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Based on interview, record review, review of the video and review of the facility's policies and documents, it was determined the facility failed to ensure that each patient's rights were protected and promoted by failing to ensure the facility's policy and procedure protected patients from abuse and by failing to providing care and treatment in a safe setting for one (1) of ten (10) sampled patients (Patient #6). Patient #6 was admitted on 05/13/13 with diagnoses that included: a rash to the torso, Mucositis, Photophobia and Headache. On 05/25/13, Patient #6 was a patient in the Medical Intensive Care Unit #2. Patient #6 was placed in bilateral upper extremity restraints, on a ventilator (to breath for the patient), Propofol (a general anesthetic for sedation), and an Electroencephalography (EEG) with video capabilities (EEG to measure the electrical activity of the brain) was in progress to monitor for seizure activity. Review of the EEG video tape revealed, on 05/25/13 at 2:40 PM, Primary Nurse (PN) #1, the Registered Nurse assigned to Patient #6, and Nurse Care Technician (NCT) #2 were in the room with Patient #6 to reposition the patient. While repositioning Patient #6, PN #1 and NCT #2 unbuckled the wrist restraints from the bed. Patient #6 was becoming increasingly agitated and pulled out the dobhoff (feeding tube). At this point PN #1 called Patient #6 "a little shit". EEG video revealed, a second registered nurse (RN), RN #1 entered the room. According to wittness statements, RN #1 forcefully pushed Patient #6's torso back onto the mattress using his hand on the patient's throat. EEG video revealed, a third RN, RN #2 entered the room. RN #2 came into the room and struck Patient #6 in the right thigh.

There was no documented evidence any of the witnesses reported the verbal and physical abuse until 05/30/13 at which time NCT #2 reported the verbal and physical abuse to Unit Manager #1. The facility initiated an investigation of the allegations on 05/31/13; however, the staff that was alleged to have been verbally and physically abusive to Patient #6 were allowed to continue to have contact with Patient #6 by working an additional two (2) twelve (12) hour shifts in the Medical Intensive Care Unit #2 (06/01/13 and 06/02/13) and continued to have access to Patient #6, while the facility was conducting the investigation. Two (2) of the three (3) RNs that participated in the above event were terminated from employment at the facility on June 5, 2013.

The failure of the facility to provide a safe environment and appropriate nursing supervision placed patients at risk for serious injury, harm, impairment or death. It was determined Immediate Jeopardy existed on 05/25/13. It is further determined because the facility's policies and procedures failed to clearly state that any allegation of abuse, neglect, or exploitation should be immediately reported to a supervisor and failed to clearly state the alleged abusive staff would be suspended or removed from patient care to ensure patients' safety during the investigation of abuse allegations, the Immediate Jeopardy is ongoing.

(refer to A0145)

Based on interview, record review, video review and review of the facility's policies and documents, it was determined the facility failed to ensure that each patient's rights were protected and promoted by failing to ensure the facility's policies and procedures protected patients from abuse. Additionally, the facility failed to have mechanisms and methods in place for immediately reporting allegations of abuse and failed to ensure each patient was free from all forms of abuse or harassment during the investigation of allegations of abuse for one (1) of ten (10) sampled patients (Patient #6).

The facility failed to protect the physical safety of Patient #6, while in the Medical Intensive Care Unit #2 (MICU #2). The facility admitted Patient #6 on 05/13/13 with diagnoses which included a rash to the torso, Mucositis, Photophobia and a Headache. On 05/25/13, Patient #6 was a patient in the MICU #2. Patient #6 was in bilateral upper extremities restraints, on a ventilator (to breath for the patient), receiving Propofol (a general anesthetic for sedation), and an Electroencephalography with video capabilities (EEG to measure the electrical activity of the brain) was in progress to monitor for seizure activity. Review of the EEG video, review of written statements and interviews revealed Patient #6 was verbally and physically abused during care on 05/25/13; however, the abuse was not reported to facility management until 05/30/13. Additionally, after the facility was made aware of the allegations of staff to patient abuse, the facility failed to protect the patient from exposure to the alleged perpetrators during the investigational process.

The findings include:

Review of the facility's admission documentation titled "Authorizations & Agreements" subsection titled "Your Rights & Responsibilities as a UK HealthCare Patient", dated 02/13, revealed patients had the right to receive care in a safe environment free from all forms of abuse, neglect or harassment.

Review of the facility's policy #A08-025, titled "Behavioral Standards in Patient Care" with a revision date of 08/11, revealed the patient's safety, health, or welfare should be protected and should not be subordinated to organizational, staff, educational, or research interests or to any other end. Additionally, the policy revealed, behavior reflecting the dignity, responsibility and service orientation of health care professionals who were worthy of the public's respect and confidence should be practiced by all individuals. Furthermore, the policy revealed, if an individual involved in patient care violates the standards, the offender's supervisor must determine the severity of the violation and take appropriate action.

Review of the facility's policy #HP06-08, titled "Protection of Adults: Reporting Abuse, Neglect, or Exploitation", dated 11/09, revealed in the event a member of the Medical Center facility or Hospital staff was implicated in an abuse or neglect situation, the Hospital would take steps to protect the patient from exposure to the individual during the investigation, care of the patient would be reassigned to avoid exposure to the involved staff. Further review of the policy revealed the policy did not address written procedures for management guidance when an abuse allegation was reported. In addition the policy did not address protecting all patients during the investigation of an abuse allegation.

Review of the video obtained by the Electroencephalography (EEG) revealed, on 05/25/13 at 2:42 PM, Primary Nurse (PN) #1 and Nursing Care Technician (NCT) #2 were in Patient #6's room repositioning the patient. During this care, the wrist restraints were unbuckled from the bed. Video revealed the patient became increasingly agitated and dislodged his/her Dobhoff tube (feeding tube). The video revealed PN #1 called Patient #6 "a little shit". The video revealed a second nurse, Registered Nurse (RN) #1 entered the room and proceeded to place his hand on Patient #6's neck area forcing the patient down on the bed. Further review of the video revealed, a third nurse, RN #2 entered the room with arm motions and audio consistent with hitting Patient #6's right thigh. At that point, Patient #6 was subdued by PN #1 and Patient #6's leg did not appear to be in motion. Audio sound on the EEG revealed a slapping noise and then staff in the room laughing.

Interview with NCT #2, on 06/13/13 at 11:25 AM, revealed she was the NCT assisting with the care of Patient #6 in the MICU #2 on 05/25/13. Further interview revealed while providing care to Patient #6 on 05/25/13, she witnessed RN #1 push the patient back in the bed by the neck. Further interview revealed she also witnessed RN #2 strike Patient #6 in the right leg. NCT #2 stated she did not know what the facility's policy was on reporting abuse to administration; however, she stated "it was wrong to treat patients like that". NCT #2 also acknowledged during the interview that PN #1 called the patient "a little shit". NCT #2 stated she worked with RN #1 and RN #2 again on 05/26/13 in MICU #2 without further incident and reported the allegations of abuse to her Unit Manager on 05/30/13. NCT #2 stated she waited to report the allegations to her Unit Manager because she felt the Unit Manager would follow up. NCT #2 further stated that she should have reported the allegations of abuse to a House Officer when it happened and should not have waited to report directly to her Unit Manager.

Review of NCT #2's witness statement, dated 05/31/13 revealed RN #1 put his hand around Patient #6's neck and pushed him/her down into the bed. Further review revealed RN #2 entered the room and punched Patient #6 in the right upper thigh.

Interview with PN #1, on 06/14/13 at 2:45 PM, revealed on 05/25/13 he was the primary nurse responsible for the care of Patient #6. Interview further revealed on 05/25/13 he requested assistance from other staff to assist him and NCT #2 to apply restraints to Patient #6's legs. Interview revealed RN #1 came to assist in placing the restraints and forced Patient #6 back down onto the bed by placing his hands around Patient #6's neck to push him/her back onto the bed. Interview revealed RN #2 came into the room, grabbed the foot of the bed, shook it hard then moved from the foot of the bed to the bedside. RN #2 then hit Patient #6 in the right leg. Continued interview revealed he did not remember calling Patient #6 "a little shit", however stated "it was said in the excitement of the moment, it was not my intent to put a patient down". PN #1 further stated he should not have said it. PN #1 stated at the time of the incident, he was not sure how to report the abuse to administration. PN #1 stated his annual education which included abuse was not completed until 05/31/13. Additionally, PN #1 revealed he would have reported this incident had there been better or more written guidance.

Review of PN #1's witness statement, undated, revealed RN #1 entered the room and reached in front of PN #1 and held Patient #6 against the bed by the neck. Further review revealed, RN #2 entered the room and punched Patient #6 in the right leg.

Review of RN #1's account of the events, undated, revealed RN #1 entered the room and was kicked in the chest by Patient #6. (Patient #6 had been kicking his legs however, RN #1's back was to the EEG camera and actual video of contact to RN #1's chest was not clear). Further review revealed RN #1 stated his initial response was to push the patient back down in the bed by his chest.

Review of RN #2's account of events, undated, revealed RN #2 entered the room saw Patient #6's right leg swinging wildly and RN #2 lunged for the leg and missed grabbing it.

Interview with Unit Manager (UM) #1, on 06/13/13 at 9:40 AM, revealed the allegations were reported to her on 05/30/13 verbally by the NCT #2. Further interview revealed UM #1 notified her manager (The Medicine Services Line Director) and the Human Resources Department on 05/31/13. She stated the one (1) day delay in reporting to Administration was because she was on her way to a training and then had an appointment. Further interview revealed the Human Resources Department advised UM #1 on 05/31/13 to obtain witness statements from the four (4) staff involved, however, did not advise her to remove the alleged perpetrators from direct patient care. Further interview revealed UM #1 stated "to allow them to work the weekend was her manager's and her mistake". The staff that were alleged to have been verbally and physically abusive to Patient #6 were allowed to continued to have contact with Patient #6 by working an additional two (2) twelve (12) hour shifts during the investigation process. These shifts were 06/01/13 and 06/02/13. Further interview revealed, the alleged perpetrators were barred from working the MICU #2 on 06/03/13 and terminated on 06/05/13. UM #1 further revealed PN #1 was given a verbal reprimand for calling Patient #6 "a little shit". Additionally, interview on 06/14/13 at 1:15 PM, revealed the facility did not have a written procedure for allegations of staff to patient abuse. UM #1 further stated she would have made different choices had there been written guidelines.

Interview with Human Resources, on 06/14/13 at 1:05 PM, revealed the focus of that department was employee based and not patient based. Further interview revealed the Human Resources Department did not have procedures for investigating allegations of abuse and the Manager of the department would be responsible for suspending the employee.

Interview with the interim Medical Services Line Director (Medical Services Line Director was on vacation during the investigation), on 06/14/13 at 2:00 PM, revealed the facility did not have written procedures for allegations of staff to patient abuse. She further stated the facility's policy was to protect the patient from exposure to the individual. She further stated her expectations would have been for minor allegations of abuse to reassign the patient to another caregiver; however, for allegations such as hitting, her expectation would have been to remove the caregiver from patient care.

Interview with the Director of Accreditation, on 06/14/13 at 10:30 AM, revealed it would be her expectation that the employee or employees of abuse allegations would be removed from patient care either in non-patient care areas or off duty pending the investigation determination. She further stated the wording of the policy "re-assigned" to avoid exposure to the involved staff was too broad and if various people were asked, she would expect to receive various responses as to what "re-assigned" meant. Further interview, on 06/14/13 at 1:15 PM, revealed the facility did not have a written procedure or guideline for management staff to utilize for allegations of abuse.

Based on interview, record review, review of the video and review of the facility's policies and documents, it was determined the facility failed to provide adequate nursing supervision and timely nursing supervisory action to protect patients from abuse for one (1) of ten (10) sampled patients (Patient #6). Patient #6 was admitted on 05/13/13 with diagnoses that included: a rash to the torso, Mucositis, Photophobia and Headache. On 05/25/13, Patient #6 was a patient in the Medical Intensive Care Unit #2. Patient #6 was placed in bilateral upper extremity restraints, on a ventilator (to breath for the patient), Propofol (a general anesthetic for sedation), and an Electroencephalography (EEG) with video capabilities (EEG to measure the electrical activity of the brain) was in progress to monitor for seizure activity. Review of the EEG video tape revealed, on 05/25/13 at 2:40 PM, Primary Nurse (PN) #1, the Registered Nurse assigned to Patient #6, and Nurse Care Technician (NCT) #2 were in the room with Patient #6 to reposition the patient. While repositioning Patient #6, PN #1 and NCT #2 unbuckled the wrist restraints from the bed. Patient #6 was becoming increasingly agitated and pulled out the dobhoff (feeding tube). At this point PN #1 called Patient #6 "a little shit". EEG video revealed, a second registered nurse (RN), RN #1 entered the room. According to wittness statements, RN #1 forcefully pushed Patient #6's torso back onto the mattress using his hand on the patient's throat. EEG video revealed, a third RN, RN #2 entered the room. RN #2 came into the room and struck Patient #6 in the right thigh.

There was no documented evidence that any of the witnesses reported the verbal and physical abuse until 05/30/13 at which time NCT #2 reported the verbal and physical abuse to Unit Manager #1. Unit Manager #1 failed to ensure protection of the patients by failing to initiate an investigation of the allegations until 05/31/13. The staff that was alleged to have been verbally and physically abusive to Patient #6 were allowed to continue to have contact with Patient #6 by working an additional two (2) twelve (12) hour shifts in the Medical Intensive Care Unit #2 (06/01/13 and 06/02/13) and continued to have access to Patient #6, while the facility was conducting the investigation. Two (2) of the three (3) RNs that participated in the above event were terminated from employment at the facility on June 5, 2013.

The facility's failure to provide a safe environment from abuse and appropriate nursing supervision placed patients at risk for serious injury, harm, impairment or death. It was determined Immediate Jeopardy existed. It was further determined that the facility's policies and procedures failed to provide clear guidance to nursing staff of reporting as well as investigating allegations of abuse, neglect, or exploitation to ensure patients' safety during the investigation of abuse allegations.The Immediate Jeopardy is ongoing.

(refer to A0395)

Based on interview, record review, video review and review of the facility's policies and documents, it was determined the facility failed to ensure that each patient's rights were protected and promoted through nursing supervision. The facility failed to provide written guidance to nursing supervisors for appropriate investigation of allegations of abuse and failed to ensure each patient was free from all forms of abuse or harassment during the investigation for one (1) of ten (10) sampled patients (Patient #6).

The facility failed to protect the physical safety of Patient #6, while in the Medical Intensive Care Unit #2 (MICU #2). The facility admitted Patient #6 on 05/13/13 with diagnoses which included a rash to the torso, Mucositis, Photophobia and a Headache. On 05/25/13, Patient #6 was a patient in the MICU #2. Patient #6 was in bilateral upper extremities restraints, on a ventilator (to breath for the patient), receiving Propofol (a general anesthetic for sedation), and an Electroencephalography with video capabilities (EEG to measure the electrical activity of the brain) was in progress to monitor for seizure activity. Review of the EEG video, review of written statements and interviews revealed Patient #6 was verbally and physically abused while receiving nursing care on 05/25/13; however, the abuse was not reported to facility management until 05/30/13. Additionally, after the nursing supervisor was informed of the allegations of staff to patient abuse, the facility failed to protect the patient from exposure to the alleged perpetrators during the investigation process.

The findings include:

Review of the facility's admission documentation titled "Authorizations & Agreements" subsection titled "Your Rights & Responsibilities as a UK HealthCare Patient", dated 02/13, revealed patients had the right to receive care in a safe environment free from all forms of abuse, neglect or harassment.

Review of the facility's policy #A08-025, titled "Behavioral Standards in Patient Care" with a revision date of 08/11, revealed the patient's safety, health, or welfare should be protected and should not be subordinated to organizational, staff, educational, or research interests or to any other end. Additionally, the policy revealed, behavior reflecting the dignity, responsibility and service orientation of health care professionals who were worthy of the public's respect and confidence should be practiced by all individuals. Furthermore, the policy revealed, if an individual involved in patient care violates the standards, the offender's supervisor must determine the severity of the violation and take appropriate action.

Review of the facility's policy "Protection of Adults: Reporting Abuse, Neglect, or Exploitation" (HP06-08), dated 11/09, it stated the following: when a health care professional or employee suspects that a patient may be suffering from abuse, neglect or exploitation, the employee will contact the social worker assigned to the appropriate service. If the social worker is unavailable, the physician or nurse should perform the responsibilities hereafter assigned to the social worker. Under the "Protection of Patients During Investigations of Abuse and Neglect" it stated: In the event a member of the Medical Center faculty or Hospital staff are implicated in an abuse or neglect situation, the Hospital will take steps to protect the patient from exposure to the individual during the investigation. During the investigation, care of the patient will be reassigned to avoid exposure to the involved staff. Further review of the policy revealed the policy did not address written procedures for management guidance when an abuse allegation was reported. In addition, the policy did not address removing the alleged abusive staff from direct patient care in order to protect all patients during the investigation of an abuse allegation.

Review of the video obtained by the Electroencephalography (EEG) revealed, on 05/25/13 at 2:42 PM, Primary Nurse (PN) #1 and Nursing Care Technician (NCT) #2 were in Patient #6's room repositioning the patient. During this care, the wrist restraints were unbuckled from the bed. Video revealed the patient became increasingly agitated and dislodged his/her Dobhoff tube (feeding tube). The video revealed PN #1 called Patient #6 "a little shit". The video revealed a second nurse, Registered Nurse (RN) #1 entered the room and proceeded to place his hand on Patient #6's neck area forcing the patient down on the bed. Further review of the video revealed, a third nurse, RN #2 entered the room with arm motions and audio consistent with hitting Patient #6's right thigh. At that point, Patient #6 was subdued by PN #1 and Patient #6's leg did not appear to be in motion. Audio sound on the EEG revealed a slapping noise and then staff in the room laughing.

Interview with NCT #2, on 06/13/13 at 11:25 AM, revealed she was the NCT assisting with the care of Patient #6 in the MICU #2 on 05/25/13. Further interview revealed while providing care to Patient #6 on 05/25/13, she witnessed RN #1 push the patient back in the bed by the neck. Further interview revealed she also witnessed RN #2 strike Patient #6 in the right leg. NCT #2 stated she did not know what the facility's policy was on reporting abuse to administration; however, she stated "it was wrong to treat patients like that". NCT #2 also acknowledged during the interview that PN #1 called the patient "a little shit". NCT #2 stated she worked with RN #1 and RN #2 again on 05/26/13 in MICU #2 without further incident and reported the allegations of abuse to her Unit Manager (UM), UM #1, on 05/30/13. NCT #2 stated she waited to report the allegations to UM #1 because she felt the UM #1 would follow up. NCT #2 further stated that she should have reported the allegations of abuse to a House Officer when it happened and should not have waited to report directly to her UM #1.

Review of NCT #2's witness statement, dated 05/31/13 revealed RN #1 put his hand around Patient #6's neck and pushed him/her down into the bed. Further review revealed RN #2 entered the room and punched Patient #6 in the right upper thigh.

Interview with PN #1, on 06/14/13 at 2:45 PM, revealed on 05/25/13 he was the primary nurse responsible for the care of Patient #6. Interview further revealed on 05/25/13 he requested assistance from other staff to assist him and NCT #2 to apply restraints to Patient #6's legs. Interview revealed RN #1 came to assist in placing the restraints and forced Patient #6 back down onto the bed by placing his hands around Patient #6's neck to push him/her back onto the bed. Interview revealed RN #2 came into the room, grabbed the foot of the bed, shook it hard then moved from the foot of the bed to the bedside. RN #2 then hit Patient #6 in the right leg. Continued interview revealed he did not remember calling Patient #6 "a little shit", however stated "it was said in the excitement of the moment, it was not my intent to put a patient down". PN #1 further stated he should not have said it. PN #1 stated at the time of the incident, he was not sure how to report the abuse to administration. PN #1 stated his annual education which included abuse was not completed until 05/31/13. Additionally, PN #1 revealed he would have reported this incident had there been better or more written guidance.

Review of PN #1's witness statement, undated, revealed RN #1 entered the room and reached in front of PN #1 and held Patient #6 against the bed by the neck. Further review revealed, RN #2 entered the room and punched Patient #6 in the right leg.

Review of RN #1's account of the events, undated, revealed RN #1 entered the room and was kicked in the chest by Patient #6. (Patient #6 had been kicking his legs however, RN #1's back was to the EEG camera and actual video of contact to RN #1's chest was not clear). Further review revealed RN #1 stated his initial response was to push the patient back down in the bed by his/her chest.

Review of RN #2's account of events, undated, revealed RN #2 entered the room saw Patient #6's right leg swinging wildly and RN #2 lunged for the leg and missed grabbing it.

Interview with Unit Manager (UM) #1, on 06/13/13 at 9:40 AM, revealed the allegations were reported to her on 05/30/13 verbally by the NCT #2. Further interview revealed UM #1 notified her manager (The Medicine Services Line Director) and the Human Resources Department on 05/31/13. She stated the one (1) day delay in reporting to Administration was because she was on her way to a training and then had an appointment. Further interview revealed the Human Resources Department advised UM #1 on 05/31/13 to obtain witness statements from the four (4) staff involved, however, did not advise her to remove the alleged perpetrators from direct patient care. Further interview revealed UM #1 stated "to allow them to work the weekend was her manager's and her mistake". The staff that were alleged to have been verbally and physically abusive to Patient #6 were allowed to continue to have contact with Patient #6 by working an additional two (2) twelve (12) hour shifts during the investigation process. These shifts were 06/01/13 and 06/02/13. Further interview revealed, the alleged perpetrators were barred from working the MICU #2 on 06/03/13 and terminated on 06/05/13. UM #1 further revealed PN #1 was given a verbal reprimand for calling Patient #6 "a little shit". Additionally, interview on 06/14/13 at 1:15 PM, revealed the facility did not have a written procedure for investigating allegations of staff to patient abuse. UM #1 further stated she would have made different choices had there been written guidelines.

Interview with Human Resources, on 06/14/13 at 1:05 PM, revealed the focus of that department was employee based and not patient based. Further interview revealed the Human Resources Department did not have procedures for investigating allegations of abuse and the Manager of the department would be responsible for suspending the employee.

Interview with the interim Medical Services Line Director (Medical Services Line Director was on vacation during the investigation), on 06/14/13 at 2:00 PM, revealed the facility did not have written procedures for investigating allegations of staff to patient abuse. She further stated the facility's policy was to protect the patient from exposure to the individual. She further stated her expectations would have been for minor allegations of abuse to reassign the patient to another caregiver; however, for allegations such as hitting, her expectation would have been to remove the caregiver from patient care.

Interview with the Director of Accreditation, on 06/14/13 at 10:30 AM, revealed it would be her expectation that the employee or employees of abuse allegations would be removed from patient care either in non-patient care areas or off duty pending the investigation determination. She further stated the wording of the policy "re-assigned" to avoid exposure to the involved staff was too broad and if various people were asked, she would expect to receive various responses as to what "re-assigned" meant. Further interview, on 06/14/13 at 1:15 PM, revealed the facility did not have a written procedure or guideline for management staff to utilize for investigating allegations of abuse.