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Based on interview, record review and review of the facility's abuse policy and procedure and incident report, it was determined the facility failed to follow their abuse policy in regards to reporting an alleged physical abuse against a patient in the facility's Progressive Care Unit (PCU) and failed to conduct a timely investigation into the alleged abuse for one (1) patient (#1), in the selected sample of ten (10) patients. The PCU staff observed the alleged physical abuse against Patient #1, on 02/11/13 and the event was not reported to the facility's Director and to the State Agency (SA,) until 02/27/13, per requirements of KRS 209. The staff member was allowed to work seven (7) shifts before being suspended and the incident investigated.

The findings include:

A review of the facility's Suspected Abuse, Harassment, Neglect or Exploitation of an Adult: Identification and Reporting policy, last revised August 2012, revealed the facility would identify adult victims of mental, physical, or sexual abuse, neglect or exploitation through the assessment process and would report such cases, immediately, when identified, to the charge nurse. Suspicions of any nature, would be reported to the Department of Community Based Services (DCBS) in accordance with KRS 209.030. The policy stated each employee has the responsibility to report related to the identification of abuse, of any nature. The responsibilities of the Nurses are to notify DCBS of the suspected abuse, perform clinical and psychosocial assessments, document findings, report to the physician, the House Supervisor and Case Management.

A record review revealed Resident #1 was admitted to the facility on 02/04/13 with diagnosis to include Acute on Chronic Bronchitis, Chronic Obstructive Pulmonary Disease, Borderline Elevation of Cardiac Enzymes, Glaucoma, Macular Degeneration and Legal Blindness, Diabetes, Hypertension and Hypoxia.

A review of the clinical record for Patient #1, revealed the patient was admitted to PCU, on 02/05/13 at approximately 8:41 AM, from the eighth (8 th) floor, after an episode of Hypoxia and shortness of breath, resulting in declining oxygen (O2) saturation rates. A review of the Discharge Summary, dated 02/13/13, revealed the patient was treated with O2, per face mask at five (5) liters per min (L/m,) nebulizer breathing treatments, intravenous (IV) antibiotics, IV steroids and Nitroglycerin, for elevations of cardiac enzymes and in addition, the patient experienced "significant confusion for a couple of days". The patient improved and was discharged back to the long term care facility, on 02/13/13.

An observation and interview with Patient #1, on 04/11/13 at 2:05 PM, at the long term care facility, revealed the resident had just completed a breathing treatment and no longer required continuous O2. He/she was alert, recalled the recent hospital admission, denied any staff being rude, yelling, speaking inappropriately towards him/her or any abuse neglect or roughness, on the part of the staff, at the hospital.

A review of the Investigation Report made by the Hospital Director revealed RN #5 reported on 02/27/13 at approximately 8:00 AM, that RN #1 had "smacked Patient #1's hand, told him/her to shut-up, and covered the patient's mouth with her hand" on 02/11/13.

An interview with Registered Nurse (RN) #1, on 04/10/13 at 11:03 AM, revealed there were three RNs working PCU, on 02/11/13, plus a nurse who was called into work on her day off and did not arrive at the unit, until approximately 10:30 PM. This resulted in four RNs on the unit, which held a maximum of 12 patients. RN #1 stated Patient #1, was calling out and upon investigation was found to have pulled out the urinary catheter, for the second time that evening. RN #1 stated she was briefed by RN #2, who was the Charge Nurse that evening, that Patient #1 was in soft-point wrist restraints, due to having removed the O2 mask, which resulted in the resident's O2 saturations dropping quickly, and pulled out the IV and catheter. RN #1 revealed the staff were attempting to regain IV access, to continue needed antibiotics and administer Ativan for anxiety, when the patient began "clawing at me with his/her fingernails." RN #1 stated she took her hand and "swatted" the patient's hand, but "not with any force, just trying to get her hand away and there was no intent to harm". The RN was unable to state if the patient realized the intent of the "swat," and stated everything she did was "to protect the patient". RN #1 denied ever telling the patient to "shut-up" and stated she did not recall touching the patient's mouth, only making a "cupped-hand gesture over his/her mouth". The RN did remember making a comment about a muzzle and stated she had "said that to myself" upon exiting the patient's room, in the hallway. RN #1 stated she told RN #3, what she had said about a muzzle and how when she looked up, she saw a visitor going down the hallway and hoped they did not hear what she had said about the muzzle. The RN stated she had received routine training on abuse/neglect from the hospital. The RN revealed she had previously been suspended for three days for saying a racial slur to a co-worker and received a written reprimand for putting a specimen in the wrong container. The RN stated no one had approached her about the "swatting" incident and she worked a 12 hour shift the next night (02/12/13), as a Charge Nurse. She revealed she worked directly with Patient #1, and described the patient as being very lucid, having no confusion, restraints or catheter and being "very apologetic" for the events that had occurred the previous evening.

A review of RN #1's Time Sheet Print-Out, for 02/10/13-03/09/13, revealed the RN worked seven (7) 12 hour shifts, in PCU, before she was approached about the events that occurred on 02/11/13. On 02/28/13, the RN was called to come to the facility for her statement and was terminated, the same day.

An interview with RN #3, on 04/09/13 at 3:35 PM, revealed she had gone into Patient #1's room to assist RN #1 and RN #2 to place a urinary catheter. She stated RN #1 had taken Patient #1's hands out of the soft wrist restraints to pull him/her up in bed and the patient grabbed RN #1's hand and RN #1 "smacked his/her hand." RN #3 revealed the Charge Nurse (RN #2) was in the room at the time and felt she did not need to inform anyone because the charge nurse saw the incident. RN #3 stated Patient #1 had pulled the urinary catheter out again, later in the shift. RN #3 revealed she and RN #3 were the only staff in the room and RN #1 stated to the patient she "wished they kept muzzles on the floor to use on him/her." RN #3 stated she witnessed RN #1 to tell the patient to "shut-up already" and RN #1 put her hand over the patient's mouth. RN #3 stated she reported this to the Charge Nurse as soon as she left the room. RN #3 revealed she confided in RN #4 "a few days later", that nothing had been done and RN #4 told her to tell the Director.

An interview with RN #2, on 04/09/13 at 3:05 PM, revealed she was the Charge Nurse on the unit on 02/11/12, when RN #1 "slapped" Patient #1's hand, "like you would slap a baby's hand". RN #2 stated she said "oh no, don't do that," to RN #1, not because she thought the patient had been hurt but because it "shocked" her. RN #2 revealed RN #1 stated "she slapped her grandbaby's hand" as the rationale for this action. RN #2 stated she worked part-time and did not discuss this incident again until she spoke with RN #5, the next time she worked, because the thought "nagged me", "I didn't want to overreact" and "my grandmother would have been livid, had she been slapped like that". RN #2 stated "that was all she saw with her own eyes" and she did not find out about RN #1 having cupped her hand over the patient's mouth until a week later.

An interview with RN #4, on 04/10/13 at 9:12 AM, revealed she was also working the unit on 02/11/13, but never actually went into the patient's room. She stated RN #3 had come out of the room and was very frustrated and told her that RN #1 had told the patient to "shut-up" and had placed her hand over the patient's mouth and had slapped the patient's hand away. She stated "a few days later", the subject had come up again and she told RN #3, "she needed to tell somebody".

An interview with RN #5, on 04/10/13 at 3:57 PM, revealed she was not working the night of the incident, but was told of the incident by RN #3, on the week-end of 02/23/13-02/24/13. RN #5 stated she talked to RN #2 about the incident on 02/25/13 and told RN #2 "if you don't report this, I will". After two days, the Director had not called RN #5 for an interview, so RN #5 called the Director and reported the incident.

Further interviews with with RN #1, #2, #3, #4 and #5 on 04/09/13 at 3:05 PM and 3:35 PM and on 04/10/13 at 9:12 AM, 11:03 AM, and 3:57 PM revealed all of them had received training on abuse and neglect to include to report up the chain of command, immediately, anytime they suspected abuse or neglect. The reasons they gave for not reporting were minimizing the events that occurred, not wanting to overact, not getting involved in someone else's business and not wanting to report something they had only heard about.

An interview with the Director of Critical Care, on 04/09/13 at 11:55 AM, and a review of the Investigation Report made by the Director, revealed the Director was made aware of the incident on 02/27/13 at approximately 8:00 AM. RN #5 reported RN #1 "smacked Patient #1's hand, told him/her to shut-up, and covered the patient's mouth with her hand". Further review and interview revealed RNs #1 through #4 were interviewed and gave their statements. RN #1 was terminated, on 02/28/13, when she came in to give her statement, to the Director, the Human Resources Officer and the Compliance Officer. The event was reported to the Department of Community Based Services (DCBS) on 02/27/13.

Based on interview, record review and review of the facility's abuse policy and procedure and incident report, it was determined the facility failed to follow their abuse policy in regards to reporting an alleged physical abuse against a patient in the facility's Progressive Care Unit (PCU) and failed to conduct a timely investigation into the alleged abuse for one (1) patient (#1), in the selected sample of ten (10) patients. The PCU staff observed the alleged physical abuse against Patient #1, on 02/11/13 and the event was not reported to the facility's Director and to the State Agency (SA,) until 02/27/13, per requirements of KRS 209. The staff member was allowed to work seven (7) shifts before being suspended and the incident investigated.

The findings include:

A review of the facility's Suspected Abuse, Harassment, Neglect or Exploitation of an Adult: Identification and Reporting policy, last revised August 2012, revealed the facility would identify adult victims of mental, physical, or sexual abuse, neglect or exploitation through the assessment process and would report such cases, immediately, when identified, to the charge nurse. Suspicions of any nature, would be reported to the Department of Community Based Services (DCBS) in accordance with KRS 209.030. The policy stated each employee has the responsibility to report related to the identification of abuse, of any nature. The responsibilities of the Nurses are to notify DCBS of the suspected abuse, perform clinical and psychosocial assessments, document findings, report to the physician, the House Supervisor and Case Management.

A record review revealed Resident #1 was admitted to the facility on 02/04/13 with diagnosis to include Acute on Chronic Bronchitis, Chronic Obstructive Pulmonary Disease, Borderline Elevation of Cardiac Enzymes, Glaucoma, Macular Degeneration and Legal Blindness, Diabetes, Hypertension and Hypoxia.

A review of the clinical record for Patient #1, revealed the patient was admitted to PCU, on 02/05/13 at approximately 8:41 AM, from the eighth (8 th) floor, after an episode of Hypoxia and shortness of breath, resulting in declining oxygen (O2) saturation rates. A review of the Discharge Summary, dated 02/13/13, revealed the patient was treated with O2, per face mask at five (5) liters per min (L/m,) nebulizer breathing treatments, intravenous (IV) antibiotics, IV steroids and Nitroglycerin, for elevations of cardiac enzymes and in addition, the patient experienced "significant confusion for a couple of days". The patient improved and was discharged back to the long term care facility, on 02/13/13.

An observation and interview with Patient #1, on 04/11/13 at 2:05 PM, at the long term care facility, revealed the resident had just completed a breathing treatment and no longer required continuous O2. He/she was alert, recalled the recent hospital admission, denied any staff being rude, yelling, speaking inappropriately towards him/her or any abuse neglect or roughness, on the part of the staff, at the hospital.

A review of the Investigation Report made by the Hospital Director revealed RN #5 reported on 02/27/13 at approximately 8:00 AM, that RN #1 had "smacked Patient #1's hand, told him/her to shut-up, and covered the patient's mouth with her hand" on 02/11/13.

An interview with Registered Nurse (RN) #1, on 04/10/13 at 11:03 AM, revealed there were three RNs working PCU, on 02/11/13, plus a nurse who was called into work on her day off and did not arrive at the unit, until approximately 10:30 PM. This resulted in four RNs on the unit, which held a maximum of 12 patients. RN #1 stated Patient #1, was calling out and upon investigation was found to have pulled out the urinary catheter, for the second time that evening. RN #1 stated she was briefed by RN #2, who was the Charge Nurse that evening, that Patient #1 was in soft-point wrist restraints, due to having removed the O2 mask, which resulted in the resident's O2 saturations dropping quickly, and pulled out the IV and catheter. RN #1 revealed the staff were attempting to regain IV access, to continue needed antibiotics and administer Ativan for anxiety, when the patient began "clawing at me with his/her fingernails." RN #1 stated she took her hand and "swatted" the patient's hand, but "not with any force, just trying to get her hand away and there was no intent to harm". The RN was unable to state if the patient realized the intent of the "swat," and stated everything she did was "to protect the patient". RN #1 denied ever telling the patient to "shut-up" and stated she did not recall touching the patient's mouth, only making a "cupped-hand gesture over his/her mouth". The RN did remember making a comment about a muzzle and stated she had "said that to myself" upon exiting the patient's room, in the hallway. RN #1 stated she told RN #3, what she had said about a muzzle and how when she looked up, she saw a visitor going down the hallway and hoped they did not hear what she had said about the muzzle. The RN stated she had received routine training on abuse/neglect from the hospital. The RN revealed she had previously been suspended for three days for saying a racial slur to a co-worker and received a written reprimand for putting a specimen in the wrong container. The RN stated no one had approached her about the "swatting" incident and she worked a 12 hour shift the next night (02/12/13), as a Charge Nurse. She revealed she worked directly with Patient #1, and described the patient as being very lucid, having no confusion, restraints or catheter and being "very apologetic" for the events that had occurred the previous evening.

A review of RN #1's Time Sheet Print-Out, for 02/10/13-03/09/13, revealed the RN worked seven (7) 12 hour shifts, in PCU, before she was approached about the events that occurred on 02/11/13. On 02/28/13, the RN was called to come to the facility for her statement and was terminated, the same day.

An interview with RN #3, on 04/09/13 at 3:35 PM, revealed she had gone into Patient #1's room to assist RN #1 and RN #2 to place a urinary catheter. She stated RN #1 had taken Patient #1's hands out of the soft wrist restraints to pull him/her up in bed and the patient grabbed RN #1's hand and RN #1 "smacked his/her hand." RN #3 revealed the Charge Nurse (RN #2) was in the room at the time and felt she did not need to inform anyone because the charge nurse saw the incident. RN #3 stated Patient #1 had pulled the urinary catheter out again, later in the shift. RN #3 revealed she and RN #3 were the only staff in the room and RN #1 stated to the patient she "wished they kept muzzles on the floor to use on him/her." RN #3 stated she witnessed RN #1 to tell the patient to "shut-up already" and RN #1 put her hand over the patient's mouth. RN #3 stated she reported this to the Charge Nurse as soon as she left the room. RN #3 revealed she confided in RN #4 "a few days later", that nothing had been done and RN #4 told her to tell the Director.

An interview with RN #2, on 04/09/13 at 3:05 PM, revealed she was the Charge Nurse on the unit on 02/11/12, when RN #1 "slapped" Patient #1's hand, "like you would slap a baby's hand". RN #2 stated she said "oh no, don't do that," to RN #1, not because she thought the patient had been hurt but because it "shocked" her. RN #2 revealed RN #1 stated "she slapped her grandbaby's hand" as the rationale for this action. RN #2 stated she worked part-time and did not discuss this incident again until she spoke with RN #5, the next time she worked, because the thought "nagged me", "I didn't want to overreact" and "my grandmother would have been livid, had she been slapped like that". RN #2 stated "that was all she saw with her own eyes" and she did not find out about RN #1 having cupped her hand over the patient's mouth until a week later.

An interview with RN #4, on 04/10/13 at 9:12 AM, revealed she was also working the unit on 02/11/13, but never actually went into the patient's room. She stated RN #3 had come out of the room and was very frustrated and told her that RN #1 had told the patient to "shut-up"