HospitalInspections.org

Based on policy review, clinical record review and staff interview, the facility failed to ensure that Patient #1, one (1) of one (1) patients reviewed, was free from verbal and physical abuse/neglect.

Findings:

Review of clinical record documentation made on 11/09/10 by the Registered Nurse (RN) revealed, "It was reported to me by the monitor tech.(technition)..that the family member in the room with patient (pt.) was shaking her fist at the pt. The charge nurse was notified by the RT (Respiratory Therapist) and Security was called. Security came up and talked with the wife and explained to her that she cannot talk to the pt. like that."

An e-mail dated 11/10/10 was sent from the Director of Case Management (CM) to the Chief Executive Officer (CEO) and Chief Nursing Officer (CNO). It stated, "Staff called security on pt's spouse last night; should an incident report be done ...Pt's spouse actually was hitting the pt. with the call light. A staff member said they have it taped on the monitor ...".

Written statements were obtained from the Monitor Tech. and the RT. Both stated they had witnessed verbal abuse and had viewed on the monitor the patient's spouse raising her fist at patient and hitting his leg or dropping the call light on his leg.

The monitor recording made in Patient #1's room on 11/10/10 at 3:15 a.m. was reviewed by the surveyor on 11/16/10 at 2:55 p.m. The woman in the recording raised her fist and shook it at a ventilator dependent male patient lying in the bed. She then dropped the call light on his leg. No audio was available on the recording.

The facility policy "Referrals to Adult Protective Services" (original date of issue 05/12/06; date of approval 07/13/06) revealed:
"Policy: It is the policy of (facility name) to allow any member of the interdisciplinary team who recognizes and suspects adult abuse/neglect to immediately initiate the Abuse-Identification and Reporting procedure and notify the Case Management Department. It is the responsibility of all (facility name) staff members to be aware of this policy and adhere to it. All health care providers and ancillary staff will be able to recognize abuse and neglect and have an "affirmative duty" to report any actual or suspected abuse or neglect to the appropriate agency or agencies as soon as validity of the suspicion of abuse or neglect had been established. Education shall be given upon hire and annually thereafter."
"Procedure:
1. The interdisciplinary team member who suspects adult abuse/neglect shall initiate Abuse-Identification and Reporting procedure and notify the Case Management Department of the suspected abuse. Identification criteria of an adult abuse victim may include but is not limited to: ...Sixty five (65) years or older who is a victim of self neglect, neglect by caregiver, physical, sexual or mental/emotional abuse or financial exploitation ...
7. Document all observations and as much information as possible - who, what, when, where, why...
8. After review of the documentation, the Case Manager will make a referral to the Social Worker who will perform a complete assessment of the situation.
9. The Case Manager will review the information regarding the suspected abuse.
Notify Senior Management and the appropriate agency or agencies when reasonable evidence of abuse is confirmed ...
10. The Social Worker shall notify the Department of Human Services, Adult Protective Services for the county in which the patient resides...
14. Complete an Incident Report and forward to Risk Management."

The facility was unable to provide any documentation showing that the11/10/10 3:00 a.m. incident involving Patient #1 and his wife had been investigated or what the conclusion was.

The CEO, CNO, Director of Quality Management, and Director of Case Management acknowledged that the facility had not reported the incident to the Department of Human Services, the Attorney General's office or to Mississippi State Department of Health (MSDH).

These findings were discussed with the CEO, CNO, Director of Quality Management, and Director of Case Management during the exit conference on 11/16/10 at 4:45 p.m. No additional documentation was provided by the facility.