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Based on interview and record review, the hospital failed to provide an environment free from abuse/neglect and failed to implement effective interventions to prevent future occurrences of abuse/neglect. This deficient practice was evidenced by:
1) 1 Patient (#5) of 5 Patients (#1 - #5) sampled records reviewed who was the victim of physical abuse by S6MHT and the allegation was substantiated by the hospital; and,
2) 3 Patients (#1, #3, #5) of 5 Patients (#1 - #5) sampled records reviewed revealed the hospital's failure to follow physician's orders including observation status and the delivery of medical treatment interventions.
Findings:

1) 1 Patient (#5) of 5 Patients (#1 - #5) sampled records reviewed who was the victim of physical abuse by S6MHT and the allegation was substantiated by the hospital; and,

Review of the policy and procedure titled, "Patient Abuse and/or Neglect" revealed, in part, definition of abuse: 1. Class I abuse means any act (or failure to act) done knowingly, recklessly, or intentionally, including an act, which caused or could have caused major physical injury to a patient. With regard to injury, any sexual activity between an employee, employee of an affiliated, or agent and a patient will be considered to be Class I abuse. Neglect is the act, series of acts, or omission of an act, of any employee, affiliated, or agent which cases or may have caused an physical or emotional injury to patient. Examples of neglect shall include, but are not limited to, failure to carry out a prescribed individual program plan or treatment plan; failure to provide a safe environment. Failure to provide a safe environment includes the failure to protect one patient from another patient's actions.

Review of the policy and procedure titled, "Patient's Rights/Organizational Ethics" revealed, in part, the hospital offers services designed to provide acute, short-term psychiatric care in a 3. Safe and structured therapeutic milieu.
Review of the policy and procedure titled, "Patient's Rights/Organizational Ethics" revealed, in part, patients have the basic rights including, in part, 29. The right to be free from all forms of abuse, harassment, and neglect; 30. The right to receive care in a safe setting; 36. The right to a copy of your rights in a language you understand; 41. The right to be disciplined in a way that is appropriate. The policy lists rights which may not be limited, in part, 3. To humane care and treatment; 9. To be treated with dignity as a human being; 14. To not be subjected to any hazardous treatment without consent, unless treatment or procedure is ordered by a court of competent jurisdiction; 17. To be free from verbal and physical abuse.

Patient #5
Review of the incident report log for February 2023 revealed, in part, on 02/13/2023 at 6:23 a.m. the type of incident as "inappropriate behavior" with a brief description including staff member used excessive force to remove patient's grip from a broom. Patient #5 was sent to a local ED for evaluation and S6MHT was terminated from employment.

Review of the hospital's self-report revealed, in part, on 02/02/2023 Patient #5 with diagnoses including mental retardation and autism would not stay dressed so he was maintained in an unlocked seclusion room and supervised 1:1 by staff. Patient #5 threw his plate of food onto the floor. S6MHT was sweeping up the food when Patient #5 grabbed the broom and would not let it go. S6MHT then pushed Patient #5 and held him down while trying to remove his grip from the broom. The conclusion was that S6MHT used excessive force on this patient and was subsequently terminated.

Review of the medical record revealed Patient #5 was admitted via a Physician's Emergency Certificate on 02/01/2023 with diagnoses of Chronic paranoid schizophrenia, Profound intellectual disability. Further review revealed Patient #5 was assigned to Unit 1.

Review of the self-report submitted by the hospital on 02/14/2023 related to Patient #5 revealed, in part, the initial action taken by the hospital included employee education in regards to proper handling of patient "done".

Review of the document titled, "February Education #2" revealed, in part, Proper handling of patients - Do not hit, push or shove patients; Do not use excessive force or "man-handle" patients; Do not place body weight on patient's head or chest; Do not taunt/tease/make fun of patients; Do not curse at patients; Do not drag patient - multiple staff members should pick up patient (each employee should have an extremity. Employee should place their arm under armpit/upper arm and under thigh) and carry him/her.

In an interview on 03/21/2023 at 1:50 p.m. S2RN indicated the method used to educate the nursing staff regarding the self-report was via folders on the units for staff to read the February education for the nurses and the mental health techs then sign the document to indicate they were educated.

Review of the active staff list provided by the hospital revealed there were 17 Registered Nurses, 14 Licensed Practical Nurses and 32 Mental Health Technicians equaling 63 active staff.

Review of the signature sheets revealed a total of 28 of the 63 staff members signed the signature sheets on the units.

In an interview on 03/21/2023 at 2:10 p.m. S2RN verified that not all staff had been educated regarding the proper handling of patients to prevent physical abuse from re-occurring.

2) 3 Patients (#1, #3, #5) of 5 Patients (#1 - #5) sampled records reviewed revealed the hospital's failure to follow physician's orders including observation status and the delivery of medical treatment interventions.

Patient #1
Review of the policy and procedure titled "Observation Precautions" revealed, in part, the purpose is to promote safety and ensure that the patient is being treated in the least restrictive environment that is clinically permitted. The policy further stated It is the policy of the hospital that each patient will be monitored throughout his or her hospitalization according to an assigned observation status. The patient's status is assigned at the time of admission, re-evaluated and changed as clinically indicated. Observation of the patient by clinical staff members will be accomplished to maintain patient/employee safety in the least restrictive manner. Procedure - The Charge RN is responsible for assigning the staff members to perform designated special observation status for each patient on his/her assigned unit. Level II: Q15 minute observation - Patient is visualized every fifteen (15) minutes by a staff member during waking hours. 2. Assigned staff members visualize patients on observation every 15 minutes or more often as indicated by patient behavior. All patients on this observation status will not be allowed in their patient rooms or down hallways without staff supervision. Documentation - The attending physician or his designee will either verbally or in writing, issue an order for required observation status. The Charge Nurse will be responsible, as noted above for assignment of staff to carry out ordered status. Staff assignments will be recorded on the MHT Team Assignment form by the Charge RN. Charge nurse or designee will make rounds every 2 hours and sign the observation sheet to ensure that MHTs are observing their assigned patient, filling the form out correctly and not charting ahead.

Review of the hospital's abuse/neglect initial report dated 02/07/2023 revealed on 02/06/2023 Pt. #1 reported that Patient #2 put his hand on her lower back then grabbed her buttock. Patient #1 stated she moved away immediately. The report verifies that Pt. #1 was moved to another unit. The hospital was not able to substantiate the complaint and indicated the patients were never unsupervised.

Review of the medical record revealed Pt. #1 was admitted to the hospital's Unit 1 on 02/04/2023 at 8:00 a.m. via a Physician's Emergency Certificate for suicidal thoughts. Subsequently, on 02/04/2023 at 10:49 a.m., Patient #1 was placed on a Coroner's Emergency Certificate.

Review of the physician's orders revealed on 02/04/2023 at 9:14 a.m., Patient #1 was placed on every 15 minute checks with suicide precautions.

Review of the nursing progress notes for Patient #1 revealed on 02/06/2023 Patient #1 reported to staff that she was groped by a male patient and that she was scared to be on the unit. Patient #1 was transferred to Unit 2.

Review of the every 15 minute observation records revealed no documentation of every 15 minute rounds completed on 02/06/2023.

In an interview on 03/21/2023 at 1:48 p.m., S3LPN verified there was no documented 15 minute observation sheet dated 02/06/2023 for Patient #1.

Patient #3
Review of the medical record revealed Patient #3 was admitted to the hospital on 03/08/2023 at 4:00 a.m. via a Physician's Emergency Certificate after presenting to an ED with delusions and non-compliance with medications. Patient #3 was diagnosed with Schizophrenia, paranoid type, Anxiety disorder and a history of diabetes. Subsequently, on 02/10/2023 at 11:35 a.m., Patient #3 was placed on a Coroner's Emergency Certificate.

Review of the physician's orders revealed, in part, on 03/08/2023 at 7:05 a.m. line of sight precautions were ordered.

Review of Patient #3's medical record revealed no documentation that the line of sight order had been implemented as per the physician's order.

In an interview on 03/21/2023 at 10:30 a.m., S2RN and S3LPN verified that Patient #3 was not on line of sight observation and had only been on every 15 minute observations since admission.

Review of the physician's orders for Patient #3 revealed, in part, finger sticks for blood glucose to be performed at 7:00 a.m., 11:00 a.m., 4:00 p.m. and 9:00 p.m. daily with sliding scale insulin.

Review of the MAR revealed no documentation for blood glucose results or the administration of insulin on the following dates and times:
03/10/2023 at 7:00 a.m., 11:00 a.m. and 4:00 p.m.;
03/11/2023 at 7:00 a.m., 11:00 a.m. and 4:00 p.m.; and,
03/16/2023 at 11:00 a.m.
Further review of Patient #3's medical record revealed no documentation regarding why the physician's orders were not followed.

In an interview on 03/21/2023 at 11:15 a.m., S3LPN verified that the finger blood glucoses were not performed or the prescribed insulin administered on the previous dates and times.

Review of the physician's orders for Patient #3 revealed, in part, weigh Pt. #3 on admit and every Thursday and Sunday.

Review of Pt. #3's medical record revealed Patient #3 was not weighed on admission, 03/09/2023, 03/12/2023, 03/16/2023, and 03/19/2023.

In an interview on 03/21/2023 at 11:20 a.m., S3LPN verified that Pt. #3 was not weighed as per the physician's order.

Patient #5
Review of the medical record revealed Patient #5 was admitted via a Physician's Emergency Certificate to the hospital on 02/01/2023 at 11:30 a.m. and was diagnosed with Chronic paranoid schizophrenia and Profound intellectual disability. Subsequently, on 02/01/2023 at 8:10 a.m., Pt. #5 was placed on a Coroner's Emergency Certificate.

Review of the physician's orders revealed on 02/01/2023 Patient #5 was placed on every 15 minute observations and then at 5:39 p.m. the order was changed to 1:1 observation.

Review of the observation forms dated 02/05/2023 and 02/06/2023 revealed the hospital failed to change Patient #5's observation status from every 15 minute observations to 1:1 observation as per the physician's order.

In an interview on 03/21/2023 at 11:55 a.m., S3LPN verified the form was not completed correctly to include 1:1 observation of Patient #5.

Based on interview and record review, the hospital failed to set priorities for its improvement activities, focusing on areas that potentially affect health outcomes, patient safety and quality of care when:
1) Review of the Quality Assurance and Performance Improvement data analysis for Human Resources revealed a 69% compliance rate for completion of orientation for 2022, 30% for January 2023 and 50% for February 2023;
2) Review of the Quality Assurance and Performance Improvement data analysis for Human Resources revealed a 76% compliance rate for employee certifications and education for 2022, 75% for January 2023 and 78% for February 2023; and, further review of the Human Resource files revealed 1 (S7LPN) of 1(S7LPN) LPN HR file reviewed and 1 (S8RN) of 2 (S8RN, S9RN) RN HR files reviewed revealed expired CPR certification.
Findings:

Review of staff orientation revealed SJ Mission/Values; Human Resources; HIPPA; Patient Rights; Safety; Abuse/Neglect; Age/Cultural; Mental Illness; Professional Boundaries; Workplace Violence; Therapeutic Communication; Contraband; Nursing Documentation/EMR; Infection Control; Covid-19; Complaints/Grievances; Seclusion/Restraint; Restraint Chair; Observations/Precautions.

Review of the staff annual re-education revealed for September 2022 Competency List; TB Screening; Flu/Covid Screening; Workplace Violence Education; EMR Documentation; Seclusion/Restraints; HIPAA; Patient Rights; Abuse/Neglect; Restraint Chair; Safety; Contraband; Infection Control; Complaints/Grievances; Observations/Precautions.

1) Review of the Quality Assurance and Performance Improvement data analysis for Human Resources revealed a 69% compliance rate for completion of orientation for 2022, 30% for January 2023 and 50% for February 2023;

In an interview on 3/21/2023 at 1:45 p.m. QM director indicated she did not know why orientation statistic was so low and had not taken any steps to make improvements.

In an interview on 3/21/2023 at 1:50 p.m. DON verified the nursing staff did not receive elements of general orientation to include items such as fire safety.

2) Review of the Quality Assurance and Performance Improvement data analysis for Human Resources revealed a 76% compliance rate for employee certifications and education for 2022, 75% for January 2023 and 78% for February 2023; and, further review of the Human Resource files revealed 1 (S7LPN) of 1(S7LPN) LPN HR file reviewed and 1 (S8RN) of 2 (S8RN, S9RN) RN HR files reviewed revealed expired CPR certification.

Review of the HR file for S7LPN revealed an expired CPR card.

In an interview on 03/21/2023 at 2:55 p.m., S2RN and S3LPN verified S7LPNs CPR certification was expired.

Review of the HR file for S8RN revealed an expired CPR card.

In an interview on 03/21/2023 at 2:55 p.m., S2RN and S3LPN verified S8RNs CPR certification was expired.

Based on record review and interview, the hospital's Quality Assurance and Performance Improvement activities failed to track an adverse patient event, analyze the cause(s) and implement preventive actions that include feedback and learning throughout the hospital. This deficient practice was evidenced by 1 Patient (#5) of 5 Patient's (#1 - #5) sampled records reviewed which revealed a substantiated allegation of physical abuse and the hospital's QAPI program failed to review the incident, implement appropriate action or track outcomes to ensure patient safety and prevent future instances of abuse.
Findings:

Review of the job description for the Quality Assurance Director revealed, in part, QA Director will be responsible for guiding the hospital's existing programs and be available for regulatory surveys as required. The QA process improvement compiles data and completes reports for the monthly and annual Quality Assurance and Performance Improvement (QAPI) reports; Assists in orientation program with employees. Further review revealed the job description was signed by S4QM on 03/08/2021.

Review of the QAPI plan effective 01/21/2021 revealed the following, in part: The purpose of the Quality Assurance and Performance Improvement Plan (QAPI) is to ensure that the Governing Body, Medical Staff, Administration, Professional service staff and support personnel demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk. The primary goals of the QAPI Plan are to plan continually and systematically, design, measure, assess and improve professional values. The QAPI Committee has the responsibility for monitoring every aspect of patient care and service from the time the patient enters the hospital through diagnosis, treatment, recovery and discharge in order to identify and resolve any breakdowns that may result in suboptimal patient care and safety, while striving to continuously improve and facilitate positive patient outcomes. Process design contains the following focus elements: Fosters a culture of safety of patients and the quality of care, treatment, and services; Utilizes the results of performance improvement, patient safety and risk reduction activities.; Assure that the improvement process organization wide; Opportunities to improve patient care and patient safety practices involve more than one department/service. To achieve fulfillment of the objectives, goals and scope of the QAI Plan, the quality structure of the program is designed to facilitate and effective system of monitoring, assessment and evaluation of the care and services provided throughout the hospital. The results of performance improvement activities medical staff and quality function review performed throughout the facility will be considered in the decision process for determination of educational needs for medical staff and hospital personnel.

Review of the Medical Executive Committee meeting minutes of 02/22/2023 revealed no agenda item related to the hospital's report of a substantiated allegation of physical abuse related to Patient #5.

Review of the Quality Assurance reports presented during the 02/22/2023 MEC meeting revealed no report regarding the hospital's substantiated allegation of physical abuse related to Patient #5.

Review of the Hospital's Abuse/Neglect self-report dated 02/14/2023 revealed, in part, a substantiated allegation of physical abuse related to Patient #5. Further review revealed "employee education in regards to proper handling of patients done".

Review of the document titled, "February Education #2" revealed, in part, Proper handling of patients - Do not hit, push or shove patients; Do not use excessive force or "man-handle" patients; Do not place body weight on patient's head or chest; Do not taunt/tease/make fun of patients; Do not curse at patients; Do not drag patient - multiple staff members should pick up patient (each employee should have an extremity. Employee should place their arm under armpit/upper arm and under thigh) and carry him/her.

In an interview on 03/21/2023 at 1:50 p.m. S2RN indicated the method used to educate the nursing staff regarding the self-report related to Patient #5 was via folders on the units for staff to read the February education for the nurses and the mental health techs then sign the document to indicate they were educated.

Review of the active staff list provided by the hospital revealed there were 17 Registered Nurses, 14 Licensed Practical Nurses and 32 Mental Health Technicians equaling 63 active staff.

Review of the signature sheets revealed a total of 28 of the 63 staff members signed the signature sheets on the units.

In an interview on 03/21/2023 at 2:10 p.m., S2RN verified that not all staff had been educated regarding the proper handling of patients to prevent physical abuse from re-occurring.

In an interview on 03/21/2023 at 1:45 p.m., S4QM indicated she had no knowledge of how the staff were being re-educated regarding the physical abuse of Patient #5. S4QM indicated she had not reported this incident to the Medical Executive Committee or the Governing Body. S4QM indicated she did "nothing" to analyze data, track trends, or assess the effectiveness of interventions to prevent further physical abuse from occurring.

Based on observation, interview and record review, the hospital failed to have adequate numbers of licensed registered nurses to provide safe care to all patients on Unit 1 during the night shift of 02/01/2023. This deficient practice occurred on the night shift beginning 02/01/2023 into 02/02/2023 at 6:23 a.m. when a substantiated allegation of physical abuse by S6MHT occurred towards Patient #5.
Findings:

Review of the hospital nursing staffing grid revealed the hospital staffed both units of the hospital (Unit 1 and Unit 2) with 1RN, 2LPNs and 6MHTs. The staffing grid failed to delineate the number of staff based on the census for each hospital unit.

Review of the map of the hospital revealed Unit 1 with a bed capacity of 24 patients. Further review of the map revealed a locked door leading to Unit 2 with a bed capacity of 12 patients.

Review of the daily unit assignments for the night shift of 02/01/2023 at 6:00 p.m. revealed on Unit 1 S7LPN, S12MHT. On Unit 2 the Charge Nurse was S8RN, Med Nurse S10LPN, Unit 2 nurse S11LPN, and Unit 2 MHT- S17MHT. Further review revealed the following staff not assigned to a specific unit: S13MHT, S14MHT, S15MHT and S16MHT. There was a census of 32 patients.

Review of the admission criteria education identified Unit 1 for acute psychotic, violent patients and Unit 2 for older "geri" patients, pregnant, 1st time - SI only.

In an interview on 03/21/2023 at 9:48 a.m., S3LPN indicated the hospital is separated by a locked door and divided into 2 separate units. S3LPN indicated that Unit 1 has beds for 24 patients and is divided into a male and female hall. S3LPN indicated Unit 1 accommodates more acute patients. S3LPN indicated Unit 2 has beds for 12 patients and accommodates mood disordered patients and a geriatric population.

A tour of the facility given by S1CEO and S3LPN revealed two separate units (Unit 1 and Unit 2) with two separate nurse's stations, dayrooms, seclusion rooms and showers. There was a locked door separating the two units.

In an interview on 03/21/2023 at 2:50 p.m., S1CEO indicated the hospital was originally structurally designed to include two separate units to accommodate two distinct populations including geriatric patients.