Chilton Medical Center

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 51555 Based on facility policy, medical record review, and staff interview, it was determined the facility failed to implement its policy for the reporting of alleged abuse in one of one medical records reviewed where abuse was alleged (Patient (P)1). Findings include: Facility policy titled, “Elder and Vulnerable Adult Abuse”, effective 2/13/23, stated, “Executive Summary: It is the policy of [facility name] to identify, treat, and report suspected elder/vulnerable adult abuse in full compliance with the Adult Protective Services Act of the State of New Jersey... Procedure... Reporting Procedures: 1. A health care professional ... who has reasonable cause to believe that a vulnerable adult is the subject of abuse, neglect, or exploitation will report the information to the county adult protective services provider. 2. Any other person who has reasonable cause to believe that a vulnerable adult is the subject of abuse, neglect, or exploitation will report the information to the county adult protective services provider. 3. The report will be made to the adult protective services provider in the county in which he/she resides. 4. The vulnerable adult who is suspected of being abused, neglected, or exploited and is a resident in a non-community setting (... assisted living facility, long-term care facility...) will be reported to the New Jersey Office of the Ombudsman ... 5. The social worker assigned to the patient’s unit is responsible for coordinating or serving as a liaison between the facility and the adult protective services provider and may serve as the designee of the healthcare professional in making the report to the county adult protective services provider. 6. The social worker and/or practice manager of the practitioner practice will serve as a liaison between the practice and adult protective services and may serve as the designee of the healthcare professional in making the report to the county adult protective services provider... Appendix A Signs and Symptoms of Abuse The patient: 1. Admits to past or present abuse.” A review of P1’s medical record was conducted in the presence of S2 and S3, and revealed the following: On 12/26/25 at 2:40 PM, P1 arrived at the ED with a complaint of fall and altered mental status. P1 was admitted with a diagnosis of fall, intracranial hemorrhage, and severe protein-calorie malnutrition. On 12/29/25 at 1:35 PM, a “CM [Case Management]/SW [Social Work] Re-Assessment” noted, entered by S10, stated, “... Social worker was made aware by CM [name] that during [his/her] assessment of the patient [he/she] had disclosed to her an incident that happened within the facility [sending facility]. This was also discussed with patients [son/daughter] that was at bedside, and they are aware of the incident per patient. CM [name] encouraged patients [son/daughter] to call [facility name] to discuss with them about the incident. Per the son and patient, they stated CM [name] that they all are in agreement for patient to return to [facility name] once medically cleared for discharge. Social worker sent clinical updates and will continue to follow for discharge planning and anything else related to facility incident.” On 12/30/25 at 12:58 PM, a “CM/SW Discharge Planning” note was entered by S10, and stated, “Care management team informed by RN [Registered Nurse]] that patient informed her about facility incident at [facility name] too. Bedside visit made to patient who presented AAOx2/3 [awake, alert, and oriented times 2-3], very pleasant, not presenting in pain and excited about getting out of hospital today. Patient continues to inform staff about incident that happened at facility but not presenting fearful/ stated ok to return to facility today. Patient stated that [he/she] wanted to make sure it did not happen to [him/her] again or anyone else. Patients [son/daughter] [name] present at bedside as well and confirmed patients’ story has been consistent but they were thankful for the ombudsmen information in which they stated they would file a report and also that [facility name] facility was notified of this incident as well. [name] stated facility would also be speaking with [facility name] too. Patient cleared for discharge today.” P1 was discharged on 12/30/26 at 7:40 PM. The medical record lacked evidence that staff reported the alleged abuse to Adult Protective Services in accordance with its policy. This was confirmed with S2 and S3 on 3/4/26 at 2:12 PM. During an interview on 3/4/26 at 1:21 PM, regarding the alleged incident documented in P1’s medical record, S10 stated, “the case manager heard from the patient’s (P1’s) nurse that the patient’s story was consistent. The patient stated that two staff members, dressed in all black, entered [his/her] room at 2:00 AM - 3:00 AM and attacked [him/her]. I went into the patient’s room to do discharge planning, and the patient said [he/she] ‘thinks it happened’. The patients [son/daughter] just wanted to see what we could do about it. I gave the family information for calling the ombudsman and offered to call the facility, but the family refused... I called the facility and spoke with [name] to give them a heads up about the allegation of abuse.” An interview was conducted with S8 on 3/4/26 at 10:57 AM. When asked what the process is when a patient is suspected of abuse, S8 stated, “we report it to the social worker, the social worker will contact the facility and give the family the ombudsman’s phone number. We will write a note, but don’t put specific details. The social worker will talk to the family and document it all into a progress note. When it comes to reporting, it depends on the family, if the family wants us to report it or not.” S5 stated, “the nurse will let leadership know and it is all collaborative.” During interview on 3/4/26 at 11:04 AM, S4 explained, abuse is a reportable event and should be put into “origami” (reporting system). S4 stated, “the nurse should let nursing management, the supervisor, and security know. It may have to go to the police. The social work team will do a complete assessment.” On 3/4/26 at 12:32 PM, when asked to explain what happened with patient (P)1, S2 stated, “the [child] demanded we [the facility] call the police and have the long-term care [LTC] staff arrested. We gave the family members the ombudsman contact information to call and told the family to call [the LTC facility] and submit a complaint. We spoke with the patients [child].” An interview was conducted with S9 on 3/4/26 at 1:10 PM. During interview S9 stated, “a couple days after admission, [P1] said that he was abused at the facility. We let social work know. Social work gave the family the information for the ombudsman and called the facility.” On 3/4/26 at 2:12 PM, when asked to confirm if the police and/or adult protective services were notified of this alleged abuse, S2 stated, “the police were not notified, APS was not notified. We did not suspect abuse, and the family just wanted information on how to contact ombudsman.””

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 48060 Based on medical record review, staff interview, and review of facility policy, it was determined the facility failed to ensure that: 1) pain assessments are performed and documented during triage according to facility policy in four (4) out of 10 medical records reviewed [Patient (P) 1, 2, 5, and 9]; 2) interventions to alleviate or lessen pain are implemented according to facility policy in one (1) out of 10 medical records reviewed (P7). Findings include: 1. Facility policy titled, “Emergency Department Triage,” effective date: 12/27/2022, states, “ ...Procedure: 1. Quick Triage: ... a. Components of quick triage include: ... ii. Vital Signs/Pain ...” On 11/21/24 at 2:00 PM, P1, P2, P5, and P9’s medical records (MR) were reviewed and revealed the following: P1 arrived at the facility’s Emergency Department (ED) on 10/28/24 at 18:41 (6:41 PM) with a chief complaint of abdominal pain. Vital Signs obtained during triage at 19:01 (7:01 PM) lacked evidence of a documented pain assessment. P2 arrived at the facility’s ED on 11/21/24 at 11:17 AM with a chief complaint of abdominal pain. P2’s triage was started at 11:18 AM and his/her vital signs (temperature, blood pressure, pulse, respirations and oxygenation) were taken at 11:23 AM. P2 was evaluated by the provider at 12:12 PM. P2’s medical record lacked evidence of a documented pain assessment during triage. P5 arrived to the facility’s ED on 10/28/24 at 5:56 PM with a chief complaint of assault. P5’s vital signs (temperature, pulse, respirations and oxygenation) were taken at 6:26 PM. The medical record lacked documentation of a pain assessment during triage. P9 arrived at the facility’s ED on 10/21/24 at 5:27 PM with a chief complaint of back pain. P9’s vital signs (temperature, pulse, respiration, blood pressure, and oxygenation) were taken at 5:29 PM. The MR lacked documentation of a pain assessment during triage. 49174 2. Facility policy, titled, “Pain Assessment/Management,” effective date 1/10/23, states, “...1. Emergency Department (ED) Pain Assessment a. Personnel: The ED nurse will work in conjunction with the practitioners to evaluate a patient’s level of pain and implement non-pharmacological as well as pharmacological treatments to alleviate or lessen the pain...c. Pain will be assessed initially and routinely. This pain assessment will be documented in the medical record. The nurse will escalate a report of new or different pain...” On 11/21/24 a review of P7’s medical record was conducted and revealed the following: P7 arrived to the facility’s ED on 6/10/24 at 4:15 PM with a chief complaint of back pain, headache, and motor vehicle crash. P7’s triage was started at 4:29 PM. P7 had a pain assessment complete at 4:31 PM and he/she rated his/her pain as a “7- Severe pain.” At 7:08 PM, P7’s ED nurse documented in the “ED Notes” that P7 “...no longer want[ed] to wait to be seen by a provider...” P7 left the hospital at 7:12 PM. The medical record lacked documentation that P7’s pain was treated or re-assessed. On 11/21/24 at 1:30 PM, an interview with Staff (S) 6, (Registered Nurse), was conducted. S6 explained that pain should be assessed during triage and if the patient is in a significant amount of pain, he/she would alert the physician and document the interaction in the medical record. On 11/21/24 at 3:43 PM, an interview with S2, (ED Director), was conducted. S2 explained that pain should be assessed “at triage” and reassessed depending on the condition and severity. S2 also stated that the ED nurses “should be” documenting pain with vital signs. These findings were reviewed with and confirmed with S2 and S3 (Risk Relations Manager) on 11/21/24 at 3:43 PM.”