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Based on document review and interview, the facility failed to ensure care in a safe setting for 1 of 10 patient (P1) medical records reviewed.


Findings include:

1. The facility algorithm titled, "Patient Allegation of Caregiver Misconduct against a Care Provider to be facilitated by Risk Management", last revised 08/19/2021, indicated Per CMS regulation 482.13(c) 3 The hospital must protect patients from abuse during investigations of any allegation of abuse, neglect, or harassment. Department Leader or Administrator on Call must take necessary action to prevent patient from abuse during investigation.

2. Review of facility incident log for dates 3/17/24-9/17/24 indicated P1 was listed twice on 8/27/24. No times were recorded for the submission of these incident reports. The details of the incident report filed by unit staff details an account of P1 grabbing at RN1's (Registered Nurse) wrist during the morning of 8/27/24 and being uncooperative with medications and wearing his/her nasal cannula. The incident report then describes the incident between PCT1 (Patient Care Tech) and P1 regarding the blood sugar check and notes Q2 (Witness) stated that PCT1 hit P1. A second was initiated by an unknown provider, made aware by Q1 of his/her concern about the patient being hit. A provider called Q1 to update on the patient's status, Q1 (Complainant) voiced concerns that the patient was hit after noncompliance with medications, the provider was unaware of the incident until Q1 voiced his/her concerns. Pt is demented, cannot describe incident. Family reported that family friend was present in room. The provider discussed that he/she would escalate concerns. The provider notified the abuse concern to the charge nurse and attending. Both incident reports were unresolved at the time of survey.

3. Associate timecard documentation for PCT1 indicated that he/she worked the following shifts during the investigation of abuse. 8/27/24, 8/30/24, 9/4/24, 9/7/24, 9/8/24, 9/9/24, 9/14/24, & 9/15/24.

4. In telephone interview on 9/19/24 at approximately 1:45 pm with A10 (Unit Manager) confirmed notifying Risk Management by email of the incident and requesting next steps, Confirms PCT1 was removed from P1's care and reassigned to a different patient care assignment.

5. In virtual interview on 9/17/24 at approximately 1:15 pm with A7 (Risk Manager) confirmed PCT1 was not removed from patient care during the investigation of alleged abuse but rather reassigned to a different patient care assignment.

Based on document review and interview, the facility failed to keep patient free from abuse for 1 of 10 patient (P1) medical records reviewed.

Findings Include:

1. The facility algorithm titled, "Patient Allegation of Caregiver Misconduct against a Care Provider to be facilitated by Risk Management", last revised 08/19/2021, indicated under Risk Management: Triages concern with AR (Administrative Representative), LC (Legal Counsel) within 24-48 hours.

2. Review of facility incident log for dates 3/17/24-9/17/24 indicated P1 was listed twice on 8/27/24. No times were recorded for the submission of these incident reports. The details of the incident report filed by unit staff details an account of P1 grabbing at RN1's (Registered Nurse) wrist during the morning of 8/27/24 and being uncooperative with medications and wearing his/her nasal cannula. The incident report then described the incident between PCT1 (Patient Care Tech) and P1 regarding the blood sugar check and notes Q2 (Witness) stated that PCT1 hit P1. A second was initiated by an unknown provider, made aware by Q1 of his/her concern about the patient being hit. A provider called Q1 to update on the patient's status, Q1 (Complainant) voiced concerns that the patient was hit after noncompliance with medications, the provider was unaware of the incident until Q1 voiced his/her concerns. Pt is demented, cannot describe incident. Family reported that family friend was present in room. The provider discussed that he/she would escalate concerns. The provider notified the abuse concern to the charge nurse and attending. Both incident reports were unresolved at the time of survey.

3. Event Timeline provided by facility's Risk Management team:
8/27/24:
Risk Management notified of event. Event investigation started.
Unit Manager to pt bedside for event review. OUTCOME: pt unable to participate.
Unit Manager talked to PCT1 involved about involvement with event. OUTCOME: PCT assignment changed while further review.
Unit Manager talked to family friend: OUTCOME: No concerns shared with him/her at this time.
Unit Manager talked to primary RN regarding patient's condition and event. OUTCOME: Continued to review.
Unit Manager called patient's child regarding event. OUTCOME: Discussed possible delirium for patient, Avasys (Video Monitor) being placed and PCT1 being changed. Family was polite.
8/28/24:
Patient condition unchanged, no new concerns.
8/29/24:
Patient discharged, no new concerns.
9/11/24:
Interviewed: PCT, Interviewed: Primary RN, OUTCOME: No additional findings.
9/13/24:
Met with legal. Discussed all information obtained from collaboration with unit leadership and interviews. OUTCOME: Unsubstantiated Claim.

4. In telephone interview on 9/19/24 at approximately 1:45 pm with A10 (Unit Manager) confirmed notifying Risk Management by email of the incident and requesting next steps, Confirms PCT1 was removed from P1's care and reassigned to a different patient care assignment.

5. In virtual interview on 9/17/24 at approximately 1:15 pm with A7 (Risk Manager) confirmed he/she was the investigator of the alleged abuse claim that occurred on 8/27/24 on P1 by PCT1, P1 was not interviewed d/t (due/to)cognitive status in medical record. No contact was made with the patient after incident by A7, Q2 (Witness) was not interviewed d/t direction of H1's legal counsel, PCA1 and RN1 were not interviewed until 9/13/24, facility legal counsel advised A7 there were no further actions to be taken after the interviews of the associates and chart review, and that H1 Legal counsel was not notified of incident within 24-48 hours, PCT1 was not removed from patient care during the investigation of alleged abuse but rather reassigned to a different patient care assignment.