Good Shepherd Homecare - Marshall

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on interview and record review, the agency had cause to believe a patient served by the agency had been abused or exploited by an agency employee, and failed to report the information immediately, meaning within 24 hours, to HHSC for 1 of 20 patients records reviewed. (Patient #14) The agency did not report an allegation of abuse, RN A proceeded to collect stool from Patient #14 after he said no, reported by a family member on 1/11/23. This failure has the potential to place the agency’s clients at risk of further abuse and prevents HHSC from doing timely investigations. 1 Record review of a plan of care dated 12/26/2022-2/23/2023 indicated Patient #14 was a 75-year-old male with diagnosis of orthopedic (musculoskeletal) aftercare, diabetes (high blood sugar), osteomyelitis (bone infection), high blood pressure, and heart failure. Record review of a complaint report dated 1/11/2023 indicated the administrator spoke with family member D regarding Patient #14’s discharge due to hitting an RN. The report indicated an unidentified RN was training a second RN in the home with her. Family member D reported during the attempt to collect stool, Patient #14 said no, and that the unidentified RN committed assault and battery by proceeding. The report indicated the regional vice president and risk management was notified of the complaint. The complaint report indicated under follow-up comments that statements were obtained from both RNs in the home. The report indicated Patient #14 would be discharged due to aggressive behavior and the physician’s office was notified. The complaint report indicated on 1/12/23 the administrator spoke with family member D again regarding her complaint and after further investigation decided the event was an isolated incident. The complainant was agreeable to continue with home health given the two RN’s present that day did not come back to the home. The report indicated due to this being isolated the home agency would continue to see Patient #14. The report indicated family member D asked for a follow up from both clinicians and complaint/request was reviewed with them. Record review of a Patient Coordination note report dated 1/6/23 by RN A indicated she saw Patient #14 on 1/15/23 for routine skilled nursing visit with lab work. The note indicated Patient #14 was a 74-year-old male who lived in his own home and required extensive help with ADLS. The note indicated Patient #14 was on homecare services with a primary focus on surgical aftercare following surgery for osteomyelitis (a bone infection) to the left index finger. The note indicated Patient #14 was unable to give a stool sample freely and while collecting stool he became combative. Patient #14 reported he had not had diarrhea, however, Patient #14 had dementia. The note indicated RN A attempted to collect the stool sample via rectal swab. The note indicated Patient #14 rolled over onto her hands, trapping them underneath his bottom and began swinging at the nurse, hitting her glasses and wrists. The note indicated Patient #14 repeatedly stated “get that shit out of me. I’m 74 years old.” The note indicated RN A instructed Patient #14 he would have to roll over so that she could remove her hands. The note indicated RN A was eventually able to free her hands, however, sample was not collected. During an interview is 11/4/24 at 2:09 p.m., Family member of Patient #14 said a nurse from the agency came out to collect a stool sample, she said Patient #14 told her “NO” he did not want to and turned over. The family member said the nurse proceeded to do it anyway and Patient #14 backhanded her to remove her hand. The family member said while she was not at home, she had a witness because the caregiver was there. The family member said the DON called her and informed her they would not be out to see Patient #14 again because he was aggressive with the nurses. The family member said she asked the DON who she wanted her to report sexual assault to because “NO” means “NO.” The family member said they should not have done that test after Patient #14 said “NO” beforehand. The family member said they could have tried another time, noted, and notified the physician. The family member said the DON told her she investigated and talked to everyone about the situation, and proceeded to tell her she would investigate more and talk to more people. She said they had about 2 more weeks with the agency for blood draws due to having a PICC (peripherally inserted catheter) line and receiving medications. The family member said she gave the DON the benefit of the doubt and waited for return call. The family member said the DON called back and apologized and told her she would like to keep him on services, she said she agreed to this because they only needed them for 2 more weeks. The family member said she could not recall the name of the nurses or caregivers at this time but would contact me this afternoon if she found them. During an interview on 11/4/2024 2:30 p.m., the regional VP of operations said these incidents should have been reported to state. She said an online incident report was completed anytime there is an allegation of abuse, neglect or exploitation and this goes to risk management. She said some emails regarding these incidents had been pulled up for review, but they are trying to track down the incident report to find out why they were not reported. The regional VP of operations said the administrators were able to self-report in TULIP (a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas). without going to risk management because that could take 24 hours or more. She said if the administrator felt it needed to be reported it should have been reported, then. The regional VP of operations said timely reporting was important for patient safety. During an interview on 11/4/2024 at 2:42 p.m., the administrator/DON said she was the one that received the complaint on Patient #14. She said the complainant wanted her spouse discharged from the agency because he said no to the stool sample and the nurse proceeded to collect it anyway. The administrator/DON said the complainant felt the incident could be classified as assault. The administrator/DON said after she did her investigation and spoke with the complainant regarding the resolution of the isolated incident, she did not feel it was necessary to report, and she and the complainant departed in pleasant ways. The administrator/DON said she was under the impression she was not supposed to report incidents on her own without the direction of the corporate office. The administrator /DON said she needed to seek clarity from the corporate office regarding incident investigation, documentation and where to get proper documents. The administrator said she had never made a self-report before but would think she would be the one that would make the report after being instructed to do so by corporate. The administrator /DON said she could not remember the name of the nurse who was training with RN A during the incident with Patient #14 and could not recall what the nurses said regarding the incidents. The administrator / DON said she could not locate any written statements from the alleged perpetrators. The administrator / DON said she did not suspend the nurses or the aide pending investigation of the incidents, she said she did not know she was supposed to do so. During an interview on 11/4/2024 at 3:29 p.m., the administrator/DON said she could not locate any in services or training done after the incident with Patient #14. During an interview on 11/7/2024 at 2:04 p.m., the administrator said once a complaint regarding abuse, neglect or exploitation was received she would start an investigation, interview staff involved, document all information, report to state agency within 24 hours, suspend the alleged perpetrator pending investigation and depending on the outcome follow agency policy for termination or put back on the Patient schedule. The administrator /DON said it was important for these to be carried out for the safety of the Patients. Record review of a policy dated 11/1/24 titled Patient abuse, exploitation, and neglect: Assessment, identification and reporting indicated its purpose was to identify, assess and report victims of actual or suspected abuse, exploitation and/or neglect. The policy indicated by law, health care providers are mandated to report cases of actual or suspected abuse and/or neglect. The policy indicated if an agency has cause to believe that a Patient served by the agency has been abused, neglected, or exploited by an agency employee, the agency must report the information immediately, within 24 hours, to HHSC. The policy indicated under Procedure: b. The supervisor will immediately upon witnessing the act or upon receipt of the allegation assess and document the situation, suspend any employee or contractor immediately should he/she be suspected of abuse, neglect or exploitation, report findings to the Patient’s attending physician, and report findings to appropriate agency according to state law and regulation.”