HospitalInspections.org

Based on hospital policy review, medical record reviews, incident log review and staff interviews, the hospital staff failed to report an allegation of staff to patient abuse for 1 of 1 sampled patients that alleged staff to patient abuse (Patient #2).

The findings included:

Review on 08/28/2019 of a policy titled "Abuse, Suspected" last revised 07/2018 revealed "...All allegations, observations or suspected cases of physical, emotional, or psychological abuse, neglect or exploitation of any patient necessitates immediate action...1. Staff Member Witnessing Event or Receiving Allegation: a. Upon receiving the allegation, the staff member is to immediately assure patient safety:...2) If the alleged perpetrator is a staff member, that person shall be removed from caring for the patient in question...2. Risk Manager: a. Assure safety of patient. b. The CEO shall be notified of the allegation promptly. c. If the alleged perpetrator is a staff member, upon discussion with the staff member's immediate supervisor and the Director of Human Resources, the staff member will be suspended from duty pending the outcome of the investigation...k. The Applicable licensing board State Board of Nursing is to be notified at (as written) as soon as possible if the alleged perpetrator is a clinical employee (Nursing, Respiratory, Therapy)..."

Closed medical record review on 08/28-29/2019 revealed Patient #2 was a 56 year old female admitted on 07/04/2019 for acute respiratory failure with hypoxia. Review of a nursing note dated 07/20/2019 at 2100 revealed "...Patient reported to nurse with supervisor that someone came to her room few (sic) days ago, pt (patient) is anxious crying pt mentioned she is not doing any accusation, (Registered Nurse RN #1) with (RN #2), assured patient that all her needs will be attended promptly pt is repositioned using supporting pillow with (RN #1) administered ativan (anti-anxiety) IV (intravenous) per orders for agitation, bed in low position with call light in reach...@2130 pt is relaxed no complaining @2200 pt is sleeping..." Review of PA #1's (Physician Assistant) note on 07/21/2019 at 1021 revealed "...Patient states that she was molested last night around 10PM. Patient states a man molested her and that she would like anxiety medication. Patient does not have any details into the person who molested her and has no name. Patient does continue to ask for anxiety medications IV. Director of nursing was notified as well as charge nurse. Per protocol the police will be called and patient will need to be transferred to the emergency room for proper evaluation..." Review revealed the police came to see Patient #2 on 07/21/2019 at approximately 1000. Review revealed Patient #2 was transported to the ED (emergency department) for evaluation at 1310. Review of the nursing note on 07/21/2019 at 1500 revealed "...Pt's (family) arrived, notified (family) about pt's location and the reason pt is in ED. (Family) said 'Oh yeah, she does that sometimes'...1650 Pt returned in her room...." Review of a nursing note on 07/22/2019 at 2015 revealed "...Pt anxious and kept asking for her PM (night time) meds earlier...Pt concerned about seeing (Certified Nursing Assistant CNA #1) and asking why he is still here and she was afraid. I told pt I would be with her all night and to call me if she needed me and that (CNA #1) works here. She seemed to accept that..." Review of a nursing note on 07/26/2019 at 1330 revealed "...(Police Officers) in to see pt. Pt. admits fabricating previous accusations of past weekend. Pt. believed she would be transferred from this facility because she does not want to be here..." Review revealed Patient #2 was discharged on 07/29/2019 to an acute rehabilitation facility.

Review on 08/28/2019 of an internal investigation revealed "...Patient reported to charge nurse that she had been molested by a staff member. Patient went on to describe the staff member in question, after a male CNA entered her room. She pointed him out indicating he was the person who had abused her. In AM patient continues to state that she had been molested by a staff member and asked several day shift staff members could she be medicated for the alleged attack. Consequently, 911 was called. Officer responded and questioned the patient with this RN in attendance. Patient was sent out to (ED Name) for evaluation/ possible 'rape kit.' Patient informed of destination and reason for ED visit. Patient refused examination and specimen collection while at (ED Name). While patient was out, her (family member) arrived. When informed by the nurse about the whereabouts of (Patient #2) and the alleged complaint of sexual assault, (family member) replied, 'she does that sometimes'. The nurse said (family member) indicated that (Patient #2) made things up at times. Patient returned to room in stable condition-account written by (RN #3)..." Further review of the internal investigation revealed "...On July 21st @ 915am CNO (Chief Nursing Officer) received a phone call from CN (charge nurse) and PA on allegations above. Both were directed to call 911, and a report needed to be filed. Also, informed patient would need to go have a rape kit completed at the ER (Emergency Room). Pt was transferred to ER, but refused the rape kit and was sent back to the (facility). CNO advised that the patient have no male employees care for her until investigation was completed. On 07/23 CMO (sic) followed up with CN (RN #2) who was working the evening the patient made the allegations. (RN #2) reported that evening she was called to the room as the pt was yelling out. Upon (RN #2) entering the patient began to make the allegation she has (sic) someone touch her inappropriately, and it was a male. The patient explained it had been a few nights prior, and she couldn't recall his name. When (CNA #1) walked into the patient's room to do vital signs, the patient yelled out, 'that's him!'. (RN #2) immediately took (CNA #1) outside the room, explained the situation, and had him switch the assignment for this patient and for the other CNA to care for her. (CNA #1) did not enter this pts room from that moment. On Friday, July 26th, (Police Officer) and CNO went to follow up with the patient - immediately upon entry to the patient's room, the patient denied that anything happened to her. "I lied, and I'm sorry. Please tell that person I accused I'm sorry." CNO informed the patient that she should let her family know that, as they were concerned about the alleged allegations she had made. (CNO name)..."

Review of the internal investigation revealed the alleged abuse allegation was not reported to the North Carolina Health Care Personnel Registry (HCPR).

Interview on 08/29/2019 at 1451 with the CNO revealed she was informed about the alleged incident on 07/21/2019 via phonecall from the charge nurse. Interview revealed on 07/23/2019 she spoke with the charge nurse who Patient #2 had initially disclosed to and was told she changed CNA #1's assignment after Patient #2 alleged abuse. Interview revealed the alleged abuse allegation was not reported to the North Carolina Health Care Personnel Registry (HCPR). Interview revealed the CNO did not know she had to report CNA #1 to the HCPR.

Interview on 08/29/2019 at 1403 with the Quality Director revealed the alleged abuse allegation was not reported to the North Carolina HCPR. Interview revealed the Quality Director did not know about the HCPR or that CNA #1 should have been reported.

NC00154464, NC00154468