HospitalInspections.org

Based on medical record review, review of facility documents, and staff interview, it was determined that the facility failed to ensure that all patient's were free from abuse for one of one abuse allegations reviewed.

Findings include:

A facility complaint and grievance record for Patient #1 (P1) indicated that on 4/19/23 at 2000 (8:00 PM), the following complaint was received regarding Staff #7 (S7), RNT (Rehabilitation Nursing Technician): "Patient called [his/her] nurse that [he/she] wanted to speak to the Charge nurse regarding her RNT at 2000. As per patient at 0640 [sic, 6:40 PM per Staff #1], the "black aide with her hair up" was with [him/her]. [He/she] asked to be placed back to bed because [he/she] was sitting in the wheelchair. Patient states, this aide was muttering under her breath. [He/she] also states that [he/she[ wasn't transferred very nicely in bed and states [he/she] was "pushed" in bed. This charge nurse tried to clarify with the patient about how [he/she] was transferred to the bed again. [Mr./Ms. Patient name] again stated, "She pushed me in the bed." Patient started crying and begged this Charge nurse not to have this RNT [S7] assigned to [him/her] for the rest of [his/her] stay. I did state to [him/her] that I'm sorry this happened to you but yes, you won't have that aide anymore. ..." The record was signed by S11, Charge Nurse. Additional documented evidence indicated that S11 changed the patient assignment so that S7 did not provide care to P1. During an interview on 5/24/23 at 10:30 AM, S1, Director Quality and Risk, S2, Chief Executive Officer, and S3, Chief Nursing Officer, stated that S7 continued to work the remainder of her shift until 7:00 AM on 4/20/23. Per S3, to ensure safety of other patients, the Charge Nurse re-educated staff on the policy for abuse and neglect and requested S7 to apologize to the patient. The complaint and grievance record lacked evidence that Charge Nurse immediately notified the hospital CEO/CNO/designee of the allegation of abuse in accordance with facility policy. Per S1, S2 and S3 they received the eCalm report on the morning of 4/20/23 and were notified by S10, Nurse manager. S10 also told them that she followed up with P1 and apologized to the patient. Per S3, S10 re-educated the rest of the staff members on the policy for abuse and neglect, patient rights, and C.P.R. (Comfort, Professionalism and Respect).

A "Safety/Security Event" report dated 4/20/23 at 8:09 AM (CST, [9:09 AM EST]), revealed that the physician was notified at 09:37 (9:37 AM) on 4/20/23 and an investigation was initiated by the facility leadership.

A review of Medical Record #1 revealed a physician's progress note dated 4/20/23 at 11:37 AM, from the Rehab (Rehabilitation) Physician which stated, "Patient seen and examined. Patient states that [he/she] is unhappy with the nursing incident yesterday night when going to bed. Felt the aide transfer [him/her] hard to the bed ... Review of Systems: 10-point review of systems completed, upset otherwise review of systems negative. ..." An "Addendum" added by the same physician at 11:48 AM stated, "No noted injury in the arms and body found with physical examination today from the nursing incident last night." A nursing assessment completed on 4/19/23 at 19:22 (7:22 PM) lacked evidence of the patient's allegations of abuse and specific assessment for injuries related to the allegation. This was not in accordance with facility policy.

As per S3, S7 was re-educated on the policy for abuse and neglect and was suspended starting 4/20/23 pending the investigation. S7 was terminated from the facility as a result of the investigation on 4/24/23. S2 and S3 stated that the police were not notified because the patient refused.

The employee file for S7 was reviewed and the following was revealed: S7 was hired on 2/13/23. The facility provided evidence of a background check on S7 prior to hiring. S7's resume stated, "Certifications and Licenses ... Certified Nursing Assistant (CNA)." As per S3, after S7 was terminated from the facility, Human Resources was contacted and S7's CNA certification could not be verified.

A review of the "Employee Counseling Form" for S7 revealed that she was off orientation on 3/10/23. On 4/6/23, the hospital received a patient complaint that S7 responded to a patient call light and was asked by the patient to assist getting changed because he/she was soiled with urine. S7 told the patient he/she was dry and exited the room. The patient stated that he/she laid in his/her wet and cold sheets until the day shift came and changed him/her. On 4/7/23, a patient complained that S7 never returned to a patient room after the patient requested to use a bedpan. On 4/19/23, a patient had several complaints about S7, including that she barely supported him/her to the bathroom when asked and S7 just stood in the room on her cell phone.

A review of the facility policy titled, Allegations of Abuse/Neglect, effective date 04/04/2022, states, "... Responsibility ... Hospital staff will take all necessary steps to ensure that patients are kept safe from abuse/neglect and that allegations of abuse/neglect by employees or visitors are investigated promptly, thoroughly, and reported to the proper authorities as necessary. ... POLICY ... The immediate response of staff will be guided by whether there has been a witnessed/confirmed act of abuse/neglect or whether there have been reports or suspicions of abuse/neglect that have not been witnessed/confirmed. ... II. Un-witnessed Report of Abuse ... 1. Take immediate action to protect the patient from harm. 2. Unit staff must contact their supervisor and/or a supervisor on duty immediately upon notification of allegation/findings of any form of abuse/neglect. 3. The patient must be: A. examined immediately for injury B. treated, if necessary C. secured from harm by taking any additional necessary actions to ensure the patient's safety and welfare, including but not limited to i. Moving the patient to another unit ii. reassigning staff and/or suspending accused staff pending investigation ... 4. The supervisor must immediately notify the hospital CEO/CNO/designee who will contact Home Office Risk Management. 5. In the event that staff can confirm abuse has occurred, local law enforcement should be notified immediately and the appropriate state and licensure agencies should be notified after consultation with Home Office Risk Management and Home Office Human Resources. 6. In the event that staff cannot confirm abuse has occurred, notification to the appropriate law enforcement, state and licensure agencies will be determined on a case-to-case basis after consultation with Home Office Risk Management. ...V. Documentation ... 1. Allegations of abuse/neglect are pertinent to assessment/treatment decisions and should be reflected as reported in the medical record. 2. Physical assessment findings by nursing staff and the physician should be documented in the medical record. ..."