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, record review, and review of hospital policies and procedures, the hospital failed to investigate a patient injury as possible patient abuse as directed by hospital policy for 1 of 1 patients reviewed (Patient #1).

Failure to investigate incidents of possible patient abuse and to act on investigation findings risks physical and psychological injury to patients due to care in an unsafe environment.


1. Review of the hospital's policy and procedure titled "Patient Abuse: Procedure for Reporting," Policy #1.29 reviewed 01/19, showed all patients had the right to treatment in an environment free of "abuse and abusive procedures." The policy defined physical abuse of a patient as "assaults, inappropriate touching, and injury due to neglect or dereliction of duty." The policy showed that employees would immediately report cases of known or suspected abuse of a patient to an "appropriate supervisor," complete an "Unusual Occurrence Report" (UOR), and document the incident in the patient's medical record. The physician/Officer of the Day would determine if "reasonable cause" existed to suspect or believe abuse may have occurred. If reasonable cause existed, the physician would document the findings and decisions and instruct the appropriate supervisor(s) to protect the patient and initiate an investigation. The supervisor would ensure the UOR was sent to the Quality Management department in accordance with hospital policy #1.45.

2. Review of the hospital's policy and procedure titled "Unusual Occurrence Report (UOR)," Policy #1.45 reviewed 06/18, showed "unusual occurrences," including all allegations of patient abuse and neglect, significant patient injuries, and medical emergencies requiring patient transport to an outside community care provider, would be reported to Quality Management within 24 hours.

3. On 10/31/19 at 10:30 AM, review of the medical records for Patient #1, a [AGE] year-old patient who had been admitted on [DATE] for treatment of neurocognitive disorder and psychosis, showed the following:

a. Review of a monthly summary dated 09/20/19 at 4:30 PM written by a social worker (Staff #1) showed on 09/17/19 the social worker and "staff" had met with the patient and encouraged her to "bathe or at least change her clothes." The patient became angry and began yelling and cursing at staff, and stated she would bathe and change her clothes when she was discharged . The summary stated that on 09/18/19 hospital staff members were "assisting" the patient to the shower and the patient "ran into staff breaking her arm."

b. A progress note dated 09/18/19 at 11:00 AM written by a physician (Staff #2) read, "Patient seen today. Staff reported patient is in the process of assisting patient [sic] to take a bath. However there is some resistance in patient taking a bath and suddenly staff heard a "snap" and noted right upper arm swelling... A/P [Assessment and Plan]: Possible fracture right humerus. Will send patient to [another hospital] for x-ray eval and ortho right away."

c. A progress note dated 09/18/19 at 1:30 PM written by a mental health technician (Staff #3) read, "Patient was walking with two staff holding her hands to the shower room. Patient leaned to her right side against this writer and a sudden "pop" sound occurred. Patient was assisted to floor and RN assessed. Patient appeared to be in pain. RN and doctor notified."

d. A progress note dated 09/18/19 at 7:00 PM written by a registered nurse (Staff #4) showed that the patient had been transferred to another hospital and was scheduled to have right arm surgery on 09/19/19. The entry read, "CNO [Chief Nursing Officer] and OD [Officer of the Day] notified."

e. A progress note dated 09/23/19 at 3:30 PM written by a physician (Staff #5) showed that the patient had undergone an open reduction internal fixation surgery for a fractured right humerus.

4. On 10/31/19 at 10:30 AM during an interview with the investigator, the Director of Quality and Compliance (Staff #6) stated she received UOR's regarding the patient's injury on 10/28/19 and that an investigation into the circumstances surrounding the event had not yet begun. The director stated she had not been notified of the extent of the patient's injuries, nor that the patient had been hospitalized and undergone surgery.

5. On 10/31/19 at 2:20 PM, review of four UOR's dated 09/18/19 submitted by three mental health technicians (Staff #3, #7, #8) and a registered nurse (Staff #9) showed Staff #3 and #7 were holding the patient's hands and "assisting" her to walk to the shower room when the patient "leaned hard to the right". The UOR's stated the staff members heard a sudden "pop sound" and that staff assisted the patient to the floor. The UOR's did not document the extent of the patient's injuries nor the fact that the patient was transferred to another hospital for surgery.

6. The interviews and medical record review showed the incident had not been considered as a possible case of patient abuse, and that the hospital's patient abuse reporting and investigation policy had not been followed.