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Based on facility investigation document review, medical record review, personnel record review, facility policy review, and staff interview, the facility failed to ensure patients received care in a safe setting (A144). The facility failed to ensure patients had the right to be free from abuse (A145).

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure patients received care in a safe setting for one of 10 patients reviewed (Patient #2). This could affect all patients receiving services from the facility. The facility census was 20.

Findings include:

The medical record of Patient #2 was reviewed on 09/07/22. Patient #2 was admitted to the facility on 08/16/22 with a diagnosis of dementia with behavioral disturbances. The patient was transferred from the memory unit of an assisted living facility. The patient had been displaying physical aggression, increased agitation, and intimidating behavior over the last 72 hours. The treatment plan noted the patient would be admitted for medication evaluation, assistance with increasing coping skills, and treatment of depressive symptoms. The patient was ordered to be monitored every 15 minutes.

The Patient Monitoring sheets from 08/16/22 until discharge, on 08/22/22, were reviewed. There was no documented monitoring noted on 08/21/22 from 7:00 AM until 08/22/22 at 7:00 AM, a 24 hour period.

The facility policy titled, Patient Rounding, issued on 01/15, was reviewed on 09/08/22 at 12:10 PM. The policy stated that rounds are to be made on the unit on all patients by the assigned nursing staff at a minimum of every 15 minutes for each 24-hour period. The purpose of the rounds is to check all aspects of security and safety while monitoring patient behavior and location. All patient accessible areas are checked to see that patients are safe and behavior is appropriate. All patient accessible areas are also visually checked for contraband items. Contraband, damage, or unsafe conditions are corrected/reported to the nurse immediately.

Staff G was interviewed on 09/08/22 at 12:30 PM. It was confirmed that the medical record lacked documentation the ordered 15 minute checks were performed as required by facility policy.

Based on review of facility investigation documents, policy review, personnel record review, and staff interview, the facility failed to ensure one of ten patients reviewed were free from abuse (Patient #2). This could affect all patients receiving services from the facility. The patient census was 20.

Findings include:

The facility policy titled, Recognizing and Reporting Suspected Abuse/Neglect/Exploitation (Policy No. CC.21), issued 05/16, was reviewed. The policy defined three forms of abuse. Emotional/Mental abuse affects the patient's sense of well-being, safety, or self-esteem. Physical abuse as any non-accidental injuries that causes bruises, lesions, or that medical attention. Sexual abuse is unwanted and/or forced sexual activity to include sexual assault, rape, and human trafficking. The policy advised staff that the hospital mandates that any healthcare worker having reasonable cause to believe that any patient is in a state of abuse report the information as soon as possible after discovering the abuse or alleged abuse. According to the policy, all staff has a responsibility to immediately report any incidents of suspected abuse involving patients by contacting the appropriate chain of command. Cases of suspected abuse will be given priority and will be investigated thoroughly. If it is proven that the patient is experiencing abuse caused by a staff member, that staff member will be suspended pending investigation by both the hospital and the Department of Health Services. If allegations exist that the patient is experiencing abuse caused by a staff member, that staff member will be placed on suspension, pending completion of an investigation.

Staff A was interviewed on 09/08/22 at 11:00 AM. Staff A explained that a facility Mental Health Technician (MHT), Staff C, met with the facility's Human Resources Director, Staff D, on the afternoon of 08/26/22 to resign the position. During the meeting Staff C revealed that during the night shift hours of 08/20/22 going into 08/21/22, she witnessed a facility State Tested Nursing Assistant (STNA), Staff E, take a patient's hand and force him to hit himself. According to Staff A, the Human Resources Director immediately notified several members of administration as required by facility policy. An investigation was conducted, statements from all staff members that worked during the shift when the event occurred were obtained, a family member of the patient was notified of the incident, and details of the incident were entered into the Web Enabled Incident Reporting System (WEIRS) as required by facility policy. It was determined that Staff E did interact with a patient in a manner that was physically abusive and Staff E was terminated on 08/26/22. Another facility STNA, Staff F, was initially suspended, however, was allowed to return to work after re-education regarding the importance and requirement of recognizing and reporting suspected abuse. Staff A also stated that during the investigation, it was revealed that Staff E did not think the incident was abuse because she did not actually hit the patient. The patient hit himself.

Review of the WEIRS Report, submitted on 08/26/22 revealed, "all staff members are currently undergoing additional training in Recognizing and Reporting Suspected Abuse/Neglect/Exploitation."

Staff A was interviewed on 09/08/22 at 1:40 PM and asked to provide documentation of education provided to staff and proof via any sign-in sheet noting the names of those staff members that received the training. A copy of a power point presentation was provided. The first page of the presentation was titled Patient Advocacy Recognizing and Reporting Suspected Abuse/Neglect/Exploitation. The training included the following information: "Reporting is 'Not' a Choice. Communication is KEY to improving and maintaining patient safety. All allegations, observations or suspected cases of abuse, neglect, or exploitation that occur in the hospital are reacquired to be reported to the CEO/DON or designee immediately." The sign-in sheet noted 13 names/signatures of staff members, including Staff F, received training. A list of current facility staff members noted there were currently 75 staff members.

Staff A was interviewed on 09/08/22 at 2:20 PM. It was confirmed that more than two weeks had elapsed since the incident of patient abuse occurred and less than 20% of staff have received training that ensured the right of patients to be free from abuse.

The investigation documentation, including the written statements of the witnesses, were reviewed. The statement of Staff F stated that at approximately 1:00 AM, she and Staff E were assisting the patient to bed when the patient became combative with Staff E. The patient "began to strike" Staff E and Staff E grabbed the wrists of the patient and "threw his hands towards his direction" making the patient hit himself in the face. The written statement of Staff C stated she was in the milieu and observed Staff E take the hand of the patient and force him to hit himself, saying, "this is what it feels like." Staff E's written statement noted the patient "began fighting and while fighting and swinging his hands I took his wrist and flung it back at him causing him to hit his own self in the face."

Review of the personnel record of Staff E revealed Staff E had a start date of 06/29/22 as a full time STNA. A copy of a job description for a STNA was signed by Staff E on 06/29/22. Under the category of miscellaneous, the job description stated the STNA must comply with all applicable federal and state laws as well as regulations and hospital policies that apply to assigned duties. The job description further stated that the STNA must comply with hospital expectations regarding ethical behavior and standards of conduct. General orientation documents listed on a new hire checklist noted, among other required facility policies, the facility policy regarding abuse and neglect and a policy for suspected elder abuse. There was no check next to the box indicating Staff E had received any of the general orientation documents, including the policies related to abuse and neglect.

Staff F, the Regional Human Resource Director, was interviewed on 09/08/22 at 1:30 PM and asked to provide documentation that Staff E had received training regarding abuse and neglect of patients. Staff F stated that the facility's Human Resource Director, Staff D, was no longer employed at the facility and she was merely filling in until another director could be hired. Staff F stated there was no documentation that Staff E had received this required training.

Staff A was interviewed on 09/08/22 at 3:50 PM. It was confirmed there was no documentation that Staff E received the required training regarding abuse and neglect of patients. It was further confirmed that this staff member admitted to patient abuse less than two months after being hired.

This deficiency substantiates Substantial Allegation OH00135518.