 1525 pm f/u (follow-up) 1:1 (one to one) redirection pt had c/o (complained of) bump on her head but no pain pt was social w/select (with select) peers prior to dinner. Upon return pt had no c/o. 1700 Spoke w/pt (with patient's) mother regarding altercation + (and) bump on pt head. Pt had no s/sx (signs and symptoms) of concussion...." Review revealed the patient had reported an allegation of abuse against healthcare personnel to the nurse.

Review on 03/21/2017 of the "December 2016 Grievance Concern Log" and Grievance File BM-16-6708, revealed a grievance was received on 12/29/2016 concerning Patient #4. Review of grievance file documentation revealed a handwritten statement signed and dated 12/28/2016 at 1840 by Patient #4 that revealed, "Date and time of incident 12-28-16 Unit on which the incident occurred: 1 west. I hit (Patient #14 name) and hit Ms. (MHW #2 name) and Ms. (MHW #2 name) hit me back, I have a big lump on my head now." Review of the grievance investigation documentation revealed the grievance was investigated and resolved on 12/30/2016 and the patient was provided a written letter of resolution dated 12/30/2016. Further review failed to reveal any available documentation the facility staff reported the allegations of abuse made against the facility's mental health worker (MHW #2) to the State's HCPR, whether the allegations were substantiated or unsubstantiated by the facility.

Interview on 03/22/2017 at 0934 with the facility's Patient Representative (PR #1) revealed she oversees the facility's grievance process. She recalled the grievance involving Patient #4. She (PR #1) opened the grievance file on-behalf of the patient after being notified of the incident on 12/29/2016. The patient reported she did not feel safe on the unit with the staff member (MHW #2). The patient reported she (Patient #4) struck the staff member (MHW #2) after an altercation with a peer. The patient became frustrated and hit the staff member. The patient reported the staff member struck her in the back of her head and pushed her down into a chair. The grievance had been investigated and resolved. The file was closed on 12/30/2016. She stated she had "no part in reporting" allegations of abuse by health care personnel to the State's HCPR.

Interview on 03/22/2017 at 1342 and at 1515 with the facility's Risk Manager (RM #1) revealed Patient #4's allegations of abuse against MHW #2 were not reported to the State's HCPR. The facility leadership's interpretation of the State requirements for reporting allegations of abuse against healthcare personnel was that the facility only had to report substantiated allegations. She was not aware that all allegations of abuse against healthcare personnel were required to be reported within 24 hours of the health care facility becoming aware of the allegation to the State's HCPR, whether or not the allegations were substantiated or unsubstantiated by the facility's investigation. Interview confirmed the medical record and grievance file documentation findings.

Telephone interview on 03/21/2017 at 1503 with Department Staff #1 with the North Carolina Department of Health and Human Services, Division of Health Service Regulation, Complaint Intake and Health Care Personnel Investigations Section, revealed there were no reports on file at the HCPR, made by the facility regarding allegations of abuse by facility staff involving MHW #2 and Patient #4 on 12/28/2016 as of 03/21/2017. Interview confirmed the findings.

NC 766
NC 504
NC 511