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Based on policy review, medical record review, internal document review, and staff interviews, the facility failed to notify the Health Care Personnel Registry (HCPR) of an allegation of staff to patient abuse within twenty four hours, after becoming aware of the allegation for a patient (Patient #4).

The findings included:

Review of the policy titled "ABUSE, NEGLECT" last reviewed/revised 07/01/2018 revealed "Purpose: To provide a mechanism for the Hospital staff to comply with the Hospital's zero tolerance on abuse, neglect, and harassment, and requiring citizens and professionals to report suspected cases of child or dependent adult abuse, neglect and/or harassment ...5. Protection of Patients: ...NOTE: Many states require that all allegations of abuse be reported with the results of the investigation. This is a requirement regardless of whether the complaint is substantiated or unsubstantiated ..."

Closed medical record review of Patient #4 revealed a 62 year old female admitted as on 04/29/2019 for respiratory failure. Review of the history and physical dated 04/30/2019 at 0300 revealed "...62-year-old female with past medical history significant for diabetes, tobacco abuse, chronic pain, anxiety/depression, chronic kidney disease ...admitted for COPD exacerbation with hypoxemia, acute kidney injury on chronic kidney disease and congestive heart failure ..." Review revealed the goals of Patient #4's treatment were to wean ventilator support, continue dialysis treatment, manage diabetes, nutrition and obesity, and improve her ability to participate in self-care needs. Review revealed Patient #4 was weaned from mechanical ventilator support, had transitioned to an oral diet and was discharged to a skilled nursing facility in her local area on 06/22/2019 where she was to continue to receive hemodialysis at an outpatient center.

Review of internal documents revealed Patient #4's spouse, in a conversation with the Director of Quality Management (DQM) on 05/20/2019 stated a staff member "threw her up in the air and slammed her down on the bed like a football player when he was putting her to bed ...this sounds like abuse to me." Review revealed the event was stated to have occurred on 05/18/2019 and a second complaint with amended allegations was filed about the incident, on 06/11/2019. Review revealed the facility responded to the complaint, and provide a letter detailing findings of a review after each complaint.

Interview on 07/17/2019 with the DQM revealed she found out about this event from another employee on 05/20/2019. Interview revealed the employee who was the object of the initial allegation was suspended until an internal investigation was completed. Interview the DQM had also notified the local police department but was informed Patient #4's family would need to file a police complaint before they could investigate, and DQM relayed this information to the family. Interview revealed the family filed a similar complaint with amendments to the original allegation and filed a police complaint the following month. Interview revealed the DQM had conducted a second review of the allegations, spoke with staff again, and the police had conducted a separate investigation, but the allegation remained unsubstantiated. Interview revealed notice of the abuse allegations had not been filed with the State regulatory agency, but the DQM had contacted the corporate legal counsel who had instructed her to report only if the allegation was substantiated.

Cross Reference: 10A NCAC 13O .0102

NC00152028
NC00152165
NC00153068