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Based on interview, medical record review, review of facility Policy, and review of Kentucky Revised Statute (KRS) 209.030, it was determined failed to ensure the patient has the right to be free from all forms of abuse for one (1) of ten (10) patients (Patient #1).

Although Emergency Room (ER) staff witnessed Certified Medical Technician (CMT) #2 hit Patient #1 in the face on 06/18/17, the facility failed to place CMT #2 on leave the day of the incident as per their Abuse Policy. In addition, the facility failed to investigate the incident in a timely manner as ER staff were not interviewed until 06/26/17 related to the incident. Also, the facility failed to immediately notify state agencies of the incident as per state law.

The findings include:

Review of the facility "Identification and Reporting Abuse, Neglect, Sexual Assault, and Exploitation" Policy, effective date 9/11/17, revealed the team member alleged to have abused, neglected, sexual assaulted or exploited a patient will be placed on immediate administrative leave and if on duty the team member will be immediately relieved and escorted off premises by Security.

Additional Review of the Policy, revealed during normal business hours team members will report suspicions of patient allegation of abuse to their Director/Supervisor who will immediately contact the Director/Manager of Social work to report the allegation. Team members can also report directly to the Director/Manager of Social Work. During normal business hours the Director /Manager of Social Work, shall notify the Director of Human Resources, the Vice President/General Counsel and the Director of Risk Management of the reported allegations.

Further review of the Policy, revealed after business hours team members should contact the Administrative Coordinator or the Administrator on call who will be responsible to notify the Director/Manager of Social Work. After normal business hours the Director/Supervisor of Social Work Shall notify the Administrative Coordinator and /or Administrator on call of the reported allegation.

Continued review of the Policy, revealed Investigation outcomes will be reported by the Director /Manager of Social Work to the Director of Human Resources, the Vice President/General Counsel and the Director of Risk Management. Additionally, investigation outcomes will be reported to the appropriate state agencies, law enforcement agencies and /or licensure boards in accordance with state or federal laws.

Review of KRS 209.030 Administrative Regulations Reports of Adult Abuse, Neglect, or Exploitation - Cabinet actions, effective 6/20/05, revealed an oral or written report shall be made immediately to the cabinet upon knowledge of suspected abuse, neglect, or exploitation of an adult.

Review of Patient #1's medical record revealed the he/she was admitted to the Emergency Room (ER) on 06/18/17 with complaints/symptoms which included Anxiety, Post Traumatic Stress Disorder (PTSD), Flight of Ideas but Denied Suicidal or Homicidal Ideation. Further review revealed an evaluation by the Advance Registered Nurse Practitioner (ARNP) dated 06/18/17, revealed the patient's behavior was bizarre and erratic with diagnoses of Unspecified Psychosis (not due to a substance or known physiologic condition), and consider Schizoaffective Disorder, Bipolar Type, and Cannabinoid Abuse.

Review of the facility Investigation for Patient #1, which was faxed to the Office of Inspector General on 08/04/17, by the facility Social Worker, revealed Emergency Room (ER) Leadership received a report on 06/19/17 from ER staff that a patient was struck in the face by a team member. Per the Investigation the patient presented to the ER on 06/18/17 with increased anxiety and aggressive behavior along with signs of mania and paranoia. The patient became physically aggressive with staff in the ER hitting a Certified Medical Technician (CMT) who struck back as patient was being restrained by significant other and staff. Per the Investigation, review of medical record and interviews conducted with involved parties revealed there was substantiation of inappropriate physical force. Per the Investigation, the Team Member (CMT #2) was terminated.

Review of the Safety/Security Event, revealed the incident related to CMT #2 striking Patient #1 in the face occurred on 06/18/17 at 6:45 PM.

Further review of the Investigation, revealed the ER staff who were on duty on 06/18/17 were not interviewed for witness statements until 06/26/17, eight (8) days after the incident. Also, per the investigation, the CMT #2 (perpetrator) was allowed to work two (2) shifts after the incident.

Telephone interview with CMT #2, on 11/03/17 at 10:57 AM, revealed she entered Patient #1's room on 06/18/17 to attempt to de-escalate the situation and Patient #1 began yelling and cussing at her. Per interview, Patient #1 leaped off the bed and punched her in the side of the face and nose. CMT #2 stated Patient #1 continued scratching and swinging which made CMT #2 feel threatened for the safety of himself; her colleagues; and the patient. She stated she defended herself by hitting Patient #1 in the face and then restraining the patient until security arrived.

Interview with Registered Nurse #2, on 10/26/17 at 10:10 AM, revealed abuse education occurred on a quarterly basis, and all ER staff must be trained in non-violent crisis intervention. Additional interview revealed on 06/18/17, CMT #2 entered Patient #1's room to help, and Patient #1 was verbally abusive to CMT #2. Per interview, Patient #1 jumped up off the bed and punched CMT #2 in the face, and while trying to restrain Patient #1, CMT #2 hit Patient #1 in the side of the head. Subsequent interview on 10/27/17 at 9:03 AM, with RN #2, revealed RN #2 considered the actions of CMT #2 inappropriate and a violation of the abuse policy.

Interview with the ER Charge Nurse, on 10/26/17 at 3:20 PM, revealed CMT #2 came in Patient #1's room on 06/18/17 when she heard screaming. Per interview, Patient #1 was verbally abusive to CMT #2, then Patient #1 jumped up off the bed and punched CMT #2 in the face. Further interview revealed Patient #1's boyfriend was able to restrain the patient, and CMT #2 used the weight of her body to restrain Patient #1 and then hit Patient #1 in the side of the head. Per interview, once security arrived, she (ER Charge Nurse) immediately told CMT #2 to leave the room, and eventually called the ER Manager to report the incident. Subsequent interview on 10/27/17 at 9:45 AM, with the ER Charge Nurse, revealed she was unable to say if what happened was abuse, only that it should not have happened which was why it was reported to the ER Manager that night.

Interview with the ER Manager, on 10/26/17 at 2:30 PM, revealed he first learned of the incident with Patient #1 when he was contacted early the morning of 6/19/17. Per interview, this led to a discussion of the incident with the ER Director, Legal Department, and Risk Management. The ER Manger stated afterward informal interviews with staff including a telephone conversation with CMT #2 were conducted. Further interview revealed the Social Work Department gets involved in situations such as this to determine if there was a need to involve Adult Protective Services and also decided if abuse had occurred. Subsequent interview on 10/27/17 at 9:30 AM, with the ER Manager, revealed he did not consider the event as abuse, did not discuss whether CMT #2 should be placed on administrative leave, and never questioned the safety of patients because CMT #2 had never hit a patient until she hit Patient #1. The ER Manager verified CMT #2 continued to work after the incident with Patient #1.

Interview with the ER Director, on 10/26/17 at 2:48 PM, revealed he was not made aware by the ER Manager of the incident which occurred on 06/18/17, until 06/23/17. He stated he was told it was self-defense and "was handled". Further interview revealed the ER Director received an email from Risk Management on the evening of 06/25/17 requesting formal interviews on 06/26/17, after which the report of the situation changed from self-defense to "it shouldn't have happened". Per interview, this lead to administrative leave and a formal statement from CMT #2, and finally CMT #2's termination. Subsequent interview on 10/27/17 at 10:06 AM, with the ER Director, revealed the facility policy stated the employee suspected of abuse should be placed on administrative leave while the investigation occurs, not afterward, and CMT#2 should not have worked subsequent shifts after the incident.

Interview with the Social Work (SW) Director, on 10/25/17 at 11:55 AM, revealed there was annual abuse education for all staff on the computer with a test at the end, and there was non-violent crisis intervention training required for ER staff and social workers. Per interview, her involvement with the situation from 06/18/17 began when she was contacted by the ER Director after staff interviews and after CMT #2 was placed on administrative leave. Further interview revealed her role was to gather information, review interviews, and talk with ER Director about recommendations. She stated she felt there was enough evidence that inappropriate behavior occurred to substantiate abuse which resulted in a report to the Office of the Inspector General (OIG) and Department of Community Based Services (DCBS).

Interview with the Risk Manager, on 10/26/17 at 3:45 PM, revealed she was not in the role of Risk Manager when the event occurred related to Patient #1. She stated the Risk Manager's become involved in a suspected abuse allegation against a team member after it was reported first to the that department's Supervisor, then to Social Work, and then to the Department of Legal Services. Additional interview revealed patient safety was ensured through staff education and investigation of an event when it occurred and then re-education as needed. Further interview revealed her role was to oversee the entire process to make sure everything gets done. Per interview, regarding the situation related to Patient #1, CMT #2 should have been placed on administrative leave immediately on 06/18/17 according to facility policy.

Interview with the Chief Nursing Officer and Vice president of Patient Services on 10/27/17 at 11:53 AM, revealed it was their expectation for staff to treat patients with dignity and respect understanding the underlying cause of what was happening with them. Per interview, team members were to follow policy and procedures and act as professionals. Further interview, revealed in the situation regarding Patient #1, CMT#2 should not have been allowed to work two (2) subsequent shifts after the incident in order to ensure patients' safety. Continued interview revealed given the timeline of the event, the investigation should have started when the incident occurred.

Interview with the Vice President /Chief Compliance Officer, on 10/27/17 at 12:12 PM, revealed the steps of an abuse investigation involving a team member included the removal of the team member from the situation; placing the team member on administrative leave; assessing the patient including documentation; conducting an investigation; interviewing people involved; and making a determination of what happened. Per interview, the SW Director was the person responsible to investigate and make notifications. Additional interview, revealed there was a delay between when the incident involving Patient #1 and CMT #2 occurred and when the team member was placed on leave. Continued interview revealed there was a delay in the investigation when one compares the incident which occurred 6/18/17, and statements from staff which were dated 6/26/17. Per interview, there was consequently a delay in reporting the abuse allegation to state agencies.