HospitalInspections.org

Based on hospital policy, document review and interviews, the hospital failed to ensure staff followed written protocols for abuse allegation incidents and failed to communicate the potential allegations to appropriate hospital administration for 1 of 1 (Patient #1) abuse allegation reviewed.

The findings included:

1. Review of the hospital policy "Event Reporting" revealed, "PURPOSE...Assure that adequate documentation and notification is provided for events or circumstances involving patients not consistent with routine care for the patient...Encourage open and honest reporting of injuries and hazards to patients, improve patient safety by decreasing system vulnerability to future events, Facilitate education and problem resolution through forthright disclosure of process failure and/or human error....Definitions- Incident...an unusual occurrence or event involving a patient, employee or visitor, which is inconsistent with the normal or expected care of the patient or operations of the Hospital and causes or has the potential to cause injury...It is the policy of the Hospital that any employee...should report and incidents...All incidents are to be documented and investigated...It is the responsibility of the individual witnessing, discovering or receiving a report of an incident/accident to initiate the events report system as follows...Immediately notify supervisor and the Director of Quality Management..."

2. Patient #1 was admitted to the rehabilitation hospital on 6/7/2021 with diagnoses of a recent fall with brief loss of consciousness,traumatic brain injury, and a rotator cuff injury. Patient #1 was an 88 year old female whose permanent residence was an assisted living facility. On 6/10/2021, the Chief Nursing Officer (CNO) was informed by the Nurse Manager that Patient #1 had reported rough treatment by a staff member, which resulted in a bruise to her right ear and damage to her hearing aid. The CNO initiated an investigation into the allegations on 6/10/2021. The CNO did not complete an incident report. The CNO did not report the potential abuse to the Director of Quality Management or to the Chief Executive Officer. The abuse allegations were not substantiated, however the hospital staff failed to follow written protocols for reporting and investigation.

3. During an interview on 6/29/2021 at 10:30 AM, the Director of Quality Management was asked when she was made aware of the alleged abuse incident. She stated, "I was not aware of it until Adult Protective Services walked into the building on 6/21/2021." The Director of Quality Management verified she should have been notified when the patient reported the allegations.

During an interview on 6/29/2021 at 11:55 AM, the CEO verified the CNO failed to follow the policy for Event Reporting.

During an interview on 6/29/2021 at 2:50 PM, the CNO was asked why she failed to initiate an incident report and inform the Director of Quality Management about the abuse allegations. The CNO stated the thought her Nurse Manager put the incident report in the system since he was helping to investigate the incident. The CNO stated the Nurse Manager had entered incidents into the system in the past and she [CNO] assumed he did for Patient #1 allegations.

The Nurse Manager was no longer employed by the hospital and was not available for interview.

The rehabilitation hospital staff failed to follow written protocols for reporting abuse allegations within their organization.

Based on medical record review and interview, the hospital failed to ensure nursing staff accurately documented skin integrity impairments and notified the physician of a change in condition for 1 of 3 (Patient #2) sampled patients.

The findings included:

1. Medical record review for Patient #2 revealed a 75 year old female with an admission date of 4/20/2021 and diagnoses that included Hypertension, Congestive Heart Failure, obesity, arthritis and generalized weakness. Review of a Physical Therapy (PT) note dated 4/29/2021 revealed PT #1 identified an inflamed area on the left outer arm pit for Patient #1. The area was documented as nickel size and hot to the touch with a scab present. PT #1 notified Licensed Practical Nurse (LPN) #1 of skin integrity issue. LPN #1 did not document about the newly identified area on 4/29/2021. LPN #1 did not notify the physician of the newly identified area.

Further review of nursing documentation revealed on 5/1/2021, two days later, Registered Nurse (RN) #1 documented Patient #2 had a left axilla boil and scabbed area.

There was no further nursing documentation about the reddened, scabbed area on Patient #2's axilla. There was no documentation the physician was notified of the area. There was no documentation whether the area worsened or improved. Patient #2 was discharged from the hospital on 5/5/2021.

2. During an interview on 6/30/2021 at 10:46 AM, LPN #1 was asked why she did not document the area identified by PT #1 when PT #1 notified her of the concern on 4/29/2021. LPN #1 stated it was a small abrasion like a scab smaller than a pea size (note: this does not match the PT #1 or RN #1 documented description of the area in the medical record). She verified she did not notify the physican of the area.

During an interview on 6/30/2021 at 12:51 PM, the Director of Quality Management stated once the area was identified it should have been documented by nursing, monitored and the physician should have been notified.

During an interview on 6/30/2021 at 12:56 PM, the Chief Nursing Officer verified nursing staff should have documented the area on 4/29/2021 and notified the physician. She verified there was no documentation the physician was notified.

The nursing staff failed to accurately and consistently document about impaired skin integrity for Patient #2 and failed to notify the physician of a change in skin status for Patient #2 so that the physician could assess and provide treatment to the impaired skin.