HospitalInspections.org

Based on staff interviews, medical record review (Patient #1), review of employee human resource records (Staff #20), and review of facility documents, it was determined that the facility failed to ensure that patients are provided care in a safe setting.

Findings include:

Reference: Facility policy titled, "R-101 Abuse and Neglect" states, "Policy Statement: ... . The facility is committed to the prevention of abuse and neglect through staff training and education. Training and education begin with new staff orientation and are carried on throughout the year in formal and informal training sessions. ... . Definitions: 1. Abuse: Any act or omission that deprives a person of his/her rights ... . a. Examples of Physical Abuse- ... . striking with a closed or open hand ... ."

1. On 10/20/2021, Staff #4 confirmed that Staff #20 (PCA) [Personal Care Assistant] hit Patient #1 on 9/8/2021. An administrative review was led by Staff #1 and Staff #5, and the incident was substantiated. The employee was recently hired and had completed his/her probationary period the beginning of August 2021.

a. Upon review of the facility log for this event, the documentation stated, "Event Date: 9/08/202; Person Affected/Last Name: (Patient #1); General Event Type: Professional Conduct; Specific Event Type: Physical Abuse."

2. On 10/21/2021 at 11:45 AM, Staff #1 stated that the Administrative Team (Staff #1, Staff #4, Staff #5, Staff #6, Staff #8, Staff #24, Staff #25, Staff #26) used their Performance Management Decision Guide Algorithm and evidence obtained through staff interviews as well as discussions, and it was determined that Staff #20 would be terminated from employment.

a. Upon review of the facility Document titled, "Employee Change of Status," the following was noted:

(i) "Employee Change of Status. ... . Separation of Employment; Last day worked: 9/8/2021. ... . A. Name: (Staff #20). ... . Department: PCA/CRA Services. Effective Date: 9/8/2021. ... . E. Remarks: Termed after an administrative review due to physical abuse of a patient. ... ."

3. Upon review of Medical Record #1, the following was indicated:

a. The Medical Note, dated 9/8/21 at 1:30 PM states, "Nursing called to report (Patient #1) was seen having a PCA hit his/her leg. Right leg. Somewhere between hip and knee. Unclear if a fist or open hand. ... ."

b. The Social Services Note, dated 9/8/21 at 2:00 PM states, "Met with (Patient #1) to address issue that was observed by another staff. He/she reported that a PCA did hit him/her. Doesn't know why and is angry. Really not hurt. Dr. and Nurse checked him/her. ... ."

c. The Nursing Note, dated 9/8/21 at 2:20 PM states," PCA Supervisor reported that he/she witnessed a PCA hit (Patient #1's) thigh at 1:00 PM. ... ."

4. On 10/21/2021 at 2:15 PM, Staff #1 stated that following this incident, they plan to add 'An Abuse and Neglect Prevention Teach Back Examination' to their New Employee Orientation Training Program.

5. The above was confirmed by Staff #1, Staff #4, and Staff #5.