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MEMORIAL HEALTHCARE SYSTEM, INC 2525 DESALES AVE CHATTANOOGA, TN 37404 Jan. 21, 2020
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical record review, review of a report from Tennessee Department of Human Services (DHS), and interview, the facility failed to document an investigation of abuse for 1 patient (#1) of 8 patients reviewed for abuse.

The findings included:

Review of the facility policy, "DOCUMENTATION-DAILY NURSING: FREQUENTLY USED INTERVENTIONS," dated 1/2019 revealed "...Documentation will delineate the coordination of care and care planning performed by the nurse in conjunction with other members of the healthcare team..."

Medical record revealed Patient #1 was admitted to the facility on [DATE] with diagnosis including Acute Respiratory Failure, Hypertension, Pleural Effusion (fluid on lungs), and Urinary Tract Infection.

Medical record review of a Nurse Practitioner's (NP #1) Progress Note dated 11/20/2019 at 10:18 AM revealed Patient #1 was "...Alert, cooperative, no distress, appropriate for age, mental cognitive delay...Evaluated external genitalia and vaginal introitus [opening] with RN [Registered Nurse] at bedside as chaperone. Moderate to severe [DIAGNOSES REDACTED] and significant swelling/edema of labia (unknown if she usually has this amount of swelling or if this is new). Mild amount of white discharge...had some agitation overnight...she is complaining of moderate vaginal discomfort and itching...continues to complain mostly of abdominal pain..." The NP diagnosed Patient #1 with unspecified vaginitis.

Medical record review of a Physician's Discharge Summary dated 12/3/2019 at 11:47 AM showed the patient was discharged back to her group home on 12/3/2019.

Medical record review revealed there was no documentation of the suspicion of sexual abuse or of the staff contacting DHS.

Review of a report dated 12/19/2019 from DHS to the Tennessee Department of Health (TDOH) showed the facility reported a suspicion of possible sexual abuse to DHS involving Patient #1 on 11/20/2019, but the facility did not report the suspicion to the TDOH.

Interview with Social Worker #1 (SW #1) on 1/15/2020 at 10:00 AM revealed she investigated a suspicion of sexual abuse of Patient #1 on 11/20/2019. SW #1 stated she was told by the facility staff the patient had started having behaviors that included touching her genitals and moving her hips up and down. SW #1 stated she reported the suspicion of sexual abuse to the facility's Risk Manager and to the DHS on 11/20/2019.

Interview with the Risk Manager on 1/15/2020 at 10:05 AM revealed he received a report that staff suspected Patient #1 was sexually abused. The Risk Manager investigated the allegation and found no evidence the patient was abused. The Risk Manager stated he did not have any documentation of the investigation.

Interview with the Patient Safety Officer (PSO) on 1/15/2020 at 11:30 AM confirmed there was no documentation in the medical record of suspected sexual abuse involving Patient #1 and there was no documentation DHS was notified. The PSO stated the suspicion of abuse and DHS notification should have been documented in the medical record.

Interview with NP #1 on 1/15/2020 at 1:15 PM revealed she had no suspicion the patient was abused and she examined Patient's #1's vagina because the patient complained of itching. NP #1 stated she saw no evidence the patient was sexually abused and the patient had no tearing, bruising, or other injury.