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Based on document review and interview it was determined that the Hospital failed to protect and promote patients rights by failing to follow the prevention of abuse policy during an investigation of alleged physical abuse. As a result, the Condition of Participation, 42 CFR 482.13 Patient Rights was not in compliance.

Findings include:

1. The Hospital failed to ensure that the patient was free from all forms of abuse, by failing to follow the procedure for prevention of abuse. See deficiency at A-145.

Based on document review and interview, it was determined that for 1 of 5 (Pt. #1) clinical records reviewed, the Hospital failed to ensure patient exercised his rights by failing to facilitate access to the Patient Advocate upon request.
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Findings include:

1. On 8/4/2022, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 7/22/2022, with psychosis /psychotic disorder (mental disorder characterized by a disconnection from reality) unspecified. Pt. #1's "Seclusion/Restraint Patient Debriefing" form dated 8/2/2022 at 1:10 PM, included, "Patient's perception of events/triggers leading to intervention: 'I want to talk to patient advocate." Pt. #1's record does not mention that Pt. #1 ever saw the Patient Advocate.

2. On 8/8/2022, the Hospital's policy titled, "Patient Rights and Responsibilities" (effective 7/2022) was reviewed and included, "... Procedure... 9... 10. The right to initiate a complaint or grievance and the appropriate procedure..."

3. On 8/8/2022, the Hospital's "Patient Grievance Procedure/Rights" (undated) was reviewed and included, "... As someone who is receiving services... you have the right to file a grievance in regard to your care... You may also leave a voicemail for the Patient Advocate by calling... while you are in campus..."

4. On 8/8/2022 at 9:40 AM, an interview was conducted with the Patient Advocate (E #12). E #12 stated that she is the only Patient Advocate in the Hospital. E #12 stated that she (E #12) was not contacted on 8/2/2022, and knew nothing about the incident, until now.

Based on document review and interview, it was determined that for 1 of 1 patient's (Pt. #1) clinical record reviewed for allegation of abuse, the Hospital failed to ensure that the patient was free from all forms of abuse, by failing to follow the procedure for prevention of abuse.

Findings include:

1. On 8/4/2022, the Hospital's policy titled, "Prevention Abuse and Neglect" (revised on 9/2020) was reviewed and included, "... Procedure... Abuse means any physical... injury... intentionally inflicted by an employee... on a patient... Process... If an employee... is told of... an incident of physical abuse... the employee is required to provide the following information to the Risk Department immediately... The Risk Department will proceed with Incident Management and Investigation..."

2. On 8/4/2022, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 7/22/2022, with psychosis /psychotic disorder (mental disorder characterized by a disconnection from reality) unspecified. E #7's (In-patient Therapist) progress notes on 8/3/2022 indicated, "...The patient (Pt. #1) processed with the writer (E #7) the altercation that occurred (on 8/2/2022)... (Pt. #1) reported that, 'I was wronged' and continued to discuss incident of the event..."

3. On 8/4/2022 between approximately 10:00 AM through 10:30 AM, an interview was conducted with Pt. #1. Pt. # 1 stated that he reported to E #7 the he (Pt. #1) was hit by a staff on 8/2/2022.

5. On 8/4/2022 at 2:00 PM, an interview was conducted with E #7. E #7 stated that she met with Pt. #1 on 8/3/2022, and that Pt. #1 was very upset on 8/2/2022, when his discharge was canceled, due to his noncompliance with taking medications, and is why Pt. #1 acted out. E #7 stated, "...(Pt. #1) told (E #7) that "he was wronged... (Pt. #1) said someone assaulted him, felt pain on his head".

6. On 8/8/2022 at 8:55 AM, the Director of Risk and Performance Improvement (E #2) stated an investigation was started on 8/4/2022 when the video of the incident was replayed, and questions were raised. E #4 (Verbal De-escalation Specialist) was suspended with pay, pending investigation.

7. On 8/8/2022 at approximately 8:45 AM, E #14 (Chief Executive Office) stated that the Hospital started the investigation on 8/4/2022 regarding Pt. #1's allegation of abuse (one day after the allegation was reported to a staff).