HospitalInspections.org

Based on policy review, record review and staff interview it was determined the facility failed to provide care in a safe setting for one (1) of one (1) patient complaints of abuse by a staff member reviewed. This failure has the potential to adversely impact all patients that make a complaint of abuse by a staff member.

Findings include:

1. The policy "Abuse and/or neglect of Adults", with a revised/review date of 05/13 was provided for review. The policy states: "Notify Case Management Department, immediately
upon receipt of information or report of known or suspected neglect, battery or exploitation." It further revealed that the case manager would then contact administration.

2. Review of the medDispense station report revealed that on 10/08/13 at 0503, RN #1 was in patient #1 room to dispense medication.

3. Review of the facilities investigation of the alleged abuse revealed, an interview with RN #1 on 10/10/13 at 1450, that RN#1 stated "I went back in about 0600 to give her meds and I was aware that I upset her and wanted to see if she was ok."

4. An interview was conducted with the administrator on 11/19/13 at 1513. She stated that she knew patient #1 on identifier list and had completed an investigation on the allegation of abuse by Registered Nurse (RN) #1. When asked if the night shift staff had notified administration on call when the allegation occurred, she stated, no we found out about it the next morning when the patient told the physical therapist (PT) at around 0800 and then when I went to talk to the patient, I immediately suspended RN #1 pending an investigation.

5. A telephone interview was conducted with the Rehabilitation Nurse Technician (RNT) on 11/19/13 at 1420. She stated she remembered the allegations with patient #1. She stated, "when the patient told me that RN #1 slapped her face I told the Licensed Practical Nurse (LPN) and we decided to wait to tell our superiors in the morning."

6. A telephone interview was conducted with the LPN on 11/19/13 at 1500. She stated she remembered the allegations with patient #1. She stated "the RNT came and told me and I told her we would report it to our superiors in the morning." When asked if anyone told the other RN on duty that night about the allegations the patient made, she stated, "I really don't remember."

7. A telephone interview was conducted with RN #2 on 11/19/13 at 1550. When asked if he remembered the allegation. He stated,"no, today is the first I knew about it."

The above findings were concurred with the administrator on 11/20/13 at 1345. The administrator also agreed that the nurse continued to have contact with patients from 0110 until approximately 0630.

Based on policy review and staff interview, it was determined the hospital failed to follow their own policy by ensuring that all patients are free of all forms of abuse, neglect, or harassment for one (1) of one (1) charts reviewed (patient #1). This has the potential to negatively affect all patients safety and the right to receive care in a safe environment.

Findings include:

1. The policy, "Abuse and/or Neglect of Adults", last reviewed 05/13, was provided for review. The policy states: "All medical staff and employees are to notify Case Management Department, immediately upon receipt of information or report of known or suspected neglect, battery, or exploitation". "All allegations of abuse, neglect, or exploitation from anyone, including staff, students, volunteers, other patients, visitors, or family members will be handled and reported in the same manner".

2. Review of the "Administrator On-Call Schedule" revealed an administrator was available for contact to report the incident of abuse during the nightshift on 10/08/13. No call was made or report given to the appropriate person. The On-call schedule is posted at the nurses station for reference if needed in an abuse, neglect, or harassment situation.

3. An interview was conducted with the Licensed Practical Nurse (LPN) on 11/19/13 at 1500. When asked if she was aware of the abuse incident she stated, "I was working the night of the incident and heard loud voices coming from the patient's room. I had my Rehab Nurse Tech (RNT) go to the patient's room to see if the nurse needed any help. When the RNT came back down the hall from the patient's room she was very upset. I asked her what was wrong and she told me the patient alleged the nurse had slapped her. The RNT wanted to address the issue with the nurse in question and I told her not to say anything we would report the incident to the nurse manager in the morning." When asked if the incident was reported to anyone in management she stated, "I left in the morning with the understanding the RNT was going to report the incident to the nurse manager. I never reported the issue to anyone."

4. An interview was conducted with the Registered Nurse (RN) #2 on 11/19/13 at 1550. When asked if he was working on the night of the alleged incident he stated, "yes I was working with the patient's on the opposite team." When asked if he knew about the incident he stated, "I was never made aware of the issue and really can't tell you anything about what happened."

5. An interview was conducted with the Administrator on 11/19/13 at 1515. She stated, "I was not made aware of the incident until 0800 on 10/08/13." She concurred with the above findings.