HospitalInspections.org

Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The hospital failed to follow the process for conducting a thorough investigation and protect the pateints for an allegation of abuse per hospital policy. See A-145.

Based on document review, video surveillance review, and interview, for 1 of 2 (Pt. #1) patients with an allegation of abuse, the hospital failed to follow the process for conducting a thorough investigation and protecting patients for an allegation of abuse per hospital policy.

Findings include:

1. On 06/13/25, the hospital's policy titled, " Response to Abuse and Neglect Allegations " (revised 01/2023) was reviewed and required, "All patients have the right to be free from all forms of abuse ... and protected if abuse and neglect is alleged or suspected ... All staff are required to report immediately ... suspected abuse ... or any received report of alleged abuse to their immediate supervisor ... complete an incident report ... an internal investigation is initiated ... interview with other patients as appropriate ... interviews with staff members ...Investigation: After receiving an allegation of abuse or neglect occurring in the hospital premises, an internal investigation is initiated by the Chief Nursing Officer and/or ... Nursing Supervisor after business hours with the collaboration with other departments deemed as necessary ... ensures, in a timely and thorough manner, objective investigation of all allegations of abuse ... B) Investigation process include but not limited to ... d. Investigation of all other possible sources of information relating to the incident and/or persona involved ... Investigation: After receiving an allegation of abuse or neglect occurring in the hospital premises, an internal investigation is initiated by the Chief Nursing Officer and/or ... Nursing Supervisor after business hours with the collaboration with other departments deemed as necessary ... ensures, in a timely and thorough manner, objective investigation of all allegations of abuse ... Protection: Any person alleged to have committed abuse ...will be removed from patient care until a preliminary investigation is completed. The organization shall provide appropriate medical attention based on assessment of patient..."

2. The clinical record of Pt.#1 was reviewed on 06/13/25. Pt.#1 was admitted to the Adult Behavioral Health Unit (5-S) on 02/19/25 at 11:30 PM through 03/06/25 at 1:45 PM. The clinical record included the following:

-Nurse Note (by E#6/RN assigned to Pt.#1) dated 02/25/25 at 5:55 PM, "(Pt.#1) approached this writer and stated, 'They attacked me, and I feel unsafe.' When asked who attacked (Pt.#1), again stated 'They.' When (E#6) asked this question, only staff were around. This writer asked if (Pt.#1) would like to go and speak somewhere privately, (Pt.#1) stated no ... was offered grievance form and stated, 'I just don't feel safe and can I please be transferred to a different unit?' Patient assessed and no apparent injuries observed ... report given to nurse on (transferring unit) and (Pt.#1) was accompanied to other unit by female CNA (certified nurse aid) and unit security officer ... Supervisor (E#16) and (MD#1/Internal Medicine Physician on-call) notified via phone, currently no new orders from (MD#1)."

-Internal Medicine Progress Note (E#14) dated 02/26/25 at 11:13 AM, "(Pt.#1) seen awake and alert, interactive in the day room, (Pt.#1) has a bruise on rt (right) cheek bone, denies pain, (Pt.#1) unable to provide information on how (Pt.#1) sustained that injury ... Apply ice and Tylenol for pain ..." The Internal Medicine Progress Notes prior to 02/26/25, did not indicate that there was a bruise on (Pt.#1's) right cheek bone.

3. On 6/13/2025, the hospital's incident investigation/follow-up report (dated 2/26/2025) was reviewed and noted, "Pt. #1's reported complaint or incident - On 2/25/2025 at approximately 5:55 PM, Pt. #1 told RN (E#6) that [They attacked me, and I (Pt. #1) feel unsafe.] When asked who attacked Pt. #1, Pt. #1 again stated, [They.] Summary/Conclusion: Based on my (Nursing Supervisors E#2/E#15) investigation, I concluded that the reported incident is unfounded. This determination was made based on patient and staff interviews, incident investigation, video surveillance and medical record review. The incident report and investigation summary did not indicate that after review of the surveillance video conducted by the nursing supervisors (E#2 and E#16) conducted follow up interviews and further investigation as to reason why two staff (E#8 and E#13) entered (Pt.#1's) room and closed the door for a prolonged period. The investigation summary did not indicate that staff were taken off the schedule pending the investigation.

4. On 6/13/2025, the hospital's video footage was reviewed along with the Nursing Supervisors (E#2 and E#15) (dated 2/25/2025 from 5:00 PM to 5:30 PM). The following was noted:

-5:10:52 PM - Pt. #1 was seen entering Pt. #1's room with door open.

-5:12:52 PM - E #13 (Agency Mental Health Counselor/MHC) enters Pt. #1's room and closes door. E #13 remains in Pt. #1's room with the door closed until 5:19:54 (7 minutes).

-5:13:44 PM - E #8 (MHC) enters Pt. #1's room at 5:13:44 and closes Pt. #1's door. E #8 comes out of Pt. #1's room at 5:14:08, closes Pt. #1's door and stands outside Pt. #1's room (with door closed - E #13 remains in room). E #8 goes back into Pt. #1 room at 5:14:35, closes the door and does not come out until 5:19:44 (5 minutes and 9 seconds).

-5:19:54 - E #13 comes out of Pt. #1's room.

-5:30:44 - Pt. #1 observed ambulating in the hallway with Pt. #1's head lowered with both hands holding Pt. #1's face. Pt. #1 goes back into Pt. #1's room with door open.

The video surveillance shows that E#8 and E#13 were in the patients room with the door closed for a prolonged time.

5. On 06/13/25 at 10:30 AM and at 1:45 PM interviews were conducted with a Mental Health Counselor (E#8/MHC). E#8 stated that patient room doors should be kept open for safety of staff and the patient. E#8 stated that they do not recall why E#8, and another staff would be in (Pt.#1's) room on 02/25/25 at approximately 5PM with the door closed for about 7 minutes.

6. On 6/13/25 at 10:45 AM, an interview was conducted with the Expressive Therapist (E#9). E#9 stated that E#9 met with (Pt.#1) during their hospitalization and noticed a small bruise around the cheekbone. E #9 stated Pt. #1 didn't have a black eye. E #9 stated that they did not report because patient would not elaborate when asked how Pt. #1 got the bruise.

7. Interviews were conducted with two nursing supervisors (E#2 and E#15) on 06/14/25 at approximately 9:50 AM. E#2 and E#15 confirmed that they conducted a video review to investigate the allegation of (Pt.#1) being attacked. E#2 and E#15 stated that they did not question the staff (E#8 and E#13) for reason they entered (Pt.#1's) room with the door closed for prolonged time. E#2 stated that the normal procedure for rounding is to visualize the patient to ensure safety. E#2 and E#15 stated that it was not appropriate to close the door to a patient's room unless they are providing care that required privacy, however the clinical record did not include any documentation that (E#8 and E#13) provided care to (Pt.#1) during this time. E#15 stated that they were notified by (E#6) on 02/25/25 of the incident, E#15 spoke with (E#6) on the phone and instructed to move (Pt.#1) to another unit. E#15 did not come to the unit to speak with (Pt.#1) or to assess the situation. During the investigation the staff E #8 and E #13 were not removed from patient care pending the results of the investigation as indicated in their abuse policy.