HospitalInspections.org

1. The hospital failed to ensure all patients are free from all forms of abuse or harassment. (See A145).

2. The hospital failed to follow policy and procedure to protect all patients during investigations into allegations of abuse or harassment by reassigning staff away from patient care areas until allegations have been investigated. (See A145).

3. The hospital failed to follow policy by assigning a "two member team" to investigate all allegations of abuse or harassment. (See A145).

4. It was determined an Immediate Jeopardy situation existed relative to ensuring every patient has been free from all forms of abuse, neglect or harassment. Hospital policies have not been enforced or followed relative to reporting, timeliness of investigation and ensuring all patients are protected from abuse during investigations of allegations of abuse, neglect or harassment.

The Patient's Rights Condition of Participation was determined to be out of compliance. The hospital's Interim Administrator was informed of the Immediate Jeopardy at 11/10/2010 at 11:50 a.m. On 11/10/10 at 5:00 p.m., the Interim Administrator stated that starting at that time, any allegation of abuse or neglect would be reported immediately to the Nurse Clinical Coordinator (NCC) (shift supervisor) and the Administrator on call. The Interim Administrator stated that a decision will be made and documented regarding reassignment of staff during the investigative process in order to keep all patients safe.

The day shift NCC on 11/11/2010 was interviewed at 10:00 a.m. She stated she understood her obligation to document and report any allegation of abuse or neglect and how to make decisions regarding reassignment of staff during an investigation. She stated that as NCC, she would contact an Administrator on call and any other supervisory or administrative personnel as needed. She stated a staff member would be removed from any patient care areas pending outcome of an investigation.

The Interim Administrator stated during the above listed interview the immediate threat has been removed by the listed procedures.

A. Based on review of documents and interview with staff it was determined the hospital failed to ensure all patients are free from all forms of abuse or harassment. This has the potential to affect the promotion of rights for all patients by not keeping them free from all forms of abuse or harassment.

Findings include:

1. The hospital's "pending" file relative to allegations of employee abuse and neglect of patients revealed there are more than twenty (20) outstanding allegations from the time frame between 9/1/2010 and 11/8/2010.

2. The Interim Chief Executive Officer (CEO) was interviewed in the afternoon on 11/9/2010. She stated the hospital's management team had "discussed" the fact there was a increase in allegations of abuse and neglect. The Interim CEO had no documented evidence that any discussions had taken place relative to the increase in the number of allegations of abuse and neglect, nor any documented evidence for specific actions being taken to immediately address the allegations with all staff in order to protect all patients and to promote the rights of all patients.

B. Based on review of documents and staff interview the hospital failed to follow policy and procedure to protect all patients during investigations into allegations of abuse or harassment by reassigning staff away from patient care areas until allegations have been investigated. This has the potential to cause harm to all patients when they are not protected during an investigation into an allegation of abuse, neglect or harassment.

Findings include:

1. Policy #45.035 "Reassignment of Staff When Alleged Patient Abuse/Neglect" (last revised 5/2008) states "Pending resolution, staff members who have been accused of abuse/neglect may be temporarily reassigned at the option of the Nurse Clinical Coordinator (NCC), Nurse Manager or the appropriate Department Head ...The NCC, Nurse Manager or the appropriate Department head will make a decision as to the reassignment of staff accused of abuse and neglect. Rationale for a decision not to reassign staff will contain at least one of the following:

a. Witness (es) statement that indicate the allegation is not true.

b. Circumstances defined in the allegation could not have happened as reported, i.e., the staff member who supposedly was involved was not even present at the time or had no contact with the patient.

Any direct care staff, not fitting the criteria listed above, who have allegations of abuse or neglect made against them will be reassigned immediately to non-care duties. The NCC, Nurse Manager or Department Head that makes the decision will ensure that a copy of the rationale for the decision is filed with the investigative report."

2. Review of the hospital's "pending" file of allegations of abuse and neglect revealed there are more than twenty (20) pending allegations from the time period between 9/1/2010 and 11/8/2010. None of the allegations had documented information included regarding the rationale for decisions made by the NCC or charge RN about reassignment of staff pending outcome of an investigation into each allegation.

3. The Interim Director of Nursing and the Interim Chief Executive Officer were interviewed in the afternoon on 11/10/2010. Both concurred with the findings in the pending file.

4. Review of the "pending" file revealed that on 10/18/2010, an Adult Protective Services (APS) form was filled out relative to an allegation that staff members #E2 and E3 had purposely injured a patient during a restraint episode when the patient was on the floor in the bathroom. The Interim Director of Nursing stated during the afternoon interview on 11/10/2010 that both employees were initially allowed to be in direct contact with other patients pending the results of the investigation and that the investigation is still incomplete.

5. On 10/25/2010, an APS form was filled out relative to an allegation that staff member #E2 had placed a towel over a patient's face who was in restraints and had hit the patient's face through the towel. During confidential interviews with staff, it was determined the incident which was referred to in the 10/25/2010 allegation actually occurred prior to the 10/18/2010 allegation but had not been reported at the time it occurred. It was noted during more than one confidential interview that certain staff members are "afraid" of staff member #E2 and have been nervous about coming forward with information relative to witnessed abuse by that employee. The Interim Director of Nursing stated during interview in the afternoon on 11/10/2010 that employee #E2 was suspended on 10/25/2010 and has not returned to work. She also stated that employee #E3 was reassigned to a non-patient care area as of 11/8/2010 pending outcome of the investigation into the 10/18/2010 complaint.

6. Review of the "pending" file revealed an APS form dated 10/22/10 filed on behalf of female patient #3 alleged that male employee #E1 had bragged about engaging in sexual activities with patient #3 to female patient #4. The APS form had been filled out by the patient advocate who is an independent advocate provided through the State Legal Aid Office and who is not a hospital employee.

7. There were additional allegations about employee #E1 on other APS forms: On 10/22/2010, patient #4 alleged the employee "stated he would have taken -- (another patient) down harder if no staff were around." On 10/22/2010, patient #4 alleged the employee "showed her Adderall and bragged about smoking pot and taking pills during work hours." On 10/26/2010, the Director of Social Work wrote out an allegation "I was informed by a staff member that (employee #E1) and another staff member mimic patients...occurs regularly." On 10/26/2010, the patient advocate wrote out an allegation that employee #E1 "mimics and makes fun of patients." On 10/27/2010, a staff member wrote out an allegation that employee #E1 "had borrowed money from two different patients." The same staff member wrote a grievance for patient #4 dated 10/27/2010 again alleging employee #E1 was making "sexual advances" towards patient #4 and other female patients.

8. The Interim Director of Nursing was interviewed in the afternoon on 11/10/2010. She stated that employee #E1 was not on duty on 10/22, 10/23 or 10/24/2010. The employee was assigned to direct patient care on 10/25 and 10/26/2010. She stated the employee was suspended on 10/27/2010 relative to the allegation that he had borrowed money from patients, pending outcome of all the investigations about him.

9. The hospital's Interim Administrator, the Chief Compliance Officer and the Interim Director of Nursing were interviewed in one group in the afternoon on 11/9/2010. They all concurred that investigations are not being completed in a timely manner and that there are situations in which staff members may remain in direct patient care positions during the investigation process without adequate documentation to support rationale for leaving staff in contact with patients during those investigations.

C. Based on review of documents and staff interview the hospital failed to follow policy by assigning a "two member team" to investigate all allegations of abuse or harassment for at least one (1) of ten (10) patients reviewed (patient #1). This has the potential to affect the quality of investigations into allegations of abuse and harassment.

Findings include:

1. Hospital policy #45.034 "Verbal and Physical Abuse/Neglect" (last reviewed 4/09) states "When verbal or physical abuse of a patient is observed or alleged by staff, another patient or interested third party, procedure as outlined in "Patient Grievance Procedure" shall be followed".

2. Policy #45.031 "Patient Grievances" (effective 7/2008) states "...The original written statements and/or other supporting documentation along with the APS (Adult Protective Services) report will be forwarded to the CEO's office immediately. Upon receipt in the CEO's office, copies will be made and forwarded to the Clinical Services Coordinator and Patient Advocate for initiation of the investigative process. Clinical Services Coordinator or designee will assign a two member team to perform the investigation. This team will work with a patient advocate to perform the investigation jointly."

3. The Interim CEO was interviewed in the afternoon on 11/9/2010. She stated the process for the investigations has changed and the policy has not changed. She stated that currently only one (1) hospital staff member will investigate each allegation of abuse or harassment. She also stated the staff member does not work "with" the independent Legal Aid Advocate. She stated that each investigation is not considered to be "completed" until the hospital staff member, the Advocate and APS (when applicable) all forward their investigation findings and recommendations to her for the final decision. She stated there is no administrative review of any allegation of abuse or harassment until all parties have provided their investigations and recommendations.

4. Review of the hospital's "Patient Grievance" log revealed a grievance was filed on behalf of patient #1 dated 9/21/2010 alleging the patient had been involved in "nonconsensual sexual activities with both past and present patients." Certain other patients were named in the grievance. No hospital staff were named. It was noted on the log that the grievance was "closed" and referred to nursing on 9/22/2010. Review of the file for the patient's grievance revealed there was no investigation conducted in accordance with hospital policy in regards to "neglect".

5. The hospital's Interim CEO was interviewed on 11/10/2010 at 11:30 a.m. relative to the allegation of neglect. She stated she had not seen the allegation or the grievance filed on the patient's behalf. She concurred the grievance and allegation of neglect had not been investigated in accordance with established policy.

6. The Interim Director of Nursing was interviewed in the afternoon on 11/10/2010. She stated the nursing staff had immediately taken steps to protect the patient from harm from other patients by placing him on face to face checks every fifteen (15) minutes and by not allowing him to be out of the view of staff at the end of the hall. She stated that no investigation had occurred in an attempt to determine if any staff members had been responsible for the patient's care at the time of the alleged abuse, nor had additional education been provided to staff relative to "neglect".

Based on review of documents and interview with staff it was determined the hospital failed to ensure a Registered Nurse followed established hospital policy in regards to making decisions about reassigning direct patient care staff when an allegation of abuse or neglect is made. This has the potential to cause harm for all patients when a person who has abused or neglected one or more patients is allowed to continue to care for any patients pending outcome of an investigation.

Findings include:

1. Hospital policy #45.034 "Verbal and Physical Abuse/Neglect" (last reviewed 4/09) states "When verbal or physical abuse of a patient is observed or alleged by staff, another patient or interested third party, procedure as outlined in "Patient Grievance Procedure" shall be followed".

2. Policy #45.031 "Patient Grievances" (effective 7/2008) states "Every staff member is a mandatory reporter of patient abuse ...When an employee, patient advocate or patient become aware or is notified of a grievance of abuse or neglect, he or she shall immediately notify the patient advocate, the local APS (adult protective services) office by phone, his or her supervisor and the CEO (Chief Executive Officer) and document the incident...When allegations of abuse or neglect are reported against staff member(s), the NCC (Nurse Clinical Coordinator) will be notified and will contact the administrator-on-call. The decision will be made whether to remove staff from the area. The charge RN (Registered Nurse) and/or the NCC will perform interviews and gather statements from staff witnesses at the time of the allegation. The charge RN/NCC will be responsible for documenting and action taken with employee. The original written statements and/or other supporting documentation along with the APS report will be forwarded to the CEO's office immediately. Upon receipt in the CEO's office, copies will be made and forwarded to the Clinical Services Coordinator and Patient Advocate for initiation of the investigative process. Clinical Services Coordinator or designee will assign a two member team to perform the investigation. This team will work with a patient advocate to perform the investigation jointly."

3. Policy #45.035 "Reassignment of Staff When Alleged Patient Abuse/Neglect" (last revised 5/2008) states "Pending resolution, staff members who have been accused of abuse/neglect may be temporarily reassigned at the option of the NCC, Nurse Manager or the appropriate Department Head ...The NCC, Nurse Manager or the appropriate Department head will make a decision as to the reassignment of staff accused of abuse and neglect. Rationale for a decision not to reassign staff will contain at least one of the following:

a. Witness (es) statement that indicate the allegation is not true.

b. Circumstances defined in the allegation could not have happened as reported, i.e., the staff member who supposedly was involved was not even present at the time or had no contact with the patient.

Any direct care staff, not fitting the criteria listed above, who have allegations of abuse or neglect made against them will be reassigned immediately to non-care duties. The NCC, Nurse Manager or Department Head that makes the decision will ensure that a copy of the rationale for the decision is filed with the investigative report."

4. Review of the hospital's "pending" file of allegations of abuse and neglect revealed there are more than twenty (20) pending allegations from the time period between 9/1/2010 and 11/8/2010. During review of each allegation it was noted that only one allegation included the original statements gathered by the RN at the time of the allegation. None of the allegations had documented information included regarding the rationale for decisions made by the RN about reassignment of staff pending outcome of an investigation into each allegation. There was also no documented evidence the RN/NCC notified the administrator on call at the time an allegation was made, as policy directs.

5. The Interim Director of Nursing and the Interim Chief Executive Officer were interviewed in the afternoon on 11/10/2010. Both concurred with the findings in the pending file.

Based on review of documents and interview with staff it was determined the hospital's Quality Assessment/Performance Improvement program failed to appropriately monitor safety and quality of care issues in a timely manner in order to insure all patients are kept free from abuse and neglect and are kept safe during investigations into allegations of abuse and neglect. This has the potential to create an environment of care in which patients may be harmed physically or psychologically.

Findings include:

1. The Chief Compliance Officer (CCO) was interviewed in the afternoon on 11/8/2010. She stated she is responsible for Compliance and for the hospital's Quality Assessment/Performance Improvement activities. She stated she is not involved in any investigations into allegations of abuse or neglect.

2. The hospital's "pending" file relative to allegations of employee abuse and neglect of patients revealed there are more than twenty (20) outstanding allegations between 9/1/2010 and 11/8/2010. The Chief Compliance Officer stated she was not involved in those outstanding allegations, nor did she have any knowledge of actions being taken in order to keep patients safe during those investigations.

3. The Interim Chief Executive Officer was interviewed in the afternoon on 11/9/2010. She stated the hospital's management team had "discussed" the fact there was a increase in allegations of abuse and neglect. The Interim CEO and the CCO had no documented evidence that any discussions had taken place relative to the increase in the number of allegations of abuse and neglect.