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Based on interview, medical record review, and review of the facility Policies, it was determined the facility failed to ensure each patient remained free from abuse and failed to ensure each allegation of abuse was reported in a timely manner for one (1) of ten (10) sampled patients, Patient #1.

Mental Health Technician (MHT) #4 alleged she observed a verbal/physical altercation toward Patient #1 by Registered Nurse (RN) #1, on 06/01/2020 some time between 7:00 PM and 8:00 PM. However, MHT #4 did not report the allegation of abuse until 06/03/2020. RN #1 continued to work the rest of the shift on 06/01/2020 through the morning of 06/02/2020 at 7:08 AM. Further, RN #1 also worked 06/02/2020 from 6:21 PM through 06/03/2020 at 7:09 AM, allowing for further potential abuse.

The findings include:

Review of the facility "Central State Hospital Leadership Incident Management" Policy, dated 03/28/16, revealed Risk management serves to promote an environment that is free from harm. The Department of Behavioral Health, Developmental and Intellectual Disabilities (DBHDID) believes all individuals served are entitled to appropriate services in a caring and hospitable environment that is free from harm. Facilities must have integrated systems to ensure all individuals served are free from abuse, neglect, exploitation, mistreatment, injuries of unknown source, peer to peer aggression, serious injuries and other harms. Facilities are to organize systems in such a manner as to proactively assure individuals are free from serious and immediate threat to their physical and psychological health and safety. Verbal Abuse is defined as use of oral, written or gestured language that willfully includes disparaging and/or derogatory terms to individuals within their hearing distance regardless of their age, ability to comprehend, or disability. Physical abuse is any physical motion or action, by which bodily harm or trauma occurs, and includes, but is not limited to hitting, slapping, pinching, punching, kicking and burning. Physical abuse also includes controlling behavior through corporal punishment as well as the use of any restrictive, intrusive procedure to control inappropriate behavior for purposes of punishment. Immediately remove the potential target employee(s), if known, from direct care, while ensuring adequate supervision of all individuals. The facility Director or designated representative shall follow KRS 209, KRS 620 and 42 CFR 483.20 for immediate reporting of harm or potential for harm to adults whether known or unknown. All immediate reports must be made to DCBS, OIG, and/or DBHDID.

Review of the facility "Central State Hospital Ethics, Rights and Responsibility Patient Rights" Policy, dated 04/20/2009, revealed Patients have the right to courteous respectful care and to be treated in a professional, courteous, respectful and caring manner. Patients have the right to a safe secure environment and to expect reasonable safety in an environment that promotes respect dignity, comfort, and freedom from all forms of abuse or harassment.

Review of Patient #1's medical record revealed the facility admitted the patient on 04/19/2018 with diagnoses including Schizophrenia. Review of the Admission History and Physical (H & P) dated 04/19/2018, revealed the patient had a history of several prior admissions to the facility and other facilities. Further, the patient had a history of yelling out, was hostile and uncooperative toward staff, and used nonsensical phrases.

Review of Patient #1's Comprehensive Treatment Plan, dated 04/03/2020, revealed the patient had a psychiatric illness, Schizophrenia, and exhibited bizarre, non-compliant and aggressive/assaultive behavior toward staff and peers. The goals stated the patient would be able to have at least ten (10) reality based conversations with staff or peers with an anticipated completion date of 07/02/2020; and patient will be able to show a decrease in symptoms by showing goal directed behaviors by attending at least two (2) groups and being compliant with his/her medications for ten (10) consecutive days within this reporting period with an anticipated completion date of 07/03/2020. Interventions included treatment team and staff to engage with Patient #1 on a daily basis to determine if he/she is showing a decrease in signs and symptoms; and treatment team and staff to encourage patient to be compliant with all forms of treatment.

Review of the facility "Report of Unusual Incident", dated 06/03/2020, completed by the Risk Manager, revealed staff reported to the Department of Behavioral Health, Developmental and Intellectual Disabilities (DBHDID) on 06/03/2020 at 3:30 PM, an incident of suspected/alleged neglect and physical abuse occurred on 06/01/2020 between 7:00 PM and 8:00 PM. The victim was Patient #1, and RN #1 was taken off the schedule on 06/03/2020 at 3:30 PM. A staff member alleged that on 06/01/2020 between 7:00 PM and 8:00 PM, RN #1 pushed Patient #1 to the ground and then spit on him/her. Allegedly, RN #1 was responding to Patient #1 acting out on the unit, spitting and yelling. The allegation was made on 06/03/2020 at 3:30 PM, and upon discovery the facility Director was alerted to the allegation. An expanded investigation was initiated. Patient #1 was assessed to have no injury related to the allegation. The allegation was reported per fax to DCBS and the Office of Inspector General (OIG) on 06/04/2020 at 2:00 PM.

Review of MHT #3's Statement, dated 06/05/2020, revealed Patient #1 was walking up and down the hallway and tried to enter another patient's room. RN #1 redirected Patient #1 to return to his/her own room. Patient #1 remained in the hallway and sat on the floor, then woke up and went back toward his/her room. Patient #1 sat in front of his/her room and started to take his/her clothes off and spit at RN #1. RN #1 shouted at Patient not to spit at him, and "You will see what will happen." Patient #1 returned to his/her room.

The State Agency Representative attempted to reach MHT #3 for interview on 06/09/2020 at 9:25 AM; however, there was no return call.

Review of MHT #4's Statement, dated 06/03/2020, revealed she witnessed Patient #1 and RN #1 in a verbal and physical interaction on 06/01/2020. MHT #4 witnessed RN #1 place his right arm on Patient #1's left hip and push the patient to the floor. RN #1 then sat on the floor with Patient #1, and the patient continued to hit at RN #1. Patient #1 then returned to his/her room and sat by the door. Patient #1 had spit at RN #1, and RN #1 yelled back at Patient #1, "Spit again at me and see what happens." Patient #1 spit at RN #1 again and RN #1 moved his mask and spit back at the patient's face three (3) times. Patient #1 then spit again at RN #1 and returned to his/her room.

The State Agency Representative attempted to reach MHT #3 for interview on 06/09/2020 at 9:30 AM; however, there was no return call.

Per the Investigation, Patient #1 was interviewed by the Investigator and Risk Management on 06/04/2020 at 2:00 PM, and the patient started spitting. The patient answered a few questions, but was unable to elaborate on how he/she was treated.

RN #1, perpetrator, came to the facility to be interviewed on 06/09/2020 at 10:30 AM, by the facility Investigator in the presence of the State Agency Representative. The State Agency Representative then followed up with additional questions. During the interview, RN #1 revealed he had worked for (4) years at the facility on Unit-G. Per interview, on 06/01/2020 about 6:30 PM, Patient #1 was "Raising cane", and entering other patient's rooms and he attempted to redirect the patient. Patient #1 began to scream at RN #1 and began scratching, and grabbing RN #1. RN #1 stated Patient #1 then started to pull his/her shirt off and he pulled the patient's shirt back down. Patient #1 continued to hit and spit at RN #1, and then Patient #1 got up and sat between two (2) other patient rooms while yelling and spitting at other staff. Per interview, RN#1 approached Patient #1 again to calm the patient down, when the Patient #1 spit toward RN #1 and he held up his hand to protect his face from the spit. RN#1 further revealed he inadvertently sneezed into Patient #1 face, as he had taken his mask off to get a drink and was not wearing it when he sneezed. RN#1 denied spitting intentionally at Patient #1, denied stating, "Spit again at me and see what happens", and denied pushing the patient to the ground.

Interview on 06/09/2020 at 1:15 PM, with RN Unit-G Manager, revealed MHT #4 did notify her of the allegation of abuse involving Patient #1 on 06/03/2020 at approximately 3:10 PM or 3:15 PM. She stated MHT #4 alleged she observed on 06/01/2020, RN #1 pushing Patient #1 down, and then the patient went to his/her room and came out and spit on RN#1. RN Unit-G Manager stated she was also informed by MHT #4, that RN #1 told Patient #1, "Spit on me again and see what happens", and Patient #1 spit on him again and he pulled his mask down and spit on the patient. RN #1 grabbed Patient #1 by the wrist and pulled him/her down and held him/her to the floor. RN Unit-G Manager stated the Director of Nursing (DON), Risk Manager and Hospital Director were immediately notified. Per interview, RN #1 was notified by phone that he was off the schedule due to the pending investigation. Further interview revealed Patient #1 was unable to provide a statement related to the alleged incident, but the patient had no physical bruising. RN Unit-G Manager further stated MHT #4 did not immediately report the allegation of abuse because she did not want to "tattletale." Per interview, MHT #4 was educated concerning reporting allegations of abuse in a timely manner.

Interview on 06/09/2020 at 3:10 PM, with the Acting Director of Nursing (DON), revealed she was informed of the allegation on 06/03/2020 and immediately ensured RN #1 was removed from the schedule. Per interview, it was her expectation staff immediately report any allegations of abuse to management in order to ensure the perpetrator is removed from direct care pending the investigation.

Review of the facility form titled "Time Detail", dated 05/29/2020 to 06/09/2020, revealed RN #1 remained on the schedule on 06/01/2020 after the alleged incident until 06/02/2020 at 7:08 AM. Further, RN #1 worked on 06/02/2020 from 6:21 PM through 06/03/2020 at 7:09 AM.

Interview on 06/09/2020 at 3:50 PM, with the Hospital Director, revealed he was made aware of the allegation involving Patient #1 on 06/03/2020 and ensured the Acting DON and the Risk Manager were notified. He stated once MHT #4 reported the allegation on 06/03/2020, RN Unit-G Manager notified RN #1 that he was taken off the schedule pending the investigation. Per interview, the investigation was ongoing and he could not say at this point whether the allegation of abuse would be substantiated. The Hospital Director acknowledged the allegation of abuse involving Patient #1 was not reported timely to management, DBHDID, DCBS or OIG, as MHT #4 did not immediately report the alleged incident. Further, as a result of MHT #4 failing to report the allegation immediately, RN #1, the alleged perpetrator continued to work and was not immediately removed from patient care in order to protect patients from further potential abuse.