Johnston Memorial Hospital

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 19883 Based on medical record review, facility document review, and staff interview, and during the course of a complaint investigation, it was determined that the facility staff failed to notify a patient’s guardian of the application of a restraint for one (1) of nineteen (19) patients included in the survey sample, (Patient #5). The findings include: Review of Patient #5’s medical record revealed that Patient #5, who is “developmentally delayed” and resides in a group home, presented to this hospital’s ED via EMS with complaints of altered mental status. While in the ED, Patient #5 was awake and alert but would not follow commands. Patient #5 was “acting out of impulse” attempting to get out of bed. Patient #5 was not “redirectable.” The ED provider ordered 2-point soft wrist restraints, so Patient #5 could receive care. Review of Patient #5’s demographic sheet indicated that two of Patient #5’s family members were listed as emergency contacts. The family members’ telephone numbers were also listed on the demographic sheet. Review of Patient #5’s “client face sheet” from their group home indicated that one of the same family members whose telephone number was on the hospital’s demographic sheet for Patient #5, was also listed as Patient #5’s “guardian” on the client face sheet from the group home. Review of the restraint monitoring sheet in Patient #5’s medical record showed no evidence that either of Patient #5’s family members, specifically Patient #5’s guardian, were notified or attempts were made to notify them about the use of restraints. Review of this hospital’s policy titled, “Restraint and Seclusion-(name of health entity)” with a revision date of 12/6/24 found in part: “...D. Notification: ...team member attempts to notify the family promptly of the restraint and/or seclusion episode.” And: “...document notification of family or any listed above and any attempts to do so in the patient’s medical record.” Staff Member #1 explained during an interview on 8/11/26 that there should have been documentation in Patient #5’s medical record indicating that either Patient #5’s guardian was notified, or that an attempt at notification to the guardian about Patient #5 been placed in restraints was made.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 33906 Based on interviews, observations, document review and investigation of a complaint, it was determined the hospital failed to meet the Condition of Participation 482.13 Patient Rights. The hospital failed to protect patients from abuse while conducting their investigation of allegations of abuse or neglect or harassment. The hospital failed to assure that any incidents of abuse, neglect or harassment are reported, analyzed, acted on and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law. Please refer to A-0145 for further information.”

“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: 33906 Based on interview, clinical record review, document review and the investigation of a complaint, the hospital failed to a) protect patients from abuse during internal investigation of an allegation of abuse, and b) failed to assure that incidents of abuse, were immediately reported, analyzed, acted on and the appropriate corrective actions occurred, in accordance with hospital policy. The findings include: Review of hospital policy “Adult Abuse and Neglect: Protection and Reporting”, PC-600-396-BH , dated October 12/2023 indicated under the heading “Procedure” that allegation, observation or suspected patient abuse by a hospital staff member should be always immediately reported to a facility Supervisor and to the attending physician or designee. The Supervisor will notify the Risk Manager. The staff accused of abuse will immediately be suspended pending the outcome of the abuse allegation. An internal investigation will occur with notification of corrective action taken (if any) to appropriate state agencies. Further, the hospital policy section titled “Reporting” indicated that anyone having reason to suspect elderly or incapacitated adult abuse has occurred must report concerns immediately to the Department of Social Services or contact the Adult Protective Services Hotline number. This policy is applicable at all times and doesn’t contain exception for weekend or night shift. Review of hospital documents, interviews and the clinical record of Patient #3 indicated the following: On November 18, 2023, and November 19, 2023, during the 7 AM- 7 PM shift, Staff #12 was the senior in-house decision-maker for the hospital. Review of the hospital’s event documentation revealed that on November 18, 2023, at 3:00 PM the nursing instructor notified Staff #12 that a student nurse observed and reported to them physical and verbal abuse of Patient #3 by Staff #10 on two separate occasions during the same shift. Staff #10 was observed verbally abusing Patient #3 and to hold/push them into the bed while forcefully applying restraints. Staff #10 verbally threatened Patient #3 and jerked their thumb up while preparing to administer i.v. medication. The alleged abuse was witnessed by the nursing student and Staff #13. Staff #12 informed Staff #11, nursing administration of the reported allegation of abuse in a phone conversation on November 18, 2023 around 3:00 PM and Staff #11 requested more information before making any decisions related to the allegation of abuse. Review of Patient #3’s medical record failed to contain evidence that the attending physician or family were notified of this event at any point. The hospital documentation related to this event evidenced that on November 19, 2023 at 4:26 PM Staff #12 emailed Staff #11 and Staff #8, members of nursing administration a notification of the alleged abuse of Patient #3 by Staff #10. The hospital documentation revealed that on November 21, 2023 at 7:19 PM, Staff #8 notified Staff #4 (Risk Manager) via email of the patient abuse allegation. The documentation revealed that Staff #4 informed (via email) Staff #1 and Staff #5 about the allegation of patient abuse allegation on November 21, 2023 at 7:39 PM. Review of the “as worked” staffing schedules revealed Staff #10 was allowed to continue to work unrestricted for the remainder of shift on November 18, 2023, caring for 5 patients, including Patient #3, and also a 12 hour shift (7 AM-7 PM) on November 19, 2023, caring for 7 patients, including Patient #3. Staff #10 was not scheduled to work on November 20 and 21, 2023. Staff #10 was suspended on November 22, 2023 at 6:34 AM, pending the outcome of the investigation. Review of hospital documentation related to the investigation of this event revealed that Staff #10 was terminated on December 1, 2023 for violation of the above noted hospital policy PC-600-396-BH and the hospital notified by email the Virginia Department of Health Professions (VDHP) of the patient abuse on December 11, 2023. Review of personnel files for Staff #11 and Staff #12 indicated that Staff #12 worked part-time and Staff #11 was in their position for less than a year. Both staff received training related to Patient Rights and Abuse and Neglect prior to the incident and were expected to follow the hospital policy and State law (Code of Virginia Section 63.2-1606). Review of the job description for “Nursing House Supervisor” on 4/10/23 evidenced in part, “On nights and weekends this position functions as the senior in-house decision-maker for the hospital.” In interviews on April 9, 2024 Staff #1, Staff #4 and Staff #5 indicated that they failed to follow the hospital “Adult Abuse and Neglect: Protection and Reporting” policy, and after receiving notification of an allegation of patient abuse, Staff #12 failing to immediately contact the Risk Manager and notify the attending physician. The hospital also failed to immediately suspended Staff #10 pending an investigation of the allegation of abuse. The hospital staff interviewed were not aware of their obligation to immediately report the patient abuse to other state agencies in addition to VDHP as outlined in the same hospital policy. At the time of survey exit, on April 11, 2024, the hospital hasn’t reported the abuse to the Department of Social Services. In addition, the hospital documentation evidenced that the attending physician was not notified as required by the above noted hospital policy. The findings above indicate a systemic failure to adhere to hospital policy related to the mandated reporting of abuse and protection of patients from abuse/harm.”