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|UNIVERSITY OF KENTUCKY HOSPITAL||800 ROSE STREET LEXINGTON, KY 40536||Sept. 11, 2018|
|VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT||Tag No: A0145|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure all alleged violations involving abuse are reported immediately in order to protect patients from further potential abuse for one (1) of ten (10) sampled patients (Patient #1).
Radiation Technologist (RT) #1 witnessed alleged verbal and physical abuse towards Patient #1 by Physician #1, the alleged perpetrator, on 08/29/18. However, RT #1 failed to report the allegation immediately in order for the facility to implement their policy related to protection of the patients from further potential abuse pending the investigation. RT #1 did not report the alleged abuse until 08/31/18, two (2) days later.
The findings include:
Review of the facility Policy "A06-140: Protection of Adults: Reporting Abuse, Neglect, or Exploitation", dated 07/16/18, revealed the purpose of the Policy was to educate and provide a definitive action plan that staff shall follow during suspected and reported cases of adult patient abuse, neglect, or exploitation. In the event that an employee or contractor is implicated in an abuse or neglect situation, University of Kentucky (UK) HealthCare shall take steps to protect the patient. Any employee or contractor having information that a patient has suffered or alleges to have suffered abuse, neglect or exploitation shall immediately notify their immediate supervisor. If the immediate supervisor is not available, the employee shall notify the Hospital Operations Administrator (HOA) at Chandler Hospital, the Divisional Charge Nurse (DCN) at UK HealthCare Good Samaritan Hospital or other Administrative Staff as listed. The immediate supervisor, HOA or DCN shall immediately remove the employee or contractor from direct patient care. The immediate supervisor, HOA, or DCN shall immediately begin an investigation of the situation. Further review revealed the employee or contractor shall complete an online report in the Safety Intelligence System or contact the Comply-Line; this report can be submitted anonymously if the employee so chooses.
Review of KRS 209.030 Administrative Regulations-Reports of Adult Abuse, Neglect, or Exploitation-Cabinet Actions-Status and Disposition Reports, revealed an oral or written report shall be made immediately to the Cabinet upon knowledge of suspected abuse, neglect, or exploitation of an adult.
Review of Patient #1's medical record revealed the facility admitted the resident on 08/29/18 with diagnoses of [DIAGNOSES REDACTED]]. Further review revealed Patient #1 had an outpatient procedure for Angiogram and Selective Internal Radiation Microspheres Shunt Evaluation on 08/29/18. Further review revealed the procedure was conducted by Physician #1, with RT #1, RT #2, Registered Nurse (RN) #1, and Resident Physician (RD) #1 present.
Review of the facility "Safety Intelligence Review Form for Managers", revealed a behavioral event occurred on 08/29/18 and was reported on 08/31/18 at 5:12 PM related to Patient #1. The section titled Reporter Role, revealed "Anonymous". The Event Detail Section, revealed it was reported today that while this patient was on the table undergoing a procedure he/she reached for the site of the intervention and Physician #1 began striking the patient, punched his /her hand five (5) times, and also screamed at the patient. No harm was evident physical or otherwise. There was no signature or name of staff who completed the report.
The State Agency Representative attempted to reach Patient #1 by phone on 09/10/18 at 12:28 PM and a message was left; however, Patient #1 did not return the call.
Interview with Senior Social Worker #1, on 09/10/18 at 4:36 PM, revealed an allegation of abuse involving Patient #1 and Physician #1 was reported the evening of 08/31/18. She stated, per the allegation, on 08/29/18, RT #1 and RT #2 were in the room during an out patient surgery for Patient #1, and while the patient was sedated the patient started to move his/her hands. She further stated, per the allegation Physician #1 yelled at the patient to be still and then hit the patient. Further interview revealed SW #1 reported the allegation to Adult Protective Services (APS) on 08/31/18, and was instructed by APS to contact OIG, which she did. She further stated she reported the allegation to Risk Management in house, on 08/31/18, and was not involved any further in the investigation process.
Interview with RT #1, on 09/11/18 at 12:40 PM, revealed on 08/29/18, Patient #1, who was under sedation for an outpatient procedure, moved his/her hands towards the sterile field of the abdominal area where the procedure was taking place. RT #1 stated Physician #1 yelled very loudly for the patient to "put your hand down," and "keep your hand down," holding the patient's left hand down while striking the patient with his right hand in the general area of the femoral axis (right side of the abdomen/hip area). RT #1 stated Physician #1 appeared frustrated going into the procedure, and she felt he took this frustration out on Patient #1. RT #1 further stated she was not aware of any injury at the site, or even if the patient would have remembered the incident, as sedation decreases awareness and makes it difficult to remember. Further interview revealed when abuse was witnessed, staff was to report the abuse to their manager, and there was also an online system in which they could report allegations of abuse as well. RT #1 stated the incident left her in shock and she was afraid of retaliation, although according to their abuse policy she should have reported the abuse immediately to prevent the possibility of further abuse occurring. Per interview, she reported the allegation of abuse on 08/31/18.
Interview with RT #2, on 09/11/18 at 1:07 PM, revealed his perception of the incident was not abuse. He stated he observed Patient #1 reaching up under the sterile drape, and Physician #1 "yelling" at the patient that he/she couldn't reach into the sterile area, and to keep his/her hand down, while Physician #1 was pushing the patient's hand back under the drape. RT #2 stated Physician #1 did slap Patient #1's hand back at one point during the procedure, but it sounded like a hand hitting cloth, and he could not determine the amount of force, although he did not perceive it to be abuse. He stated he was interviewed by the Social Worker related to this incident. He further stated if he observed an incident which he felt was abusive, he would get on the "care web" and file an Incident Report.
Interview with RN #1, on 09/11/18 at 1:38 PM, revealed she did not perceive anything that went on to be abusive during Patient #1's procedure on 08/29/18. She stated she did perceive Physician #1 as being frustrated when Patient #1 moved his/her hand into the sterile area where the surgical procedure was taking place, and remembered Physician #1 had to keep reminding Patient #1 to keep his/her hand down. She further stated from her position, she did not observe Physician #1 to strike Patient #1's hand. Continued interview revealed if she observed an incident which she felt was abusive she would notify her supervisor as soon as possible.
Interview with Resident Physician #1, on 09/11/18 at 1:49 PM, revealed he was present when Physician #1 was conducting the procedure involving Patient #1 on 08/29/18. Resident Physician #1 stated he did observe Patient #1 reaching up through the opening of the surgical drape, and heard Physician #1 telling the patient to keep his/her hands down and remain still. Further interview revealed Physician #1 was not verbally or physically abusive to Patient #1 during the procedure.
Interview with Physician #1, on 09/11/18 at 1:56 PM, revealed he was conducting a mapping procedure on Patient #1 on 08/29/18, to determine if he/she was a candidate for radio embolization of a tumor. He stated Patient #1 was under sedation, and he (Physician #1) had a scalpel in his right hand and an ultrasound device in his left hand when Patient #1 started coming out of sedation and flung his/her arm up into the sterile field. Physician #1 stated it happened suddenly, and he was startled and yelled out "no", using the back of his left hand to push the patient's hand back under the drape. Per interview, after placing the scalpel down on the table he noticed Patient #1 had his/her hand back in the sterile field rubbing against the surgical wound. Physician #1 stated he then took Patient #1's hand, and was trying to control the situation to keep the patient's hand out of the wound. Per interview, Patient #1 was disoriented and was pushing against his (Physician #1's) hand and trying to move his/her hand into the sterile field until the patient realized he (Physician #1) was telling him/her to keep his/her hand down. Physician #1 denied striking Patient #1, but admitted to pushing Patient #1's hand away from the blade and the ultrasound probe. Further interview revealed he had not worked at the facility since 08/31/18, when he took administrative leave following the allegation.
Interview with Risk Management #1, on 09/11/18 at 8:46 AM, revealed Senior Social Worker #1 made her aware of the allegation towards Physician #1 by RT #1 and RT #2 on the night of 08/31/18. Per interview, SW #1 left messages for Patient #1, but could not reach the patient. She stated the Chief Medical Office, Chief Nursing Office, and the Head of Medical Staff were notified of the allegation on 08/31/18. Per interview, Risk Management did not complete the investigation as the allegation involved a medical staff member, and therefore the investigation of Physician's #1's conduct was placed in the hands of medical staff, and the information was privileged under KRS 311.77, peer review process. She stated the allegation was currently under investigation. and the President of Medical Staff would know where the Medical Staff was in the investigation.
Interview with the President of Medical Staff on 09/11/18 at 11:24 AM, revealed he was notified of the event involving Physician #1, and the Medical Staff was enlisted to do the review for voluntary remediation evaluation. Per interview, Physician #1 was on administrative leave and would remain on administrative leave pending review. Further interview revealed the investigation was ongoing and the results of the investigation could find no substance of foundation to make recommendations; however, there existed the possibility there could be disruptive behaviors by Physician #1 and if so, they would go forward with remediation until a determination was made.
Interview with the Assistant Operations Executive, on 09/11/18 at 3:58 PM, revealed she was on the executive team and reported to the Chief Nurse Executive and the Chief Nursing Officer. Per interview, she was responsible for oversight of regulatory compliance. She stated if a team member witnessed potential abuse, they were to report the allegation immediately to their supervisor and their supervisor was to give appropriate notification through the chain of command. She stated timely reporting was necessary in order for the facility to take steps to protect the patient involved and other possible victims from further potential abuse. She further stated it was her expectation staff follow facility policy related to reporting allegations of abuse.