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Facility Representatives were notifed at 3:26 PM on 03/21/19 there was an Immediate Jeopardy to patient health and safety in that the facility staff failed to report physical abuse directed towards Patient #1 by Mental Health Assistant (MHA) #1. A safe environment was not maintained in that MHA #2 and #3 did not report the incident the day it occurred so the facility could begin the investigation immediately, and the facility failed to complete a thorough investigation of the abuse allegation. Failure to ensure staff were aware of what to report, when to report, and the facility's failure to complete a thorough investigation had the potential for continued abuse.
See CMS A-0144 and CMS A-0145.

Based on review of the complaint log, the complaint investigation form, observation of video, and interview, it was determined the facility failed to provide care in a safe setting to one (#1) of fifteen (#1-15) patients in that one (#2) of two Mental Health Technicians (#2 and #3) failed to report the incident the day it occurred so the facility could begin the investigation immediately, and the facility failed to complete a thorough investigation of the abuse allegation. Failure of staff to report the incident and the facility's failure to perform a thorough investigation into the abuse allegation allowed Mental Health Technician #1 to continue working and placed other patients at risk of abuse until 03/21/19. Findings follow:

A. Review of the February 2019 complaint log, received on 03/20/19, showed only one complaint, which was filed by Patient #16 alleging a staff member abused another patient (Patient #1).

B. Review of the complaint investigation form showed the video of the incident was reviewed by the CEO (Chief Executive Officer), the CNO (Chief Nursing Officer), the Director of Risk Management/Compliance/Regulatory and the Patient Advocate and that the incident was not a case of abuse. The Complaint Investigation form was signed by the Patient Advocate on 02/28/19 and a copy of the letter sent to the Complainant was attached.

C. The CNO stated during an interview at 11:00 AM on 03/21/19 that the Complainant did not make the complaint until her discharge on 02/26/19. The CNO stated she was called to the office of the discharging therapist and the Complainant told her of the incident. The CNO stated the Complainant initially said it was breakfast or lunch of the day Patient #1 was admitted but review of Patient #1's clinical record showed an admission time of 6:50 PM. The Complainant told the CNO the incident occurred at either breakfast or lunch.

D. On 03/21/19 the Director of Risk Management/Compliance/Regulatory was asked if the video was still available for viewing and she stated it was.

E. At 12:20 PM on 03/21/19 the video of the incident was queued up by the Director of Risk Management/Compliance/Regulatory and observed by the CNO, the Director of Risk Management/Compliance/Regulatory and Surveyor #1. The video was dated 02/21/19 and timed at 7:50 AM. The video recording showed the ACU (Acute Children's Unit) patients and MHA #1, #2 and #3 in the cafeteria. Patient #1 was identified by the CNO and the Director of Risk Management/Compliance/Regulatory and the employee was identified as MHA #1. Review of the video recording for 02/21/19 at 7:50 showed Patient #1 up, out of his chair, and MHA #1 pick him up and place him back in a chair. The Director of Risk Management/Compliance/Regulatory stated the executive staff that reviewed this on 02/26/19 felt this was not abuse. The Complainant was observed not to be looking at Patient #1 when MHA #1 picked him up and placed him in the chair. The CNO and Director of Risk Management/Compliance/Regulatory was asked if this was the only portion of the video they reviewed. The CNO stated no, they looked at several days of meals on the days MHA #1 worked because Patient #16 was vacillating on what day and what meal the incident occurred. After viewing the video several times, the Director of Risk Management/Compliance/Regulatory was asked to just let the video continue to run after the incident in question. At approximately 07:54:14 Patient #1 was observed on the video standing on the right side of the viewing area, in front of the glass windows in the dining room. MHA #1 was observed to go to Patient #1, grab him forcefully by the upper arm, and pull him to the dining chair where he forcefully placed him in the chair. During this part of the video the Complainant was looking at Patient #1 and MHA #1 as was almost everyone else in the dining room. The CNO and Director of Risk Management/Compliance/Regulatory stated they had not seen this section of the video. Observation of the video showed MHA #2 and MHA #3 seemed to be looking at Patient #1 and MHA #1. During an interview at 12:35 PM on 03/21/19 with the CNO and the Director of Risk Management/Compliance/Regulatory, they were asked if MHA #1 was working today and the CNO stated MHA #1 was working on the Adult Unit today. The CNO and Director of Risk Management/Compliance/Regulatory was asked why MHA #2 and #3 did not report the incident and the Director of Risk Management/Compliance/Regulatory stated when they interviewed MHA #3 about the incident they thought was the issue, MHA #3 said he didn't see it. During the same interview, the CNO and Director of Risk Management/Compliance/Regulatory were asked why MHA #2 did not report the incident that occurred at 7:54:14 AM on 02/21/19. The Director of Risk Management/Compliance/Regulatory stated MHA #2 acknowledged she saw the incident but did not report it as she felt no harm was done to Patient #1. During the above interview, the findings of the video were verified by the CNO and the Director of Risk Management/Compliance/Regulatory.

F. Review of the policy and procedure titled "Suspected Child Abuse and Neglect," received on 03/20/19, showed an allegation of abuse made by a patient, family member, or guardian that involved abuse, neglect or any harm to a patient must be reported immediately to the supervisory chain of command.

Based on review of the policy and procedure titled "Patient Allegations of Staff Abuse or Neglect," the complaint log, the complaint investigation form, observation of video, and interview, it was determined the facility failed to protect one (Patient #1) of fifteen (#1-15) patients from abuse in that one (#2) of two (#2 and #3) Mental Health Technicians (MHT) failed to report the incident at the time it occurred so the facility could begin the investigation immediately, and the facility failed to complete a thorough investigation of the abuse allegation. Failure to ensure patients were free from abuse had the potential to allow vulnerable patients in the psychiatric setting to regress in their treatment and have prolonged hospitalizations. The failed practice affected Patient #1 on 02/21/19. Findings follow:

A. Review of the policy and procedure titled "Patient Allegations of Staff Abuse or Neglect," received on 03/21/19, showed every employee of the facility was responsible for assuring patients are not abused or neglected by staff members and that any suspected or witnessed incidents of either abuse or neglect was to be reported immediately to the staff member's immediate supervisor, or in their absence, the hospital supervisor and the Risk Manager.

B. Review of the February 2019 complaint log, received on 03/20/19, showed only one complaint, which was filed by Patient #16 on 02/26/19 alleging a staff member abused another patient (Patient #1).

C. Review of the complaint investigation form showed video of the alleged incident was viewed by the CEO (Chief Executive Officer, the CNO (Chief Nursing Officer), the Director of Risk Management/Compliance/Regulatory and the Patient Advocate on 02/26/19, and the incident was deemed not to be abuse.

D. At 12:20 PM on 03/21/19 the video of the incident was queued up by the CNO, the Director of Risk Management/Compliance/Regulatory and Surveyor #1. The video was dated 02/21/19 and timed at 7:50 AM. The video recording showed the ACU (Acute Children's Unit) patients and Mental Health Assistants (MHA) #1, #2 and #3 in the cafeteria. Patient #1 was identified by the CNO and the Director of Risk Management/Compliance/Regulatory and the employee the executive staff felt was the accused was identified as MHA #1. Review of the video recording for 02/21/19 at 7:50 showed Patient #1 up, out of his chair, and MHA #1 pick him up and place him back in a chair. The Director of Risk Management/Compliance/Regulatory stated the executive staff that reviewed this on 02/26/19 felt this was not abuse. The complainant was observed not to be looking at Patient #1 when MHA #1 picked him up and placed him in the chair. After viewing the video several times, the Director of Risk Management/Compliance/Regulatory was asked to just let the video run after the incident in question. At approximately 07:54:14 Patient #1 was observed on the video standing on the right side of the viewing area, in front of the glass windows in the dining room. MHA #1 was observed to go to Patient #1, grab him forcefully by the upper arm, and pull him to the dining chair where he forcefully placed him in the chair. During this part of the video the Complainant was looking at Patient #1 and MHA #1 as was almost everyone else in the dining room. The CNO and Director of Risk Management/Compliance/Regulatory stated they had not seen this part of the video.

E. Observation of the above video showed MHA #2 and MHA #3 seemed to be looking at Patient #1 and MHA #1. During an interview at 12:35 PM on 03/21/19, the CNO and the Director of Risk Management/Compliance/Regulatory were asked why MHA #2 and #3 did not report the incident and the Director of Risk Management/Compliance/Regulatory stated when they interviewed MHA #3 about the incident they thought was the issue, MHA #3 said he didn't see it. During the same interview, the CNO and Director of Risk Management/Compliance/Regulatory were asked why MHA #2 did not report the incident that occurred at 7:54:14 AM on 02/21/19. The Director of Risk Management/Compliance/Regulatory stated MHA #2 acknowledged she saw the incident but did not report it as she felt no harm was done to Patient #1. During the above interview, the findings of the video were verified by the CNO and the Director of Risk Management/Compliance/Regulatory.

F. Review of employee personnel files showed Handle With Care training, restraint and seclusion training and abuse training was present for all employees sampled.

Based on clinical record review, and interview, it was determined a Registered Nurse failed to assess and manage the care of five (Patients #1, #8, #9, #14 and #15) of fifteen (#1-15) whose physician issued orders for vital signs to be checked once a day. Failure to ensure vital signs were obtained and the readings documented did not allow the responsible physician to have available information needed to make informed decisions regarding the patient's care. The failed practice had the potential to affect Patients #1, #8 #9, #14 and #15. Findings follow:

A. Review of Patient #1's clinical record showed an admission date of 02/19/19 and orders dated 02/19/19 for vital signs to be checked daily. Review of the clinical record showed no evidence vital signs were checked and documented for two (02/23/19 and 02/24/19) of seven (-2/20/19 - 02/26/19) days. During an interview with the Chief Nursing Officer (CNO) at 10:35 AM on 03/25/19 the above findings were verified.

B. Review of Patient #8's clinical record showed an admission date of 03/10/19 and orders dated 03/10/19 for vital signs to be checked daily. Review of the clinical record showed no evidence vital signs were checked and documented for one (03/14/19) of eight (03/10/19 - 03/17/19) days. During an interview with the CNO at 10:26 AM on 03/25/19 the above findings were verified.

C. Review of Patient #14's clinical record showed an admission date of 03/13/19 and orders dated 03/13/19 for vital signs to be checked daily. Review of the clinical record showed no evidence vital signs were checked and documented for two (03/14/19 and 03/16/19) of seven (03/14/19 - 03/20/19) days. During an interview with the CNO at 10:40 AM on 03/25/19 the above findings were verified.

D. Review of Patient #15's clinical record showed an admission date of 03/08/19 and admission orders dated 03/08/19 for vital signs to be checked daily. Review of the clinical record showed no evidence vital signs were checked and documented for four (03/09/19, 03/10/19, 03/14/19 and 03/16/19) of fifteen (03/09/19 - 03/22/19) days. During an interview with the CNO At 10:27 AM on 03/25/19 the above findings were verified.

E. Review of Patient #19's clinical record showed an admission date of 03/10/19 and admission orders dated 03/10/19 for vital signs to be checked daily. Review of the clinical record showed no evidence vital signs were checked and documented for three (03/14/19, 03/15/19 and 03/16/19) of twelve (03/10/19 - 03/22/19) days. During an interview with the CNO at 10:45 AM on 03/25/19 the above findings were verified.


Based on clinical record review, and interview, it was determined the facility failed to ensure a Registered Nurse assessed and managed the care for two (Patients #5 and #10) of three (#2, #5 and #10) CIWA (Clinical Institute Withdrawal Alcohol Assessment) patients in that medications were not administered and documented on the Medication Administration Record (MAR), as ordered by the physician. Failure to provide the treatment and assess the effects had the potential to prolong the patient's hospitalization and recovery time. The failed practice had the potential to affect Patient #5 and #10. Findings follow:

A. Review of Patient #5's clinical record showed the following parameters on the CIWA MAR:
Chlordiazepoxide 25 mg (Milligram) po (per mouth) for CIWA 0-7 if systolic blood pressure over 150 or diastolic blood pressure over 95 or pulse over 100 for 2 readings divided by 5 minutes observed rest; Chlordiazepoxide 25 mg for CIWA score of 8-10; Chlordiazepoxide 50 mg for CIWA score 11-15; Chlordiazepoxide 75 mg for CIWA score of 16-20; and Chlordiazepoxide 100 mg for CIWA score of 21 or above. Review of the MAR showed no evidence Chlordiazepoxide was given at 4:00 PM and 8:00 PM on 03/05/19 for blood pressure readings of 163/95 and 159/91 respectively; at 4:00 PM on 03/06/19 for blood pressure of 163/90; and at 8:00 PM on 03/07/19 for blood pressure of 163/91. During an interview with the Chief Nursing Officer (CNO) at 10:35 AM on 03/25/19 the above findings were verified.

B. Review of Patient #10's clinical record showed the following parameters on the CIWA MAR: 0.5 mg Ativan po for CIWA score of 1-15, 0.5 mg Ativan for CIWA score of 0-6 if Heart rate > (greater than) 100 x (times) 2, and 1 mg Ativan for CIWA score of 16-30. Review of Patient #10's CIWA scoring page scored CIWA scores of 0 at 8:00 AM and 12:00 PM on 03/14/19 with heart rates of 118 and 132 respectively. Review of the MAR showed no evidence Ativan 0.5 mg was administered. During an interview with the CNO at 11:00 AM on 03/25/19 the above findings were verified.