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 interview and document review, the facility staff failed to: (a) Include their procedure of investigating allegations of abuse and neglect in their current written Policy, and (b) Fully implement their Workplace Violence (WPV) Prevention Program.

This lack of implementing a clearly written WPV Policy may lead to staff not identifying factors that place patients and staff at risk.

Findings pertinent to (a) include:

The facility Policy and Procedure titled "Workplace Violence Policy and Prevention Program" last revised on 01/25/2018, stated the following: "... in matters wherein a Nassau Health Care Corporation (NHCC) employee is alleged to be the offender, an investigation by ... leadership needs to be immediately initiated ... to ascertain the alleged offender's ability to continue in (their) employment capacity while the investigation proceeds ... [and] a WPV Incident Report Form must be completed. Corrective or disciplinary actions ... may be taken against the employee ... who is found to have ... abused any individual at the workplace." However, the Policy did not include the procedure currently used by NHCC Leadership to investigate allegations of patient abuse.

During an interview with Staff H (Quality Assurance/QA Coordinator) on 11/29/18 at 2:00PM, she stated: "Any act of violence including sexual and physical abuse is considered to be WPV. All allegations of WPV are entered into Verge [the Incident Reporting System] which notifies the appropriate NHCC Leadership by email. Our normal protocol, if an allegation is made against an employee, is to send them off duty immediately for up to twenty (20) days, or until the investigation is completed. The investigation is started as soon as possible, but no more than twenty-four (24) hours after the allegation is made."

This was confirmed by Staff A (QA Coordinator) and Staff C (Vice President) during the afternoon of 11/29/18.

Findings pertinent to (b) include:

The facility Policy and Procedure titled "Workplace Violence Policy and Prevention Program" last revised on 01/25/2018, stated the following: "a WPV Prevention Team ... establish and implement the WPV program ... identify factors ... that might (indicate) risk of WPV ... review incidents of WPV to identify areas of concern ... review previous incidents of violence and conduct assessments within units or departments annually." No documented activity by the WPV Prevention Team was found for 2018.

Electronic mail from Staff G (Director of Risk Management) to Staff E (Director of QA for Behavioral Health) and Staff F (Director of Hospital QA/Performance Improvement) on 12/13/17 at 12:25PM, indicated that Staff G had informed Staff Members E and F of the outcome from the WPV Committee Meeting that morning. No additional documentation for 2018 could be provided.

Per interview with Staff A (QA Coordinator) on 11/30/18 at 1:00PM, this staff member stated that: "The WPV Committee used to meet quarterly, but since the person who ran them retired, there haven't been any Committee Meetings. They still discuss issues as they are identified, but not in a formal meeting."