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Based on facility policy review, medical record review, facility document review, and interview, the facility failed to thoroughly investigate an allegation of abuse for one (1) of three (3) (Patient #1) sampled patients.

The findings included:

1. Review of the facility's policy titled, "Abuse and Neglect of Patients" revised on 11/2015 revealed, "It is the policy of [Hospital #1] and its associates to prohibit all forms of abuse and neglect and harassment whether from staff, other patients or visitors...Each hospital shall ensure that patients are free from all forms of abuse, neglect, or harassment...Allegations information indicating that abuse or neglect may have occurred will be thoroughly and promptly investigated with appropriate follow-up action taken...Whenever there is an allegation of abuse or neglect, appropriate Hospital staff should immediately assessess [assess] patient's personal safety the potential of harm to the patient and/or other patients, including the removal of any alleged perpetrator from the patient care area...The investigation process begins when a Nursing Supervisor, the Director of Nursing, the Hospital CEO [Chief Executive Officer], or another member of the Hospital Leadership receives an allegation that abuse or neglect may have taken place...The receipt of information triggers a process for taking action to protect patients and employees and collecting information to determine facts that will either substantiate a finding that abuse or neglect took place or lead to the conclusion that it did not. In all cases, the emphasis is on finding facts and taking appropriate action to protect all parties, including people who may be victims of abuse and neglect and people who may be unfairly accused..."

2. Medical record review for Patient #1 revealed the patient was transferred to Hospital #1 from Hospital #2 on 10/30/2019 for rehabilitation services following an inpatient stay where he underwent spinal fusion surgery to decompress and stabilize his spine after he sustained a traumatic fracture of his Cervical spine. (Spinal fusion is surgery to join two or more vertebrae into one single structure. Patient #1's inpatient stay at Hospital #2 was complicated with new onsets of diagnoses which included Acute Respiratory Failure, (a condition in which the usual exchange between oxygen and carbon dioxide in the lungs does not occur), Atrial Fibrillation, (an irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications), Acute Kidney Injury, (a condition in which the kidneys suddenly can't filter waste from the blood), and Deep Vein Thrombosis in his left upper arm (a condition in which a blood clot develops in a deep vein.).

3. The facility's Patient Experience Supervisor allowed this surveyor to view their documentation regarding an allegation of abuse the facility received from the Better Business Bureau (BBB) on 10/8/2020 at 1:35 PM. This surveyor was not provided the actual letter the facility received, only their documentation of the nature of the complaint. The documentation indicated staff member's attitude and behavior directed toward Patient #1 was considered to be abusive. The facility's Investigative Summary revealed Patient #1 fell outside of the hospital and that is what resulted in his admission to Hospital #1. The patient fell off a bar stool and was taken to Hospital #3, then transferred to Hospital #2 for a higher level of care. Patient #1 was then transferred to Hospital #1 for rehabilitation services. The documentation indicated the facility immediately consulted with their corporate legal team seeking guidance on how to respond to the BBB. There was no documentation the allegation of abusive attitudes and behaviors directed toward Patient #1 were thoroughly investigated or addressed by the facility.

In an interview on 3/2/2021 at 1:25 PM, the Patient Experience Manager (PEM) was asked what steps the facility did after they received the complaint alleging abusive attitudes and behaviors directed toward Patient #1. The PEM stated, "We responded to the BBB." When asked if any staff members were interviewed and/or investigated for the abuse allegations, the PEM stated "Not to my knowledge." The PEM continued and stated "I do not know what the [complainant] means by abuse and neglect took place...I was never aware any complaints or concerns were voiced by the patient or family during the short time he [Patient #1] was here." The PEM then verified no staff members were interviewed regarding the abuse allegations.

In a telephone interview on 3/2/2021 at 1:34 PM, the Risk Manager (RM) was asked if an investigation regarding the abuse allegations was completed. The patient's death event reporting had gone to the Medical Examiner's (ME) office because the patient's initial injuries were the result of an assault. The RM continued and stated they hadn't heard anything else regarding Patient #1 until they received the complaint from the BBB in which the complainant had voiced concerns that Patient #1's PEG tube was occluded and when it was un-occluded, the patient received all of his medications at once resulting in an overdose . The RM stated the facility reached out to the ME's office and patient's cause of death was "complications related to blunt force trauma, and was ruled a "homicide." The RM was asked if the facility conducted any interviews or further investigation regarding the allegations that staff attitudes and behaviors were abusive toward Patient #1. The RM stated, "If I would have done anything, it would have been to email the manager. I know there were no concerns voiced while he [Patient #1] was here [Hospital #1].

In an interview on 3/2/2021 at 1:58 PM, the Nurse Manger verified she had received an email from the RM that included the letter from the complainant. The RM had a list of questions regarding the complaint for her to respond to. The Nurse Manager then stated, "I did the investigation then sent my response." This surveyor was provided a copy of the email correspondence, and continued the interview. The email contained a series of questions that addressed many of the complainant's allegations; however, when asked how she determined her responses, she stated by reviewing the medical record. The Nurse Manager was asked if she interviewed any staff members regarding the abuse allegations. The Nurse Manager stated, she didn't because the description of the Patient Care Technician (PCT) matched a person that was no longer working at the facility. The Nurse Manager was asked if she interviewed any other staff members or potential witnesses to abuse allegations. She stated, "No."

In an interview on 3/2/2021 at 2:38 PM, Therapist #2 stated she didn't really remember Patient #1. The therapist read the documentation from the medical record and stated, "He refused to participate...it looks like he was cattywampus in the bed." Therapist #2 was asked if the patient was repositioned. The therapist stated, "I imagine I tried, I would have never left him that way." The therapist was asked if she forcefully attempted to pull Patient #1's hand off the bed rail. Therapist #2 stated, "I would grab them and try to loosen them and try to get him to let go. I don't remember him [Patient #1], but that's probably what I would have done." Therapist #2 was asked if any members of management or administration had interviewed her regarding Patient #1. The therapist stated, "No."

In a telephone interview on 3/4/2021 at 3:04 PM, RN #2 was asked if she could recall caring for Patient #1. She stated she remembered taking care of somebody that fell off a barstool, but she couldn't recall anything specific about the patient. RN #2 was asked if anyone from the facility had interviewed her regarding the care she or any other staff members provided to Patient #1 or any allegations of abuse regarding Patient #1. RN #2 stated "No." RN #2 was asked if she observed PCT #3 or any other staff member verbally or physically abuse Patient #1. The RN stated, "No." RN #2 was asked if the patient or his family voiced any concerns regarding the care and treatment the patient had received. RN #2 stated, "No."

In a telephone interview on 3/4/2021 at 3:10 PM, RN #1 was asked if she could recall caring for Patient #1. The RN stated, she did recall caring for the patient and verified she was there the night the patient expired. RN #1 was asked if anyone from the facility had interviewed her regarding the care she or any other staff members provided to Patient #1 or any allegations of abuse regarding Patient #1. RN #1 stated "No." ." RN #1 was asked if she observed any other staff members verbally or physically abuse Patient #1. The RN stated, "No." RN #1 was asked if the patient or his family voiced any concerns regarding the care and treatment the patient had received. RN #1 stated, "No."

In a telephone interview on 3/4/2021 at 3:32 PM, RN #3 was asked if she could recall caring for Patient #1. The RN stated she remembered him and she took care of him on the day he died. RN #3 was asked if anyone from the facility had interviewed her regarding the care she or any other staff members provided to Patient #1 or any allegations of abuse regarding Patient #1. RN #3 stated "No." RN #3 was asked if she observed PCT #3 or any other staff member verbally or physically abuse Patient #1. The RN stated, "No, if I had I would have punched him." RN #3 was asked if the patient or his family voiced any concerns regarding the care and treatment the patient had received. RN #3 stated, "No."

In a telephone interview on 3/4/2021 at 4:26 PM, PCT #1 was asked if he could recall caring for Patient #1. The PCT stated, "I remember that entire situation, it was my first week there." PCT #1 was asked if anyone from the facility had interviewed him regarding the care he or any other staff members provided to Patient #1 or any allegations of abuse regarding Patient #1. The PCT stated "No." PCT #1 was asked if he observed any staff members verbally or physically abuse Patient #1. The PCT stated, "No." PCT #1 was asked if the patient or his family voiced any concerns regarding the care and treatment the patient had received. PCT #1 stated, "No."

In a telephone interview on 3/4/2021 at 5:22 PM, PCT #2 was asked if she could recall caring for Patient #1. The PCT stated, "Yes, I believe we coded him." The PCT verified she had helped move the patient up in his bed sometime between 8 or 9:00 PM on the night of 10/31/2019. PCT #2 was asked if anyone from the facility had interviewed her regarding the care she or any other staff members provided to Patient #1 or any allegations of abuse regarding Patient #1. The PCT stated "No." PCT #2 was asked if she observed any staff members verbally or physically abuse Patient #1. The PCT stated, "No." PCT #2 was asked if the patient or his family voiced any concerns regarding the care and treatment the patient had received. PCT #2 stated, "No."

In a telephone interview on 3/8/2021 at 11:00 AM, PCT #3 was asked if he could recall caring for Patient #1. The PCT stated, "Yes," The PCT continued and stated Patient #1 kept trying to get out of bed on his own and wouldn't call for help." PCT #3 was asked if anyone from the facility had interviewed him regarding the care he or any other staff members provided to Patient #1 or any allegations of abuse regarding Patient #1. The PCT stated "No." PCT #3 was asked if he observed any staff members verbally or physically abuse Patient #1. The PCT stated, "No." PCT #3 was asked if the patient or his family voiced any concerns regarding the care and treatment the patient had received. PCT #3 stated, "No."

Based on facility policy review, medical record, and interview, the facility failed to ensure facility staff assessed pain management effectiveness for one (1) of three (3) (Patient #1) sampled patients.

The findings included:

1. Review of the facility's policy titled, "Pain Assessment" dated 11/2015 revealed, "...Every patient has the right to appropriate assessment and management of pain. Every patient is screened for presence of pain upon initial admission to the hospital or other setting...In patients experiencing moderate to severe pain, pain intensity scores should be obtained at least every four (4) hours and additional scores obtained within one hour after administration of oral analgesics..Adult and pediatric pain terminology would equate to a numeric scale as follows; "Mild" = [equals] a pain score of 1-3, "Moderate" = a pain score of 4-6, "Severe" = a pain score of 7-10..."

2. Medical record review for Patient #1 revealed the patient was transferred to Hospital #1 from Hospital #2 on 10/30/2021 for rehabilitation services following an inpatient stay where he underwent spinal fusion surgery to decompress and stabilize his spine after he sustained a traumatic fracture of his Cervical spine. (Spinal fusion is surgery to join two or more vertebrae into one single structure.) Patient #1's inpatient stay at Hospital #2 was complicated with new onsets of diagnoses which included Acute Respiratory Failure, (a condition in which the usual exchange between oxygen and carbon dioxide in the lungs does not occur), Atrial Fibrillation, (an irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications), Acute Kidney Injury, (a condition in which the kidneys suddenly can't filter waste from the blood), and Deep Vein Thrombosis in his left upper arm (a condition in which a blood clot develops in a deep vein.).

Review of the admission nursing assessment dated 10/30/2019 at 3:00 PM revealed Patient #1 complained of moderate pain at a level of four (4) on a scale of zero (0) to ten (10).

The admission physician's orders dated 10/30/2019 at 4:48 PM, revealed, Patient #1 to be given the analgesic Oxycodone 5 milligrams (mg) via his percutaneous endoscopic gastrostomy (PEG) tube every 6 hours as needed for severe pain. (A PEG is a medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate.)

Review of the nursing documentation dated 10/30/2019 through 10/31/2019 revealed the following pain assessments, medication administration and pain management reassessments:

10/30/2019 at 3:00 PM - Patient #1 reported moderate pain at a level of four (4). No analgesics were administered.

10/30/2019 at 10:05 PM - Patient #1 reported severe pain at a level of nine (9). Oxycodone 5 mg was administered by Registered Nurse (RN #2) via the patient ' s PEG tube.

10/31/2019 at 2:35 AM, a total of four (4) hours and thirty (30) minutes after the Oxycodone was administered - Patient #1 was reassessed by RN #2 and his pain level was documented as level zero (0) indicating no pain.
RN #2 failed to assess pain management effectiveness for Patient #1 within an hour after administering the Oxycodone.

10/31/2019 at 4:59 AM - Patient #1 reported severe pain at a level of nine (9). Oxycodone 5 mg was administered by RN #2 via the patient ' s PEG tube.

10/31/2019 at 7:00 AM, a total of two (2) hours and one (1) minute after the Oxycodone was administered - Patient #1 was reassessed by RN #3 and his pain level was documented as level ten (10) indicating the worst possible pain.
RN #2 failed to assess pain management effectiveness for Patient #1 within an hour after administering the Oxycodone.

In a telephone interview on 3/8/2021 at 3:41 PM, the Quality Manager verified RN #2 failed to assess pain management effectiveness for Patient #1 within an hour of administering Oxycodone per the facility ' s policy on 10/30/2019 at 10:05 PM, and on 10/31/2019 at 4:58 AM.