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Based on a review of medical records, review of Governing Body Bylaws, review of policy and procedures, observations, staff interviews, and personnel file review, it was determined that the facility's Governing Body failed to ensure that the facility was in compliance with facility policies and Conditions of Participation when one Patient (P) #1 out of four (P#1, P#2, P#3, P#4) sampled patients was assaulted by a staff member and the facility failed to take immediate action; and the facility failed to ensure that the use of restraints according to standards, regulations and facility policies.

Cross reference to A0174 as it related to the facility's failure to discontinue restraints for P#1 at the earliest possible time.

Cross reference to A0145 as it relates to the facility's failure to protect P#1 from all forms of abuse or harassment when P#1 was physically assaulted by a staff member and staff witnesses failed to intervene and report the assault per facility policy.

Cross reference to A0263 as it relates to the facility's failure to take immediate actions per policy when P#1 was assaulted by a staff member.

Based on facility policy, medical record review, observations, and staff interviews, it was determined that the facility failed to promote and protect the patient rights of one Patient (P) #1 out of four (P#1, P#2, P#3, P#4) sampled patients while receiving care in the facility.

Cross reference to A0174 as it relates to the facility's failure to discontinue restraints for P#1 at the earliest possible time.

Cross reference to A0145 as it relates to the facility's failure to ensure P#1 was free from abuse while receiving care in the facility.

Based on a review of policy and procedures, video surveillance, medical records, and staff interviews, it was determined that the facility failed to protect one patient (P) #1 of four (P#1, P#2, P#3, P#4) sampled patients from abuse. Specifically, P#1 was physically assaulted by a staff member (RN YY), and staff witnesses failed to intervene. Staff witnesses falsified witness statements and documentation. In addition, staff witnesses failed to report the incident to the facility administration.

Findings:

A review of the facility's "You Have Rights" poster revealed that inpatient rights included being free of mental, physical, sexual, or verbal abuse.

A review of the facility's policy titled "Incident Management in Adult Mental Health and Forensic Units, 03-515" policy, last reviewed 6/30/21, revealed that staff who engaged in, failed to intervene, and/or failed to report incidents of abuse/neglect/exploitation were subject to personnel actions up to and including termination of employment. Staff was required to cooperate with any ensuing investigation. The policy further revealed that staff would take immediate and appropriate actions to protect the rights and safety of all individuals and report the incident to the nurse in charge or supervisor. The charge nurse would notify the physician, who would make an assessment to determine if an additional intervention was necessary to address patient safety. An incident report would be filed for each incident per policy and reported to Incident Management within eight hours. Allegations of abuse would be reported to the hospital administrator within one hour. For allegations of abuse, the person of interest would be immediately reassigned away from the alleged victim. The person of interest would remain reassigned pending an Executive Leadership Team Review decision and, if necessary, the completion of the investigation. For all incidents involving abuse, neglect, or exploitation, the supervisor would ensure the collection of physical evidence, written statements from individuals involved, witnesses, photographs of injuries, and other evidence no later than the end of the shift during which the incident occurred. The policy further revealed that the Quality and Risk Management Director would confirm external notifications were made as required by law. In the case of Abuse, Neglect, or Exploitation, a report would be sent to appropriate entities and the individual or the individual's guardian, if indicated.

A medical record review revealed that Patient (P) #1 was admitted to the facility on 5/7/2020 at 8:58 a.m. to the Forensic Inpatient Unit 4-Secure Unit. P#1 was admitted per a court order for a comprehensive evaluation and was diagnosed with paranoid schizophrenia and antisocial personality disorder.

A review of Nursing Notes by the Health Service Technician (HST) NN on 1/21/23 at 4:10 a.m. revealed that P#1 was sitting in the dayroom saying things to the staff. P#1 said the staff was beating on her family members, and she was going to beat them up if they did not stop. As the staff member came onto the unit, P#1 approached the staff member at that time. P#1 said the staff member was hitting on her family member, and she was about to take care of it. P#1 began to swing at staff, hitting and kicking staff.

A review of video footage from 1/21/23 revealed the following:

12:36 a.m. Two staff members were observed seated at a table, and P#1 was walking around the dayroom, moving from door to door with her back toward the camera. There were no other patients in the dayroom.
12:36:34 P#1 was observed speaking to a staff member.
12:37:02 The staff member got up from the table and walked behind the nurses' station out of camera view.
12:38:00 P#1 was standing at a counter near the nurses' station with her back to the camera. P#1 continued to fumble with a blanket and wrapped the blanket around her shoulders.
12:38:13 An additional staff member was observed seated at the table.
12:39:58 The staff member returned to the dayroom, followed by a staff member identified as Registered Nurse (RN) YY. RN YY was heard yelling across the dayroom to P#1, asking P#1, "Who am I hitting? Who am I hitting?"
12:39:12 P#1 left the counter and walked toward RN YY. P#1 could be heard on the video saying something about her family. RN YY yelled loudly at P#1 to go sit down multiple times; then RN YY yelled at P#1 to go to her room. RN YY was observed in what appeared to be a fighting stance with her right hand drawn back and clinched near her side. P#1 swung her right arm toward RN YY.
12:39:40 Staff members were observed on each side of P#1, with one staff member holding P#1's left arm. An additional staff member was standing on P#1's right side. RN YY was observed swinging at and charging toward P#1. The other staff members pulled P#1 back away from RN YY. RN YY continued to approach P#1 and appeared to be swinging at P#1. P#1 attempted to kick RN YY, and the staff members pulled P#1 to the side, away from RN YY.
12:40:04 As the staff members continued to escort P#1 to the side away from RN YY, P#1 fell to the floor, surrounded by RN YY and two additional staff members. P#1 was observed kicking at RN YY, and RN YY was swinging her arm at P#1's legs. RN YY walked toward P#1's head and was observed bending over P#1's head with two staff members bending over at P#1's sides. P#1 was on the floor, mostly outside the camera view, and crying on the audio could be heard. As three staff members stood around P#1, RN YY continued to bend over P#1 and was heard saying, "You going to stop, you going to stop, I'm asking you a question, are you going to stop?" Additional staff had entered the unit, and RN YY told the staff to get restraints.

Video surveillance continued with staff assisting P#1 to her feet and escorting P#1 through a door, which Risk Management identified as the seclusion room.


A telephone interview took place with the Registered Nurse (RN) XX on 2/15/23 at 4:30 p.m. RN XX stated P#1 accused RN YY of hitting people on the other side of the unit and asked RN XX to check on RN YY. P#1 said if RN YY did not stop, P#1 would hit RN YY. RN XX stated that when she went to check the other unit, RN YY was on the way to the female side. RN XX told RN YY not to go to the female side because of P#1's threats. RN YY went to the female side anyway. RN YY was yelling at P#1, asking P#1 who RN YY was hitting. P#1 said RN YY was hitting her grandma. RN YY kept yelling, saying she was not hitting anyone, and asked P#1 if she wanted to hit RN YY. RN YY put her arms up like she was going to fight, and P#1 swung at RN YY. P#1 did not hit RN YY, but RN YY hit P#1 in the face. P#1 and RN YY tried hitting each other, and three other staff members tried to remove P#1. P#1 tripped over a blanket and was on the floor. The staff had P#1 in a manual hold when RN YY came over and hit P#1 in the face four to five times. The bridge of P#1's nose was bleeding because RN YY had keys in her hand. The next day, there was swelling and bruising, and a nurse asked RN XX what had happened to P#1's nose. RN XX told the nurse it was from the incident between P#1 and RN YY. RN XX further said the night the incident happened, RN YY filled out an incident report, and the other staff was told to fill out witness statements. The witness statements filled out were not the whole story. RN YY said Risk Management called her the following Tuesday or Wednesday, and RN YY told them what really happened. RN XX worked on the unit Monday and Tuesday. It was reported to the unit staff on Wednesday that RN YY was not coming back to the unit.

A telephone interview took place with the Health Aide (HA) ZZ on 2/15/23 at 5:01 p.m. HA ZZ said when RN YY came back to the unit from the male side, RN YY said to P#1, "What did you say? Did you say I'm beating someone?" P#1 walked over to RN YY, and RN YY's voice started to get loud. RN YY took a stance like she was ready to hit P#1. P#1 swung weakly and did not look like she was trying to hit RN YY. That was when RN YY threw the first punch. When P#1 fell on the floor, RN YY came over and started hitting P#1. HA ZZ said she backed away and would not be part of what was happening. RN YY asked someone to get restraints, but they were the wrong restraints. Other staff members came to the unit and took P#1 to seclusion. HA ZZ said RN YY should have stayed away from P#1 while P#1 was agitated. HA ZZ said that RN YY brought a statement and told the staff to write statements agreeing with what she wrote, which was a lie. The staff hesitated to write the statements. HA ZZ further said the staff did not intervene to stop RN YY because they were all caught off-guard and were in shock. HA ZZ said RN YY returned to work on the unit after the incident and was reassigned the following week.


A review of the personnel file on 2/15/23 for RN YY revealed that the Employee Relations Specialist (ERS) said RN YY had been reassigned to Health Information Management after the facility became aware of the allegations of abuse on 1/24/23. RN YY signed a resignation letter on 2/14/23 in lieu of a termination letter. On 2/13/23, RN YY was recommended for separation due to substantiated allegations of individual physical abuse by staff. RN YY signed a resignation letter on 2/14/23 in lieu of a termination letter.

Based on facility policy, medical record review, observations, and staff interviews, it was determined that the facility failed to discontinue restraints at the earliest possible time for one Patient (P) #1 of four (P#1, P#2, P#3, P#4) sampled patients. Specifically, P#1 was placed in wrist-to-waist restraints on 1/23/23 at 4:00 p.m. due to assaultive behaviors on 1/20/23 and 1/21/23. P#1 remained in wrist-to-waist restraints through 2/7/23 and had no documented assaultive behavior.

Findings:

A review of the facility's "You Have Rights" poster revealed that inpatient rights included but were not limited to having health and safety protected; being treated with respect and dignity; and being free of restraints or seclusion, except as a last resort for safety.

A review of the "Safety Plan to Manage Severe, Persistent Aggression to Self or Others" policy #03511, last reviewed 9/27/21, revealed a Safety Plan that utilized wrist to waist restraints was to be undertaken in the most limited circumstances after less restrictive options had been shown to be ineffective or determined to be unlikely to address imminent harm. As with all restraints, wrist-to-waist restraints were to be discontinued at the earliest possible time and would not be imposed as a means of coercion, discipline, convenience, punishment, or retaliation by staff. The application of wrist-to-waist restraints was required to be based on current clinical risk assessments that indicated imminent danger or harm was likely unless these measures were taken. At all times, the rights, dignity, and well-being of the individual would be preserved. The individual's recovery planning team would determine that criteria for release from restraints had been met and it was safe to discontinue the wrist-to-waist restraint when the following had been met:

1. The individual had demonstrated understanding and verbalized use of alternatives to aggression or self- injurious behavior to contract for safety, OR
2. The individual's behavior was no longer so severe and imminent, that it could have escalated into an emergency resulting in harm to the individual or others, OR
3. Wrist-to-waist restraint was no longer the only intervention that would be effective to protect the individual from harm.


A medical record (MR) review revealed that Patient (P) #1 was admitted to the facility on 5/7/2020 at 8:58 a.m. to the Forensic Inpatient Unit 4-Secure. P#1 was admitted per a court order for a comprehensive evaluation and was diagnosed with paranoid schizophrenia and antisocial personality disorder.

A review of a Nursing Evaluation and Physician Order form for Seclusion or Restraint on 1/21/23 revealed that P#1 became physically aggressive toward a charge nurse at 12:40 a.m. and was taken to seclusion. P#1 was observed sitting quietly in the seclusion room from 1:30 a.m. to 1:45 a.m. P#1 was encouraged to relax at 2:00 a.m. and was quiet with her head down at 2:14 a.m. P#1 met the criteria for release and was escorted to her room at 2:48 a.m.

A review of a progress note by the Health Services Technician (HST) UU on 1/21/23 at 7:26 p.m. revealed that P#1 was on routine observation with no problems to report.

A review of a note by HST MM on 1/22/23 at 1:34 p.m. revealed that P#1 was on routine observation and was calm. P#1 spent most of the day in her room sleeping.

A review of a note by the HST VV on 1/22/23 at 10:03 p.m. revealed that P#1 was calm and cooperative with no problems during the shift.

A review of the Nursing Evaluation and Physician Order form on 1/23/23 at 4:00 p.m. revealed that wrist-to-waist restraints were placed on P#1 for repeated attempts of assaultive behavior. The Physician Notes section of the form completed by Physician Assistant (PA) SS revealed that P#1 continued to threaten and assault staff. There were multiple assaults from 1/20/23 to 1/21/23. Wrist-to-waist restraints were placed on P#1, and there were no further incidents. One-to-one staff was assigned. The Nursing Notes section of the form revealed that P#1 was released from restraints during toileting and was cooperative when placed back into the restraints. The order would continue for 24 hours.

A review of the Nursing Evaluation and Physician Order form on 1/24/23 at 3:30 p.m. revealed that Medical Doctor (MD) FF noted on the form that P#1 was verbally aggressive, threatening to staff, and not compliant with the team's directions. Nursing Evaluation Progress Notes for each shift revealed that P#1 spent most of the shift in bed, was calm and cooperative throughout the day, and followed directions. The left-hand restraint was removed during the evening for hygiene and breakfast, with no behavioral issues noted.

A review of the Nursing Evaluation and Physician Order form on 1/25/23 at 9:30 a.m. revealed that the purpose of the restraints was delusional thoughts, argumentative, and cursing staff. The Nursing Evaluation revealed that P#1 remained in wrist-to-waist restraints for assaultive behavior and verbal threats. No behavioral issues were noted. P#1 slept through the night and was compliant with care. During a treatment team meeting on 1/26/23 at 9:15 a.m., it was documented by MD FF that P#1's thought pattern was disorganized, and there were paranoid and delusional thoughts. P#1 said she would hit others if threatened.

A review of a progress note by HST NN on 1/30/23 at 12:26 p.m. revealed that P#1 seemed confused about why she was still in wrist-to-waist restraints when she had been calm and not causing harm to anyone. P#1 said she felt like a dog tied down and would file a lawsuit against the facility. P#1 was reading and singing to herself to deal with what she was going through.

A review of a progress note by HST WW on 2/5/23 at 6:36 a.m. revealed that P#1's left hand was not in the restraint. HST WW said P#1 had blisters from forcing the restraints off her hand. P#1 did not give staff any issues during that shift.

A continued review of the Nursing Evaluation and Physician Order for Seclusion or Restraints forms revealed that the wrist-to-waist restraint orders were renewed daily 1/21/23 through 2/7/23. A review of the nurse evaluations forms revealed that P#1 was calm, cooperative, compliant with medications and did not exhibit assaultive behaviors during this time.

A review of the Nursing Evaluation and Physician Order for Seclusion or Restraints form on 2/7/23 revealed that the restraints would be released for two hours daily.

Physician notes on 2/7/23 at 9:30 a.m. revealed that P#1 had been calmer, and the restraints would be released gradually if stable. One hand was removed during breakfast and for two hours, as ordered, and P#1 was placed back into the restraint with no behavioral problems noted.
These actions were taken the day after the survey began on 2/6/23.

A tour of the fourth-floor female unit took place on 2/6/23 at 1:50 p.m. with Clinical Director (MD) AA and Nurse Executive (RN) GG. It was observed that P#1 was seated at a table, hunched over in a chair across from Registered Nurse (RN) DD, and had leather wrist-to-waist restraints on both arms. P#1 was observed to be quiet and calm. It was observed that there was an adhesive bandage on the right forearm. The Nurse Manager (RN) CC confirmed that there was the same type of bandage on the left forearm underneath the restraint. P#1 was able to vocalize understanding to the surveyor that the restraints would be removed when she quit hitting people, and P#1 said she wanted them removed because they made it hard for her to use the restroom. P#1 said she would not hit anyone if the restraints were removed.


An interview took place with the HST LL on 2/7/23 at 3:26 p.m. in the Conference Room. HST LL said she had never witnessed P#1 hitting or threatening anybody. Additionally, P#1's left hand would come out of the restraints when eating, and there were no issues when out of restraints.

An interview took place with HST MM on 2/7/23 at 3:31 p.m. in the Conference Room. HST MM had not heard any verbal threats from P#1 since P#1 dumped a tray of food on a staff member's head on 12/22/22. HST MM said there was a meeting on 1/23/23 informing the staff that P#1 would be put into restraints because of prior things P#1 had done. HST MM said the staff woke P#1 up and put restraints on her. P#1 was confused as to why she was getting tied down. The staff understood that P#1 had not done anything when the restraints were put on, but action was being taken because of P#1's past actions. HST MM said P#1 cried and asked why the staff were putting restraints on her when she had not harmed anyone. HST MM said the meeting with the staff on 1/23/23 was about old stories that had started in July of 2022. Staff questioned why the restraints were being put on P#1 when she was being good and not when an incident had occurred. P#1 had made threats but had not put her hands on anyone. HST MM further said there had not been any issues since P#1 had been in restraints, and P#1 was very calm and cooperative on the date of the interview. HST MM further said the restraints had been removed from P#1's left arm for two hours earlier on the day of the interview. P#1 was very good during the time the restraints were removed. HST MM stated HST MM felt like the restraints were a form of punishment because the restraints were placed on P#1 without the occurrence of an incident. HST MM further said that he helped bandage the wounds the first day bandages were put on P#1's arms. HST MM stated there were blister-like wounds because the restraints were too tight.

An interview took place with RN CC on 2/8/23 at 10:29 a.m. in the Conference Room. RN CC said P#1's last aggressive incident was on 1/21/23, when P#1 came into contact with one of the nurses and kicked a staff member in the stomach. P#1 was placed in wrist-to-waist restraints the following Monday. RN CC further said wrist-to-waist restraint was used because many staff, including the treatment team, felt intimidated by P#1. Wrist-to-waist restraints were implemented to help build a rapport and a more therapeutic relationship with P#1. It also helped staff on the unit. RN CC said that the nursing staff had felt for over a week that the restraints should begin to be discontinued. Each discipline would provide feedback at the treatment team meeting, and the manager would give feedback about how the unit staff felt. The staff had been pushing for P#1 to come out of restraints for a while. RN CC said the moment a patient was calm and cooperative, the patient was supposed to be released from restraints. RN CC further said the restraints should have been implemented immediately, not days after an incident of aggression. RN CC further said wrist-to-waist restraints were first discussed for P#1 in October of 2022 because incidents of aggression had been happening more frequently since July of 2022. Since October 2022, wrist-to-waist restraints had been discussed among the treatment team. P#1 would be put into wrist-to-waist restraints the next time she hit someone. P#1 went from October to December 2022 without aggression. RN CC said she favored wrist-to-waist restraints in October of 2022, but there had been no physical aggression since 1/21/23.

An interview took place with Heath Aide (HA) NN on 2/8/23 at 11:07 a.m. in the Conference Room. HA NN said P#1 had been provoked by another staff during the incident on 1/21/23. Since the restraints had been placed on P#1, there had been no signs of aggression. HA NN said the treatment team was stating that P#1 was going to stay on restraints and were documenting that P#1 was aggressive when P#1 was not. HA NN further said that P#1 started getting wounds from the restraints. The restraints were new leather and would slide back and forth.

An interview took place with the Licensed Practical Nurse (LPN) BB on 2/8/23 at 1:40 p.m. in the Conference Room. LPN BB stated restraints were not to be used for conditioning or punishment. Restraints were a temporary measure for a block of time. Restraints were not to be harmful to an individual. There would be criteria to meet during the time the individual was restrained. LPN BB said the restraints were causing wounds to P#1's wrists and problems with her posture. LPN BB stated she felt that P#1's spirit was broken. P#1 was restrained, and nothing allowed her to become unrestrained. LPN BB said that the restraints had become conditioning and punishment. LPN BB stated she felt the restraints were inhumane and that no exit plan was in place. In addition, LPN BB said that P#1 was not getting therapy and there needed to be some therapy in place. LPN BB said P#1 had not been combative or verbally abusive. P#1 had been very compliant, and whatever they were trying to achieve by implementing restraints had been accomplished.

An interview took place with Medical Doctor (MD) FF on 2/15/23 at 1:22 p.m. in the Conference Room. MD FF said P#1 was not being assaultive but was still having delusional thoughts and cursing the treatment team. P#1 refused medications a couple of times and took herself off of restrictions, so the treatment team decided to continue the safety plan because of non-compliance with treatment. MD FF said the restraints were discontinued on 2/10/23. MD FF was not aware of a meeting with the Human Rights Committee.

Based on a review of the facility's Quality Improvement Plan, policies, investigation documentation, staff interviews, and personnel record, it was determined that the facility failed to develop and implement performance improvement activities that tracked adverse patient events, analyze their causes, and implement preventative actions and provide feedback throughout the facility. Specifically, P#1 was physically assaulted by a staff member (RN YY) on 1/21/23. RN YY was removed from patient care on 1/25/23. RN YY was separated from employment on 2/13/23.


Cross-reference A-2086 as it relates to the facilty's failure to develop and implement performance improvement activities that tracked adverse patient events, analyze their causes, and implement preventative actions and provide feedback throughout the facility.

Based on a review of the facility's Quality Improvement Plan, policies, investigation documentation, staff interviews, and personnel record, it was determined that the facility failed to develop and implement performance improvement activities that tracked adverse patient events, analyze their causes, and implement preventative actions and provide feedback throughout the facility. Specifically, P#1 was physically assaulted by a staff member (RN YY) on 1/21/23. RN YY was removed from patient care on 1/25/23. RN YY was separated from employment on 2/13/23.

Findings:

A review of the facility's 'Hospital Performance Improvement Plans, 03-315', last reviewed 12/29/21, revealed that the leadership of the facility, under the guidance of the Governing Body, and based on data, set priorities for QAPI through the Hospital Quality Council.
Each Hospital Quality Council used data to identify high-risk, high-volume, or problem-prone areas.

A review of the "Incident Management in Adult Mental Health and Forensic Units, 03-515" policy, last reviewed 6/30/21, revealed that staff who engaged in, failed to intervene, and/or failed to report incidents of abuse/neglect/exploitation were subject to personnel actions up to and including termination of employment. Staff was required to cooperate with any ensuing investigation. An incident was defined as an occurrence that was actually or potentially physically and/or psychologically harmful to an individual served at the hospital or an incident that was inconsistent with the individual's expected behavior, conditions, treatment, or plan of care. All facility staff had a responsibility to report any event that may have met the criteria of an incident.

The policy further revealed that staff would take immediate and appropriate actions to protect the rights and safety of all individuals and report the incident to the nurse in charge or supervisor. The charge nurse would notify the physician, who would make an assessment to determine if additional intervention was necessary to address patient safety. An incident report would be filed for each incident per policy and reported to Incident Management within eight hours. Allegations of abuse would be reported to the hospital administrator within one hour. For allegations of abuse, the person of interest would be immediately reassigned away from the alleged victim.
The person of interest would remain reassigned pending an Executive Leadership Team Review decision and, if necessary, the completion of the investigation. For all incidents involving abuse, neglect, or exploitation, the supervisor would ensure the collection of physical evidence, written statements from individuals involved, witnesses, photographs of injuries, and other evidence no later than the end of the shift during which the incident occurred. The policy further revealed that the Quality and Risk Management Director would confirm external notifications were made as required by law. In the case of Abuse, Neglect, or Exploitation, a report would be sent to appropriate entities and to the individual or the individual's guardian, if indicated.
The policy further revealed that staff would be trained on identification of incidents, appropriate interventions, and incident reporting procedures upon hire and at least annually thereafter.

A review of an 'Investigative Report Summary' revealed the incident involving P#1 was reported on 1/21/23. The incident was reported on 1/25/23. Registered Nurse (RN) YY was reassigned to a non-direct care area on 1/26/23. The results of the investigation revealed that the allegations of individual physical abuse by staff against RN YY were substantiated. During the investigation, staff admitted to leaving out pertinent information in their report of the incident involving P#1. Specifically, RN YY had struck P#1 several times. Further review revealed that Health Service Technician (HST) ZZ's Incident Management training had expired in December of 2022. Corrective actions in response to the investigation included but were not limited to the following:
1. RN YY was separated from employment with the facility on 2/13/23
2. The facility would notify law enforcement concerning the physical abuse.
3. HS TT was enrolled in the annual Incident Management and was expected to attend on 2/16/23
The investigation was completed on 2/3/23.

A review of the personnel file for RN YY revealed that RN YY signed a resignation letter on 2/14/23 in lieu of a termination letter. On 2/13/23, RN YY was recommended for separation due to substantiated allegations of individual physical abuse by staff. The Employee Relations Specialist (ERS) said RN YY had been reassigned to Health Information Management after the facility became aware of the allegations of abuse on 1/24/23.

A telephone interview took place with RN XX on 2/15/23 at 4:30 p.m. RN XX stated that the night the incident occurred involving P#1, RN YY filled out an incident report, and the other staff was told to fill out witness statements. RN XX, the witness statements filled out were not the whole story. RN YY stated Risk Management called her the following Tuesday or Wednesday, and RN YY told them what really happened. RN XX worked on the unit Monday and Tuesday. It was reported to the unit staff on Wednesday that RN YY was not coming back to the unit.

A telephone interview took place with the Health Aide (HA) ZZ on 2/15/23 at 5:01 p.m. HA ZZ stated that RN YY brought a statement and told the staff to write statements agreeing with what she wrote, which was a lie. HA ZZ said the staff hesitated to write the statements. HA ZZ further said RN YY returned to work on the unit after the incident and was reassigned the following week.