HospitalInspections.org

Based on staff interview, review of medical records and review of facility documents, it was determined that the facility failed to ensure the Department of Health was notified of a potential criminal act, in one (1) of two (2) medical records.

Findings include:

Reference #1: Chapter 43E General Licensure Procedures and Standards Applicable To All Licensed Facilities, Authority N.J.S.A. 26:2H-1 et seq., specifically 26:2H-5, 5b, 5c, 5e, 5.12, 5.16, 5.23, 7, 7.21, 13, and 14: and 34:11-56a31 et seq,. particularly 56a38. 8:43e-10.11 Other reporting requirements unrelated to the Patient Safety Act ..."(b) A facility licensed in accordance with N.J.S.A. 26:2H-1 et seq. shall notify the Department immediately of the type of reportable events described in (c) and (d) below... (d) Examples of reportable events in the nature of potentially criminal acts include, but are not limited to, the following:..."

1. Review of Medical Record #2, indicated the following:

a. The "Notes for Administrative Review", indicated, on 2/14/17 at 1500, the Peapack Police were called and given a report.

2. Review of facility documents indicated the following:

a. There was an incident reported on 2/12/17 for physical and verbal abuse of Patient #2 by Staff #10.

b. The initial incident report stated, ..."PCA reported to PCA Supervisor seeing Staff #10 PCA push Patient #2 into his/her bathroom and close the door. PCA reported hearing a slap and also hearing Staff #10 verbally scold Patient #2..."

3. The above was confirmed with Staff #1 and Staff #2.

4. The facility failed to report to the Department of Health, an event which was reported to the police.

Based on two (2) of two (2) medical records reviewed, facility document review, and staff interview, it was determined that the facility failed to ensure that all patients receive care in a safe setting.

Findings include:

Reference #1: Facility policy and procedure Abuse and Neglect stated, "...Reporting: Child Abuse and Neglect... C. Upon receipt of an alleged incident of abuse or neglect that threatens the safety or well-being of a child, the supervisor in charge is mandated to take the necessary actions to ensure that all individuals are safe. Such actions may include staff rotation, staff suspension, contacting local police"... D. Staff members shall immediately report all cases of actual or suspected child abuse or neglect to the Division of Child Protection and Permanency (DCP&P). The staff member, who has first-hand knowledge of the suspected abuse or neglect, shall immediately report it to DCP&P by telephone..."

Patient #1 and Patient #2 were involved in two separate incidences in 2017. The facility failed to provide a safe environment for Patient #1 and Patient #2. Please refer to 482.13(c)(3) at Tag 0145 for details and description.

Based on observation, staff interviews, review of two (2) of two (2) medical records, and review of facility documents, it was determined that the facility failed to ensure that all patients are free from all forms of abuse or harassment.

Findings include:

Reference #1: Facility policy and procedure Abuse and Neglect stated, "...Reporting: Child Abuse and Neglect... C. Upon receipt of an alleged incident of abuse or neglect that threatens the safety or well-being of a child, the supervisor in charge is mandated to take the necessary actions to ensure that all individuals are safe. Such actions may include staff rotation, staff suspension, contacting local police"... D. Staff members shall immediately report all cases of actual or suspected child abuse or neglect to the Division of Child Protection and Permanency (DCP&P). The staff member, who has first-hand knowledge of the suspected abuse or neglect, shall immediately report it to DCP&P by telephone..."

Reference #2: 2017 Incident Reports stated, Patient #1 had a "...Type of Incident, Neglect-no injury...". Patient #2 had a "...Type of Incident, Abuse-physical-no injury and abuse-verbal..."

1. In Medical Record #1:

a. The "Incident Reports 2017" indicated, on 1/12/17, there was a incident of neglect.

b. The "Client Incident Event" indicated, ..."At 2015 RN was called by PCA Staff... have to see Patient #1 in her room now... 1:1 PCA (Staff #9) is not present at that time... PCA Staff #9 came back into the room at around 2137."

c. Upon request of the PCA sign in sheet with Staff #7, it was determined this document was not available for the date of the incident 1/12/17.

2. The above was confirmed with Staff #1 and Staff #8.

3. The facility failed to maintain a safe environment for Patient #1.

4. Review of facility documents for Patient #2, indicated the following:

a. The "Incident Report 2017",indicated, on 2/12/17, there was a physical and verbal abuse incident.

b. The "Initial Incident Report" indicated, ..."PCA reported to PCA Supervisor seeing Staff #10 PCA push Patient #2 into his bathroom and close the door. PCA reported hearing a slap and also hearing Staff #10 verbally scold Patient #2..."

6. Upon interview with Staff #8, who confirmed the incident was reviewed with the "Adverse Team" that is held biweekly, and the Patient Safety Committee per policies and procedures. It was confirmed that the Adverse Team Committee reviewed these incidences, and determined they did not rise to the matter of a Root Cause Analysis.

7. The above was confirmed with Staff #1 and Staff #8.

8. The facility failed to maintain a safe setting, free of suspected abuse and neglect.