HospitalInspections.org

Based on interview, record review and document review, the facility failed to provide care to a patient in a safe setting (Tag A144); and failed to ensure a patient was free from all forms of abuse or harassment (Tag A145).

The cumulative effects of these systemic practices resulted in the facility's inability to ensure the provisions of quality health care in a safe environment.

Based on interview, record review and document review, the facility failed to ensure a patient who was subjected to verbal and physical abuse by a family member received continued care in a safe setting and failed to provide appropriate security measures and an abuse protection program to protect the patient from further potential abuse (Patient #1).

Findings include:

A facility History and Physical dated 08/20/11 indicated Patient #1 was admitted to the facility for diagnoses that included dementia, pneumonia, sepsis, left lower extremity cellulites and antibiotic management.

An Elder Protective Services Report dated 09/29/11 and an interview conducted 10/14/11 included the following information: On 08/28/11 a CNA (Certified Nursing Assistant) witnessed Patient #1's son become verbally abusive and assault the patient several times by placing a pillow over the patients face. The CNA reported the physical abuse to a nursing supervisor. The nursing supervisor notified the on call administrator and nurse manager by phone of the incident but did not follow facility abuse reporting policy or state mandated reporting requirements and immediately call or notify Law Enforcement and Elder Protective Services of the abuse in a timely manner.

The facility failed to take steps to protect the patient against further abuse by allowing the patients son, who assaulted the patient earlier to return and have contact with the patient on 08/28/11 during dinner hours. Elder Protective Services was contacted on 08/29/11 and a report of the incident was given. The facility had to be instructed by an Elder Protective Services Caseworker to immediately contact the police and report the witnessed assault. On 08/29/11 the patient's son was arrested in the front lobby of the facility by the police department after arriving to visit the patient and charged with elder abuse and attempted murder.

NRS 200.5093: Report of abuse, neglect, exploitation or isolation of older person; voluntary and mandatory reports; investigation; penalty: included the following:

1. Any person who is described in subsection 4 (includes professional or practical nurse, any personnel of a hospital or similar institution engaged in the admission, examination, care or treatment of persons or an administrator, manager or other person in charge of a hospital) and who in his professional or occupational capacity, knows or has reasonable cause to believe that an older person has been abused, neglected, exploited or isolated shall: report the abuse, neglect, exploitation or isolation of the older person to:

1. The local office of the Aging Services Division of the Department of Health and Human Services.

2. A police department or sheriff's office.

3. The county's office for protective services.

4. A toll free telephone service designated by the Aging Services Division of the Department of Health and Human services.

The facility's Patient Abuse Policy last reviewed 02/07 included the following:

Policy: The facility shall strive to ensure the preservation of the dignity and personal safety of those served by prohibiting physical, verbal, sexual and psychological abuse.

Purpose: To identify types, signs and symptoms of abuse and neglect and to intervene in a way that promotes the safety of patients.

Procedure: Included conditions of abuse that are noted prior to admission, on admission or at any time during hospital stay will be:

1. Documented in the pre-admission evaluation, interdisciplinary assessment or progress notes in the medical record.

2. Reported to the physician

3. Reported to the case manager for notification and follow-up to the appropriate agency. If after hours the in-house supervisor will be notified.

4. Nevada law requires that suspected abuse or neglect must be reported within 24 hours.

a. For patients 18-65 in Nevada: Metropolitan Police Department.

For patients over the age of 65 in Nevada: Clark County Social services Division of Aging.

5. All facility employees are mandated to report any suspicion of patient abuse or neglect, either through their Supervisor, Case Manager or Administrator.

A review of the facility's Patient Abuse policy revealed there was no written procedure for investigating allegations of abuse and neglect including methods to protect patients from abuse during investigations of allegations.

On 10/11/11 at 10:30 AM, Employee #1 (Nursing Supervisor) reported on 08/28/11 around noon time a patient located in a room next to Patient #1 reported a verbal altercation between Patient #1 and her son who was visiting. The patient voiced concerns about Patient #1's safety and welfare. Employee #1 reported during a conversation with a CNA (Employee #4) about Patient #1's son verbal abuse the CNA reported an incident early in the morning of 08/28/11 during breakfast time where the CNA saw the son become verbally abusive towards Patient #1 and assault the patient by placing a pillow over the patients face several times. The CNA waited four hours to report the patient abuse to Employee #1. The unit secretary also reported hearing verbal abuse from the son to the patient during the morning of 08/28/11.

Employee #1 called and notified Employee #3, (Administrator on Call) and shortly afterwards was called by Employee #2 (Acting Chief Nursing Officer) and both employee's were informed of the verbal and physical abuse of the patient. Employee #1 reported being instructed by Employee #2 to notify case management of the situation. Employee #1 reported Employee #2 and Employee #3 did not provide any instructions to report the incident to Law Enforcement or Elder Protective Services.

Employee #1 acknowledged neither Law Enforcement or Elder Protective Services were called and notified of the reported physical abuse of the patient. Employee #1 reported the patient son returned to the facility on 08/28/11 during dinner time to visit with the patient unsupervised and was told the facility would be investigating the incident. Employee #1 reported case management was notified of the incident on Monday morning, 08/29/11. Case management notified Elder Protective Services who instructed the facility to immediately notify law enforcement about the reported assault on Patient #1.

The Case Manager then notified police on 08/29/11. The police responded to the facility on 08/29/11 at noon and conducted an investigation. The patients son was arrested in the lobby of the facility by police after he arrived to visit Patient #1 and charged with elder abuse and attempted murder. Employee #1 acknowledged nursing staff failed to follow the facility's Patient Abuse policy and procedure and state law by failing to immediately notify Law Enforcement and Elder Protective Services to report the incident and failed to take steps to protect the patient from further contact and potential abuse by the son. Employee #1 reported she had not received any training on recognition, investigation and reporting of patient abuse since being hired at the facility.

A Nursing Note by Employee #1 dated 08/28/11(no time) included the following: "Patient in (another room) reported hearing (patients son) yell and curse at patient earlier today and yesterday when he was visiting her. Patient is visually impaired and denied seeing interaction between patient and son only hearing interaction. Patient voices concerns about (Patient #1's) well being. While discussing situation with assigned CNA (Employee #4) CNA reported incident with patient and son at breakfast time. CNA stated son placed pillow front of patients face several times and cursed at patient. Spoke with (Employee #3) Administrator on call and (Employee #2) Nurse Manager about incident. Unit Secretary also reported hearing altercation between patient and son. When son came in at mealtime informed of staffs concerns, his behavior with his mother. Denies ever hurting patient, states he has to yell at her because she is hard of hearing."

A facility Incident Report completed by Employee #1 and dated 08/28/11 at 2:30 PM included the following documented statement from CNA, (Employee #4). "I went in 120 west to help patient get out of bed at breakfast time. Patient's son was yelling at patient to get up and told her to shut up and stand up. The son then got the pillow and put it over the patients face, and did it again. I told him to stop doing that, then he did it again and said that's my mother and I can do whatever I want. He also told her to eat her eggs. Patient did not eggs so he told her to eat the (F) eggs or I will make you eat them. Patient told me that at home it is even worse for her and I told her to tell. She stated she had nowhere else to go."

On 10/11/11 at 12:55 PM an interview was conducted with Employee #2 (Acting Chief Nursing Officer/Nurse Manager) who reported on 08/28/11 being called and notified by Employee #3 that Patient#1 had been slapped on the wrist and verbally abused by her son. Employee #2 reported at no time did Employee #3 mention Patient #1 had been physically assaulted by the son who repeatedly placed a pillow over Patient #1's face. Employee #2 called Employee #1 at the facility and was informed that Patient #1 had been slapped on the hand and verbally abused by her son who had been visiting the patient.

Employee #2 instructed Employee #1 to review the facility's abuse policy and report the incident to case management. Employee #2 responded to the facility and reviewed the facility's abuse policy with Employee #1 and instructed Employee #1 to call Elder Protective Services to report the incident. Employee #2 acknowledged no steps were immediately taken to protect Patient #1 from further contact and potential abuse from the son. Employee #2 reported some training in patient abuse was conducted after the incident occurred with nursing staff but no records of the participants, or training were kept. Employee #2 acknowledged there was no investigation conducted by the facility in regards to the abuse incident.

On 10/11/11 at 2:15 PM an interview was conducted with Employee #3 (On Call Administrator) who reported on 08/28/11 being called by Employee #1 who reported a CNA had witnessed Patient #1 being verbally abused by her son and slapped on the hand during breakfast. Employee #3 reported Employee #1 did not tell her about the patient's son assaulting Patient #1 by repeatedly placing a pillow over the patients face. Employee #3 instructed Employee #1 to call Employee #2 the Acting Chief Nursing Officer and follow patient abuse policy and procedure. Employee #3 acknowledged no instructions were given to Employee #1 to report the incident to Law Enforcement and Elder Protective Services. Employee #3 acknowledged no instructions were given to Employee #1 to protect Patient #1 from further contact and abuse by the patients son. Employee #3 reported receiving training in patient abuse recognition and reporting during orientation.

A Case Management Note dated 08/29/11 at 9:15 AM documented Elder Protective Services was called and notified of the incident on 08/29/11 that involved the patient's son assaulting the patient by placing a pillow over the patients face.

A Case Management Note dated 08/29/11 at 10:45 AM documented the facility received a call from a case worker from Elder Protective Services who instructed the facility to immediately contact law enforcement and report the abuse incident and report back with a crime event number.

A Case Management Note dated 08/29/11 at 12:00 PM documented the police department arrived and was taking statements from staff.

A Review of Personnel files regarding patient abuse training revealed the following:

Employee #1 had a hire date of 10/23/95. There was no documented evidence the employee received any training in recognition, investigation and reporting of patient abuse located in the personnel file.

Employee #4 had a hire date of 02/03/10. There was no documented evidence the employee received any training in recognition and reporting of patient abuse located in the personnel file. There was documented evidence the employee had been disciplined by the Nevada State Board of Nursing on 05/18/06 for unprofessional conduct and patient abandonment. Information obtained through the Nevada State Board of Nursing indicated the employees CNA license was revoked on 09/14/11 due to NRS 632.320 (1) (g) unprofessional conduct and NAC 632.890 (26) violation of State/Federal nursing law.

Employee #6 had a hire date of 03/12/09. There was no documented evidence the employee received any training in recognition and reporting of patient abuse located in the personnel file.

Employee # 7 had a hire date of 09/17/05. There was no documented evidence the employee received any training in recognition and reporting of patient abuse located in the personnel file.

On 10/12/11 at 9:00 AM an interview was conducted with Employee # 5 (Chief Nursing Officer ) who confirmed there was no documented evidence the facility conducted an investigation of the verbal and physical abuse that occurred to Patient #1 on 08/28/11. Employee #5 confirmed the appropriate agencies that included the Police Department and Elder Protective Services were not notified in a timely manner when the allegation of verbal and physical abuse against Patient #1 was witnessed by a staff member and reported to a nursing supervisor and administrative staff. Employee #5 reported the facility did not have an abuse protection program.

Employee #5 confirmed there was no documented evidence staff had been trained on patient abuse recognition and reporting following the patient abuse incident on 08/28/11 and the facility's patient abuse policy and procedures had not been revised or changed since the patient abuse incident. Employee #5 reviewed the personnel files of Employee' s #1, #4, #6, and #7 and confirmed there was no documented evidence of any orientation or annual training in the recognition and reporting of patient abuse located in the files.

Employee #5 confirmed documentation in Employee #4's personnel file indicated the employee had been disciplined by the Nevada State Board of Nursing in 2006 for unprofessional conduct and patient abandonment. Employee #5 did not know how the employee could have been hired in 2010 with a history of patient abandonment.

Employee #5 acknowledged Employee #4's CNA nursing license was found to be revoked by the Nevada State Board of Nursing effective 09/14/11 due to unprofessional conduct and violation of State and Federal nursing law. Employee #5 reported the revocation of Employee #4's license was discovered today during the complaint survey at the facility.

Complaint # 29625

Based on interview, record review and document review, the facility failed to ensure a patient was kept free from verbal and physical abuse (Patient #1).

Findings include:


A facility History and Physical dated 08/20/11 indicated Patient #1 was admitted to the facility for diagnoses that included dementia, pneumonia, sepsis, left lower extremity cellulites and antibiotic management.

An Elder Protective Services Report dated 09/29/11 and an interview conducted 10/14/11 included the following information: On 08/28/11 a CNA (Certified Nursing Assistant) witnessed Patient #1's son become verbally abusive and assault the patient several times by placing a pillow over the patients face. The CNA reported the physical abuse to a nursing supervisor. The nursing supervisor notified the on call administrator and nurse manager by phone of the incident but did not follow facility abuse reporting policy or state mandated reporting requirements and immediately call or notify Law Enforcement and Elder protective Services of the abuse in a timely manner.

The facility failed to take steps to protect the patient against further abuse by allowing the patients son, who assaulted the patient earlier to return and have contact with the patient on 08/28/11 during dinner hours. Elder Protective Services was contacted on 08/29/11 and a report of the incident was given. The facility had to be instructed by an Elder Protective Services caseworker to immediately contact the police and report the witnessed assault. On 08/29/11 the patient's son was arrested in the front lobby of the facility by the police department after arriving to visit the patient and charged with elder abuse and attempted murder.

NRS 200.5093: Report of abuse, neglect, exploitation or isolation of older person; voluntary and mandatory reports; investigation; penalty: included the following:

1. Any person who is described in subsection 4 (includes professional or practical nurse, any personnel of a hospital or similar institution engaged in the admission, examination, care or treatment of persons or an administrator, manager or other person in charge of a hospital) and who in his professional or occupational capacity, knows or has reasonable cause to believe that an older person has been abused, neglected, exploited or isolated shall: report the abuse, neglect, exploitation or isolation of the older person to:

1. The local office of the Aging Services Division of the Department of Health and Human Services.

2. A police department or sheriff's office.

3. The county's office for protective services.

4. A toll free telephone service designated by the Aging Services Division of the Department of Health and Human services.

The facility's Patient Abuse Policy last reviewed 02/07 included the following:

Policy: The facility shall strive to ensure the preservation of the dignity and personal safety of those served by prohibiting physical, verbal, sexual and psychological abuse.

Purpose: To identify types, signs and symptoms of abuse and neglect and to intervene in a way that promotes the safety of patients.

Procedure: Included conditions of abuse that are noted prior to admission, on admission or at any time during hospital stay will be:

1. Documented in the pre-admission evaluation, interdisciplinary assessment or progress notes in the medical record.

2. Reported to the physician

3. Reported to the case manager for notification and follow-up to the appropriate agency. If after hours the in-house supervisor will be notified.

4. Nevada law requires that suspected abuse or neglect must be reported within 24 hours.

a. For patients 18-65 in Nevada: Metropolitan Police Department.

For patients over the age of 65 in Nevada: Clark County Social services Division of Aging.

5. All facility employees are mandated to report any suspicion of patient abuse or neglect, either through their Supervisor, Case Manager or Administrator.

A review of the facility's Patient Abuse policy revealed there was no written procedure for investigating allegations of abuse and neglect including methods to protect patients from abuse during investigations of allegations.

On 10/11/11 at 10:30 AM an interview was conducted with Employee #1 (Nursing Supervisor) who reported on 08/28/11 around noon time a patient located in a room next to Patient #1 reported a verbal altercation between Patient #1 and her son who was visiting. The patient voiced concerns about Patient #1's safety and welfare. Employee #1 reported during a conversation with a CNA (Employee #4) about Patient #1's son verbal abuse the CNA reported an incident early in the morning of 08/28/11 during breakfast time where the CNA saw the son become verbally abusive towards Patient #1 and assault the patient by placing a pillow over the patients face several times. The CNA waited four hours to report the patient abuse to Employee #1. The unit secretary also reported hearing verbal abuse from the son to the patient during the morning of 08/28/11.

Employee #1 called and notified Employee #3, (Administrator on Call) and shortly afterwards was called by Employee #2 (Acting Chief Nursing Officer) and both employee's were informed of the verbal and physical abuse of the patient. Employee #1 reported being instructed by Employee #2 to notify case management of the situation. Employee #1 reported Employee #2 and Employee #3 did not provide any instructions to report the incident to Law Enforcement or Elder Protective Services.

Employee #1 acknowledged neither Law Enforcement or Elder Protective Services were called and notified of the reported physical abuse of the patient. Employee #1 reported the patient son returned to the facility on 08/28/11 during dinner time to visit with the patient unsupervised and was told the facility would be investigating the incident. Employee #1 reported case management was notified of the incident on Monday morning, 08/29/11. Case management notified elder protective services who instructed the facility to immediately notify law enforcement about the reported assault on Patient #1.

The Case Manager then notified police on 08/29/11. The police responded to the facility on 08/29/11 at noon and conducted an investigation. The patients son was arrested in the lobby of the facility by police after he arrived to visit Patient #1 and charged with elder abuse and attempted murder. Employee #1 acknowledged nursing staff failed to follow the facility's Patient Abuse policy and procedure and state law by failing to immediately notify Law Enforcement and Elder Protective Services to report the incident and failed to take steps to protect the patient from further contact and potential abuse by the son. Employee #1 reported she had not received any training on recognition, investigation and reporting of patient abuse since being hired at the facility.

A Nursing Note by Employee #1 dated 08/28/11(no time) included the following: "Patient in (another room) reported hearing (patients son) yell and curse at patient earlier today and yesterday when he was visiting her. Patient is visually impaired and denied seeing interaction between patient and son only hearing interaction. Patient voices concerns about (Patient #1's) well being. While discussing situation with assigned CNA (Employee #4) CNA reported incident with patient and son at breakfast time. CNA stated son placed pillow front of patients face several times and cursed at patient. Spoke with (Employee #3) Administrator on call and (Employee #2) Nurse Manager about incident. Unit Secretary also reported hearing altercation between patient and son. When son came in at mealtime informed of staffs concerns, his behavior with his mother. Denies ever hurting patient, states he has to yell at her because she is hard of hearing."

A facility Incident Report completed by Employee #1 and dated 08/28/11 at 2:30 PM included the following documented statement from CNA, (Employee #4). "I went in 120 west to help patient get out of bed at breakfast time. Patient's son was yelling at patient to get up and told her to shut up and stand up. The son then got the pillow and put it over the patients face, and did it again. I told him to stop doing that, then he did it again and said that's my mother and I can do whatever I want. He also told her to eat her eggs. Patient did not eggs so he told her to eat the (F) eggs or I will make you eat them. Patient told me that at home it is even worse for her and I told her to tell. She stated she had nowhere else to go."

On 10/11/11 at 12:55 PM an interview was conducted with Employee #2(Acting Chief Nursing Officer/Nurse Manager) who reported on 08/28/11 being called and notified by Employee #3 that Patient#1 had been slapped on the wrist and verbally abused by her son. Employee #2 reported at no time did Employee #3 mention Patient #1 had been physically assaulted by the son who repeatedly placed a pillow over Patient #1's face. Employee #2 called Employee #1 at the facility and was informed that Patient #1 had been slapped on the hand and verbally abused by her son who had been visiting the patient.

Employee #2 instructed Employee #1 to review the facility's abuse policy and report the incident to case management. Employee #2 responded to the facility and reviewed the facility's abuse policy with Employee #1 and instructed Employee #1 to call Elder Protective Services to report the incident. Employee #2 acknowledged no steps were immediately taken to protect Patient #1 from further contact and potential abuse from the son. Employee #2 reported some training in patient abuse was conducted after the incident occurred with nursing staff but no records of the participants, or training were kept. Employee #2 acknowledged there was no investigation conducted by the facility in regards to the abuse incident.

On 10/11/11 at 2:15 PM an interview was conducted with Employee #3 (On Call Administrator) who reported on 08/28/11 being called by Employee #1 who reported a CNA had witnessed Patient #1 being verbally abused by her son and slapped on the hand during breakfast. Employee #3 reported Employee #1 did not tell her about the patient's son assaulting Patient #1 by repeatedly placing a pillow over the patients face. Employee #3 instructed Employee #1 to call Employee #2 the Acting Chief Nursing Officer and follow patient abuse policy and procedure. Employee #3 acknowledged no instructions were given to Employee #1 to report the incident to Law Enforcement and Elder Protective Services. Employee #3 acknowledged no instructions were given to Employee #1 to protect Patient #1 from further contact and abuse by the patients son. Employee #3 reported receiving training in patient abuse recognition and reporting during orientation.

A Case Management Note dated 08/29/11 at 9:15 AM documented Senior Protective Services was called and notified of the incident on 08/29/11 that involved the patient's son assaulting the patient by placing a pillow over the patients face.

A Case Management Note dated 08/29/11 at 10:45 AM documented the facility received a call from a case worker from Elder Protective Services who instructed the facility to immediately contact law enforcement and report the abuse incident and report back with a crime event number.

A Case Management Note dated 08/29/11 at 12:00 PM documented the police department arrived and was taking statements from staff.

A Review of Personnel files regarding patient abuse training revealed the following:

Employee #1 had a hire date of 10/23/95. There was no documented evidence the employee received any training in recognition, investigation and reporting of patient abuse located in the personnel file.

Employee #4 had a hire date of 02/03/10. There was no documented evidence the employee received any training in recognition and reporting of patient abuse located in the personnel file. There was documented evidence the employee had been disciplined by the Nevada State Board of Nursing on 05/18/06 for unprofessional conduct and patient abandonment. Information obtained through the Nevada State Board of Nursing indicated the employees CNA license was revoked on 09/14/11 due to NRS 632.320 (1) (g) unprofessional conduct and NAC 632.890 (26) violation of State/Federal nursing law.

Employee #6 had a hire date of 03/12/09. There was no documented evidence the employee received any training in recognition and reporting of patient abuse located in the personnel file.

Employee # 7 had a hire date of 09/17/05. There was no documented evidence the employee received any training in recognition and reporting of patient abuse located in the personnel file.

On 10/12/11 at 9:00 AM an interview was conducted with Employee # 5 (Chief Nursing Officer ) who confirmed there was no documented evidence the facility conducted an investigation of the verbal and physical abuse that occurred to Patient #1 on 08/28/11. Employee #5 confirmed the appropriate agencies that included the Police Department and Elder Protective Services were not notified in a timely manner when the allegation of verbal and physical abuse against Patient #1 was witnessed by a staff member and reported to a nursing supervisor and administrative staff. Employee #5 reported the facility did not have an abuse protection program.

Employee #5 confirmed there was no documented evidence staff had been trained on patient abuse recognition and reporting following the patient abuse incident on 08/28/11 and the facility's patient abuse policy and procedures had not been revised or changed since the patient abuse incident. Employee #5 reviewed the personnel files of Employee' s #1, #4, #6, and #7 and confirmed there was no documented evidence of any orientation or annual training in the recognition and reporting of patient abuse located in the files.

Employee #5 confirmed documentation in Employee #4's personnel file indicated the employee had been disciplined by the Nevada State Board of Nursing in 2006 for unprofessional conduct and patient abandonment. Employee #5 did not know how the employee could have been hired in 2010 with a history of patient abandonment.

Employee #5 acknowledged Employee #4's CNA nursing license was found to be revoked by the Nevada State Board of Nursing effective 09/14/11 due to unprofessional conduct and violation of State and Federal nursing law. Employee #5 reported the revocation of Employee #4's license was discovered today during the complaint survey at the facility.

Complaint # 29625