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Based on medical record review, the facility complaint log, facility policy and procedure, and staff interview, the facility staff failed to timely report an allegation of abuse, make physician notification of the allegations, or conduct thorough or timely abuse allegation investigations for two patients (#5 and #8) of four patients reviewed. The facility census was 50.

Findings include:

1) Review of the medical record for Patient #5 revealed the patient was admitted to the facility on 10/14/14 with diagnoses which included necrotizing fascititis, acute respiratory failure, acute renal failure, and obstructive sleep apnea. Review of the medical record revealed Patient #5 had physician's order for Bi-level positive air pressure (BiPAP is used in the treatment of obstructive sleep apnea) apparatus use at bedtime. Patient #5 also had a physician's order for Zolpidem (sedative type sleeping medication) every night as needed. The medical record revealed Patient #5 had received a Zolpidem at 11:23 PM on 10/17/14. Review of the respiratory daily data record revealed the respiratory therapist; Staff H had placed the patient on his/her BIPAP apparatus at midnight on 10/18/14. Respiratory Staff MM documented the patient was maintained on BIPAP at a 4:10 AM rounding check. The Patient was converted to nasal cannula oxygen at 4:30 A.M. on 10/18/14 per Staff MM's chart documentation.

Review of the facility's Complaint/Grievance Log for the months of September 1, 2014 through January 20, 2015 revealed the facility had logged receipt of a complaint for Patient #5 on Monday, 10/20/14. Review of the facility's documentation revealed Staff Nurse K11 and Respiratory Therapist MM both worked the 7:00 PM to 7:00 AM shift on 10/17/14 until the morning of 10/18/14. The complaint and grievance form documentation read as follows: Administrative Staff P wrote that on Saturday 10/18/14 at 5:35 PM he/she received a text message from Staff K11 that read, Nurse Staff K11 had entered Patient
#5's room at approximately 6:00 AM when nurse Staff K11 was notified by Patient #5 that the respiratory therapist Staff MM had slapped him/her. Nurse K11 spoke with the respiratory therapist Staff MM who replied, I tapped Patient #5's hand due to the patient taking off the BIPAP. Nurse K11 informed Respiratory Therapist MM that Patient #5 said he/she was slapped in the face. Staff MM responded with if Patient #5 says anything, "I'll just deny it."

Review of the facility's investigation documentation revealed Staff K11 failed to notify the facility's administrative staff until 10/18/14 at 5:35 PM, or approximately eleven hours after receipt of this allegation of abuse made by Patient #5. The abuse investigation documentation revealed Administrative Staff P notified a superior administrative staff member, Staff A on 10/18/14 at 8:40 PM. Review of the facility's staff assignment sheets revealed both Staff K11 and Staff MM completed their work assignments as scheduled for the twelve hour shift as documented above.

Review of the facility's policy and procedure entitled Patient Abuse/Neglect, with a most recent revision date of 06/2014, revealed that all employees are directed to report any circumstances of abuse or neglect immediately to their supervisor. The facility policy directed the attending physician to be informed of the alleged incident by the nurse manager. In addition the policy directed that the facility was to thoroughly investigate the allegations, which included obtainment of written statements from the patient victim, witnesses, and any other persons with reported knowledge as appropriate.

Review of the facility documentation and complaint investigation failed to document the physician of Patient 5 was notified of the allegation of abuse per facility policy and procedure.

Interviews conducted on 01/22/15 at 3:22 PM with Administrative Staff A and P confirmed the expectation of Staff K11 was that he/she should have notified supervisory facility staff immediately and not ten or eleven hours after report of the incident. Staff P verbalized the facility only obtained written statements from nurse Staff K11 and respiratory therapy Staff MM and no other written statements were solicited or obtained from other staff witnesses during the investigative process.


2) On 01/21/15, a medical record review was conducted for Patient #8. According to the record, the patient was admitted to the unit on 09/18/14 after being discharged from intensive care. The patient's diagnoses included septicemia, vascular insufficiency of the intestine, acute kidney failure, urinary tract infection, diabetes mellitus, and failure to thrive. The patient was discharged home with hospice care on 09/22/14.

The medical record contained documentation of a late entry dated 09/22/14 at 1:15 PM. This documentation by staff nurse (Staff KK) revealed the following: "Patient noted to have purple bruising on left eyelid as well as a tear drop from left inner corner. Bruising was not noted at morning assessment. Reported to daughter."
On 01/21/14 at 10:25 AM a telephone interview was conducted with Staff KK regarding whether the patient's physician was notified of the patient's bruised eye. Staff KK stated the physician was not notified of the bruising.

Review of facility investigation of the patient's left eye bruising revealed the investigation was conducted by Staff P (nurse manager). The documentation of the investigation was silent to any other staff members being interviewed, with the exception of the staff nurse (Staff KK) and the nursing assistant (Staff L12) who cared for the patient on 09/22/14 at the time the eye bruising was discovered. Staff P confirmed there were no witness statements from these two employees or any other employees who were in the vicinity of the patient. The medical record contained documentation of a respiratory therapist assisting the patient with oxygen on that same date; however, there was no witness statement obtained by this therapist.

The policy titled Incident Reports, last revised on 07/13, was reviewed on 01/21/15. Documentation in the policy included the following verbiage: "An incident is any happening that is not consistent with the routine operation of the hospital or the routine care of a particular patient. It may be an accident or situation that could result in bodily injury or property damage or has future legal implications, lost or damaged equipment. All incidents are to be reported by the following procedure: Incident investigation reports should be in writing. The Incident Report is to be completed by the employee, supervisor, or Department Manager involved. The incident report should be sent to the Administrative Assistant/Admissions Coordinator within 24 hours of the time of the occurrence of the incident.

During an interview with Staff KK on 01/21/15 at 10:30 AM, Staff KK confirmed there was no incident report completed in regards to Patient #8's left bruised eye, and confirmed there was no documented evidence of notification of the patient's physician in regards to the left bruised eye.

















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Based on medical record review, the facility complaint log, facility policy and procedure, and staff interview, the facility staff failed to provide the complainant written notice of the investigation, steps taken to investigate, the results of the investigation, and the date of completion. This affected one (Patient #8) of four sampled patients reviewed for abuse investigations. The facility census was 50.

Findings include:

On 01/21/15, review was conducted of a complaint filed by Patient #8's family member in regards to the patient being discovered with a black eye while in the facility. According to the facility complaint log, Patient #8's family member called the nurse manager at the Fairview location on 09/30/14 at 1:52 PM to question how the patient obtained a black eye during their hospitalization on 09/22/14. A second phone call from the same family member was documented as received on 10/1/14 at 9:35 AM for the same concerns voiced on the previous phone call.

On 10/16/14, the nurse manager (Staff P) received an email from the Fairview host hospital Ombudsman. The Ombudsman documented an email was written and sent by the patient's (#8) family member (different than the family member who conducted the aforementioned phone calls). The context of the email included concerns about the patient's black eye. The email stated the family member wanted the facility to investigate how the black eye occurred.
A review was conducted of an email dated 10/30/14. The author of the email was the Chief Nursing Officer (Staff A) and was addressed to the Chief Executive Officer (Staff L13) and the Administrative Director of Human Resources (Staff L14). The email stated Staff A received a phone call from the family member of Patient #8 (same family member who complained on 09/30/14 and 10/01/14). Staff A stated the family member is "demanding" to know how her mother got a black eye at Grace (Hospital).

On 01/21/14, a review was conducted of the complaint/grievance log for 09/01/14 to 01/20/15. Patient #8's name was listed having two complaints, one on 10/1/14 and one on 10/20/14. According to this log, both complaints were unresolved, and no written response was sent to the complainant. On 01/21/15 at 3:40 PM, an interview was conducted with Staff A, Staff P, and Staff L14 regarding the complaint/grievance process. Staff L14 stated the facility sends a letter within seven days to the complainant after the investigation is conducted to inform them of the status of the investigation. Staff L14 confirmed there was no letter sent to the complainant of Patient #8. Staff A confirmed a letter of resolution should have been sent within seven days of the initial complaint received on 09/30/14.

On 01/21/15, a review was conducted of the facility polity titled Complaint and Grievance Process, last revised on 04/14. According to the policy, the Administrative Director of Human Resources will assist with the investigation as needed and ensure the investigative procedure has been completed, corrective action taken, and a written response sent within 7 days of receipt of grievance. The Administrative Director of Human Resources, along with the CEO, will prepare a written response to the patient's grievance. The written response is required whether or not a meeting was held to discuss the investigation. The written response must contain the following: a) Name of the hospital contact person, b) The steps taken to investigate the grievance, c) The results of the grievance process, and d) The date the grievance was resolved.

On 01/22/15 at 9:50 PM, Staff A stated the complaints received in regard to Patient #8 were grievances, stating they were received in writing and involved alleged abuse. Staff A confirmed the aforementioned facility policy was not followed in regard to sending a letter of resolution to the complainant within seven days after receiving the initial complaint on 09/30/14.