HospitalInspections.org

Based on review of facility policy, medical record review, review of facility documentation, and interview, the facility failed to ensure a patient (#1) was free from abuse of 3 patients reviewed.

The findings included:

Review of facility policy" Prevention of Patient Abuse" last reviewed on 12/15/17 revealed "...purpose: to ensure that the dignity and personal safety of patients of all ages is preserved and to take prompt and immediate action to investigate/correct any alleged patient abuse/neglect/exploitation situation..." Further review revealed "...Investigation of suspected events of abuse, exploitation or Misappropriation of Funds...the reporting staff member is required to complete in detail an unusual occurrence report listing the date, time, alleged nature of abuse, location and any person or persons involved...the unusual occurrence form is processed confidentially and is used to initiate a full investigation...the manager receiving this report notifies the Patient Safety Officer, the attending physician and a member of the administrative staff...an accurate summary of the investigation is maintained by the administrative staff..."

Medical record review revealed Patient #1 was admitted to the facility on 9/11/17 with diagnoses including: Traumatic Brain Injury, acute Subdural Hemorrhage with a midline shift (bleeding in the brain), Hemiparesis (partial paralyses to one side of the body), Abnormal Gait, and Wheelchair Dependence.

Medical record review of an admission History and Physical dated 9/12/17 at 1:38 PM revealed Patient #1 fell from his wheelchair at home and suffered an ischemic stroke. Continued review revealed the patient had severe impairment to the left upper and lower extremities and had functional impairment with transfers and bed mobility.

Review of facility documentation dated 9/18/17, with no time, revealed the Human Resource Director and the Nurse Manager (NM) met with Certified Nursing Assistant (CNA) #1 regarding an alleged incident between CNA #1 and Patient #1 on 9/17/17. Continued review revealed "...monitor technician saw it [abuse] and called [named charge nurse]...[named charge nurse] called the nurse manager..." Further review revealed "...[CNA #1] brought [Patient #1] to room, didn't lock wheelchair...left and came back in the room...didn't talk to him at all...took his gown off...put gown on...backed him next to bed...picks him up and throws him in the bed...never said a word to him...threw blanket and sheet completely over his head..." Further review revealed "...every measure we trained you [CNA #1] for, you disregarded...you humiliated him [Patient #1]..."

Interview with the Chief Nursing Officer (CNO) on 1/9/18 at 11:15 AM, in the Administration Conference Room, revealed "...on 9/17/17 the monitor technician observed the CNA enter [Patient #1] room and did not handle him kindly and without respect to the patient. She left him naked and went out of the room, then came back into the room and put the patient in the bed very roughly. The monitor tech told the charge nurse and that is when we began the investigation..."

Interview with the Nurse Manager on 1/11/18 at 9:45 AM, in the Administration Conference Room, revealed "...I received a text from the Monitor Technician on 9/17/17 around 6:00 PM and she said she had observed an incident in a patient's room that appeared to be neglectful and abusive to the patient...I told her to let the charge know and look at the video and have her call me..." Further interview revealed the investigation was started that night...the CNA was not removed from patient care...it was late in the shift..." Further interview revealed "...I do not have documentation of my interviews and investigation and an occurrence report was not completed...we did not notify the state of the allegation..." Further interview confirmed the facility failed to ensure Patient #1 was free from abuse and the facility failed to follow facility policy.

Interview with Registered Nurse (RN) #1 on 1/11/18 at 10:30 AM, in the Administration Conference Room, revealed "...I walked by the monitor room and the monitor tech asked me to come in the room...she told me that she had observed [CNA #1] treat a patient very aggressive on the camera...she said the CNA threw the patient in the bed...she told me she had texted [named nurse manager] and told her...[named nurse manager] wanted her to check on the patient and to watch the video..." Further interview revealed "...I should have called the house supervisor...the CNA was not removed from patient care after the incident...I did not complete an occurrence report..."

Interview with the Vice President of Quality Management on 1/11/18 at 2:30 PM, in the conference room, confirmed the facility failed to document and maintain an investigation of alleged abuse and the facility failed to follow facility policy.