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Based on interview and record review, the facility failed to develop and implement a policy that protected patients from abuse while under the care of the facility, resulting in the potential for negative outcomes for all patients served by the facility. Findings include:

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A-145 Failure to develop and implement a policy protecting patients from abuse.

Based on interview and record review, the facility failed to develop and implement a policy that protected patients from abuse while under the care of the facility, resulting in the potential for unsatisfactory outcomes for all patients served by the facility. Findings include:

On 01/30/2024 this surveyor requested the facility abuse policy. The surveyor was provided the facility's policies for reporting suspected abuse of adult and child when presenting for care at the facility. The surveyor provided clarification and again requested the hospital wide abuse prevention, screening, recognition, training, and reporting, protecting, and investigation of abuse policy. The facility provided the facility, "Termination of Employment", "Complaints and Grievances", "Harassment Free Workplace" and "Investigation Guidelines" policies. Review of documents provided failed to detail how the hospital would protect all patients during investigations of allegations of abuse, neglect, or harassment while under the care of the facility.

In an interview on 01/30/2024 at 1215, Staff A stated if a patient made an allegation of abuse regarding a staff member, the staff member would be removed from caring for that patient only. They would not be removed from all patient care during the investigation. Staff A stated the facility would offer the patient the right to call local authorities to report the allegations. Staff A also said the facility had no policy and procedure indicating what steps to follow.

During an interview on 01/31/2024 at 1045, Staff A was asked by the surveyor if the facility had a policy regarding what to do when a patient reported allegations of abuse from a staff member or another patient. Staff A was further queried on what the facility does to prevent abuse through training staff on how to react, respond and report abuse, and how does the facility investigate allegations of abuse? Staff A stated the facility did not have an abuse policy regarding allegations of abuse made by a patient.

In an interview on 1/30/2024 at 1340, Staff G stated she was a Supervisor during the day shift. If it was reported to her that a patient had made an allegation about a staff member being sexually inappropriate, Staff G would follow up with an interview of the patient, fill out incident report, then interview the staff member. Staff G said she would not assign that staff member to that particular patient during the investigation. Staff G said she would find out if the patient was confused and call the family to report the allegations, Staff G said she would then assign two care givers at all times to the patient, because many times the patient is just confused. When Staff G was asked by the surveyor what she would do if she determined the patient was alert and oriented, Staff G stated she wasn't sure what to do at that point and would leave it to the manager of the unit. When the surveyor asked to speak to the manager of the unit, Staff G stated the manager was gone for the day.

On 01/31/2024 at 1025 review of Clinical Care Supervisor job description, with a revision date of 08/2023 revealed the Clinical Care Supervisor plays an important role in providing a safe environment for all patients and staff.