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Based on observation, interview, and record review, the hospital failed to recognize and investigate signs of potential abuse for three of 30 sampled patients (Pts), Pt 3, Pt 15, and Pt 19.

These failures resulted in missed opportunities for the hospital to identify and correct patient care issues and placed all patients at risk for signs of abuse to go unnoticed and unrecognized.

Findings:

During a concurrent observation and interview in Pt 3's room on 8/13/19 at 1:35 p.m., Pt 3's family member (FM) 2 stated medical personnel dropped Pt 3 during a bed transfer and pointed to Pt 3's right arm. Pt 3 had one large purple/green bruise to her right upper arm which extended from the elbow to the base of the arm's deltoid (muscle attached to the shoulder) region. FM 2 asked Pt 3 if she was dropped during a transfer and Pt 3 nodded "yes."

During a telephone interview on 8/13/19 at 1:45 p.m., FM 1 stated licensed vocational nurse (LVN) 1 called him on 8/8/19 to report Pt 3 was transferred via ambulance to an area general acute care hospital (GACH). FM 1 stated he met Pt 3 at the GACH's emergency room and noted a large bruise on Pt 3's arm. FM 1 stated Pt 3 told him she was dropped by medical personnel during the transfer. FM 1 stated Pt 3 was transferred from the GACH back to the hospital on 8/9/19 where he reported the fall and bruising to LVN 1. FM 1 stated he met with the Clinical Coordinator (CC) who stated there was no evidence of a fall and did not provide FM 1 with an explanation.

A review of Pt 3's medical record titled, "Nursing Assessment," dated 8/8/19 at 7:49 a.m., indicated Pt 3's cognitive level was appropriate for age and her level of consciousness/ mental state was alert and oriented to person, place, and time. Pt 3's skin was within normal limits, warm and dry.

A review of Pt 3's medical record titled, "Nursing Assessment" dated 8/9/19, at 12:30 p.m., indicated Pt 3's level of consciousness/ mental state was alert and oriented to person, place, and time. Pt 3's skin was within normal limits, warm and dry.

During an interview on 8/13/19 at 2 p.m., registered nurse (RN) 1 stated she performed a physical nursing assessment on 8/13/19 and noted generalized bruising to the stomach and the right arm of Pt 3. RN 1 stated Pt 3's clinical record did not indicate the cause of the bruising. RN 1 stated she thought the bruising was caused by the blood thinner medication administered to Pt 3. RN 1 stated she did not feel it was important to investigate since the record did not indicate Pt 3 had a fall.

During an interview on 8/20/19 at 12:15 p.m., LVN 1 stated FM 1 reported Pt 3 was dropped during the transfer to the GACH on 8/8/19. LVN 1 stated she was present during the transfer and the fall did not occur. LVN 1 stated she was unsure if emergency personnel caused the bruise during the transfer and the origin of the bruise was still unknown. LVN 1 stated she notified the Clinical Supervisor (CS) 2 in writing of FM 1's concerns on 8/9/19. LVN 1 stated she was not asked to provide further information and was unaware if an investigation was done.

During a concurrent interview with CS 2 and the Chief Nursing Officer (CNO) on 8/21/19 at 8:40 a.m., CS 2 stated LVN 1 reported the alleged fall and bruising, on 8/8/19. CS 2 stated, on 8/9/19, she collected written statements from LVN 1 and a sitter (a member of hospital personnel that will monitor the behavior and habits of a particular patient) present in the room at the time of the incident and placed the written statements in a file in her office. CS 2 stated she reported the incident to the Clinical Coordinator (CC) 1 and asked that he follow up with FM 1. CS 2 stated she did not conduct an assessment of Pt 3 and did not investigate the incident any further. CNO stated CS 2 did not follow hospital policy and protocol for reporting and investigating complaints nor injuries of an unknown origin to the Chief Executive officer (CEO) and appropriate regulatory agencies. The CNO stated the expectation was for staff to immediately investigate any complaint and to report findings to the CEO and CNO. The CNO stated the reported incident required follow up and it did not happen.

During a telephone interview on 8/21/19 at 3:35 p.m., CC 1 stated he met with FM 1 on 8/9/19 to discuss Pt 3's bruising to her right arm. CC 1 stated FM 1 was angry and believed Pt 3 was dropped during her transfer to the GACH. CC 1 stated he did not assess Pt 3 nor initiate an investigation, as required by hospital policy. CC 1 stated he thought CS 2 had examined Pt 3 and investigated the incident, since the incident was previously reported to CS 2. CC 1 stated he did not do any follow up with CS 2 or the CNO.

During a review of the hospital document titled, "History and Physical" dated 7/1/19, indicated Pt 15 was admitted on 7/1/19 for continued nursing care and physical rehabilitation. Pt 15 had been hospitalized at another hospital due to uncontrolled hypertension (high blood pressure), multiple subacute infarcts (stroke- loss of blood flow and oxygen to the brain), left hemiplegia (paralysis to left side of the body), dysphagia (difficulty swallowing), and aspiration pneumonia (lung infection caused by inhaled food, saliva, or stomach contents). The record indicated Pt 15 required total assistance with care, was non-verbal, and could not walk. Pt 15's family member (FM 3) was identified as the responsible party.

During a telephone interview on 8/1/19 at 4 p.m., FM 3 stated Pt 15 was transferred to a local area GACH on 7/31/19 to have a gastrostomy (surgical opening of the stomach to introduce food) placed. FM 3 stated she met Pt 15 at the GACH and noted a large bruise over Pt 15's right eye and cheek. FM 3 stated Pt 15 did not have a bruise on his face when he was admitted to the hospital and she alleged Pt 15 was hit during his hospital stay.

On 8/2/19, at 11:35 a.m., an unannounced visit was made to the hospital to investigate the alleged abuse. The purpose of the unannounced visit was explained to the CNO and the Quality Officer (QO). The complaint investigation was carried through in to the hospital's survey initiated on 8/13/19. The occurrence log was reviewed as part of the survey process and it was identified that the complaint of potential abuse and injury of unknown origin (bruise to right side of face) was not logged in the occurrence report. The CNO and Chief Operating Officer (COO) stated the complaint was not listed on the occurance log nor the grievance log. The CNO stated all allegations of abuse should be logged for tracking purposes and investigated.

During a review of the hospital document titled " History and Physical" dated 1/22/19, the document indicated he was admitted on 1/22/19 for continued nursing care and management of respiratory status. Pt 19 had Parkinson's disease (a progressive nervous system disorder causing muscle stiffness, shaking, balance problems and changes in speech) and had been hospitalized at another hospital due to progressive weakness, decreased mental status, dysphagia (difficulty swallowing), and respiratory failure. The record indicated Pt 19 required total assistance with care, was non-verbal, could not walk, and had contractures (chronic loss of joint motion due to structural changes in muscles, and other non-bony tissue) in all extremities (arms and legs). Pt 19's family member was identified as the responsible party. Pt 19 was a full code (all life saving measures to be attempted in the event the patient suffers a cardiac arrest [heart stops beating] or cannot breathe).

During a concurrent interview and record review on 8/14/19 at 10:15 a.m., Pt 19's photographic wound documentation, dated 6/24/19, was reviewed with the wound care nurse (WCN) 1. On 6/23/19 at 1:27 p.m. a telephone order for a wound care consult for a blister on the left foot was obtained by LVN 10, and on 6/24/19 at 9:55 a.m. photographs were taken of Pt 19's left foot by WCN 1. The photographs documented three different wounds first observed on 6/23/19: On the left lateral (outer edge) foot an 8.5 centimeter (cm-unit of measurement) x 4 cm blister with surrounding dark red/purple tissue swelling; on the left medial (inside edge) foot a 2.5 cm x 1.5 cm dark red/purple discoloration; and on the left lateral ankle a 1.5 cm x 2 cm blister with dark red/purple skin surrounding the blister. WCN 1 stated he did not know how these wounds occurred; he responded to an order for a consult and was not given information about how the wounds occurred. WCN 1 stated he does not keep a list of wounds other than pressure injuries for the purpose of reporting or tracking and does not complete an occurrence (incident) report.

During a concurrent interview and record review on 8/14/19 at 10:25 a.m., Pt 19's nursing progress notes was reviewed with the Chief Nursing Officer (CNO). The nursing progress notes for 6/23/19 was reviewed and did not include any mention of the wounds being discovered. The CNO stated it was her expectation that the nursing staff document wounds when they are discovered and follow through with notification of the supervisor on duty, and completion of an occurrence report. The CNO stated she had been made aware of a family complaint about the wounds last week but an occurrence report had not been completed and no investigation was initiated by the hospital yet into how those wounds occurred.

During a concurrent interview and record review on 8/21/19 at 10:50 a.m., Pt 19's nursing progress notes was reviewed with LVN 10 who stated she was Pt 19's primary nurse for the day shift on 6/23/19. The record indicated LVN 10 had entered a telephone order for the wound care consult on 6/23/19 but no other documentation existed on 6/23/19 regarding the wounds to Pt 19's left foot. LVN 10 stated she should have documented the discovery of the wounds and their appearance. LVN 10 stated FM 5 was visiting and the patient had been moved from the bed to a Geri chair. LVN 10 described Pt 19's arms and legs as very stiff and stated Pt 19 required total assistance for bathing and turning. FM 5 removed the hospital-provided slipper socks from Pt 19's feet on 6/23/19 to check her toenails and discovered the wounds. LVN 10 stated FM 5 notified her about the wounds that day, and asked LVN 10 how they occurred. LVN 10 stated she did not know how the wounds occurred and that was what she told FM 5. LVN 10 stated she did not know when the socks were removed last and stated the slipper socks should be removed each shift to check the condition of the foot underneath. LVN 10 stated she did not think about completing an occurrence report.

A review of the hospital's policy titled, "ELDER ABUSE REPORTING" dated 4/2019, indicated, "...All personnel must report any allegation regarding mistreatment, neglect, or abuse, including injuries or unknown origin...a designated staff member of the facility will conduct a complete investigation...The following indicators do not always mean abuse and neglect has occurred, but they can be clues that an investigation is needed...PHYSICAL INDICATORS: Bruises, discoloration, swelling..."

A review of the hospital's policy titled, "OCCURRENCE REPORTING" dated 5/2019, indicated, "...Occurrence-any adverse event, accident, or circumstance that led to harm, loss or damage... Serious occurrence- allegations of abuse...All staff have a responsibility to report occurrences via the occurrence reporting system...as soon as possible...before the end of the staff's shift..."

A review of the hospital document titled, "Patient Rights and Responsibilities" dated 4/18/19, indicated, " ...You have the right to receive care in a safe setting, free from mental, physical, sexual, or verbal abuse and neglect ..."

Based on observation, interview, and document review the hospital failed to develop a data driven quality program which effectively and accurately evaluated the operation of the Food and Dietetic Services, and provided an accurate evaluation of the ongoing correction of deficient practices cited during the two previous surveys.

This failure placed 62 patients at risk for food borne illnesses and compromised nutritional status, and hindered the development of programs to improve patient care.

Findings:

During an interview with the Infection Preventionist (IP), on 8/13/19, at 1:30 p.m., he stated he completed an audit in the kitchen two times per week. The IP stated he was not familiar with the requirements as outlined by the Food and Drug Administration (FDA - government agency) Food Code 2017. The IP stated he looked at the basic cleanliness of the kitchen and not the Food Code requirements. The IP stated he did not look at the shelving in the reach-in or walk-in refrigerators and their sanitation and cleanliness was not evaluated. The IP stated he did not inspect the condition nor storage of dishware and beverage cups.

During a concurrent interview with the Food Service Manager (FSM) 2 and record review of the tray accuracy forms, on 8/14/19, at 8:20 a.m., FSM 2 validated the data on the tray accuracy form was incomplete. FSM 2 stated incomplete data could not be evaluated correctly and opportunities for performance improvement would be difficult to identify.

During an interview with the Director of Respiratory Department (DRD), on 8/14/19, at 8:20 a.m., he stated he was not knowledgeable of the items listed on the kitchen review form to be evaluated. The DRD stated there were areas of the kitchen he did not observe.

During an interview with the Director of Quality Management (DQM) and Quality Committee, on 8/16/19, at 9 a.m., the DQM stated the kitchen data was collected weekly and consisted of daily audits by the FSM 2 and the DRD. The DQM stated a weekly audit was also conducted by the IP. The DQM stated the Director of Food and Nutrition (RD) 1 was responsible for the data collected. The DQM stated data collected by the FSM 2 was accurate because of FSM 2's background in food and nutrition processes. The DQM did not state how the DRD or the IP collected their data in the kitchen. The DQM stated the DRD and the IP were not trained or qualified to review all aspects of the kitchen. The DQM stated she took responsibility for the quality program and was not aware that the system in place did not provide validated data that accurately reflected the total operation of the kitchen and food service.

During an interview with the Chief Executive Officer (CEO), on 8/16/19, at 9 a.m., he stated the kitchen audits performed by the DRD and IP were, "To put new eyes in the kitchen."

During a review of the hospital document titled, "Infection Control Plan FY 2019" dated 6/16/19, indicated (for the kitchen) audits of food preparation, sanitation, food temperatures, and food storage would be performed.

Review of the weekly Quality Assurance and Performance Improvement (QAPI) indicators spread sheet data from 6/2019 through the second week of 8/2019 indicated the following information:

1. DRD reported at 89 percent (%) to 99%;
2. Infection Preventionist check reported at 95% to 99 %;
3. Therapeutic diet accuracy reported at 71% to 100 %;
4. FSM 2 General Sanitation report indicated 85% to 100%, and;
5. Therapeutic diet tray accuracy form indicated 88% to 99 %.

A review of the hospital document titled, "Performance Improvement Plan for Food and Nutrition Services", dated 6/15/19, indicated "To ensure an on-going planned systemic process for evaluating and monitoring the quality and appropriateness of all patients' nutritional care and for resolving identified problem."