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 review of the patient medical records, time card reports, review of the facility grievance reports, review of facility policy and procedures, and staff interviews the hospital failed to ensure 1 of 4 patients remained free from abuse and harassment. (Patient #17)

Findings include:

1. The facility failed to recognize the alleged abuse allegations by Patient #17 (A 0145)

2. The hospital failed to separate the alleged victim (Patient #17) from the alleged perpetrator (Staff FF) therefore ensuring the safety of Patient #17. (A 0145)

3. The hospital failed to assess Patient #17 surgical site after the reported abuse. (A 0145)

4. The facility failed to develop a policy intervention to separate an alleged perpetrator from patient care and the alleged victims. (A 0145)

5. The hospital failed to train staff on separating the victim and all patients/alleged victims from alleged perpetrator when there are abuse allegations. (A 0145)

During the incident investigation ( -I), the survey team identified an Immediate Jeopardy (IJ) situation related to the Condition of Participation for Patient Rights 42 CFR 482.13. Facility staff failed to protect a patient from abuse and harassment.

1. Administrative staff, failed to initially develop and implement a corrective action plan to separate the alleged victim from the alleged perpetrator when there was an allegation of abuse.

2. While onsite, the survey staff identified an Immediate Jeopardy (IJ) situation and notified the administrative staff on 11/10/16. The Administrative staff promptly took action to abate the immediacy of the situation. Facility staff removed the immediacy prior to exiting the incident/complaint investigation when they took the following actions.

a. Hospital staff developed and/or updated policies and procedures for identifying, responding to, separating to ensure patient safety, assessing patients following an allegation of abuse, and investigating, patient abuse and neglect and high-risk patient safety activity.

b. 11/8/16, Administrative personnel required orthopedic staff to review new policies and procedures.

c. 11/8/16 at 11:00 p.m., Administrative personnel initiated required staff education to nursing staff prior to their shift.

d. 11/10/16, Vice President of Patient Services conducted an educational meeting with Nurse Managers regarding the new policy, Patient Abuse or Neglect, with a focus on separating staff from direct patient care when an allegation of abuse or neglect is made.

e. 11/10/16, beginning with the evening shift, all nursing units required their staff to review Patient Abuse and Neglect Policies prior to providing patient care.

f. Hospital Administrative staff implemented a system to monitor ongoing compliance. Vice President of Patient Services/CNE (Chief Nurse Executive) is responsible for monitoring ongoing compliance.

The following condition level deficiency remained (A 115) for the Condition of Patient Rights; see A 145 for findings.

Based on review of the patient's medical record, employee time card reports, grievance reports, policies & procedures, and staff interviews, the hospital failed to ensure all patients remained free from abuse and harassment. On 10/27/16, a patient reported an allegation of abuse by Staff FF, RN (Registered Nurse). Hospital staff failed to take immediate action to separate Staff FF from patient care on 10/27/16 allowing Staff FF to continue caring for Patient #17, and other patients, for the remainder of her shift. The facility also allowed Staff FF to return to work, on the same unit, 10/28/16. Problem identified with 1 of 4 orthopedic patients interviewed who reported an allegation of abuse (Patient #17).

Findings include:

Review of Patient #17's medical record revealed an admission to the hospital on [DATE], for left total knee joint replacement and discharged on [DATE].

Patient #17 reported an allegation of abuse to Staff C, RN Manager, on 10/27/16. According to the patient, Staff FF grabbed the patient's left sweat pant leg and lifted the patient's surgical leg off the bed; the patient began screaming and told Staff FF to put the leg down. Staff FF then released her grasp on Patient #17's leg, allowing the leg to fall back on to the bed.

Additionally, on 10/28/16, Patient #17's spouse reported to Staff C, when Staff FF was administering pain medication to Patient #17 on 10/27/16, she extended her hand, holding the medication, and then pulled it back asking Patient #17 to say please. This happened 4 times before Staff FF finally gave Patient #17 the pain medication.

According to a hospital self-report to the State agency hotline on 10/27/16, the hospital investigated an incident that involved Patient #17 and staff member FF. However, hospital staff failed to recognize the allegation of abuse, failed to separate the alleged victim Patient #17 from the alleged perpetrator Staff FF, and failed to assess Patient #17's surgical site after the reported allegation of abuse.

The hospital did not have policy interventions or training in place directing staff to separate an alleged perpetrator from patient care upon receipt of an allegation of abuse.

Time card reports dated 10/23/16-11/05/16 showed, on 10/27/16 Staff FF clocked in at 2:45 PM and clocked out at 11:30 PM and on 10/28/16 Staff FF clocked in at 2:51 PM and clocked out at 11:23 PM. Additionally, the time card revealed that all work occurred in department , the orthopedic unit.

Review of a hospital document titled Patient Relations Worksheet from, November 2015 to current, revealed Patient #17 phoned a grievance to the hospital on [DATE] reporting the allegation of abuse a second time. The documentation showed Staff HH, RN, recorded the following information during the call:

Patient #17 reported undergoing total knee replacement surgery and on 10/27/16, Staff FF, RN abused Patient #17 while in the hospital's care.

On 10/27/16, Staff FF entered Patient #17's room and woke him up for an assessment and vital signs. Patient #17 requested Staff FF wait a minute so the patient could wake up completely and the nurse said no. Staff FF failed to help the Patient roll over and proceeded to pick up the patient's surgical leg, then, according to Patient #17, Staff FF dropped the patient's leg onto the bed.

Patient #17 reported being in a lot of pain while hospitalized . According to the documentation, Patient #17 requested pain medication 15-minutes prior to the time it was due. Twenty five minutes past the due time, Staff FF placed the pills out of the patient's reach and told the patient to say please. Staff FF pulled the pills back 4 times, until the patient said please, then administered the pain medication.

On 10/27/16, Patient #17 activated the call light because the urine receptacle was out of reach. Staff FF entered Patient #17's room then exited without assisting the patient with the urine receptacle or moving the call light within reach. Staff FF placed a sign on the patient's door that read, "quiet time requested." Patient #17 reported urinating in the bed as a result of these actions and was very embarrassed by this.

Documentation in the Patient Relations Worksheet also revealed the patient spoke to Staff D, RN, Charge Nurse, Staff D said she would take care of the patient. Patient #17 reported feeling "unsafe" around Staff FF and feeling "physically and mentally abused" by Staff FF. Documentation showed the facility sent a letter informing Patient #17 they had brought the reported concerns to the attention of Staff C, RN manager and Staff A, Director of Nursing Operations.

Review of an undated document titled Patient rights and Responsibilities, provided to patients upon admit, reads in part...While you are a patient in the hospital, you have the right to...receive care in a safe environment...expect an environment that preserves dignity, contributes to a positive self-image and optimal comfort and dignity...expect to be free from mental, physical, sexual and verbal abuse, neglect and exploitation.

Review of Patient #17's care flow sheet dated 10/27/16 between 3:00 PM to 11:00 PM, revealed Staff FF interacted with Patient #17 at the following times.

a. 4:00 PM Staff FF, RN completed the nursing assessment (heart sounds, neurological, skin integrity and extremity checks). Staff GG, CNA (Certified Nursing Assistant)obtained vital signs (pulse, temperature, and respirations).

b. 5:45 PM Staff FF administered Oxycodone (narcotic pain medication) 10 mg (milligrams), and Toradol (pain medication) for a pain intensity of 8 (on 1-10 scale).

c. 6:36 PM Staff FF completed a wound assessment with no abnormal findings.

d. 8:20 PM Staff FF entered a Progress Note Comment: Due to the patient's aggressive behavior and foul language earlier in shift-HS (hours of sleep) cares will not be completed. Patient sleeping at this time.

f. 8:23 PM Staff FF entered a CMST (Circulation, movement, sensation, and temperature) Comment: Unable to reassess due to patient's behavior.

g. 10:07 PM Staff FF entered a Shift Report Review Test: 3-11:00 PM patient very disrespectful and verbally abusive this shift-refused cares, demanding pain medications-given ASAP (as soon as possible).

During a phone interview on 11/8/16 at 2:05 PM, Staff C verified her written statement was a correct account of the incident dated 10/27/16 that involved Patient #17 and Staff FF.

Review of Staff C's statement and documentation, related to the events that occurred on 10/27/16 between Patient #17 and Staff FF, revealed the following information.

Staff FF came from the patient's room to the charge nurse desk and said Patient #17 just called her a vulgar name and she was not going to stand for it. Staff D, RN Charge Nurse, told Staff FF she was going to round on the patient then Staff C would talk to Staff FF. According to the documentation, Patient #17 was crying and shaking when Staff C entered the patient's room. Staff C introduced herself and asked if they could talk about Staff FF. The patient said I do not want to talk, I want a new nurse because that one purposefully hurt me. Patient #17 stated, Staff FF didn't listen to a word the patient said. Patient #17 reported getting upset and yelling at Staff FF. According to Patient #17, Staff FF came in and said she needed to do an assessment. I asked to wait a few minutes, because I just woke up and was in a lot of pain. Staff FF just pulled off the blanket, listened to my chest and told me to roll over. Patient #17 replied I can't, I am in too much pain and I can't push myself with the other leg because that knee is also bad. Patient #17 said Staff FF grabbed the left sweat pant leg and lifted the surgical leg off the bed. I started screaming, and told Staff FF to put my leg down. That is when I called her a name and Staff FF said why are you refusing my care? Staff C apologized for Staff FF's behavior and the patient's increased pain, and stated she understood why Patient #17 was upset.

Staff C left the room and spoke with Staff FF, who denied Patient #17's account of what had happened. Staff FF reported, the patient was just being difficult and she didn't have time for that. Following this conversation, Staff FF and Staff C went to Patient #17's room to perform some "service recovery" (a thought out, planned process of returning aggrieved/dissatisfied customers to a state of satisfactions). Staff C explained how sorry Staff FF was for what happened. Patient #17 turned to Staff FF and asked what you were trying to do, you didn't have to hurt me. Staff FF replied I wasn't trying to hurt you, but you were refusing my care. Staff C documented Patient #17 and Staff FF started to argue. Staff C asked Staff FF to leave the room, and told Patient #17 that Staff C would check into the pain medication requested. According to Staff C's documentation Staff FF didn't agree with anything Staff C said, and stated she was not comfortable with it. Staff C then asked Staff D to round on Patient #17 a couple of times during the shift.

Review of hospital policy titled, Patient Rights and Responsibilities/Nondiscrimination, reviewed 11/9/15 reads in part...Purpose:Supports the establishment and protection of patient effectively provide all rights for patients, certain responsibilities must be assumed by caregivers as well as patients and their families... Practice/Procedure: 2. Patient rights and responsibilities policy shall be communicated to all new employees during the orientation process. Standards and policies which ensure ongoing awareness and observance of these policies shall be developed at the departmental the event of a desire to file a complaint alleging violation of this policy...10. Receive care in a safe environment...28. Expect an environment that preserves dignity and contributes to a positive self image. 29. Expect to be free from mental, physical, sexual and verbal abuse, neglect and exploitation.

Review of hospital policy titled, Unusual Occurrence, revised 8/15/13 reads in part...VI. General Considerations B. Documentation: 1. Actual Events relating to a patient are documented in the medical record...the staff member who discovered or was informed of the Unusual Occurrence is responsible for completing the Unusual Occurrence Report unless other arrangements are made.

The investigation revealed the hospital failed to complete an unusual occurrence report related to dropping or potential injury to Patient #17's surgical leg from the incident on 10/27/16.

An interview on 11/7/16 at 4:40 PM, with Staff D, RN Charge nurse, revealed the administration of pain medication around 8:30 PM on 10/27/16 for Patient #17. According to Staff D, Patient #17 continued to show anger towards Staff FF. I said that I would answer the patient's call light the rest of the night. I did notice a pile of linens on the floor and asked about them. Patient #17 reported wetting the bed, and called his spouse to come from home to change the bed and give the patient a bath. Staff D commented she gave Patient #17 the urine receptacle and did not ask any further questions. Staff D stated she did not want to irritate Patient #17. Staff D did not recall where the call light was upon exiting the room. Additional interview on 11/8/16 at 5:00 PM, revealed Staff D answered Patient #17's call light one more time after the pain pill, about 10:00 PM on 10/27/16.

Interview on 11/8/16 at 2:30 PM, with Staff HH, RN Patient Advocate revealed she spoke with Patient #17 by phone. Patient #17 shared concerns regarding Staff FF and care received while a patient at the hospital. Patient #17 reported feeling abused both physically and mentally. According to Staff HH, Patient #17 discussed the medication administration where Staff FF required Patient #17 to say please before giving the medications to the patient. Staff HH identified Patient #17 requested a urine receptacle from Staff FF, however Staff FF left the room without providing it. Staff HH commented that Patient #17 informed her that Staff FF dropped Patient #17's surgical leg.

Interview on 11/10/16 at 11:15 AM with Staff FF, RN revealed, during the 4:00 PM assessment, Staff FF acknowledged she pulled up Patient #17's sweatpants to assess the surgical wound. According to Staff FF Patient #17 started screaming, because this was pulling on the dressing. Staff FF left the room, and reported to Staff C, RN manager and Staff D, RN charge nurse that Patient #17 was calling her vulgar names . Staff C and I re-entered the room, and confirmed the patient's behavior and that the leg was not dropped, it was the dressing pulling on the sweat pants. According to Staff FF's interview, Patient #17 then recanted and stated I dropped ice bags on the surgical leg. I did not say a word while we were in the room. After leaving the room I spoke with Staff C and stated 'I did not feel comfortable with the patient and the hostile, aggressive, abusive behavior. Staff C stated, Just make the patient happy.' Within the next hour, Patient #17 requested pain medication. After I entered the room Patient #17 started screaming I was late. I asked the patient to rate the pain and administered the medication. The call light was within reach, I asked if the patient would like a do not disturb sign put on the door so the patient could rest, the patient agreed. My assignment was never changed but Staff D did take over answering Patient #17's call light about 5:00 PM on 10/27/16, following administration of the pain medication.

Review of the policy titled, Stop the Line, revised on 6/15/15 reads in part...Policy: All organizational employees...have the responsibility and authority to immediately "Stop the Line: to protect the safety of the patient. It is the expectation that all participants will immediately stop and respond by reassessing the patient safety. Purpose: To define the responsibility and authority for anyone to intervene when necessary to protect the safety of patients. VII. Practice/Procedure: A. Identification of a situation warranting immediate intervention: The following situations warrant immediate intervention:...4. Imminent violation of legally established patient rights that pose an immediate threat to patient safety...6. Imminent patient safety risks (not otherwise specified). Patient deemed to be otherwise at imminent risk of potentially permanent physical, mental or emotional sequelae (consequence of another condition). 7. Willful intent to do harm. Knowledge that an individual has willful intent to do harm to a patient...B. Priorities of intervention: The method of intervention chosen should maximize timeliness and effectiveness in restoring patient safety while minimizing intrusion into the process of care. 1. Direct communication of the identified problem should occur at the point of care and should include but is not limited to the attending physician and the staff providing the care. If this does not resolve the issue the following progression steps of communication using the chain of command as appropriate, should occur until the issue is resolved and the patient safety has been restored:
1. Charge Nurse
2. Nurse Manager
3. Department Director
4. Chief Nurse Executive

The onsite investigation revealed the hospital policy lacked information related to separating the patient from the alleged perpetrator when an abuse allegation was made.

Interview on 11/7/16 at 3:00 PM, with Staff A, RN Director of Nursing Operations, acknowledged the behavior Staff FF demonstrated was against Hospital values. According to Staff A, Patient #17, was not separated from Staff FF at the time of the allegations, because Staff C felt we were dealing with inappropriate behavior. We followed the guidelines established in "Stop the Line Policy."
Staff A agreed that the Stop the Line Policy failed to address the separation of the victim from the alleged perpetrator when an abuse allegation was made.

Interview on 11/7/16 at 3:30 PM, with Staff B, RN Manager of Nursing Standards and Behavior Health, revealed administrative nurses are to take the responsibility to maintain kind considerate care, the nurses must adhere to Board of Nursing practice and the hospital Stop the Line Policy, and remove the nurse from the situation if any patient states they were abused or received what they felt was unkind care.