The Arizona Department of Health Services has completed an investigation into Mesa’s Banner Desert Medical Center in response to a foster mother’s complaint that her deaf daughter with special needs was neglected while in the hospital’s care.
The state’s report concluded there were several “deficiencies” related to the girl’s case, including a failure to ensure proper treatment of a wound, failure to properly document her care, and a failure to properly compare active medications with discontinued medications.
The hospital has provided a required written plan of correction to remedy the violations. Corrections include staff education about treating deaf patients, a revised reporting system to prevent medication errors, and the hiring of a behavioral health manager.
“At Banner Health we strive to meet the unique needs of every patient, every day,” said Banner's Jennifer Ruble in a written statement to 12 News. “This means making interpreters available for those who prefer to communicate in a different language, including American Sign Language, as well as other accommodations to make patients feel safer and more comfortable while in our care.”
The investigation stems from a complaint filed against the hospital last year. As 12 News previously reported, 16-year-old Zainab Elliott stayed at the hospital for 45 days in early 2016 while she was temporarily in the custody of the state. Elliott is deaf and is diagnosed with autism and a seizure disorder. Her mother, Cynthia Elliott, made an unannounced visit to the hospital on Jan. 21, 2016 and alleged that she found her daughter naked and restrained in a hospital "posey" bed with no ASL interpreter accompanying her.
"She smelled like urine and it appeared no one had been taking care of her," Cynthia Elliott said at the time.
She filed a complaint with ADHS in August of 2016. In response, the agency conducted an unannounced, on-site “investigation survey” over the course of three days in April of 2017. The investigation included interviews with hospital staff. The results of the investigation are detailed in a May 16, 2017 “statement of deficiencies” letter sent to the hospital. It includes the following findings:
-Failure to ensure that nursing staff utilized video remote interpreting services or a qualified interpreter for effective communication
-Failure to have a process to ensure that active medications ordered are checked and compared with discontinued medications
-Failure to ensure the pediatric patient was properly assessed when in restraints
-Failure to complete an assessment on the patient every 15 minutes as required
-Failure to ensure that nursing staff completed wound care of the patient
The report also notes that three nurses recognized a wound on the patient’s buttocks during her stay and there was no evidence the wound was treated. “There is no documented evidence they started wound care, according to the hospital’s wound care guidelines,” the report states.
The report also confirmed there is a gap in documentation by the hospital, as first reported by 12 News last year. A hospital senior manager confirmed to a state investigator that records, known as “direct observation forms”, were available for every day of Zainab’s hospitalization, except for the day of Jan. 21, 2016. That was the same day Cynthia Elliott made her unannounced visit to the hospital.
“The hospital failed to ensure that this pediatric patient was properly assessed when in restraints and there is no documentation for 1/21/16 that BHT (behavioral health technician) #45 completed an assessment on this patient every 15 minutes as required,” the report states.
“I have to question if those records were destroyed on purpose so that what I witnessed could not be substantiated,” Cynthia Elliott said Wednesday. “My concern remains that my 16-year-old handicapped, deaf daughter was abused at Banner Desert and was left with no supervision.”
In response to the allegation the hospital purposely destroyed records, a spokesperson for Banner Desert issued a statement to 12 News that reads:
"Most of Banner’s patient records are electronic, but the level of care required by Zainab included some paper documentation. It is true that we were unable to locate one specific paper document in the overall record of care for that day. We have taken this opportunity to provide staff education on related policies. We understand and appreciate the concerns expressed by Ms. Elliott. We are glad that she has elected to allow Banner Health to continue to provide care for Zainab,"
As part of its corrective action plan, the hospital also purchased equipment to ensure all patient units have video remote interpreting services. Staff members also signed off on education of impaired patients, records show.
Elliott said she’s not sure if she will pursue the matter further.
“I’m not aware of any other recourse I have at this point, other than to never take my child to Banner Desert hospital again,” she said.
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