Dyersburg Regional 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: 37530 Based on policy review, medical record review, and interviews, the hospital failed to ensure patient rights were protected for 1 of 4 (Patient #10) sampled patients by failing to adequately monitor and protect Patient #10 from alleged abuse and failed to conduct a thorough investigation. The findings included: 1. Review of the hospital policy titled, “Patient Abuse Protection,” dated 1/31/2017, revealed “...The intent of this policy is to prohibit all forms of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients or visitors. The hospital will ensure the patients are free from all forms of abuse, neglect, or harassment and properly and thoroughly investigated all allegations and complaints. All patients have the right to be free from physical or mental abuse and corporal punishment... POLICY... All... personnel are expected to provide protection of patients from abuse, neglect and harassment of all forms... train employees in abuse prevention, intervention and detection... Protect patients during investigation... Investigate all allegations of abuse, neglect, or mistreatment... Report/Respond to incidents of abuse, neglect or mistreatment in accordance to Local, State and/or Federal law... Employees who witness, discover or learn of alleged misconduct shall... Take immediate action to protect, comfort and assure the treatment and safety of the patient...Verbally notify their supervisor and the appropriate nurse manager... Initiate and occurrence report and document observations... Nursing personnel shall... Immediately assess the patient, assist in providing care and follow-up care and notify the patient’s physician... Facility investigation should include... Interviewing the patient victim... Interviewing the alleged perpetrator... I nterviewing all persons with first-hand knowledge of alleged incident... Obtaining written statements from victim, witnesses, and other persons with reported knowledge as appropriate...” Review of the hospital policy titled “Patient Rights/Responsibilities,” dated 10/2024, revealed “...To improve patient outcomes by respecting, protecting, and promoting each patient’s rights... The patient... has the right... To be treated in a dignified and respectful manner that supports his or her dignity... To be free from... any type of abuse, including verbal, mental, physical... abuse..” 2. Review of the closed medical record revealed Patient #10 was admitted to the hospital on 8/3/2024 with diagnosis of Urinary Tract Infection (UTI) and Fall. Review of the “Discharge Report,” dated 8/3/2024, revealed “... History of Present Illness... Patient is a 77-year-old male medical history remarkable for Hypertension and Dementia. He presents to the emergency room with generalized weakness of several days duration. Patient had prostate biopsy at [Named Hospital #2] 2 days ago, wife reports patient had been more confused with decreased p. o. [oral intake]... since his biopsy... Patient was seen in emergency room the day before presentation diagnosed with UTI and discharged home. Since discharge, he has had 2-3 falls...” Review of the “Emergency Dept (Department),” dated 8/3/2024, revealed Medical Decision Making...Rationale...Escalation of Care Considered Admission indicated, patient workup resulted in criteria for observation/admission to the hospital...presents to emergency department generalized weakness and multiple falls with workup consistent with cystitis...” Review of the “Medication Administration Records” dated 8/5/2024 and 8/6/2024 revealed Registered Nurse (RN) #1 provided care for Patient #10. Review of the Hospital Orders dated 8/6/2024, revealed “...Discharge ... Inpatient Rehab [Rehabilitation]...Signed by RN #1...” Review of the Email dated 8/6/2024, documented by the Medical -Surgical Manager, revealed “...Yesterday around 1300 (1:00 PM), I received a call from [Named Patient Care Technician [PCT #1]...that she observed [Name Registered Nurse [RN #1] being too aggressive for a patient. I immediately went to one east where [Named PCT #1] was working. At this time another PCT, [Named PCT #2]...told me she observed [Named RN #1] being aggressive with the patient too. [Named PCT #5]...was on the cameras at this time and stated she witnessed [Named RN #1] raising his voice at the patient and being agitated. The patient was picking and pulling at his IV [Intravenous line]. [Named RN #1] then swatted at the patient’s wrist. Telling him not to pick at the IV. [Named PCT #5] stated [Named RN #1] then walked out of the patient’s room and walked back in and was calmer with the patient. [Named PCT #2]...stated she was not in the room with the patient and [Named RN #1] yet she heard [Named RN #1] screaming at the patient and throwing his arms up at the patient, raising his fist as the patient was trying to pick out his IV. [Named PCT #2] stated she saw [Named RN #1] grab towards the patient’s wrist but she stated she could not see if he grabbed it or hit it. Again, [Named PCT #1]...was the sitter of the patient in [Named Patient #10’s] room...[Named PCT #1] stated the patient was trying to pick and pull at his IV. She stated [Named RN #1] slapped the patient’s wrist where the IV was. [Named RN #1] kept telling the patient not to pull at his IV. [Named RN #1] then put his fist up at the patient...[Named Physical Therapy [PT] was asked to come in by [Named RN #1] as the patient was very agitated. [Named PT] stated she [he] was trying to calm the patient. He stated he saw [Named RN #1] with his fists raised but he did not see [Named RN #1] hit the patient. When asked if staff had ever witnessed [Named RN #1] being aggressive with patients...told patient she was being ridiculous when the patient did not want to swallow her meds [medications]...[Named PT] stated he has heard [Named RN #1] yell at a very unruly patient who was trying to pull a fire alarm. [Named Surgery Manager]...was brought in as a neutral party to witness this conversation. She witnessed me talking to [Named RN #1] about the perception of what was witnessed with the patient’s care. [Named RN #1] stated he did not hit the patient. He stated he tapped his hand to prevent him from pulling out his IV, I reviewed perception as well as keeping his voice down...Today we had a meeting about 1020 [10:20 AM] reviewing the follow up from yesterday. [Named RN #1] agreed that he can be too loud at times...He told me this patient had just been to much and it really got the best of him. He stated if we could have some extra education on the care of the dementia patients he would be willing to participate for sure. I informed him if he has a patient that is really too hard to handle or is too taxing, let his charge nurse, house supervisor, a lead or myself know. I told him if we had to we are able to swap with another nurse for the remainder of the shift so we care not too overwhelmed, as we want the best care for the patient. [Named RN #1] seems very remorse [remorseful] about the situation yesterday and told me he would never harm a patient. [Named RN #1] denies having any issues or concern outside of work we could assist him with...I have reminded him and other staff we do have the [Named Mental Health] program they are welcome to use if they need it, as mental health is very important for the success of our healthcare team...[Named Chief Nursing Officer] I know how we had previously mentioned [Named RN #1] might need a de-escalation class, I feel like given the conversation I had with [Named RN #1] I would rather look for some information/training/education on the care of dementia patient with redirecting...” Review of the Emailed Witness Statement dated 8/5/2024, documented by Physical Therapy (PT) revealed “...I was in Hallway at... Nursing station PCT [Patient Care Technician] came to door of room [Patient #10’s]...stating that he is trying to pull his IV out. I went into the room to Help PCT, nurse [Named RN #1] asked me if I could so he could call and gets some Meds [Medication] to help calm pt [patient]...while in room pt trying to pull covering off the IV site, I helped re-direct Pt from pulling out IV...after a few min [minutes] [Named RN #1] came in room, and I moved out of front of Pt to let him get next to pt...As [Named RN #1] was in front of Pt [Patient #10...he continued to try to remove his IV. [Named RN #1] attempted to stop Pt from pulling out is [his] IV telling Him No...and at one time patted at his hand to get it away from the IV...he patted his hand maybe twice...both Pt and Nurse [RN #1] tempers increased at this time with Pt and nurse Bringing fist up then Pt first then Nurse...at that time I steeped [stepped] in and attempt to calm pt and then stayed with pt until he calmed down...after a few min pt wife came in room and we were able to put some pajama pants on pt and get him to lie down from sitting Position...PCT in room to watch pt and I left room...to the best of My Knowledge this is what I saw...” 3. During an interview on 11/5/2024 at 8:54 AM, the Physical Therapist (PT) was asked if he was aware of any incident with RN #1 and any alleged patient abuse. The PT stated, “...I saw [Named RN #1] fist raised but he did not hit the pt [Patient #10]...I heard [Named RN #1] yell at pt who was trying to pull the fire alarm...I was standing in the hallway and heard him [RN #1] hollering “don’t touch the fire alarm”, it was a male pt... the pt was confused and disorient and very mobile...he [RN #1] was walking along with him...and trying to direct him back to his room...with his open hand he was going to pop his hand to keep it off the fire alarm...” The PT was asked if RN #1 made any contact with the patient. The PT stated, “...No, I did not see that...the incident in the patients room [Patient #10] when the patient tried to pull out his IV...he wanted me to help the PCT calm the pt down...I witnessed...he came into the room and did raise his hand...acting like he was going to swat his hand away with an open hand...his [RN #1] voice got up...I stepped in and asked the patient to let me see your hand...the patient calmed down...” The PT was asked if he agreed with the witness statement he documented on 8/5/2024 that at one time [RN #1] patted his [Patient #10] hand to get it away from the IV...he patted his hand maybe twice...both Pt and Nurse tempers increased at this time with Pt...Nurse Bringing fist up...” The PT confirmed what he wrote down that day is what happened. The PT signed, dated and confirmed the witness statement on 11/5/2024 at 9:13 AM. During a telephone interview on 11/5/2024 at 10:20 AM, PCT #1 was asked if she was the sitter in Patient #10’s room during the incident with RN #1. PCT #1 stated, “...Yes, I was the sitter in the room...don’t remember the room number...the patient was uncooperative and tried to pull the IV [Intravenous line] out...then [Named RN #1] comes in the room...gets agitated with the patient...he [RN #1] started slapping the patient’s wrist...then put his fist up towards the patient...” PCT #1 was asked if she remembered how many times RN #1 hit/slapped the patient. PCT #1 stated, “...I want to say once or twice on the wrist where the IV was...” PCT #1 was asked if she reported the incident. PCT #1 stated, “...Yes to [Named Med-Surg Manager]...” PCT #1 was asked if she was interviewed by the Med-Surg Manager and the Surgery Manager. PCT #1 she did not sit down with the Med-Surg manager and I don’t know who the Surgery Manager was. PCT #1 was asked if RN #1 continued to take care of Patient #10 on 8/5/2024. PCT #1 stated, “...Yes...as far as I know he did...” During a telephone interview on 11/5/2024 at 10:43 AM, RN #1 was asked to tell me about the incident with Resident #10. RN #1 stated, “...That same day my supervisor [Named Medical Surgical [Med-Surg] Manager] and the...[Name Surgery Manager] they talked to me about the same thing...they told me a couple of PCT’s was in the room...a gentleman with dementia a geriatric patient...they [PCT’s] were yelling for help...I came in there [the room]...he was swinging his arms...I tried to calm him down...he was trying to get out of the bed...he said “I’m leaving I don’t want to be here”...[Named PCT #1] was one of the PCT’s...not sure who the other one was...I was loud and firm with him...asking him to stop...I’m sure I grabbed his wrist...to stopped him from crawling or falling out of the bed...I was loud and trying to redirect him to get his attention...I believe the manager talked to all the people...[Named Med-Surg Manager] did call me...I told them [Med-Surg manager and Surgery Manager] I was loud...I did grab his wrist but did not use in violence...when I talked to the managers I told them we need training for Geri Psy [Geriatric Psychiatric ] patients...” RN #1 was asked if he was provided the training. RN #1 stated, “...No, I did not get the training on deescalating Geri Psy patients...they [Geri Psy patients] are a problem for us nurses...” RN #1 was asked at any time did he slap or hit the Patient #10’s wrist. RN #1 stated, “...No, I grabbed it...I don’t remember slapping the wrist...” RN #1 was asked if he remember raising his fists up towards Patient #10. RN #1 stated, “...I don’t remember...” RN #1 was asked you say you grabbed Patient #10’s wrist. RN #1 stated, “...Yes, he may have pulled away when I grab the wrist...I don’t think I was the aggressor...I was being defensive...the patient was the aggressor...” RN #1 was asked if he had told a female patient she was she was being ridiculous because she would not swallow her medication. RN #1 stated, “...I don’t recall that...if I said something like that...it was not mean or belittling...if anything it was taken out of context by the patient...” RN #1 was asked if he remembered an incident with a male patient trying to pull the fire alarm. RN #1 stated, “...I don’t remember anything like that...” RN #1 was asked if he was assigned to Patient #10 care on 8/5/2024. RN #1 stated, “...I don’t know if I was assigned to him at this point...I was on the floor and asked to handle a unrulily situation...I don’t know why I would not take care of him...I would not have any reason to switch patients...” During a telephone interview on 11/5/2024 at 9:29 AM, PCT #2 was asked is she was aware of any incident with male RN and a patient. The PCT #2 stated, “...I was not in the room with [Named RN #1] and the patient...I heard [Named RN #1] screaming at the patient and throwing his arms up at the patient...I saw him grab towards the patient’s wrist, but she stated she could not see if he grabbed it or hit it [the wrist]...I was at the nurse station on one east and saw into the room the door was open...I don’t recall the room number...I witnessed him [Named RN #1] yelling at a combative patient and him swatting his [Patient #10’s] hand...” PCT #2 was asked if RN #1 touched or made contact with the patient. PCT #2 stated, “...there was another PCT in the room at the time...she may have seen a little closer [Named PCT #1]...” PCT #2 was asked if she witnessed RN #1 raise his fists at Patient #10. PCT #2 stated, “...He had his arms up and his hand was in the shape of a fist...he was agitated with the patient...” During an interview on 11/6/2024 at 3:00 PM, the Medical-Surgical Manager (Med-Surg Manager) was asked if the hospital provided the training that RN #1 had requested. The Med-Surg Manager stated, “...No...they [staff] have access to the training...we prefer them to do it during the work hours...he has access to the training when needed...” The Med-Surg Manager was asked what the hospital did to protect the patient during the investigation and was RN #1’s assignment changed. The Med-Surg Manager stated, “...I have to look at the patients’ records...I know we reassign in different situations...” The Med-Surg Manager was asked if an occurrence report was completed and the physician notified. The Med-Surg Manager confirmed there was no occurrence report completed and no documentation the physician was notified of the incident. The Med-Surg Manager was asked if Patient #10 was assessed during and after the incident with RN #1. The Med-Surg Manager confirmed she did go and see the patient but have no documentation the patient was assessed or examined. The Med-Surg Manager asked if the allegation of abuse was reported to the state. The Med-Surg Manager stated, “...No, I reported it to my chain of command and CNO [Chief Nursing Officer]. The Med-Surg Manager was asked if she felt she did a thorough investigation of the allegation of abuse. The Med-Surg Manager stated, “...Yes ma’am...I can see there are things...that could be improved upon with my investigation...” The hospital failed to ensure Patient #10’s rights were protected during the investigation, failed to initiate, and completed an occurrence report, and failed to ensure Administration fully investigated the alleged allegation of abuse identified by direct care staff on 8/5/2024. The hospital was unable to provide documentation the patient was immediately assessed for evidence of abuse, the physician was notified, and that follow-up care was provided. The hospital failed to provide training to RN #1 post incident that accrued on 8/5/2024.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 19001 Based on policy review, medical record review and interview, the hospital failed to appropriately document the transfer for one of 21 (Patient #15) sampled patients who presented to the Emergency Department (ED) seeking medical treatment that was transferred. The findings included: Medical record review for Patient #15 revealed a 26 year old female who presented to Hospital #1’s ED on 8/1/2024 at 12:43 PM, with reported suicidal ideations. The Medical Screen Examination (MSE) was initiated at 1:09 PM and included an evaluation by Mobile Crisis services. The Mobile Crisis evaluator recommended psychiatric hospital placement. Patient #15 was transferred to an acute psychiatric facility on 8/1/2024 at 4:52 PM. Review of the Acute Care Transfer Form revealed ED Physician #2 did not fully complete the Patient Consent Section or the Risks and Benefits of Transfer Section. Cross Refer to A 2409.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 19001 Based on policy review, medical record review and interview, the hospital medical staff failed to document the risks and benefits for transfer for one of 21 (Patient #15) sampled patients who presented to the Emergency Department (ED) seeking treatment that was transferred. The findings included: 1. Review of the hospital policy “EMTALA [Emergency Medical Treatment and Labor Act], Definitions and Terminology” revised 11/2019, revealed, “...Transfer means the movement of an individual outside the Hospital’s facilities at the direction of any person employed (or affiliated with) the Hospital... Transfers include transfers to a higher level of care and transfers requested by the individual...” Review of the hospital policy “EMTALA Stabilization and Transfer” revised 11/2029, revealed, “... To ensure compliance with the Emergency Treatment and Active Labor Act [EMTALA] requirements to stabilize and in some instances transfer, individuals presenting to [named Hospital] that are found to have emergency medical conditions... Transfer Documentation... Acute Care Transfer Form: For any patient care transfer involving a potentially emergent condition, each section of the Acute Care Transfer Form must be completed to document that the Hospital followed both its policies and procedures and the requirements of EMTALA...” 2. Medical record review for Patient #15 revealed a 26 year old female who presented to Hospital #1’s ED on 8/1/2024 at 12:43 PM, with reported suicidal ideations and a recent voluntary hospitalization for suicidal ideations. Triage was initiated at 12:50 PM, and MSE was initiated at 1:09 PM. Patient #15 had laboratory testing and a Mobile Crisis evaluation. The Mobile Crisis evaluator recommended psychiatric hospital placement. Patient #15 was transferred to an acute psychiatric facility on 8/1/2024 at 4:52 PM. Review of the Acute Care Transfer Form revealed ED Physician #2 did not fully complete the Patient Consent Section or the Risks and Benefits of Transfer Section. In a telephone interview on 11/1/2024 at 11:58 AM, the Quality Director stated Physician #2 was not available for interview, as he was not on the schedule for Hospital #1 for the month of November, and she had been unable to reach him by telephone. The Quality Director verified the expectation was for the ED Physician to fully complete the Acute Care Transfer Form on all patients transferred to a higher level of care.”