HospitalInspections.org

Based on interview, record review and policy review, the facility failed to immediately identify a patient's fear of a staff member as potential abuse, immediately investigate the allegation of fear of one patient (#3), when the information was relayed from a staff member to a Charge Nurse, and immediately remove the alleged perpetrator from patient care while the investigation was completed.

This deficient practice resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient Rights. The facility census was 81, and the satellite campus census was four.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 07/03/17, after the survey team informed the facility of the IJ, the staff created education related to the different types of abuse and neglect as well as example scenarios, and began educating all of the staff immediately at both locations.

As of 07/05/17, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Staff G, Licensed Practical Nurse (alleged perpetrator) was suspended pending the investigation's completion.
-The Chief Nursing Officer immediately began an investigation of the alleged incident and interviewed all current in-house patients (15) who had been cared for by Staff G.
-Emails were sent to all staff as well as Medical staff, by the Chief Executive Officer on 07/03/17 explaining the importance of Abuse and Neglect reporting and education.
-Education and case study examples were created to be shared with all staff during Huddles (meetings done before each shift begins) and will be required before the staff member can work. A sign in sheet will be collected during these meetings, along with attestation statement signatures from all staff.
-In addition to concurrent daily huddles, the CNO or designee will randomly choose 15 staff members weekly to verify their understanding of the education for approximately four weeks or until 100% of compliance was achieved. The random staff member number will then drop to 10 per week for two weeks, and if 100% was achieved, the spot checks will be done randomly as part of their quarterly quality measures reporting.
-The CNO or designated leaders will conduct daily rounding on all patients questioning their stay and asking for any concerns regarding their care.
-The Abuse and Neglect Prevention Policy was amended to include the specific definition of abuse, including mental anguish. The policy was to be presented for approval by the Governing Body on 07/07/17.

Based on interview, record review and policy review, the facility failed to recognize alleged abuse of a patient, and did not conduct an abuse investigation based on those allegations for one discharged patient (#3) of one patient reviewed. This failure had the potential to place all patients at risk for their safety from abuse by staff members. The facility census was 81 at the main hospital, and four at the satellite campus.

Findings included:

1. Record review of the facility's policy titled, "Abuse and Neglect of Patients, Prevention", dated 05/2017, showed that each patient had the right to be free from mistreatment, neglect, and misappropriation of property. A patient's behavior that would be an indicator of abuse, neglect, or exploitation that should be taken into consideration when they were assessed would be withdrawing and no desire for family or outside contact, unjustified fear, depressed affect (no eye movement), and if they could not remember who you were or where they were at the time.

Record review of the facility's policy titled, "Allegations of Abuse", dated 05/2017 showed:
-It was the facility's policy to protect its patients from physical abuse/sexual abuse/molestation/harassment.
-The facility would take all necessary steps to ensure that patients were kept safe from abuse; allegations of abuse by employees or visitors was investigated promptly, thoroughly, and reported to the proper authorities as necessary.
-An unwitnessed report of abuse required them to take immediate action to protect the patient from harm.
-Staff must contact their supervisor and/or a supervisor on duty immediately upon notification of allegation/findings of any form of abuse.
-The supervisor must immediately notify the Chief Executive Officer (CEO)/Chief Nursing Officer (CNO)/or designee who will promptly contact Corporate Risk Management.
-The investigation was to include an interview with the person reporting the incident, an interview with the alleged victim, and a review of the medical record.
-An interview was to be conducted with all pertinent staff that may have had knowledge of the event surrounding the alleged incident.

2. Record review of Patient #3's medical record dated 06/13/17 showed that she was a 53 year old female admitted on 06/13/17 with a primary diagnosis of Neuro Myelitis Exacerbation (an inflammation of the spinal cord). She had left upper and lower extremity weakness, and was admitted to the facility for intensive physical and occupational therapy.

During an interview on 07/03/17 at 2:10 PM, Staff H, Physical Therapist (PT), stated that:
-She was working with Patient #3 when she noticed something was bothering the patient.
-Patient #3 initially refused to explain what was wrong and just stated that she didn't want to talk about it.
-Staff H encouraged Patient #3 to explain the issue, and she then reported that her nurse (Staff G, Licensed Practical Nurse [LPN]) was rushing her and not giving her the time she needed to get ready.
-Patient #3 was fearful of the nurse, and she didn't want anyone to know because she didn't want anyone to think she was tattling on the nurse.
-The patient stated she was afraid, and didn't want the nurse back in her room.
-Staff H told Staff I, Charge Nurse, of the situation, but was informed that they were already aware, and that the nurse wouldn't be working with the patient any more.
-Due to the fact that the patient had been fearful of the nurse, she went back to inform the patient that the nurse would no longer be caring for her.

During a telephone interview on 07/03/17 at 2:34 PM, Staff I, Charge Nurse, stated that:
-She initially denied investigating any abuse or neglect complaints recently.
-Upon discussion of Patient #3, she did report speaking with the patient after she received a complaint about Staff G.
-Patient #3 expressed she was rushed by a staff member to get ready for bed, and she had to remind the staff member to be gentle because she had nerve pain, but the nurse told her that she needed to get to her paperwork so she rushed and pushed her when she just needed more time.
-Patient #3 was afraid of Staff G because she was so stern.
-She spent approximately 45 minutes with the patient, and didn't feel as though this was abuse or neglect, but that it was a not a good match up with this patient and the nurse.
-She did not address the nurse about the situation with Patient #3.
-Verbal abuse at the minimum was when someone disregarded the patient's feelings or what they were telling them.
-In regards to the situation with Patient #3, it could be considered verbal abuse because of the patient's perception.

During an interview on 07/03/17 at 1:32 PM, Staff G, LPN, stated that:
-She did not remember whether or not she cared for Patient #3;
-She had received training on Abuse and Neglect;
-The patients had the right to not want you back in the room, and staff were given another assignment;
-Sometimes the staff member was made aware of the patients concern;
-She had never been told that a patient didn't want her back in their room; and
-She had never hurt a patient and had never seen abuse at this facility.

During an interview on 07/03/17 at 4:00 PM, Staff B, CNO, stated that:
-If a patient ever felt they were abused, no matter the initial evidence, she would follow policy and investigate thoroughly.
-She would expect staff to report a patient who expressed being fearful, so that it could be investigated further and more questions asked regarding the fear.
-In the therapy environment, patients were pushed to certain levels where they were uncomfortable, so therefore fear might not necessarily be abuse, but it needed to be looked at further.
-Staff G was someone that they had counseled verbally in the past regarding her bedside manner and her blunt manner of speaking.
-She had never been made aware of any issues like this with Patient #3, but she did remember that during an end of shift report (the off-going leadership team reports to the on-coming team any issues/updates from the shift) one day during the patients stay, the leadership team had mentioned the patient had a few concerns, but that they were nothing that rose to this level.
-No investigation had ever occurred because she had never been made aware of any abuse or neglect complaints by Patient #3 or staff.

The facility failed to follow policy and properly investigate an allegation of abuse, when a patient relayed to a Charge Nurse (Staff I) her fear of an LPN (Staff G) who was caring for her, and the Charge Nurse then failed to take the appropriate actions necessary to investigate the allegation and protect the patient.