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WESTPARK SPRINGS LLC 6902 S PEEK ROAD RICHMOND, TX March 7, 2018
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the Facility Governing Body failed to investigate an alleged case of staff to patient physical abuse in 1 of 10 sampled Patient. Patient #2


Findings:

Review of the Facility's current Policy and Procedure on Suspected Child, Adult, Disabled Person or Elderly Abuse / Neglect / Exploitation; Policy # 98 directed staff as follows:

"All allegations, observations or suspected cases of abuse, neglect or exploitation that occur in the Hospital will be investigated by the Hospital.
Physical abuse: Physical injury that results in substantial harm to the person, or the genuine threat of substantial harm from physical injury to the person, including an injury that is at variance with history or explanation given, and excluding an accident or reasonable discipline by a patient, guardian, or managing possessory conservator that does not expose the patient to a substantial risk of harm. "


Patient #2

Review of Patient #2's discharged clinical record revealed, the Patient was admitted to the facility on [DATE] from an acute care hospital, with admitting diagnosis of Anemia, Syncope, Tachycardia, Hematuria and metabolic acidosis.

Assessment by the triage staff revealed the Patient presented with chief complaint of depression and anxiety. "Patient reported daily depression and frequent crying, severe anxiety coupled with panic attacks. Patient reports decreased sleep and lost 15 pounds in past two weeks."

Review on 03/07/2018 of Patient #2's discharged clinical record ( Close Observation Record) dated 06/29/2017, revealed the following documentation by Patient Care Attendant (A):
" Patient is visible on the unit. Patient have been crying and complaining that she is sick. Patient also said that a staff kick her and bruise her arm. Patient is now laying --"

Review of the Patients' clinical record revealed no documentation that the Patient's allegation of being kicked by a staff was investigated.


Interview with Patient Care Assistant (A)
Interview on 03/06/2018 at 2:03 p.m. with Patient Care Assistant ( A ) revealed she cannot recall what happened, but what she wrote in the Close Monitoring Sheet, is to let the next shift know, what is going on with the Patient. She said she always try to tell the nurse what is happening with the Patient. She said what she wrote on the Close Monitoring Sheet is what the Patient told her. She said the Patient alleged that she was kicked by a staff.


Interview with the Facility's Director of Nursing (B)
During an interview on 03/06/2018 at 2:25 p.m. with the Facility's Director of Nursing, he said he cannot recall any time that he witnessed or heard a staff being abusive to a patient. He said the Nurse who was assigned to Patient #2 during the allegation of been kicked, is no longer employed to the facility. He said he was not made aware of the allegation of Patient #2 being kicked by a staff , so an investigation was not done.

Registered Nurse (C)
Interview on 03/06/2018 at 2:42 p.m. with Registered Nurse Manager (C) revealed she does recall the Patient. She said during the Patient's stay at the facility, the patient was upset, not wanting to be at the facility but wanted to transfer to another facility. She said no one saw the patient fall.
Registered Nurse Manager (C) said she was the Nursing Supervisor when the allegation of the Patient falling, but she was never told, or made aware that the Patient had alleged that she was kicked by a staff.


Interviewed (Facility's Medical Director)
Interview on 03/07/2018 at 10:53 a.m. with the Facility's Medical Director revealed he was following Patient #2. He said he has some recollection of the Patient who he described as having somatic concerns instead of actual physical.
He said the Patient wanted to transfer back to the acute care hospital, because they were familiar with her illness but there were no beds available in the hospital.
He said in regards to the allegation of the Patient been kicked by a staff while on the floor in the treatment room. He said he had no knowledge of this, but since the Patient made that allegation, an incident report should have been completed and get the Quality Director involved.


Record review of of incident report provided by the Facility's Director of Nursing revealed no documentation of an incident report or investigation of the allegation by the Patient of being kicked by a facility's staff.

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