HospitalInspections.org

Based on interview, policy review and record review the hospital failed to follow their internal policy when they failed to:
- Prevent abuse to one patient (#13) of one patient who was abused. (A-0145)
- Immediately remove an alleged perpetrator (AP, Staff W) from patient care after abuse to Patient #13 was witnessed by two staff members. (A-0144)
- Recognize the need for immediate house-wide education after the abuse was reported to hospital administration. (A-0145)

These failures created an unsafe environment and had the potential to place all patients admitted to the facility at risk for their safety. The facility census was 43.

The severity and cumulative effect of these systemic practices resulted in the overall noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights that resulted in a condition of Immediate Jeopardy (IJ).

As of 11/04/21, at the time of survey exit, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented the following actions:
- The AP had been placed on administrative leave the day following the event (10/27/21) and remained on administrative leave until she was terminated on 11/02/21.
- House wide education began to all staff, including physicians, on 11/02/21 and continued until all employees were educated and prior to their next scheduled shift.
- Education related to hospital Abuse/Neglect, Suspected and Reporting with emphasis on reporting potential abuse to the supervisor and that the AP was to be removed from patient care immediately by the Charge Nurse or Chief Nursing Officer (CNO) was given to all staff.
- 100% review of staff compliance before starting shift/work day.
- Monitoring of new hires will begin as a key indicator and will be reported to the monthly Patient Safety Committee and to the Quality Council quarterly.
- A checklist was provided to Charge Nurses regarding immediate action to be taken with any allegation of suspected abuse and neglect.

Based on interview, policy review and record review, the hospital failed to follow their internal policy when they failed to immediately remove an alleged perpetrator (AP), Staff W, Registered Nurse (RN), from patient care after a witnessed verbal abuse event. These failed practices by the hospital placed all patients admitted to the facility at increased risk for their safety. The hospital census was 43.

Findings included:

1. Review of the hospital's policy titled, "Abuse/Neglect, Suspected-Reporting," dated 06/12/19, showed the following:
- All patients have a right to be free from abuse and protected if abuse and neglect is suspected.
- All cases of suspected or possible abuse or neglect are reported to the supervisor immediately.
- The Charge Nurse/Department Manager receiving the report will assess the patient, the co-worker will be immediately removed from patient care if abuse is suspected or witnessed, the patient/family and co-worker would be interviewed upon report or discovery of the abuse or neglect concern, the Administrator-on-Call (AOC) will be notified, and co-worker alleged to have committed abuse or neglect will be escorted from the hospital premises pending further investigation.

Review of Patient #13's medical record showed that he was a 69 year old male who was admitted on 10/14/21 for rehabilitative care and treatment following a complication during heart surgery.

During a telephone interview on 11/03/21 at 9:00 AM, Staff P, Patient Care Associate (PCA), stated that:
- She was the PCA for Staff W, RN, AP, on the evening of 10/26/21.
- When she walked by Patient #13's room she noticed he had attempted to get out of bed, got his leg wedged in between the side rail, and was about to fall out of bed so she entered the room and repositioned him.
- When she exited the room, Staff W was in the hall and asked what happened. She explained how the patient almost fell out of bed and Staff W replied, "We aren't doing this tonight."
- When Staff W entered Patient #13's room and was antagonistic (showing opposition or hostility toward someone) toward him. The patient became agitated and he attempted to kick, scream, hit and bite.
- When the patient would yell, Staff W would tell him to "shut-up" and called him a "mother fucker."
- Staff O, Charge Nurse, entered the room shortly after and asked if the patient had any orders for medications that might calm him down. When Staff O returned with medications it required all three staff members to administer them.
- The patient had a percutaneous endoscopic gastrostomy (PEG, a tube inserted through a person's abdomen directly into the stomach to provide a means of feeding when oral intake is not possible) that needed to be flushed with water after he received his medication and Staff W waved the syringe, like a gun, in the patient's face and said, "pew pew."
- Eventually Staff O asked Staff W to leave the room because she kept laughing at the patient and she replied with, "I'm not really helping, am I?"
- Staff P knew to report any abuse or neglect to her immediate supervisor, which was Staff O, Charge Nurse, and Staff P assumed that since Staff O was also a witness to the event, he would report it to whomever he was required to.
- Staff P did not formally report the event to Staff O her immediate supervisor.

During a telephone interview on 11/03/21 at 8:40 AM, Staff O, Charge Nurse, stated that:
- He was paged to come to Patient #13's room and when he arrived the patient was angry and trying to get out of bed.
- The mood was escalating and that Staff W kept telling the patient to "shut-up" and he heard her call him a "mother fucker."
- Due to the patient's mood, he exited the room and called the physician for medication orders. When he returned he needed Staff P and Staff W's assistance while he administered the patient's medications through the PEG tube.
- When he flushed the PEG tube he felt some resistance so he asked Staff W to flush the tube again to see if she felt any. She took the 60 milliliter (ml; unit of measurement) syringe, filled with water, and waved it in the patient's face, like it was a gun, and kept saying, "pew pew."
- The patient yelled at Staff W and stated that he was going to "rip her arm off and shove it up her ass" to which Staff W replied "go ahead" and turned and shook her buttocks toward the patient.
- At that time he asked Staff W to exit the room and she asked, "Why, am I making things worse?" and he replied yes to which Staff W replied, "I thrive on this kind of stuff."
- When he initially entered the room he knew there was tension but he didn't think it was an issue until Staff W's behavior continued. However, he did not immediately ask her to leave the room as he needed her assistance for the medication administration, for the patient's safety, and for their safety.
- At the time he was not aware that he was to report abuse or neglect immediately so he waited until Staff D, Chief Nursing Officer (CNO), arrived the following morning to report the incident.
- He did not feel that Staff W, RN, AP, was a threat to any of the other patients after this incident because she had calmed down.

During an interview on 11/04/21 at 11:30 AM, Staff D, CNO, stated that:
- He received a text from Staff O, Charge Nurse, around 7:00 AM on 10/27/21 that requested a call back regarding an incident.
- When he arrived at the hospital he obtained statements from the staff that witnessed the alleged event.
- He called Staff W, RN, AP, to notify her of the allegations, and placed her on suspension, pending an investigation.
- It was his expectation that abuse or neglect would be reported immediately.
- It was hospital policy that any AP would be immediately suspended pending the outcome of an investigation.
- Staff O, Charge Nurse, did not report it immediately as he was unsure of who and when to call because he had never had to deal with a similar situation prior.

Review of Staff W, RN's time card showed that she clocked in for her shift on 10/26/21 at 6:30 PM and clocked out on 10/27/21 at 8:08 AM. The abuse incident occurred on 10/26/21 at approximately 9:00 PM. Staff W continued to work the remainder of her shift, approximately 11 hours and provided patient care during that time.

Based on interviews, record review and policy review the hospital failed to:
- Prevent the verbal abuse of one current patient (#13) by Staff W, Registered Nurse (RN), Alleged Perpetrator (AP).
- Follow their internal policy for abuse and neglect when staff failed to immediately report the abuse of Patient #13 to administration.
- Ensure staff were competent to prevent, recognize and respond to all forms of abuse by co-workers.
- Ensure staff were immediately re-educated about identifying and reporting abuse, after a witnessed staff-to-patient abuse incident occurred.

These failed practices by the hospital placed all patients admitted to the hospital at increased risk for their safety. The hospital census was 43.

Findings included:

1. Review of the hospital's policy titled, "Abuse/Neglect of Dependent Adult, Elder or Child-Criteria," dated 06/12/19, showed that staff were provided education and information designed to assist employees and healthcare providers associated with the hospital in recognizing patient abuse, neglect and exploitation and the correct mechanism to report and provide patients with appropriate information and support. Criteria to identify abuse, neglect, or mistreatment by a hospital coworker included but was not limited to failure to intervene or protect a patient from abuse/mistreatment by another patient, employee or family member.

Review of the hospital's policy titled, "Abuse/Neglect, Suspected-Reporting," dated 06/12/19, showed the following:
- All patients have a right to be free from abuse and protected if abuse and neglect is suspected.
- All cases of suspected or possible abuse or neglect are reported to the supervisor immediately.
- The Charge Nurse/Department Manager receiving the report will assess the patient, the co-worker will be immediately removed from patient care if abuse is suspected or witnessed, the patient/family and co-worker would be interviewed upon report or discovery of the abuse or neglect concern, the Administrator-on-Call (AOC) will be notified, and co-worker alleged to have committee abuse or neglect will be escorted from the hospital premises pending further investigation.
- All incidents of suspected abuse, neglect or exploitation by a co-worker will be investigated and if confirmed, the behavior will be considered grounds for immediate dismissal of the employee.

2. Review of Patient #13's medical record showed that he was admitted on 10/14/21 for rehabilitative care and treatment following a complication during heart surgery.

Record review of the hospital's investigation timeline showed that:
- The alleged abuse occurred on 10/26/21 sometime between 9:00-9:15 PM.
- On 10/27/21, at 7:00 AM, Staff D, CNO received a text message from Staff O, Charge Nurse, requesting a call back.
- At 7:10 AM, Staff D, initiated the investigation.
- At 7:30 AM, Staff D, took an initial statement from Staff O, Charge Nurse.
- At 7:45 AM, Staff D, took an initial statement from Staff Q, LPN.
- At 8:00 AM, senior leadership were notified of the event and a formal investigation was initiated.
- At 8:55 AM, Staff D, left a voicemail for Staff W, RN, AP, requesting a call back.
- At 10:03 AM, Staff W, returned the call, and was placed on suspension, pending the outcome of the investigation.

During a telephone interview on 11/03/21 at 9:00 AM, Staff P, Patient Care Associate (PCA), stated that:
- She was the PCA for Staff W, RN, AP, on the evening of 10/26/21.
- When she walked by Patient #13's room she noticed he had attempted to get out of bed, got his leg wedged in between the side rail, and was about to fall out of bed so she entered the room and repositioned him.
- When she exited the room, Staff W was in the hall and asked what happened. She explained how the patient almost fell out of bed and Staff W replied, "We aren't doing this tonight."
- When Staff W entered Patient #13's room and she was antagonistic (showing opposition or hostility toward someone) toward him. The patient became agitated and he attempted to kick, scream, hit and bite.
- When the patient yelled, Staff W told him to "shut-up" and one time she called him a "mother fucker."
- Staff O, Charge Nurse, entered the room shortly after and asked if the patient had any orders for medications that might calm him down. When Staff O returned with medications it required all three staff members to administer them.
- The patient had a percutaneous endoscopic gastrostomy (PEG, a tube inserted through a person's abdomen directly into the stomach to provide a means of feeding when oral intake is not possible) that needed to be flushed with water after he received his medication and Staff W waved the syringe, like a gun, in the patient's face, and said, "pew pew."
- Eventually Staff O asked Staff W to leave the room, because she kept laughing at the patient, and replied with, "I'm not really helping, am I?"
- Staff P knew to report any abuse or neglect to her immediate supervisor, which was Staff O, Charge Nurse, and Staff P assumed that since Staff O was also a witness to the event, he would report it to whomever he was required to.
- Staff P did not formally report the event to Staff O her immediate supervisor.
- There had been instances where patients reported concerns regarding Staff W's behavior and she would have to be re-assigned to other patients. She never documented those concerns or reported them to her supervisor.
- She received abuse and neglect training upon hire but could not recall any abuse or neglect training after that.
- She did not recall abuse and neglect training being one of the yearly education requirements. Review of her personnel record showed her most recent abuse and neglect training was 08/23/21.
- After the event, they were assigned online education on 10/28/21 and they had until 11/11/21 to complete it. She had not yet completed the education as there was still time before the deadline.

During a telephone interview on 11/03/21 at 8:40 AM, Staff O, Charge Nurse, stated that:
- He was paged to come to the Patient #13's room and when he arrived the patient was angry and trying to get out of bed.
- The mood was escalating and that Staff W kept telling the patient to "shut-up" and he heard her call him a "mother fucker."
- Due to the patient's mood, he exited the room and called the physician for medication orders. When he returned he needed Staff P and Staff W's assistance while he administered the medications through the PEG tube.
- When he flushed the PEG tube he felt some resistance so he asked Staff W to flush the tube again to see if she felt any. She took the 60 milliliter (ml; unit of measurement) syringe, filled with water, and waved it in the patient's face, like a gun and kept saying, "pew pew."
- The patient yelled at Staff W and stated that he was going to "rip her arm off and shove it up her ass" to which Staff W replied "go ahead" and turned and shook her buttocks toward the patient.
- At that time he asked Staff W to exit the room and she asked, "Why, am I making things worse?" and he replied yes to which Staff W replied, "I thrive on this kind of stuff."
- When he initially entered the room he knew there was tension but he didn't think it was an issue until Staff W's behavior continued. However, he did not immediately ask her to leave the room as needed her assistance for the medication administration, for the patient's safety, and for their safety.
- At the time of the event, he was not aware that he was to report abuse or neglect immediately, so he waited until Staff D, Chief Nursing Officer (CNO), arrived the following morning to report the incident.
- He did not feel that Staff W, RN, AP, was a threat to any of the other patients after this incident because she had "calmed down".
- There were times, in the past, he had to give Staff W different patient assignments after reports that she was loud, or that she was "tweaking", and patients would refuse to have her care for them. He never documented the patient's concerns and he never reported patient re-assignments of Staff W to the CNO.
- Staff received abuse and neglect education once a year for "corporate compliance", but prior to this incident, he could not recall the last time he received any education. Review of his personnel record showed he had no abuse and neglect education in 2020 or 2021.

During a telephone interview on 11/03/21 at 9:45 AM, Staff Q, Licensed Practical Nurse (LPN), stated that:
- On 10/26/21, Patient #13's unit was short-staffed so she went to see if staff needed any assistance.
- When she entered the patient's room he was mumbling but not yelling or being combative.
- She walked over and introduced herself and noticed that his hospital gown was tied a little tight around his neck. She asked the patient is she could loosen it so it wouldn't choke him and Staff W stated, "Oh just let it."
- She felt that her tone and statement were inappropriate and she reported it to Staff O, Charge Nurse after she left the room. Staff O stated he would report the incident to Staff D, CNO.
- She had three or four patients over the last six to seven weeks state that they were upset with their care when Staff W, RN, AP, was their nurse. She felt as though she was always doing damage control for Staff W, as it was a direct reflection of the hospital. She never documented these patient's concerns or reported them to her supervisor.
- Abuse and neglect training was provided upon hire but she had not received any other training or education since then prior to this event. Review of her personnel record showed her most recent abuse and neglect training was on 08/11/21.

3. During an interview on 11/04/21 at 11:30 AM, Staff D, CNO, stated that:
- He received a text from Staff O, Charge Nurse, around 7:00 AM on 10/27/21 that requested a call back regarding an incident.
- When he arrived at the hospital he obtained statements from the staff that witnessed the alleged event.
- He called Staff W, RN, AP, to notify her of the allegations, and placed her on suspension, pending an investigation.
- It was hospital policy that any AP would be immediately suspended pending the outcome of an investigation.
- It was his expectation that abuse or neglect would be reported immediately.
- Staff O, Charge Nurse, did not report it immediately as he was unsure of who and when to call because he had never had to deal with a similar situation prior.
- He had never received any reports from staff regarding Staff W's interactions with patients.
- He was not aware that there were times Staff W had to be re-assigned patients due to complaints or concerns.
- All patient care staff were assigned an online abuse and neglect module on 10/28/21, with a required completion date of 11/11/21.
- He assumed the initiation and deadline for the online abuse and neglect education was appropriate as the hospital's policy did not specify immediate education was required.

The alleged abuse occurred on 10/26/21 but wasn't reported to leadership until the morning of 10/27/21. Staff education was sent out to all patient care staff on 10/28/21, with a required completion date of 11/11/21. At the time of the survey the staff involved with the incident had not completed the re-education.

Review of Staff W, RN, AP's, personnel record showed that:
- She was hired on 3/1/21.
- She had no previous disciplinary actions.
- On 04/02/21, she received education titled, "Patient Rights and Responsibilities."
- On 04/02/21, she received education titled, "Behavior Management/Age Appropriate Care."
- On 04/02/21, she received education titled, "Abuse/Neglect."
- On 05/31/21, she received education titled, "Workplace Violence Reduction: De-escalation."
- On 09/01/21, she received education titled, "Patient Rights and Reporting Suspected Abuse and/or Neglect by a Co-worker."

4. Review of Staff W, RN's time card showed that she clocked in for her shift on 10/26/21 at 6:30 PM and clocked out on 10/27/21 at 8:08 AM. The abuse incident occurred on 10/26/21 at approximately 9:00 PM. Staff W continued to work the remainder of her shift, approximately 11 hours and provided patient care during that time.