HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 2 (Pt. #1) grievance records reviewed regarding allegation of abuse, the Hospital failed to ensure that a written notification regarding the resolution of the grievance was provided, as required.

Findings include:

1. On 04/01/2021, at approximately 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to Hospital A's emergency department (ED) on 03/02/2021 with a chief complaint of left side weakness. Pt. #1 was transferred via ambulance to Hospital B (Acute Care Hospital) for further neurology evaluation on 03/05/2021. Pt. #1 was readmitted to Hospital A on 03/06/2021 and was discharged to a Rehabilitation Hospital on 03/13/2021.

2. On 04/01/2021 at approximately 1:30 PM, the Hospital's Patient Abuse Report Form, dated 03/09/2021 was reviewed and included, " ...on 03/06/2021, (Pt. #1 states she) was touched by a Caucasian male...while in care at (Hospital B)... during (Pt. #1's) MRI (Magnetic Resonance Imaging)... However, (the) MRI was completed at (Hospital A) on 03/04/2021 ...The MRI was completed by an African American male (at Hospital A) ..." The abuse report indicated that Hospital A conducted a follow-up investigation regarding Pt. #1's allegation. However, Pt. #1 or her representative was not provided a written notification regarding resolution of the allegation.

3. On 04/01/2021 at approximately 1:45 PM, the Hospital's policy titled, "Resolving Patient/Family Complaints and Grievances" (dated 11/04/2020) was reviewed and included, " ...B. Grievance - a grievance includes any of the following: ...allegations of abuse or neglect ...iii. ...the hospital will inform the patient or their representative in writing of the situation and that the hospital will follow-up with another written response within a specified timeframe and provide them with an estimated date of completion ...4. a) Once the grievance is resolved, the patient or their representation will be provided with a written response ..."

4. On 04/01/2021 at approximately 3:00 PM, Patient Advocacy Coordinator (E #9) was interviewed. E #9 stated, "We did not send any letter to the patient or family members with regards to this grievance." E #9 stated that the Hospital should have provided Pt. #1 or her representative a written notification regarding the resolution of the allegation.

Based on document review and interview, it was determined that for 1 of 2 abuse allegations reviewed for Pt. #1, the Hospital failed to follow the process for reporting and conducting an investigation for an allegation of abuse, to ensure patient was free from all forms of abuse.

Findings include:

1. On 04/02/2021 at approximately 10:50 AM, the Hospital's policy titled, "Abuse Neglect Domestic Violence" dated 02/16/2021 was reviewed and included, "All allegations, observations, or suspected cases of abuse...that occur in the hospital should be investigated by the Hospital..."

2. On 04/01/2021, at approximately 10:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to Hospital A's emergency department (ED) on 03/02/2021 with a chief complaint of left side weakness. Pt. #1 was transferred via ambulance to Hospital B (Acute Care Hospital) for neurology evaluation on 03/05/2021. Pt. #1 was readmitted to Hospital A on 03/06/2021 and was discharged to Rehabilitation Hospital on 03/13/2021.

3.On 04/02/2021 at approximately 8:45 AM, the Hospital's Incident Report by the Public Safety Officer dated 03/07/2021 was reviewed. The report included, " ...Patient (Pt. #1) has been calling the operator stating she wants to leave the Hospital , claiming medical staff raped her...and wants public safety officer to bring her to (Name of Hospital C) ...In summary, received a call for dispatch stating that the patient (Pt. #1) stated she had been raped and attempted to be raped by a staff member..." However, the Hospital's process for reporting and conducting investigation for an allegation of abuse was followed.

4. On 04/02/2021 at approximately 10:30 AM, the Manager of Quality and Regulatory (E#3) was interviewed. E #3 stated that she was not made aware of an incident report dated 3/7/21 of Pt. #1 allegation of abuse. E #3 stated this allegation was not not reported thru the proper channels. Therefore a follow-up investigation of Pt. #1 initial allegation of abuse was not conducted.