HospitalInspections.org

Based on interview and document review, the facility staff failed to promptly report a grievance of potential physical abuse, and failed to promptly investigate or provide the patient with written results of an investigation, for 1 (#10) of 1 patients alleging abuse, resulting in the potential for less than optimal outcomes. Findings include:

See specific tags:
A-118 Failure to promptly report or investigate a grievance
A-123 Failure to promptly investigate or provide written results of an investigation

Based on document review and interview, the facility failed to promptly report and/or investigate an allegation of physical and/or sexual abuse for 1 (#10) of 1 patients alleging abuse, resulting in the potential for less than optimal outcomes. Findings include:

On 3/18/19 at 1200, review of the Grievance Logs revealed no entries for 2018 or the last three years. There was one complaint in the Complaint Log for 2018, unrelated to a grievance of abuse. Interview with Staff B, on 3/18/19 at 1210, revealed that there had been a police investigation of alleged abuse in August 2018.

Interview with the President/Chief Nursing Officer (CNO) on 3/18/19 at approximately 1430, revealed that she had spoken with patient #10 during her stay on 7/20/18 and the patient had alleged being violated (sexual abuse) during the insertion of a Foley catheter on 7/10/18. On 3/18/19 at approximately 1430, when the President/CNO was asked to see the facility's internal investigation of abuse, only email notes of the Police Officer questions and staff responses (dated 8/21/18 - 8/23/18) were provided.

Interview with Staff L, on 3/19/19 at 1500 to 1515 revealed the following: Staff L had helped with the successful Foley catheter insertion on 7/10/18 on the second shift. Staff L stated that approximately a week later when she went into the patient's room the patient yelled, "You hit me." Staff L stated, "I never hit her, I only helped with the Foley catheter insertion." Staff L stated that she left the room and told staff at the Nurses's Station what the patient said. When queried if Staff L had reported this allegation to Management or the President/CNO, she stated, "No."

On 3/19/19 at 1400, review of the facility policy/procedure titled "Grievance #87, Approval date December 2017" documented, "...an allegation of abuse...shall be considered a grievance... refer to his/her supervisor or the Patient Advocate as soon as possible... The subsequent investigation and intervention shall be imitated as soon as possible, and shall not exceed five (5) working days from the date the complaint was received." There was no evidence provided that an internal investigation had been performed and/or documented within this time frame.

Based on document review and interview, the facility failed to provide the patient with a written response of the facility's investigation regarding the patient's grievance alleging physical or sexual abuse, for 1 (#10) of 1 patients alleging abuse, resulting in the potential for less than optimal outcomes. Findings include:

On 3/18/19 at 1200, review of the Grievance Logs revealed no entries for 2018 or the last three years. There was one complaint in the Complaint Log for 2018, unrelated to a grievance of abuse. Interview with Staff B, on 3/18/19 at 1210, revealed that there had been a police investigation of alleged abuse in August 2018. Interview with the President/Chief Nursing Officer (CNO) on 3/18/19 at approximately 1430, revealed that she had spoken with patient #10 during her stay on 7/20/18 and the patient had alleged being violated (sexual abuse) during a Foley catheter insertion on 7/10/18.

On 3/18/19 at 1500, review of the President's "Progress Note Inquiry" dated 7/20/18 at 1803 documented the following: "Conversation held with the patient per her request. Concerned that staff are talking about her in the nurses' station. Shared that the other night three nurses tried to put in a catheter, and she felt like she was violated. They attempted for what felt like 30 minutes. According to the patient the three nurses couldn't get the catheter placed and a fourth nurse came in to try and got it in right away. Attempted to reassure this concern would be followed up on. Stated she was going to call the police. Again, reassured her that she was safe and her concern would be looked into. Patient appeared angry. Was not sure what night this happened. Continued to share that she was going to call the police. (Nurse) aware of patients concerns. Will follow this patient closely." On 3/19/19 at 0930, review of Nursing "Progress Notes Report" verified that the catheter insertion attempts were done on 7/10/18.

On 3/18/19 at approximately 1500, the President provided email documented notes regarding the patients allegations and staff responses, during the time of the police investigation (8/21/18 - 8/23/18). On 3/18/19 at approximately 1530, when queried if the findings had been summarized and a written response sent to the patient, she shook her head "No." On 3/19/19 at 1400, review of the facility policy/procedure titled "Grievance #87, Approval date December 2017" documented, "...an allegation of abuse or neglect...shall be considered a grievance... Upon completion of the grievance investigation, the complainant shall be provided with written response to the grievance, to include investigation findings, the steps taken on behalf of the patient, the results of the grievance process and its resolution, the name of the hospital contact person in the event of any further questions, and the date of completion." This had not been done.






providing patients written notice of its decision...."