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Based on interviews, record review, and review of the facility's policies and documents, it was determined the facility failed to protect the rights of their patients. It was determined the facility failed to ensure patients were protected from abuse and failed to ensure vulnerable patients received care in a safe setting for one (1) of ten (10) sampled patients (Patient #1). Review of a performance evaluation dated 08/16/16 revealed Certified Nursing Assistant (CNA) #1 needed improvement in the areas of the ability to set limits for patients and other de-escalation techniques, communicating appropriately and clearly with co-workers, and demonstrating the ability to be flexible, organized, and act appropriately under stressful situations. Further review of the facility documentation and interview with the Unit Manager revealed no evidence the facility developed a performance improvement plan to ensure CNA #1 could safely care for the patients. Review of the facility investigation dated 10/24/16 revealed on 10/20/16 CNA #1 was "hyped up" and "mad" because the attending physician had ordered therapeutic showers for three (3) patients on the unit that evening. The investigation stated that while CNA #1 was providing the shower to Patient #1, staff overheard "yelling" and "screaming" coming from the shower room. Registered Nurse (RN) #1 and RN #2 went into the shower room to intervene and found Patient #1 agitated and "screaming" to the point that the patient was inconsolable. Even though the nurses heard yelling from the shower room and observed Patient #1 "shy away" from CNA #1 for the remainder of the evening of 10/20/16, the nursing staff failed to report the incident because this was considered "normal" behavior for CNA #1. On 10/21/16, Patient #1 reported to CNA #2 that CNA #1 physically abused the patient in the shower on 10/20/16. An assessment of the patient revealed bruising over Patient #1's thoracic spine (area of the back) with the imprint of the mesh from the shower chair on the patient's upper back. Further review of the facility investigation and interview with nursing staff revealed the Registered Nurses knew CNA #1 was "angry" because she had to administer showers that evening. Furthermore, the three (3) registered nurses were aware that CNA #1 had a history of "yelling and screaming" at patients, being aggressive on the geriatric unit, and not being kind to patients. Additionally, the three (3) RNs failed to report the incident or her history to facility Administration.

Refer to A0144 and A0145.

Based on interview, record review, review of the facility policies, review of the facility investigation, and review of a performance evaluation, it was determined the facility failed to ensure vulnerable patients received care in a safe setting for one (1) of ten (10) sampled patients (Patient #1). Review of a performance evaluation dated 08/16/16 for Certified Nursing Assistant (CNA) #1 revealed the Unit Manager identified that CNA #1 needed improvement in areas that included de-escalating geriatric patients and staying calm and tolerant with aggressive and agitated [geriatric] patients. There was no evidence, within the personnel file, that a performance improvement plan was implemented to ensure the CNA could safely care for patients. Review of the facility investigation revealed on 10/20/16 CNA #1 was "hyped up" and "mad" because the attending physician had ordered therapeutic showers for three (3) patients on the unit that evening. The investigation stated while CNA #1 was administering the shower to Patient #1, "yelling" and "screaming" was heard coming from the shower room by nursing staff. Registered Nurse (RN) #1 and RN #2 went into the shower room to intervene and found Patient #1 agitated and "screaming" to the point that the patient was inconsolable. Interviews with nursing staff revealed problems with CNA #1's temper and her "yelling" was "nothing new" and the Unit Manager was aware of her behavior. On 10/21/16 Patient #1 reported to CNA #2 that CNA #1 physically abused the patient in the shower on 10/20/16 resulting in a bruising over Patient #1's thoracic spine with the imprint of the mesh from the shower chair on the patient's upper back.

The findings include:

Review of the facility policy titled, "Patient Rights," revised 07/28/14, revealed patients have the right to be treated in a safe environment that is free from all forms of neglect, abuse, exploitation, or harassment.

Review of the facility policy titled, "Abuse and Neglect," revised 01/09/12, revealed the purpose of the policy was to protect patients from verbal, sexual, physical, and mental abuse. Continued review of the facility policy revealed it was the responsibility of any team member having reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation to initiate reporting immediately. Team members were to immediately notify the House Supervisor or Department Supervisor if neglect/abuse was suspected.

Review of the "Job Description/Performance Review Evaluation" sheet, revised June 2016, revealed on a performance evaluation if an employee has an area that "does not meet" expectation, then a work improvement plan is needed with a re-evaluation in sixty (60) days. There was no guidance for a manager on how to address an employee that "needs improvement" in a performance area.

Review of the personnel file for CNA #1 revealed the facility hired CNA #1 on 08/18/08 and all background checks and training were conducted as per facility policy. Review of a performance evaluation for the period of 06/01/15 through 05/31/16 revealed CNA #1 needed "improvement" in five (5) areas on the evaluation. CNA #1 needed improvement in the area of "the ability to set limits for patients and other de-escalation techniques." The Unit Manager had written, "[CNA #1] needs to work on staying calm and tolerant with aggressive and agitated [geriatric] patients" and that CNA #1 needed to "work on learning more about de-escalating tips for geriatric patients and staying calm."

Review of the facility investigation dated 10/24/16 revealed on 10/21/16 Patient #1 reported to CNA #2 that CNA #1 "hurt my back and was mean to me and I don't know what I did" on 10/20/16 while administering a shower to Patient #1. Continued review of the facility investigation revealed RN #2 stated, "[CNA #1] is just not kind to our [geriatric] patients. I have tried to change her so she seems more kind but it hasn't happened." Further review of the investigation revealed RN #3 stated, "[CNA #1] yells all the time, so it wasn't anything new." In addition, the facility investigation revealed the investigation of the event reflected consistency in reporting by Patient #1. The facility investigation further revealed bruising over the patient's thoracic spine supported the allegation of abuse. Continued review of the facility investigation revealed information received from nursing staff interviews supported substantiating the allegation of abuse. The decision was made to terminate the employment of CNA #1.

Review of the medical record for Patient #1 revealed the facility admitted Patient #1 on 10/12/16 with diagnoses that included Major Depressive Disorder, Dementia with Psychotic Features, and Anxiety Disorder. Continued review of the medical record revealed on 10/14/16 Patient #1's physician ordered a shower at 8:00 PM every day. The facility discharged Patient #1 on 10/24/16.

Interview with RN #1 on 10/31/16 at 2:41 PM revealed she was the charge nurse on 10/20/16. RN #1 stated that she knew CNA #1 was "mad" when they were coming out of report because of the showers that were ordered to be given on the evening shift. RN #1 stated she told CNA #1 that Patient #1 could have a bed bath that evening. RN #1 stated she was working with another patient when she heard "yelling" and "screaming" coming from the shower room. Continued interview revealed RN #1 went to the shower room and found CNA #1 "yelling" at Patient #1 and Patient #1 "screaming to the point that you could not understand the patient." RN #1 stated CNA #1 left the room and she and RN #2 finished Patient #1's shower and dressed the patient. Further interview with RN #1 revealed that throughout the rest of the evening, Patient #1 would point his/her finger and "scrunch up [his/her] face" and say "no" to CNA #1 and would have "nothing else to do with [CNA #1]." RN #1 stated that CNA #1 had "a temper" and was always "on edge." RN #1 stated, "I always kind of watched [CNA #1] because of her temper." RN #1 stated she had never reported CNA #1 to the Unit Manager for concerns she had with her behavior/temper.

Interview with RN #2 on 10/31/16 at 3:00 PM revealed she was working on 10/20/16 and was aware that CNA #1 was "mad" when leaving report because she had to shower Patient #1. RN #2 stated she offered to assist with the shower for Patient #1, but CNA #1 went ahead and started it. RN #2 stated that she was working with another patient when she heard Patient #1 "screaming" in the shower room. RN #2 also stated she heard CNA #1 "yelling" at Patient #1. Continued interview with RN #2 revealed that she went to the shower room and CNA #1 was leaving when she arrived. RN #2 stated she assisted RN #1 in calming Patient #1 and getting the patient dressed. RN #2 stated that CNA #1 was not "kind" to the patients and that she was "trying to mentor her." Further interview with RN #2 revealed that this behavior from CNA #1 was the "norm" and it did not "shock" her.

Interview with RN #3 on 10/31/16 at 3:15 PM revealed she was working on 10/20/16 and was aware that CNA #1 was "upset" that she had to give showers that evening and stated she heard CNA #1 say "I don't have time to give showers this evening." RN #3 stated she was at the nursing station and heard "yelling" and "screaming" coming from the shower room. She further stated she saw RN #1 and RN #2 go into the shower room. RN #3 stated it was "routine" for CNA #1 to be negative and angry on the unit. Further interview with RN #3 revealed that "if [CNA #1] treated my mother like she does some of these patients, I'd have a problem." RN #3 stated that the Unit Manager was more than aware of CNA #1's problem with her temper, her impulse control, and her "yelling" on the unit.

Interview with the Unit Manager on 11/01/16 at 9:00 AM revealed that she became aware of the allegation of abuse on 10/21/16 after Patient #1 reported to CNA #2. The Unit Manager stated that she was aware that CNA #1 was "loud" and had incidents with her peers on the unit, but was not aware that nursing staff had a problem with the way CNA #1 treated the patients on the unit. The Unit Manager stated she conducted the performance evaluation on CNA #1; however, a performance improvement plan was not in place because she did not meet the criteria for a performance improvement plan. Further interview with the Unit Manager revealed a performance improvement plan was only needed when an employee had an area in the "does not meet" category on the evaluation. The Unit Manager stated she was having CNA #1 "mentored" to improve her behavior and skills. Continued interview with the Unit Manager revealed that she was evaluating CNA #1's behavior; however, there was no specific plan in place to monitor and evaluate her improvement. The Unit Manager stated RN #1 should have notified her or the House Supervisor immediately after CNA #1's behavior on 10/20/16.

Based on observation, interviews, record review, review of the facility's policies, and review of a facility investigation, it was determined the facility failed to ensure one (1) of ten (10) sampled patients (Patient #1) was free from abuse. Review of the facility investigation dated 10/24/16 revealed on 10/21/16 Patient #1 reported to Certified Nursing Assistant (CNA) #2 that CNA #1 had "hurt my back" and was "mean" to the patient during a shower on 10/20/16. Further review of the investigation revealed on 10/20/16 at approximately 8:00 PM, Registered Nurse (RN) #1, RN #2, and RN #3 heard CNA #1 "yelling" and heard Patient #1 "screaming inconsolably" while in the shower room. The Registered Nurses were aware after the incident that evening that Patient #1 refused to speak to, or interact with, and would "shy away from" CNA #1. Even though the facility's investigation revealed the incident was investigated and the facility terminated CNA #1 on 10/24/16, the facility failed to identify that the three (3) nurses that were present on 10/20/16 failed to immediately report the incident as required.

The findings include:

Review of the facility policy titled, "Patient Rights," revised 07/28/14, revealed patients have the right to be treated in a safe environment that is free from all forms of neglect, abuse, exploitation, or harassment.

Review of the facility policy titled, "Abuse and Neglect," revised 01/09/12, revealed the purpose of the policy was to protect patients from verbal, sexual, physical, and mental abuse. Continued review of the facility policy revealed it was the responsibility of any team member having reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation to initiate reporting immediately. Team members were to immediately notify the House Supervisor or Department Supervisor if neglect/abuse is suspected.

Review of the facility investigation dated 10/24/16 revealed on 10/21/16 Patient #1 reported to CNA #2 that CNA #1 had "hurt my back and was mean to me and I don't know what I did" on 10/20/16 while administering a shower to Patient #1. Continued review of the facility investigation revealed RN #2 stated she was working in another patient's room and heard "yelling" and "screaming" coming from the shower room and she responded. RN #2 stated, "[CNA #1] is just not kind to our [geriatric] patients. I have tried to change her so she seems more kind but it hasn't happened." Further review of the investigation revealed RN #3 stated, "[CNA #1] yells all the time, so it wasn't anything new." RN #1 stated she was working in another patient's room and heard "yelling and screaming" coming from the shower room. RN #1 stated she went into the shower room and had CNA #1 leave the shower while she calmed the patient and removed him/her from the shower. In addition, the facility investigation revealed the investigation of the event reflected consistency in reporting by Patient #1. Further review of the facility investigation revealed bruising over the patient's thoracic spine which supported the allegation of abuse. Continued review of the facility investigation revealed information received from nursing staff interviews supported substantiating the allegation of abuse. The decision was made to terminate employment for CNA #1.

Review of the medical record for Patient #1 revealed the facility admitted Patient #1 on 10/12/16 with diagnoses that included Major Depressive Disorder, Dementia with Psychotic Features, and Anxiety Disorder. Continued review of the medical record revealed on 10/14/16, Patient #1's physician ordered a shower at 8:00 PM every day. The facility discharged Patient #1 on 10/24/16.

Interview with RN #1 on 10/31/16 at 2:41 PM revealed she was the charge nurse on 10/20/16. RN #1 stated that she knew CNA #1 was "mad" when they were coming out of report because showers were ordered on the evening shift. RN #1 stated she told CNA #1 that Patient #1 could have a bed bath that evening. RN #1 stated she was working with another patient when she heard "yelling" and "screaming" coming from the shower room. Continued interview revealed RN #1 went to the shower room and found CNA #1 "yelling" at Patient #1 and Patient #1 "screaming to the point that you could not understand the patient." RN #1 stated CNA #1 left the room and she and RN #2 finished Patient #1's shower and dressed the patient. Further interview with RN #1 revealed that throughout the rest of the evening Patient #1 would point his/her finger and "scrunch up [his/her] face" and say "no" to CNA #1 and have "nothing else to do with [CNA #1]." RN #1 stated that CNA #1 had "a temper" and was always "on edge." RN #1 stated, "I always kind of watched [CNA #1] because of her temper." In addition, RN #1 stated that Patient #1 had not been aggressive toward staff members during the time she provided care for the patient. RN #1 stated she did not report this incident to the House Supervisor or the Unit Manager because CNA #1's behavior on the evening of 10/20/16 was normal behavior for her. RN #1 also stated she did not report her concerns to her supervisor with CNA #1's temper or behaviors in the facility because she felt like everyone was well aware of her behavior.

Interview with RN #2 on 10/3/16 at 3:00 PM revealed she was working on 10/20/16 and was aware that CNA #1 was "mad" when leaving report because she had to shower Patient #1. RN #2 stated she offered to assist with the shower for Patient #1 but CNA #1 stated she would do it. RN #2 stated that she was working with a patient when she heard Patient #1 "screaming" in the shower room. RN #2 also stated she heard CNA #1 "yelling" at Patient #1. Continued interview with RN #2 revealed that she went to the shower room and CNA #1 was leaving and she assisted RN #1 in calming Patient #1 and getting the patient dressed. RN #2 stated that Patient #1 had not been aggressive or combative toward staff during his/her admission to the facility. The interview revealed that CNA #1 was not "kind" to patients and that RN #1 was trying to mentor her. Further interview with RN #2 revealed that this behavior from CNA #1 did not "shock" her because it was the "norm." RN #2 stated she did not report this incident to the House Supervisor or the Unit Manager because this was normal behavior for CNA #1. In addition, RN #2 stated she had not reported her concerns with CNA #1 to the Unit Manager because she thought the Unit Manager was aware of CNA #1's problems with her temper and her "yelling."

Interview with RN #3 on 10/31/16 at 3:15 PM revealed she was working on 10/20/16 and was aware that CNA #1 was "upset" that she had to give showers that evening. RN #3 stated she heard CNA #1 say "I don't have time to give showers this evening." RN #3 stated she was at the nursing station and heard "yelling" and "screaming" coming from the shower room and saw RN #1 and RN #2 go into the room. RN #3 stated it was "routine" for CNA #1 to be negative and angry on the unit. Further interview with RN #3 revealed that "if [CNA #1] treated my mother like she does some of these patients, I'd have a problem." RN #3 stated that the Unit Manager was more than aware of CNA #1's problem with her temper, her impulse control, and her "yelling" on the unit. RN #3 stated she never reported any of her concerns to facility Administration.

Interview with CNA #2 on 10/31/16 at 2:30 PM revealed she was working on 10/21/16 when Patient #1 reported allegations of abuse. CNA #2 stated Patient #1 told her "my back hurts" and also stated "I can't tell you why." Further interview with CNA #2 revealed that Patient #1 told her "that blonde girl was really rough; shouted and yelled at me, and threw me in the shower chair last night;" CNA #2 stated she immediately reported the allegations to the Unit Manager.

Interview with the Unit Manager on 11/01/16 at 9:00 AM revealed that she became aware of the allegation of abuse on 10/21/16 after Patient #1 reported to CNA #2. The Unit Manager stated she assessed Patient #1 and found bruising and the imprint of the mesh shower chair on Patient #1's upper back. The Unit Manager stated that she was aware that CNA #1 was "loud" and had incidents with her peers on the unit, but was not aware that nursing staff had concerns with the way CNA #1 treated the patients on the unit. The Unit Manager stated the Registered Nurses should have notified her or the House Supervisor immediately after CNA #1's behavior on 10/20/16.

Based on interview, record review, and review of the facility policy it was determined the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as outlined in the facility job description for one (1) of ten (10) sampled patients (Patient #1). In addition, the facility failed to ensure nursing staff protected and reported abuse as per facility policy. Interview and record review revealed Registered Nurse (RN) #1 was the charge nurse for the unit from 7:00 PM on 10/20/16 until 7:00 AM on 10/21/16. The RN stated on 10/20/16 (when in report) she was aware that CNA #1 was "angry" because therapeutic showers were ordered for three (3) patients on their shift. RN #1 stated while she was providing care to another patient, she heard CNA #1 "yelling" at Patient #1 and Patient #1 "screaming inconsolably." RN #1 stated she went to investigate the incident and removed CNA #1 from the shower room. RN #1 stated she calmed Patient #1 down and dressed him/her. RN #1 stated for the remainder of their shift, Patient #1 would point his/her finger and "scrunch up [his/her] face" and say "no" to CNA #1 and had "nothing else to do with [CNA #1]." On 10/21/16 Patient #1 reported to CNA #2 that CNA #1 physically abused the patient in the shower on 10/20/16. The facility's investigation revealed bruising over Patient #1's thoracic spine with the imprint of the mesh from the shower chair on the patient's upper back.

Refer to A0395.

Based on interview, record review, and review of the facility job description and facility policy it was determined the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as outlined in the facility policy for one (1) of ten (10) sampled patients (Patient #1). In addition, the facility failed to ensure nursing staff protected and reported abuse as per facility policy. Interview and record review revealed Registered Nurse (RN) #1 was the charge nurse for the unit from 7:00 PM on 10/20/16 until 7:00 AM on 10/21/16. The RN stated on 10/20/16 when in report she was aware Certified Nursing Assistant (CNA) #1 was "angry" because therapeutic showers were ordered for three (3) patients on their shift. RN #1 stated while she was providing care to another patient, she heard CNA #1 "yelling" at Patient #1 and Patient #1 "screaming inconsolably." RN #1 stated she went to investigate the incident and removed CNA #1 from the shower room. RN #1 stated she calmed Patient #1 down and dressed him/her. RN #1 stated for the remainder of their shift Patient #1 would point his/her finger and "scrunch up [his/her] face" and say "no" to CNA #1 and have "nothing else to do with [CNA #1]." On 10/21/16 Patient #1 reported to CNA #2 that CNA #1 physically abused the patient in the shower on 10/20/16. The facility's investigation revealed a bruise over Patient #1's thoracic spine with the imprint of the mesh from the shower chair on the patient's upper back. The facility failed to ensure nursing staff protected and reported abuse as per facility policy.

The findings include:

Review of the facility policy titled, "Abuse and Neglect," revised 01/09/12, revealed the purpose of the policy was to protect patients from verbal, sexual, physical, and mental abuse. Continued review of the facility policy revealed it was the responsibility of any team member having reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation to initiate reporting immediately. Team members were to immediately notify the House Supervisor or Department Supervisor if neglect/abuse was suspected. Further review of the policy revealed indicators of abuse/neglect for the elderly included: agitation/anxiousness, withdrawal, hesitation to talk openly, anger, fearful, confusion, and disorientation.

Review of the Behavioral Health RN Job Description, undated, revealed the RN would provide nursing care through physical and mental assessment and perform crisis intervention when needed. Further review of the job description revealed the RN would continuously observe patient behavior, mental status, and activities.

Review of the facility investigation dated 10/24/16 revealed on 10/21/16 Patient #1 reported to CNA #2 that CNA #1 had "hurt my back and was mean to me and I don't know what I did" on 10/20/16 while administering a shower to Patient #1. Continued review of the facility investigation revealed RN #2 stated she was working in another patient's room and heard "yelling" and "screaming" coming from the shower room and she responded. RN #2 stated "CNA #1 is just not kind to our [geriatric] patients. I have tried to change her so she seems more kind but it hasn't happened." Further review of the investigation revealed RN #3 stated, "[CNA #1] yells all the time, so it wasn't anything new." RN #1 stated she was working in another patient's room and heard "yelling and screaming" coming from the shower room. RN #1 stated she went into the shower room, had CNA #1 leave the shower while she calmed the patient, and removed him/her from the shower. In addition, the facility investigation revealed the investigation of the event reflected consistency in reporting by Patient #1. Further review of the facility investigation revealed bruising over the patient's thoracic spine supported the allegation of abuse. Continued review of the facility investigation revealed the information received from nursing staff interviews supports substantiating the allegation of abuse. The decision was made to terminate employment for CNA #1.

Review of the medical record for Patient #1 revealed the facility admitted Patient #1 on 10/12/16 with diagnoses that included Major Depressive Disorder, Dementia with Psychotic Features and Anxiety Disorder. Continued review of the medical record revealed on 10/14/16 Patient #1's physician ordered a shower at 8:00 PM every day. The facility discharged Patient #1 on 10/24/16.

Interview with RN #1 on 10/31/16 at 2:41 PM revealed she was the charge nurse on 10/20/16. RN #1 stated that she knew CNA #1 was "mad" when they were coming out of report because showers were ordered on the evening shift and she told CNA #1 that Patient #1 could have a bed bath instead of a shower. RN #1 stated she was working with another patient when she overheard "screaming" coming from the shower room. Continued interview revealed RN #1 went to the shower room and found CNA #1 "yelling" at Patient #1 and Patient #1 "screaming to the point that you could not understand the patient." RN #1 stated CNA #1 left the room and she and RN #2 finished Patient #1's shower and dressed the patient. RN #1 stated she did not assess Patient #1 for injury but she did not notice any injuries at that time. Further interview with RN #1 revealed that throughout the rest of the evening Patient #1 would point his/her finger and "scrunch up [his/her] face" and say "no" to CNA #1 and have "nothing else to do with [CNA #1]." RN #1 stated that CNA #1 had "a temper" and was always "on edge." RN #1 stated, "I always kind of watched [CNA #1] because of her temper." RN #1 stated she did not report this incident to the House Supervisor or the Unit Manager because this was "normal" behavior for CNA #1.

Interview with RN #2 on 10/3/16 at 3:00 PM revealed she was working on 10/20/16 and was aware that CNA #1 was angry when leaving report because she had to shower Patient #1. RN #2 stated she offered to assist with the shower for Patient #1 but CNA #1 went ahead and started it. RN #2 stated that she was working with a patient when she overheard Patient #1 "screaming" in the shower room. RN #2 also stated she heard CNA #1 "yelling" at Patient #1. Continued interview with RN #2 revealed that she went to the shower room and CNA #1 was leaving and she assisted RN #1 in calming Patient #1 and getting the patient dressed. RN #2 stated they did not assess Patient #1 at that time for injuries, but she did not recall seeing any marks or bruises at that time. RN #2 stated that CNA #1 was not "kind" to patients and that she was trying to mentor her. Further interview with RN #2 revealed that this behavior from CNA #1 was the "norm" and it did not "shock" her. RN #2 stated she did not report this incident to the House Supervisor or the Unit Manager because it was considered normal behavior for CNA #1.

Interview with RN #3 on 10/31/16 at 3:15 PM revealed she was working on 10/20/16 and was aware that CNA #1 was "upset" that she had to give showers that evening and stated she heard CNA #1 say, "I don't have time to give showers this evening." RN #3 stated she was at the nursing station and overheard "yelling" and "screaming" coming from the shower room and saw RN #1 and RN #2 go into the room. RN #3 stated it was "routine" for CNA #1 to be negative and angry on the unit. Further interview with RN #3 revealed that "if [CNA #1] treated my mother like she does some of these patients, I'd have a problem." RN #3 stated that the Unit Manager was more than aware of CNA #1's problem with her temper, her impulse control, and her "yelling" on the unit. RN #3 stated she never reported any of her concerns with CNA #1 to facility Administration and did not report the incident on the night of 10/20/16 because that was "normal" behavior for CNA #1.

Interview with CNA #2 on 10/31/16 at 2:30 PM revealed she was working on 10/21/16 when Patient #1 reported allegations of abuse. CNA #2 stated Patient #1 told her "my back hurts" and also stated "I can't tell you why." Further interview with CNA #2 revealed that Patient #1 told her "that blonde girl was really rough; shouted and yelled at me, and threw me in the shower chair last night;" CNA #1 stated she immediately reported the allegations to the Unit Manager.

Interview with the Unit Manager on 11/01/16 at 9:00 AM revealed that she became aware of the allegation of abuse on 10/21/16 after Patient #1 reported to CNA #2. The Unit Manager stated she assessed Patient #1 and found bruising and the imprint of the mesh shower chair on Patient #1's upper back. The Unit Manager stated the Registered Nurses should have immediately notified her or the House Supervisor after CNA #1's behavior on 10/20/16. Continued interview with the Unit Manager revealed that it was the charge nurse's (RN #1) responsibility to provide supervision to the unit and she failed to do this on 10/20/16.