Observations:
Based on review of facility policy and procedures, review of the medical record (MR) and interviews with staff (EMP), it was determined the facility failed to ensure the Emergency Department (ED) staff followed the facility's approved policy for reporting a patient's alleged abuse at a transferring facility in one of one medical records reviewed (MR1).
Findings include:
Review on April 23, 2025, of facility policy, "Reporting Abuse/Neglect Allegations: Child Abuse; Domestic Violence/Spousal/Partner; Victims of Assault/Battery," revised October 2023, revealed, " ... Definitions ... Required reporter: Any employee who suspects, witnesses, or is informed of an allegation of any one or more of the following: mental abuse, physical abuse, sexual abuse, financial exploitation, or neglect ... Policy: ... 2. Complete appropriate reporting forms per state and local regulations ... 5.5 Cases of child abuse or elder/dependent adult abuse also require reporting but have specific reporting mandates. Please refer to the specific sections in this policy ...
PROCEDURE 1. Reporting 1.1 If an employee witnesses, is told of, or suspects an incident of physical abuse, sexual abuse, mental abuse, financial exploitation, neglect, or a death has occurred, the employee or agency shall report the allegation to the CNO. The facility shall report the allegation immediately, but no later than the time frames specified herein ... 1.3 The facility shall then ensure that allegations of abuse, neglect and deaths are reported to PA Department of Health (PA DOH) no later than the time frames specified herein. 2. PA Department of Health Reporting 2.1 At a minimum, the following details must be reported to the PA Department of Health concerning the allegation or death:
a. Information about the victim, including name, date of birth, sex, disability, and
identification number
b. Information about the incident, including what happened, when it happened,
where it happened, how it happened and the identification of all witnesses;
c. Information about the accused (if known), including name, contact information
and if the accused is presently working with or will be working with the alleged
victim, and
d. Information about the person initiating the complaint, including name, contact
information, and relationship to the victim ... Elder Abuse and Neglect ... Indicators for possible elder abuse include but are not limited to: Patient brought in to Emergency Department by someone other than caregiver ... reluctant to go home with caregiver ... ".
Review on April 23, 2025, of MR1 revealed the patient was transferred from a behavioral health facility to the facility's Emergency Department (ED) via ambulance on May 21, 2024, and was transferred back to the same facility on May 22, 2024, with complaints of a cough, right shoulder pain and a skin tear of the left hand.
Review on April 23, 2025, of ED Triage nursing documentation for MR1 dated May 21, 2024, revealed the patient stated they were neglected and that the staff pulled her right arm out the socket.
Continued review of nursing documentation for MR1 dated May 21, 2024, in "Abuse Indicators" revealed the patient reported they did not feel safe and was at risk at the transferring facility; that they were in immediate danger with threats or direct abuse to them, were afraid their life was in danger and did not have a safe place to go.
Review on April 23, 2025, of ED provider documentation for MR1 dated May 22, 2024, revealed the patient presented with complaints of poor treatment at the transferring behavioral health facility and felt they were mistreated there with nursing staff being rough on her. They believed the staff pulled hard on their right arm and they are unsure if it is out of the socket with pain described as moderately intense. The patient also complained of a mild skin tear to the left hand.
Further review of ED provider documentation for MR1 revealed they advised the patient they would need to speak with the social work team at the transferring facility and request a transfer.
Email interviews with EMP1 on April 25, 2025, at 8:38 AM and 1:58 PM, confirmed there was no further documentation in MR1 available stating the abuse was reported and there were no event reports submitted for this patient. Continued interview with EMP1 confirmed the facility policy stated that alleged abuse should be reported immediately, and standard operation procedure dictates to report any suspected abuse to the Department of Health within 24 hours of notification.
| | Plan of Correction - To be completed: 05/31/2025
Roxborough Memorial Hospital, including the Medical Staff and Governing Board, will ensure the plan of correction is implemented, monitored, and managed. The Nursing Director of the Emergency Department will ultimately be responsible for the plan of correction to address noncompliance with reporting alleged abuse immediately.
The following actions will take place: The policy, Reporting Abuse/Neglect Allegations: child abuse, domestic violence/spousal/partner; victims of assault/battery, will be revised. It will clearly state that reporting of suspected abuse will be reported immediately (or as soon as practically possible). The reference to timeframes that are not listed in the policy will be removed. This will be completed by May 7th, 2025.
All Emergency Department medical staff and nurses will be educated on the need to ensure alleged abuse is reported immediately to the appropriate departments. Education will be completed with sign off via the electronic education system and/or one on one education. The education will be completed by May 31st, 2025.
100% compliance of reporting alleged abuse will be tracked through random chart audits and reporting via our electronic reporting system. The Nursing Director of the Emergency Department and Director of Performance Improvement will have oversight. The Nursing Director of the Emergency Department will ensure reporting and documentation is completed when alleged abuse is identified.
Any employee that does not complete the reporting of alleged abuse will receive disciplinary action as warranted. Any physicians that do not complete the reporting of alleged abuse will be referred to Peer Review.
The results of the monitoring will be submitted to the Quality Committee on a monthly basis for three months, Medical Executive Committee on a monthly basis for three months, and Governing Board on a quarterly basis.
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