HospitalInspections.org

Based on record review, policy review and staff interviews, the staff failed to document assessment data received from the patient or the patient's family, in one (1) of 11 records reviewed (Patient #1).


Findings included ...


Record review of the hospital's policy, "Assessment and Reassessment of Patients, dated 03/17, showed that staff are to document assessment data received from the patient, as well as from the patient's family.


The surveyor conducted a review of Patient #1's medical record on 07-13-17 at approximately 9:30 AM, which lacked documented evidence that the patient shared allegations of assault to the staff.


The surveyor conducted a face to face interview on 07-13-17at approximately 10:45 AM, with Employee #2, Chief Clinical Officer, who explained that the nursing supervisor called her at approximately 3:00 PM on 07-09-17 to report Patient #1's claim of inappropriate touching. The patient's assigned nurse interviewed the patient, who provided "a couple of different versions" of the claim. She reported it to the supervisor, who called her for direction. She instructed the supervisor to notify the police. A detective came out that same day and the hospital notified the patient's family.


Employee #2 was asked to provide the documentation of the events that were described. She explained the nurse did not document her assessment because she didn't know what to write. Employee #2 added but she spoke to the nursing agency on 07-10-17, regarding the event. Additionally, she could not provide any documentation from medical staff or the supervisory staff, regarding the occurrence.


The surveyor conducted a telephone interview on 07-13-17 at approximately 11:55 AM, with Employee #14, Attending Physician, who explained the patient's nurse notified her on Sunday, 07-09-17 between 1:00 PM and 3:00 PM of the patient's allegation of being raped by two men. The nurse inquired about the patient's mental capacity because first the patient explained it happened on the day shift, and then she said it happened at night. Employee #14 told the nurse that patient had ICU Delirium. She explained that when she saw the patient on Saturday, 07-08-17, she was completely non-communicative and on Sunday morning, the patient was awake and agitated. Employee #14 explained she had doubts that the assault occurred but that she was aware of the investigation and did not reassess the patient, as the patient was calm. She didn't want to interfere with the process, as the police came, but she did speak with the family, when they arrived. Employee #14 explained the daughter shared that she found it hard to believe because the patient made the same allegation at another hospital.


Employee #14 was asked to provide the documentation of the events that were described. She could not provide the documentation but explained that the patient's diagnosis of ICU Delirium is documented throughout the patient's record.


The surveyor conducted a telephone interview on 07-13-17 at approximately 3:35 PM, with Employee #18. The purpose of the interview was explained and she agreed to participate.


The surveyor requested Employee #18 to explain how social work and case management staff addressed Patient #1's allegation of sexual assault. Ms. Hughes explained that the daughter notified her of the incident on Monday, 07-10-17. She notified the physician covering that day and the plan of care was reviewed, and staff provided support to the patient and family. The daughter and different family members were allowed to come and stay, even spend the night.


Employee #18 was asked to provide the documentation of the events that were described. She could not provide the documentation of the events described; however a social work note was provided that indicated staff continued to provide support and assistance to the patient and family.


Although interviews with the nursing, medical, and case management staff revealed they all had knowledge of the patient's alleged safety concerns; review of Patient #1's medical record on 07-13-17, lacked evidence that staff to include medical, nursing, social work, or case management, documented the patient's concerns that was provided to the staff.


The practice lacked evidence that staff followed the hospital's policy to document assessment data received from the patient.


Employees #2, 14, and 18 acknowledged the findings.