HospitalInspections.org

Based on interview and record review, the facility's Case Manager (Personnel #9) who received information of an alleged sexual abuse reported by 1 of 1 patient (Patient #1) failed to:
1) Notify administrative personnel; and
2) Implement the facility's policy and procedure.

Findings included:

In an interview on 04/04/13 at 10:55 AM, the Case Manager (CM/Personnel #9) was asked if she received a complaint from Patient #1 that she was sexually abused. Personnel #9 replied she did. She stated the patient reported she woke up and observed male staff inappropriately touching her. The patient did not know who the staff was. The patient told her not to pursue the allegation because she was afraid of retaliation. The CM was asked if she reported the alleged sexual abuse to her supervisor or any of the administrative staff. The CM replied she reported the incident to a nurse supervisor. She was asked if she had a record of this event and/or filed an incident report. The CM replied "no."

In an interview on 04/04/13 at 12:25 PM, the Administrator (Personnel #1) was asked if she received a report about Patient #1's alleged sexual abuse. The administrator replied "no." She was asked what she expected the staff to do if they receive this type of complaint or allegation. The administrator replied she expected her staff to report the matter to administration and follow the facility's protocol. She was informed about Patient #1's alleged sexual abuse which was reported to Personnel #9. "This is a serious matter. Even though the patient did not want the incident investigated, the staff still needed to report the matter to administration, and follow the policy and procedure."

Policy # 001-01-035.5: "Abuse, Neglect, Assault Alleged or Suspected" revised 06/2012 pages 1 and 2 required "Employees will report any suspected abuse or neglect of a patient. All accusations of physical, emotional, or psychosocial abuse of any patient necessitate immediate action. Foremost, patient safety is to be ensured by removing the alleged perpetrator from contact with the patient...It is the policy...to provide appropriate psychosocial counseling and immediate follow-up medical care ...Any reports of sexual assault...should be reported to the Nurse Executive...and to the Quality/Risk Manager ..."

Based on record review and interview, the facility's Registered Nurse did not supervise and evaluate the nursing care of 1 of 4 patients (Patient #1) whose medical records were reviewed during the survey. The following nursing care for Patient #1 was not performed as required:
1) The nurse did not activate the wound care team to evaluate the patient since the "Braden Score for risk of skin breakdown" was less than 16; and
2) Non-assistance in turning and repositioning the patient every 2 hours.

Findings included:

The medical record of Patient #1 reflected she was admitted on 05/04/12 for antibiotic management of "aortic valve endocarditis." She was subsequently discharged on 05/31/12.

1) The initial nursing assessment dated 05/04/12 noted the following: the patient had no pressure sores only "redness on the sacrum area..." On the "Musculoskeletal" assessment, the nurse noted "Weak and spastic on the left leg and left arm." On the "Skin Assessment," the patient's "Braden Score for risk of skin breakdown" was "15; IF <16, SKIN PRECAUTIONS IMPLEMENTED AND WOUND TEAM NOTIFIED." However, there was no evidence in the medical record that the wound care team evaluated the Patient #1.

2) On 05/07/12, Patient #1 was initially seen for occupational therapy (OT) evaluation. The OT noted the following: feeding was a minimum assist, grooming was moderate assist, dressing, bathing, toileting, and transfers were dependent. The nursing flowsheet did not reflect that Patient #1 was assisted in turning and repositioning every 2 hours on 05/07/12 (during the night shift) and on 05/09/12 (from 10:30 AM to 11:00 PM).

In an interview on 04/03/13 at approximately 11:20 AM and 04/10/13 at approximately 11:30 AM via phone, the CNO (Personnel #4) was informed of the above findings. The CNO was asked to provide evidence that the nurse activated the wound care team to evaluate Patient #1's risk for skin breakdown. The CNO replied the nurse did not notify the wound care team so an evaluation was not conducted. The CNO confirmed the above findings.

In an interview on 04/04/13 at 10:48 AM, Personnel #8 was asked if Patient #1 needed assistance in turning and repositioning while in bed. The OT stated "yes."

Policy # 001-01-017.5: "Hospital Scope of Services" revised 08/2010 pages 3, 12, and 13 required "B ...1. Patient services are provided through organized and systematic processes designed to ensure the delivery of safe, effective, and timely care and treatment...and supervised by professional health care providers who recognize...each person...p. Nursing Services...Nursing care is an organized and systematic process provided by or under the direction of a registered nurse...adequate staffing is maintained...to meet the identified needs of the patient..."

Policy: 201-21-025.7: "Nursing Assessment, Daily" revised June 2011 pages 1 and 3, required "Purpose: To ensure a Registered Nurse (RN) assesses the patients' need for nursing care and plans, implements and evaluates that care...Procedure...2. Each patient's need for nursing care related to his/her admission is assessed and includes consideration of biophysical, psychosocial, environment, self-care...6. Evaluation...A RN supervises and evaluates the nursing care for each patient..."