HospitalInspections.org

2023-3-029
A. Based on medical record review, document review, and staff interview, it was determined the facility failed to prevent the abuse/neglect of a patient, and follow their policies and procedures for reporting the abuse and neglect to Adult Protective Services (APS), for one (1) of one (1) patient involved in an investigation, Patient #1. This failure has the potential to negatively impact all patients receiving services at the facility.

Findings include:

Review of the medical record for patient #1 revealed they were admitted on 6/9/22 for myopathy with symptoms of weakness, decreased indurance, and difficulty with balcance. Patient #1 had been given stool softener for constant constipation and rounds were made every two (2) hours to offer toileting and hygiene. A discharge note dated 6/27/22 with Social Worker (SW) #1 stated in part: "[Patient #1's family member] again stated that a nursing technician had talked to [patient #1] very rudely to the point that [patient #1] was afraid to sleep that night."

Review of an internal investigation regarding an incident with patient #1 revealed in part that on 6/11/22, patient #1's family member reported an incident to Case Manager (CM) #1 of staff being rude and refusing to assist patient #1 to the bathroom. On 6/12/22, Nurse Manager (NM) #1 was notified of the incident. On 6/13/22, NM #1 met with patient #1 who reported that staff was rude with them about using the bathroom. Patient #1 stated that they did not want any staff members to get in trouble so patient #1 would not provide many details about what had occurred nor who it involved. NM #1 notified Director of Quality (DOQ) #1 and Chief Nursing Officer (CNO) #1 about the complaint. All staff members were interviewed, and they all denied any unpleasant interactions with the patient. Following the interviews, all staff members were re-educated on professional conduct and expectations of the facility.

Review of the medical record for patient #1 and the internal investigation revealed in part that on 6/28/22, CM #1 emailed the family member's comments to CNO #1, DOQ #1, NM #1, Director of Case Management (DCM) #1, and the Chief Executive Officer (CEO). On 6/28/22, NM #1 and DOQ #1 met with patient #1. Patient #1 was encouraged to give all the facts regarding the allegations so the issues could be resolved. Patient #1 stated that one (1) of the first nights they were here, the rehabilitation nursing technician (RNT), who was a tall, black woman, had assisted patient #1 to the bathroom several times after being medicated for constipation. Patient #1 stated that they were not able to have a bowel movement. Patient #1 stated that the last time the nursing technician assisted patient #1 to the restroom, they stated, "Do not shit in your pants because I will not clean you up and you will lay in it all night." Patient #1 stated they were afraid to call out the rest of the night.

A review of staffing assignment sheet and payroll records revealed only one (1) staff member, RNT #1, fit the description provided by patient #1. RNT #1 was assigned to patient #1's care, documented on the patient, and had previously stated that they had cared for the patient on the night of 6/11/22.

Further review of the internal investigation revealed the facility's home office was notified on 6/28/22 of the incident between RNT #1 and patient #1. RNT #1 was placed on administrative leave pending the outcome of the investigation for allegations of profanity, refusal to take patient #1 to the bathroom in a timely manner, and patient fear of retaliation. The allegations were found to be substantiated for verbal abuse. RNT #1 was allowed to keep their job, was placed on a ninety (90)-day probationary period, removed from the night shift and placed on day shift (where it was felt they would have more supervision), and re-educated on Comfort, Professionalism, and Respect training.

A review was conducted of the policy titled "Recognition and Reporting of Suspected Abuse or Neglect," last revised 05/06/22, which states in part: "Assessing for and reporting of suspected abuse/neglect/abandonment of a patient is a shared responsibility across all clinical disciplines ... Attachment A: Mandatory Abuse Reporting Requirements ... if a clinician observes a vulnerable adult or facility resident being subjected to conditions that are likely result in abuse ... the clinician should immediately make an oral report, followed by a written report within [forty-eight] 48 hours, to the department's adult protective services agency."

An interview was conducted with DOQ #1 on 2/27/23 at 3:35 p.m. DOQ #1 stated that no report was made to APS regarding the abuse/neglect according to their policy, as they felt it was more of an internal staff issue, but they had self-reported to OHFLAC (Office of Health Facility Licensure and Certification). DOQ #1 stated that they thought reporting it to OHFLAC was all they were supposed to do and that they had not been reporting to APS.

An interview was conducted on 02/29/23 at 3:15 p.m. with the Chief Executive Officer (CEO) regarding investigation outcomes and notifications to OHFLAC and APS. The CEO stated that they get daily updates from the management staff regarding any incidents or complaints and that any disciplines for staff are ultimately decided on the regional level. Regarding reporting to OHFLAC and APS, the CEO concurred the facility's policy, and state and federal law, require all allegations of abuse and neglect to be reported to APS, and stated, "I pay people to do that ... We thought we were being transparent with our investigation by self-reporting to OHFLAC."




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2023-3-030
B. Based on medical record review, document review, observation, and staff interview, it was determined the facility failed to prevent the abuse and neglect of a patient, and follow their policies and procedures for reporting the abuse and neglect to Adult Protective Services (APS), for one (1) of one (1) patients involved in an investigation, Patient #1. This failure has the potential to negatively impact all patients receiving services at the facility.

Findings include:

A medical record review of Patient #1 revealed the patient was admitted from 02/10/22 through 10/22/22 for strength training following a hospital stay for Congestive Heart Failure (CHF) exacerbation and pneumonia. There was photographic evidence of a new hospital acquired skin tear on the right shin, dated 02/15/22. There was documented evidence that the physician was notified, and an order from the physician regarding the dressing changes and monitoring of the skin tear.

A review of an internal investigation timeline involving Patient #1's hospital acquired skin tear, included in part:

"02/15/22-Nurse Manager interviewed patient. Patient alert and oriented. Patient reported employee was rough with [Patient #1] and that while assisting [Patient #1] back to bed, the patient's leg was between the bed and chair and developed a skin tear. Skin tear noted, 2-2.5 cm [centimeters] in diameter. First aid implemented."

"02/24/22-Director of Quality and Risk received call from patient's [family member] about one [1] staff being rough with patient and causing skin tear. Informed [family member] that investigation will be conducted with nursing leadership."

"02/25/22-Upon launch of investigation with nursing leadership, employee in question was progressively disciplined per hospital policy on 02/17/22 regarding professionalism."

"02/25/22-Case Manager performed routine follow up call. [Family member] states that hospital failed to report abuse."

"02/25/22-Called OHFLAC [Office of Health Facility Licensing and Certification] ..."

A review of the policy titled "Recognition and Reporting of Suspected Abuse or Neglect," last revised 05/06/22, states in part: "Assessing for and reporting of suspected abuse/neglect/abandonment of a patient is a shared responsibility across all clinical disciplines ... Attachment A: Mandatory Abuse Reporting Requirements ... if a clinician observes a vulnerable adult or facility resident being subjected to conditions that are likely result in abuse ... the clinician should immediately make an oral report, followed by a written report within 48 [forty-eight] hours, to the department's adult protective services [APS] agency."

Review of the internal investigation revealed there was no documented evidence that the abuse/neglect of Patient #1 was reported to APS per the facility's policy, and state and federal law.

An observation was conducted on 02/29/23 at 9:58 a.m. during a tour of the facility. Posters were observed in the patient hallways and rooms with information for filing complaints and grievances within the facility, and with OHFLAC.

An interview was conducted on 02/28/23 at 9:08 a.m. with the Human Resources Director (HRD) regarding the internal investigation for Patient #1, dated 02/15/22. The HRD stated that Rehab Nurse Tech (RNT) #1 was the RNT named in the patient complaint, and that there had been six (6) complaints from different patients regarding physical abuse, verbal profanity, and intimidation by RNT #1 within a week, and that RNT #1 was within their ninety (90) day probationary period - hire date 11/30/21 - and corporate terminated them on 02/17/22. The HRD stated that following the incident, all clinical staff were sent an instructional training e-mail that addressed various reminders regarding respect, dignity, and compassion; promptly assisting patients to the bathroom, and not using bedpans; addressing pain promptly; following physician orders as written; and notifying physicians of a change in patient condition.

An interview was conducted on 02/28/23 at 9:40 a.m. with the Quality/Risk Director (QRD) regarding the incident with Patient #1 getting a skin tear as the result of RNT #1's roughness. The QRD concurred that the incident was "absolutely abuse/neglect." The QRD stated that it was their responsibility to conduct investigations and report abuse and neglect. The QRD stated that two (2) internal investigations were completed by them since moving into the position, both substantiated abuse/neglect, and the staff involved were disciplined. The QRD stated there have been no allegations of abuse/neglect in the past six (6) months. The QRD stated that no report was made to APS regarding the abuse/neglect according to their policy, as they felt it was more of an internal staff issue, but they had self-reported both internal investigations to OHFLAC.

An interview was conducted on 02/29/23 at 3:15 p.m. with the Chief Executive Officer (CEO) regarding investigation outcomes and notifications to OHFLAC and APS. The CEO stated that they get daily updates from the management staff regarding any incidents or complaints, and that any disciplines for staff are ultimately decided on the regional level. Regarding reporting to OHFLAC and APS, the CEO concurred the facility's policy, and state and federal law, require all allegations of abuse and neglect to be reported to APS. The CEO denied contacting APS, and stated, "I pay people to do that."