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Based on observations, review of facility policies and procedures, and interviews with staff (EMP), it was determined that the hospital failed to have an effective governing body as evidence by failing to ensure electronic devices, utilized for audio and video monitoring and communications, were acquired and utilized in accordance with facility policy and were secure and monitored to ensure that the devices were restricted from unauthorized access. In addition, the Governing Body failed to ensure that a patient's injuries were adequately investigated to rule out abuse, including neglect (A0145- Cross Reference 482.13(c)(3) Patient Rights: Free From Abuse/Harassment).

Findings include:

During a tour on March 11, 2024, at 8:15 AM, an electronic video doorbell (a type of doorbell that has an ability to display and record images when movement is detected within its range. It also requires an account and subscription to store and access video recordings) was observed located at the door of the facility's carport area. On the right side of the facility's entrance door was an intercom system which is utilized to gain access inside the building. Another electronic device, a "smart" speaker with a screen display that was voice activated and contained a built-in virtual assistant that could perform various tasks, such as answering questions, monitoring purchases, and connecting to other compatible electronic devices- such as video doorbells, etc. was observed at the admission's window. This device was paired with the electronic video doorbell giving the device access to see outside the facility, in the carport area. An interview at 8:35 AM, with EMP5, revealed that they didn't know who had access to video footage that may have been recorded and stored by the electronic video doorbell. Interview at 8:45 AM, with EMP1, the Chief Executive Officer, revealed that after a State Licensure survey, in June 2023, they purchased the items to address Emergency Medical Treatment and Active Labor Act (EMTALA) concerns and law enforcement activity. They would utilize the devices to communicate to law enforcement after hours if needed. EMP1 further indicated that they couldn't remember their passwords for the accounts, and they didn't know who had access to the video footage that may have been stored by the electronic video doorbell nor did they know who maintained the account for the devices.

Interview on March 11, 2024, at 9:55 AM, with EMP2, the Assistance Chief Executive Officer, indicated that EMP2 did not know who had access to the video doorbell or footage acquired by the video doorbell. EMP2 indicated that they had the application to access the devices but deleted it once they were notified, by Admissions, that their personal purchases were viewable.

Interview on March 11, 2024, at 12:49 PM, with EMP1 and EMP2, indicated that neither knew who maintained the account or had access to the accounts for these devices.

A review of facility document, "Request for Purchase", dated July 11, 2023, revealed that the head of security submitted a request for a "video doorbell for admissions." This request was documented as approved and authorized by EMP2. The request contained an order for an electronic video doorbell and "smart" speaker. Review of a purchase order, dated July 14, 2023, revealed that the electronic video doorbell and "smart" speaker was ordered through an online retailer. The order was stamped by EMP7 on July 19, 2023, stating "I hereby certify that the items listed heron have been received and approved for payment." On the receipt it was stamped "I hereby certify that the items listed heron have been received and approved for payment."

Interview on March 12, 2024, at 7:02 AM, with EMP9, revealed that they learned that a patient had attempted to elope upon arrival to facility grounds; the patient tried to run away through the carport area after returning from an acute care hospital. However, EMP9 reported that no one could obtain access to the electronic video doorbell's account to see if the incident was recorded by the device. EMP9 also indicated that one night, while in the admissions area, the "smart" speaker started to speak and was reading out recently purchased items from an online retailer. EMP9 indicated that they were later informed that the purchases belonged to EMP2.

Interview on March 12, 2024, at 11:05 AM, with EMP7, revealed that a "couple of weeks ago" they heard the "smart" speaker speaking and it was reading out ordered items and when the items were delivered. In addition, it provided the name and address of an employee, EMP2, when one of the items was preparing to ship. EMP7 indicated that they notified EMP2 that the device was providing verbal alerts regarding personal items that they [EMP2] were ordering and when they were preparing to ship.

Review of facility policy, "Video Monitoring", effective March 25, 2022, revealed " ... The video monitoring system is installed and in use in certain areas in hospital facilities to help monitor observation/seclusion rooms, day rooms, corridors, admissions ... Monitors are placed at nursing stations and at the Hospital's front desk. ... The video monitoring system includes a recording feature that stores images in a digital format for a limited period of time. ... Copes of records from the archived data may be made and stored separately when authorized by this policy or when litigation or any other legal action is anticipated ... Hospital employees who are within range of the video monitoring system have no expectation of privacy regarding any of their activities that are recorded. All images and records of whatever sort generated by the system may be used in investigations or complaints and or respect to disciplinary action. ... With the exception of those doing regulatory required investigations, requesting review of or access to video monitoring system records must obtain authorization from the hospital administrator or the administrator's designee ... Safety and Security Departments will maintain the video monitoring system and as authorized by the hospital administrator or the administrator's designee, produce secondary records from the system's archival capacity." There was no evidence that the Safety and Security Departments were monitoring or maintaining the electronic video doorbell or the "smart" speaker and there was no evidence that the facility was managing any audio or video footage that may have been recorded by the devices.

Review of facility document, "Bylaws of the Governing Board of William R Sharpe, Jr. Hospital (Sharpe Hospital)", revised May 3, 2023, revealed " ... The term CEO means the hospital's Chief Executive Officer who is qualified by education and experience, and is appointed by the Secretary of the Department of Health and Human Resources and represents the Governing Board, acting as its agent in the overall administration of Sharpe Hospital ... Responsibilities: ... the CEO will be responsible for the management of Sharpe Hospital. The Governing Board will hold the CEO accountable for the application and implementation of established policies to the operation of the hospital and for providing liaison between the Governing Board and the departments of the hospital. ... The CEO shall ensure effective communication (through committee membership, distribution of minutes, reports and effective organizational structure) between members of the Governing Board, the Medical Staff and Hospital Administration.

A review of the Governing Board meeting minutes from July 2023 through January 2024 revealed no mention of the addition of an electronic video doorbell and the "smart" speaker device to the facility's video monitoring/surveillance system. In addition, there was no documented evidence that the Governing Body ensured that the electronic video doorbell or "smart" speaker was installed and utilized in accordance with facility policy and that it was secure and monitored to ensure that the devices were restricted from unauthorized access.

Based on observations, review of medical records (MR) and facility documents, and interviews with staff (EMP), it was determined that the facility failed to promote and protect each patient's right as evidence by failing to adequately investigate a patient's injury to rule out abuse, including neglect (A0145).

Cross Reference:
482.13(c)(3) Patient Rights: Free From Abuse/Harassment

Based observations, review of medical records (MR) and facility documents, and interviews with staff (EMP), it was determined that the facility failed to adequately investigate a patient's injury to rule out abuse, including neglect for one out of ten medical records reviewed (MR6).

Findings include:

Review of MR6 revealed that the patient was admitted to the facility in October 2020 as a transfer from another facility. Further review of MR6 revealed that the patient was diagnosed with intellectual developmental delays, intermittent explosive disorder, and autism spectrum disorder.

Review of "Mental Health Therapist Progress Note," dated March 4, 2024, timed 12:28 PM, by EMP18, indicated that the patient was in a "good mood interacted positively." Further review of the note indicated that upon the end of the session, the patient stood up and said their foot was "hurting" and "fell forward landing on [their] hands and knees" but "did not appear to be hurt." Patient was assisted back to the gym and then returned to their Unit. The note did not identify which foot.

Review of "Nursing Shift Evaluation," dated March 4, 2024, timed 1:05 PM, by EMP19, revealed " ... Irritable. Monitored every 15 minutes for safety. Neurological evaluation: Awake, Alert, and oriented to person, place, time, speech clear, face symmetrical. Moves all extremities. No seizure activity." Further review of the nurse's evaluation revealed no mention of the incident that occurred earlier that day as the patient was leaving their therapy session.
Review of "Nursing Note," dated March 4, 2024, timed 6:33 PM, by EMP20, indicated that the patient was in the day area and reported that they were unable to walk. EMP20 documented that the patient was unable to put weight on their right leg and was assisted back to their room. The on-call provider was contacted and ordered a medical consult with the medical team to evaluate the patient in the morning. The provider wrote an order for ice pack for 15 minutes every two hours and to evaluate the right foot for two days.

Review of "Nursing Note," dated March 5, 2024, timed 9:00 AM, by EMP21, revealed "Patient seen on the Unit. Left ankle swelling with bruising. The ankle is tender to touch, and palpation movements are restricted. Send to local hospital for possible fracture."

Review of MR6's x-ray report, dated March 5, 2024, timed 1:57 PM, revealed " ... some soft tissue swelling about the great toe and toenail. ... no displaced fracture is demonstrated. Recommend follow-up if there is persistent pain or concern for occult fracture."

Later that day the patient was returned to the hospital, with complaints of bilateral foot pain, and the hospital took additional x-rays. Further review of the patient's medical record revealed that the patient had closed fractures of the left fibula and tibia (the two long bones in the leg that connect the knee and ankle).

Interview on March 12, 2024, at 9:30 AM, with EMP24 (a health service worker), revealed that on the day of the incident they reported being in the hallway and being asked, by EMP18, to help get the patient up from the floor as the patient was sitting on the floor. I asked if the patient had fallen and EMP18 indicated no and that the patient "sat down." I assisted the patient back to the gym and the patient indicated that their foot "hurts" and was favoring their left leg. EMP25 (another health service worker) came over and was speaking with the patient. EMP24 indicated that they did not complete an incident report.

Interview on March 12, 2024, at 10:40 AM, with EMP25, indicated that EMP25 was in the hallway when EMP18 and EMP24 "yelled" for me. EMP25 indicated that when they went over to the patient, the patient was in the gym sitting down and that the patient had a seizure. EMP25 reported that EMP18 indicated that the patient fell. I asked the patient if they could walk back to their Unit and the patient replied "yes." EMP25 reported that they have not known the patient to have seizures. EMP25 indicated that when they returned the patient back to their Unit that they informed Unit staff of the fall, but that they couldn't remember who they told, but stated it may have been EMP20. EMP25 indicated that they did not complete an incident report.

Interview on March 12, 2024, at 11:10 AM, with EMP18, indicated that on March 5, 2024, they walked the patient to their group therapy and that the patient was the only one in the session. They indicated that the patient did not voice any complaints of pain in their foot when going to their session. EMP18 indicated that the only time the patient voice a complaint of foot pain was when the patient went to stand up and then fell forward on their hands and knees. I saw EMP24 in the hallway and asked for help getting the patient off the floor. EMP18 indicated that the patient said that they had a seizure. EMP18 indicated that there were no signs of a seizure and no indication that the patient appeared hurt. EMP18 indicated that EMP25 took the patient back to their unit. EMP18 indicated that they did write a note in the patient's medical record and "tagged" the "treatment team". EMP18 indicated that the health service worker informed the nurse as they took the patient back to the Unit.

Review of video footage, dated March 4, 2024, shows EMP25 assisting MR6 back to their Unit. The patient is observed walking with a limp while staff hold the patient's arm for support.

Review of facility policy, "Patient Care: Incident Reporting and Review," dated March 30, 2021, stated " ... Employees that witness or are aware of an incident are responsible for completing and signing an Incident Report form at the time they become aware of the incident. Reporting must be completed and submitted prior to the end of the current shift or within 8 hours of the incident, whichever is earlier. ...".

Review of facility policy, "Reporting and Investigation Verbal Abuse, Physical Abuse, Neglect and Sexual Harassment of Patient," dated April 21, 2023, stated " ... All patients have the right to be free from all forms of abuse or neglect. It is the responsibility of staff to identify and report ... neglect and to promote and environment free of abuse or neglect consistent with prevailing standard and the exercise of staff professional judgement. ... B. Mandatory Reporting of Neglect, Physical Abuse ... 1. Facility Mandatory Reporters shall make a Good Faith Report as soon as practicable to the RN and/or Nurse Manager assigned to the unit where the patient resides ... C. Response to Good Faith Report; 1. The RN/Nurse Clinical Coordinator shall take all precautions and implement all reasonably necessary interventions to ensure the patient or patients, against Neglect, Physical Abuse ... occurred or likely occurred are safe and that the risk of such further conduct is redressed. ... E. Investigation ... The facility investigator will review any available video. 7. The initial APS response completed by the Nurse Clinical Coordinator (NCC) will be submitted to the Chief Executive Officer (CEO) within (1) working day. NCC or administration personnel shall IMMEDIATELY suspend the alleged perpetrator pending completion of the investigation into the allegations, the findings are reviewed by the Administrator, and the alleged perpetrator is approved by the Administration to return to work or entry into the facility."

Review of facility documentation, dated March 6, 2024, revealed that EMP18 reported that the patient had an "unanticipated fall" and that the patient reported that their foot was hurting when they stood up and that there was "no apparent injury." Further review of the document revealed that on March 7, 2024, EMP4 assigned an ACA (Apparent Cause Analysis) and APS (Adult Protective Services) filed. It was indicated that EMP18 failed to call for a rapid response after the patient's fall, failed to follow the hand off communication to nursing and reporting process protocols.

Interview on March 12, 2024, at 1:09 PM, with EMP26, revealed that they, along with the staff on the Unit, were unaware of the incident until the patient was observed with complaints of foot pain. EMP26 indicated that they were instructed to file an APS report for neglect on EMP18 and that nothing was said about the other staff involved [EMP24 and EMP25].

Review of the MR6 revealed no documented evidence that EMP18, EMP24 or EMP25 notified nursing or called a rapid response after the patient's fall to ensure that the patient was immediately assessed to rule out injuries related to the "fall" on March 5, 2024. In addition, the on-call provider was not contacted until several hours later when the patient was observed by nursing with difficulty bearing weight on their right leg. There was no documented evidence that EMP24 and EMP25, reported or completed an incident report, and at the time of the survey, two of three employees involved in the incident were still on the schedule whereas one employee had been suspended pending the investigation.