HospitalInspections.org

Based on record review and staff interviews it has been determined that the faciliuty has failed to meet the Conditions of Participation relative to Patient's Rights.

Findings include:

1) Failing to meet the standards of practice related to A 145


1. A review of the clinical record for patient ID #1 and interviews with staff reveal that the patient is a 37-year-old with a history of Dandy-Walker malformation, cerebral palsy, seizure disorder, pica and pressure ulcers. The patient requires a tracheostomy and has a gastrostomy tube. The patient is totally dependent on staff for all care, and is non-verbal. Both hands and arms are contracted as well as both legs, and the patient is non-ambulatory. Tracheostomy care is done by the nursing staff every shift with frequent suctioning, and oxygen 28% is administered via a trach mask.

The clinical record reveals that on 6/12/14, the patient had hypoactive bowel sounds and a distended abdomen. Upon rectal exam, a mass was noted in the patient's rectum that could not be removed, and the patient was transferred to the acute care hospital for evaluation.

Review of the acute care hospital Operative Note dated 6/14/14, reveals the patient was taken to the Operating Room and under general anesthesia a digital exam revealed a foreign body that was palpable. The note reveals the foreign body was gently grasped and removed from the rectum. The mass grossly appeared to be either a sock or grossly consistent with a hospital shoe cover or booty. The foreign body was sent to Pathology for examination.

Review of the Surgical Pathology Report dated 6/18/14 reveals under gross description, in part, "..Received fresh is a 20.5 x 11.0 x 4.5 cm dark, coarse, fabric pouch, which is diffusely covered by an partially filled with feculent material. The open end of the specimen is partially sewn closed at one end. The specimen may be consistent with a shoe cover, however, definitive identification cannot be made. Gross diagnosis only, consistent with foreign body, rectum."

Review of the Discharge Summary reveals the patient was discharged to a long term care facility on 6/23/14. The summary reveals the findings were suspicious for possible sexual abuse. Social Service was involved. The Discharge Summary reveals this information was sent (carbon copied) to the physician at the Long Term Acute Care (LTAC) hospital.

Additionally, a review of the LTAC incident report indicates that the LTAC was notified by the Alliance for Better Long Term Care that the impaction had been removed at the acute care hospital and discovered the cause was a "mesh sock or sack." The Alliance revealed these findings were a concern for abuse.

It was determined that the LTAC hospital failed to investigate and protect when made aware of the abuse allegation, and failed to report this allegation to the licensing agency in accordance with State law which reveals, "The hospital shall report within 24 hours, or by the end of the next business day to the licensing agency, allegations of patient abuse, neglect or mistreatment as defined in Chapter 23-17.8-2 of the Rhode Island General Laws."

When interviewed on 12/3/14 at approximately 11:30 AM, the Interim Risk Manager and Clinical Manager were unable to produce evidence that the alleged abuse had been investigated and reported.

2. Record review for Patient ID# 3 reveals the patient is non verbal with a tracheostomy and is ventilator dependent and requires total care with all activities of daily living. Review of an LTAC incident report dated 9/28/14 reveals that a superficial abrasion in a horizontal and vertical pattern was noted on Patient ID #3's right upper thigh. Further review of the LTAC incident report indicated ,"superficial abrasion right upper thigh etiology unknown". There is no evidence of any investigation of this incident or report to the Department of Health (DOH).

Again on 11/13/2014 a review of an LTAC incident report indicates that the patient was observed during PM care to have a scratch of unknown origin on his/her abdomen in the form of a cross measuring 10 cm x 2 cm., right upper thigh with a scratch shaped like an L measuring 3 cm x 2 cm and the right hip with a scratch measuring 3 cm. The MD was made aware.

The LTAC incident report further indicates that the above areas are of unknown origin. Although witness statements were obtained, there is no evidence this information was reported to the DOH.

3. Record review for patient ID #2 reveals the patient is non verbal and ventilator dependent. This patient requires total care for all activities of daily living. Review of the LTAC incident report for patient #2 dated 10/13/14 revealed ," CNA called writer into patient's room. Patient had a superficial scratch in the shape of a cross, Dr. ...notified". Further review of the incident report revealed that when examined by nursing, they documented that "patient is noted to have a cross shaped scratch on the right posterior upper thigh. Etiology unknown at this time".

Review of an employee statement dated 10/15/14 for employee A revealed that the employee noted a cross or letter T like scratch on the patient's right upper thigh on the first shift on both 10/11 & 10/13/14. The employee further stated in her statement that she reported this to the charge nurse.

Review of employee statement dated 10/15/14 for employee B revealed that on 10/13/14, this employee was informed by another employee that the resident had a large scratch on the right upper thigh in the shape of a cross.

During an interview on 12/3/14 at 1030 AM with the Interim Risk Manager, she reported that she assumed the 9/28/14 and 10/13/14 incidents had been reported to the DOH by the prior Risk Manager, in accordance with State law.

The failure to investigate, report and protect for an allegation of abuse for ID #1 and the failure to report allegations of abuse for ID # 2 and ID #3 triggers a condition of participation level deficiency.

Based on record review, staff interview and review of a hospital incident, it has been determined that the facility failed to investigate, report, and protect for an allegation of abuse related to 1 of 6 sample patients (ID #1), and failed to report allegations of abuse for 2 of 6 relevant sample patients (ID #'s 2 and 3).

Findings are as follows:

1. Review of the medical record for patient ID #1 and interviews with staff reveal that the patient is a 37-year-old with a history of Dandy-Walker Malformation, Cerebral Palsy, seizure disorder, pica and pressure ulcers. In July of 2013 the patient developed pneumonia and required a tracheostomy and G (gastrostomy) tube placement. The patient is totally dependent on staff for all care, and is non-verbal. Both hands and arms are contracted as well as both legs, and the patient is non-ambulatory. Tracheostomy care is done by the nursing staff every shift with frequent suctioning, and oxygen 28% is administered via a trach mask.

A review of the LTAC hospital incident form dated 6/17/14 related to patient ID #1 reveals that this patient was transferred from the LTAC hospital to an acute care hospital on 6/12/14. A review of the clinical record reveals the patient had hypoactive bowel sounds and a distended abdomen. Upon rectal exam a mass was noted in the patient's rectum that could not be removed, and the patient was transferred to the acute care hospital for evaluation.

When made aware of the acute care hospital findings, the LTAC hospital conducted an investigation relative to the patient swallowing something that they believed may have led to the impaction, as the patient had a history of pica. The LTAC hospital was notified by the Alliance for Better Long Term Care on 6/16/14, that the patient had an impaction removed at the acute care hospital, which appeared to be a "mesh or sock", and the Alliance revealed these findings were a concern for abuse by the acute care hospital staff.

Although the LTAC hospital investigated the incident relative to the patient swallowing something that they believed caused the fecal impaction and put an action plan in place, the LTAC hospital failed to investigate and protect when made aware of the abuse allegation, and failed to report this allegation to the licensing agency in accordance with State law which reveals, "The hospital shall report within 24 hours, or by the end of the next business day to the licensing agency, allegations of patient abuse, neglect or mistreatment as defined in Chapter 23-17.8-2 of the Rhode Island General Laws."


2. Record review for Patient ID# 3 reveals the patient is non verbal with a tracheostomy and is ventilator dependent and requires total care with all activities of daily living. Review of a facility incident report dated 9/28/14 reveals that a superficial abrasion in a horizontal and vertical pattern was noted on Patient ID#3's right upper thigh. Further review of the incident report indicated ,"superficial abrasion right upper thigh etiology unknown.

Again on 11/13/2014 a review of an LTAC hospital incident report indicates that the patient was observed during PM care to have a scratch of unknown origin on his/her abdomen in the form of a cross measuring 10 cm x 2 cm., right upper thigh with a scratch shaped like an L measuring 3 cm x 2 cm and the right hip with a scratch measuring 3 cm. MD made aware.
The LTAC hospital incident report further indicates that the above areas are of unknown origin. Although witness statements were obtained, there is no evidence this information was reported to the DOH in accrdance with state law.


3. Record review for patient ID # 2 reveals the patient is non verbal and ventilator dependent. This patient requires total care for all activities of daily living. Review of an LTAC hospital incident report for patient # 2 dated 10/13/14 revealed ," CNA called writer into patient's room . Patient had a superficial scratch in the shape of a cross,. Dr. ...notified". Further review of the incident report revealed that when examined by nursing, nursing noted, "patient is noted to have a cross shaped scratch on the right posterior upper thigh. Etiology unknown at this time".

Review of an employee statement dated 10/15/14 for employee A revealed that the employee noted a cross or letter T like scratch on the patient's right upper thigh on the first shift on both 10/11 & 10/13/14. The employee further stated in her statement that she reported this to the charge nurse.

Review of employee statement dated 10/15/14 for employee B revealed that on 10/13/14, this employee was informed by another employee that the resident had a large scratch on the right upper thigh in the shape of a cross.

Although the LTAC hospital suspected abuse, conducted an investigation relative to the cross like areas an action plan was not implemented until 11/12/14 that included daily skin assessments. However, they failed to report the suspected abuse to the licensing agency in accordance with State law.

When interviewed on 12/3/14 at approximately 11:30 AM, the Interim Risk Manager and Clinical Manager were unable to produce evidence that the abuse had been reported and investigated for ID #1, and that the suspected abuse for ID #'s 2 and 3 had been reported to the licensing agency in accordance with state law.

Based on record review, staff interviews and review of a hospital incident, it has been determined the facility failed to analyze, track and provide preventive action for an adverse patient event for 1 of 6 sample patients, relative to an allegation of abuse ( ID #1).

Findings are as follows:

Record review indicated patient ID #1 was transferred to an acute care hospital on 6/12/14. A review of the clinical record reveals the patient had hypoactive bowel sounds and a distended abdomen. Upon rectal exam a mass was noted in the patient's rectum that could not be removed, and the patient was transferred to the acute care hospital for evaluation.

Although interview with staff at the acute care hospital and the Alliance (Ombudsman for Long Term Care) revealed the LTAC (Long Term Acute Care) had been informed of an allegation of abuse, the LTAC failed to report, investigate and protect related to patient abuse.

The acute care hospital discharge summary dated 6/19/2014 was included in the correspondence to the LTAC and revealed findings suspicious for possible sexual abuse. These documents were sent carbon copy to the facility physician.

During surveyor review on 12/3/14 and 12/4/14, there was no documented evidence found related to analysis, tracking, and preventive action of an abuse allegation.

During interviews on 12/3/14 and 12/4/14 at approximately 11:00 AM with the Medical Director, Clinical Manager and the Acting Risk Manager, they were unable to provide evidence that analysis, tracking and preventive action had been done for an allegation of patient abuse.