HospitalInspections.org

Based on document review and staff interview it was determined the facility failed to follow its own policy on Abuse/Neglect. This failure has the potential to negatively effect patient safety and lead to poor patient outcomes

Findings include:

1. A review of the medical record of patient #1 revealed the patient and his family did participate in the patient's plan of care. The family and patient were provided the necessary information related to the patient's care to make medical decisions.

2. In an interview with the Case Manager on 1/3/18 at approximately 9:55 a.m. it was revealed the family of patient #1 wanted to speak to her about concerns with the nursing staff caring for the patient. The patient's son wanted to know why his urinal was removed from his beside and he also felt like the nursing staff was laughing at his dad and himself. The Case Manager stated she would get her boss and the nurse manager to speak with them.

3. In an interview with the Nurse Manager on 12/3/17 at approximately 10:30 a.m. it was revealed that patient #1's son and ex-wife spoke to her in regards to feeling like his dad was 'being abused'. She stated the son complained about the patient's urinal being removed from the bedside and he felt like the nursing staff was laughing and making fun of his dad and him. The son stated that the patient's call light wouldn't be answered. The Nurse Manager stated she asked the son if he thought his dad was 'afraid of them' and the son stated he didn't know. She then spoke to the patient to see if he was afraid of the staff and he said he wasn't. The Nurse Manager stated the patient nor the family could describe who on the staff was supposed to be laughing at the patient. She stated she sent an email to risk management notifying them of the complaint.

4. A review of the email sent from the Director of Case Management to the Risk Management Director dated for 12/18/17 at 4:34 p.m. revealed risk management was notified that a complaint was filed by patient #1's family. The family complained that the staff had taken his father's urinal and he had to pee in the trash because nursing was asleep behind the desk and wouldn't help the patient to the bathroom. The son saw nursing laughing at his dad and he wanted the patient's door left closed because his dad was afraid of nursing.

5. A review of the medical record for patient #1 revealed the patient had hearing and vision impairments and he was incontinent of bowel and bladder and unable to ambulate without the assistance of staff to the bathroom. The record revealed the patient had multiple episodes of incontinence while he was a patient at the facility.

6. A review of the facilities call light log for Room 215 revealed that patient #1 waited greater than five (5) minutes eighteen (18) times from his admission on 12/2/17 to 12/11/17 for his call light to be answered by a staff member. Patient #1 was moved to Room 214, due to facility remodeling, on 12/12/17. The call light log for Room 214 revealed from 12/12/17 to 12/27/17 patient #1 waited greater than five (5) minutes for staff to answer the call light thirty (30) times.

7. In an interview with the Chief Nursing Officer on 1/3/18 at approximately 9:10 a.m. it was revealed that the facility does not have an actual 'Call Light Policy' but her expectation of a patient's call light to be answered is two (2) to three (3) minutes.

8. A review of the call light log for Room 214 revealed after the family filed a complaint with the facility on 12/18/17 to 12/27/17 that on twenty (20) different occasions patient #1 had to wait greater than five minutes for assistance from nursing staff.

9. A review of the facility policy entitled 'Abuse/Neglect Policy' with the last reviewed date of 3/17/17 under the un-witnessed report of abuse category states in part 'The patient must be:... iii. secured from harm by taking any additional necessary actions to ensure the patient's safety and welfare.'

10. During the exit conference on 1/4/18 at approximately 1:15 p.m. the Director of Risk Management concurred with the above findings.
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Based on document review and staff interview it was determined the facility did not follow its own policy in investigating an allegation of abuse (patient #1). This failure has the potential to negatively effect any patient receiving care at the facility and could potentially lead to poor patient outcomes.

Findings include:

1. A review of the facility policy entitled "Abuse/Neglect Policy" (last reviewed 3/17/17), related to an un-witnessed report of abuse, revealed it states, in part: "The supervisor must immediately notify the Hospital CEO/CNO/designee who will promptly contact Corporate Risk Management."

2. In an interview with the Nurse Manager on 12/3/17 at approximately 10:30 a.m. it was revealed that patient #1's son and ex-wife spoke to her in regards to feeling like his dad was 'being abused'. She stated the son complained about patient's urinal being removed from the bedside and he felt like the nursing staff was laughing and making fun of his dad and him. The son stated that the patient's call light wouldn't be answered. The Nurse Manager stated she asked the son if he thought his dad was 'afraid of them' and the son stated he didn't know. She then spoke to the patient to see if he was afraid of the staff and he said he wasn't. She stated she sent an email to risk management notifying them of the complaint.

3. A review of the email sent to the facility's Risk Management Director dated 12/18/17 at 4:53 p.m. revealed the Nurse Manager notified risk management that a complaint had been made by the family of patient # 1 that the patient was being abused by staff.

4. A review of the email sent from the Director of Case Management to the Risk Management Director dated for 12/18/17 at 4:34 p.m. revealed risk management was notified that a complaint was filed by patient #1's family. The family complained that the staff had taken his father's urinal and he had to pee in the trash because nursing was asleep behind the desk and wouldn't help the patient to the bathroom. The son saw nursing laughing at his dad and he wanted the patient's door left closed because his dad was afraid of nursing.

5. A review of the facility document entitled 'Patient Complaint Log' revealed that on 12/18/17 that an entry was made in regards to patient #1. Under the column entitled 'Complaint' the log states, 'Concerned that urinal was removed from patient'. The complaint log does not mention the delay of staff answering the patient's call light, being afraid of the staff nor does it mention the staff laughing at the patient.

6. In an interview with the Director of Risk Management on 1/3/18 at approximately 11:20 a.m. it was determined that Corporate Risk Management was not notified promptly as the policy indicates. He further stated that he did not speak to patient #1 or the family about the above complaint because the Nurse Manager had spoke to them. He concurred that the only complaint listed on the log was about the family being upset about the urinal being removed from bedside even though the emails sent to him by the Director of Case Management and the Nurse Manager notified him of the additional allegations.

Based on document review and staff interview it was determined the nursing staff failed to provide assistance in a timely manner after a patient's call light was activated indicating the need for assistance (patient#1). This failure has the potential to negatively effect any patient that may need assistance from nursing staff.

Findings include:

1. In an interview with the Chief Nursing Officer on 1/3/18 at approximately 9:10 a.m. it was revealed that the facility does not have an actual 'Call Light Policy' but her expectation of a patient's call light to be answered is two (2) to three (3) minutes.

2. In an interview with the Nurse Manager on 1/3/18 at approximately 10:30 a.m. it was revealed that her expectation for a call light to be answered by staff is five (5) to seven (7) minutes.

3. A review of the facilities call light log for room two fifteen (215) revealed that patient # 1 waited greater than five (5) minutes eighteen (18) times from his admission on 12/2/17 to 12/11/17 for his call light to be answered by a staff member. Patient #1 was moved to Room 214, due to facility remodeling, on 12/12/17. The call light log for Room 214 revealed from 12/12/17 to 12/27/17 patient #1 waited greater than five (5) minutes for staff to answer the call light thirty (30) times.

4. In an interview with Registered Nurse (RN) #1 on 1/2/18 at approximately 3:35 p.m. it was revealed that if a Licensed Practical Nurse (LPN) was scheduled for the shift he/she was the 'medication nurse'.

5. A review of the staffing schedule for the month of December 2017 on 12/05/17 the staffing for the patient floor was three (3) Registered Nurses (RN) and two (2) Licensed Practical Nurses (LPN) with a patient census of thirty-seven (37) leaving two (2) RN's with twelve (12) patients to supervise the care of and one (1) RN with thirteen (13) patients to supervise. The two (2) LPN's were the medication nurses.

5. These findings were discussed with the Chief Nursing Officer on 1/3/18 at 9:10 a.m. and she agreed with these findings.