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Based on interviews, patient record review, facility investigative report review, and policies and procedures review, it was determined the facility failed to ensure the safety of one (1) patient (Patient #1), in the selected sample of ten (10) patients due to the facility's failure to have a system in place to address employees with Major Disciplinary Action (MDA) pending. In addition, the facility failed to have an effective communication system and failed to adhere to their policies and procedures related to abuse.

The facility failed to remove PA #1 from direct patient care as directed due to a pending Major Disciplinary Action (MDA). Additionally, after an altercation between Patient #1 and Patient Aide (PA) #1, on 07/08/13 where PA #1 put Patient #1 in a choke hold causing Patient #1 to sustain a scratch to his/her left upper arm and redness to his/her neck, the facility failed to adhere to their policy and pull PA #1 from direct patient care and immediately contact the Coordinator's Office. PA #1 was told to go to the nurse's office, however, he returned to the unit and had a verbal altercation with Patient #1.

These failures placed patients at risk for injury, harm, impairment or death. On 07/17/13, Immediate Jeopardy was identified and determined to exist related to Patient Rights. The facility initiated corrective actions on 07/19/13. It was determined the Immediate Jeopardy was abated on 07/24/13 prior to the survey exit.

Refer to A-144

Based on interviews, policy and procedure review, review of employee file of Patient Aide #1, the facility's investigation, and patient record review, it was determined the facility failed to ensure care in a safe setting for one (1) of ten (10) sampled patients (Patient#1) due to failure to have a system in place to address employees with Major Disciplinary Action (MDA) pending; failure to have an effective communication system; and, their failure to adhere to their policies and procedures related to abuse.

The findings include:

Review of the facility's policy, titled Abuse, Standard Operating Procedure No. 10 P, dated April 2013, revealed the policy stated, " In accordance with SOP 35 A, "Reporting Patient Abuse, Neglect, and Exploitation", any employee (state or contract) of (the hospital) who is accused of patient abuse, neglect, or exploitation shall be removed from direct patient care pending the outcome of the facility's internal investigation".

Review of the facility's policy titled, "Standard Operating Procedure No. 35 A, Reporting Patient Abuse, Neglect, and Exploitation", dated 07/01/1996, states, "If any employee (state or contract) of (the Hospital) who is accused of patient abuse, neglect, or exploitation shall be removed from direct patient care pending the outcome of the facility's internal investigation".

Review of the facility's policy titled "Nursing Standard Operating Policy No. VIII-N, Nursing Investigation Process", dated 12/2001, revealed the policy stated "for the protection of all patients, staff shall IMMEDIATELY upon witnessing abuse, neglect, of exploitation of any form whether from staff or other individuals (peer-to-peer), visitors or other persons. "Intervene" is defined as immediately ensuring patient safety and reporting the incident to his/her immediate supervisor, or designee. If the immediate supervisor is involved in the incident, or takes no action, then staff shall follow their chain of command to report. If a staff member observes any form of non-therapeutic behaviors by staff towards a patient, such as exhibiting any angry demeanor, raising their voice, arguing with a patient and/or using threatening gestures, as well as using non-approved restraint techniques they shall intervene immediately to ensure patient safety." It also states the Nursing Coordinator shall be notified immediately and if the allegation involves an employee (state or contract) of (the hospital), the first line supervisor on the unit is to immediately remove the staff member from direct patient care areas.

Review of the facility's investigation, revealed an allegation of staff to patient abuse was made on 07/09/13. It was reported Patient Aide (PA) #1 and Patient #1 were in an argumentative situation. Patient #1 slapped PA#1. Further review revealed PA#1 wrestled Patient #1 into the wall and proceeded to place Patient #1 into a chock hold. Four (4) staff intervened to get PA #1 off of Patient #1 and told PA #1 to go to the nurse's office. However, PA #1 returned to the unit a few minutes later and started arguing with Patient #1 again. Patient #1 sustained a small scratch to his/her upper left arm and redness to the left side of his/her neck. The incident was reported by Patient Aide II (PAII) #4.

Review of Patient #1's medical record revealed, the facility admitted him/her on 07/13/13 after a medication appointment when the psychiatrist requested an evaluation for hospitalization as the patient was considered manic, hyperactive, not sleeping adequately, reported voices and was paranoid. The patient had been medication non-compliant. Further review revealed Patient #1's diagnosis upon admission was Bipolar 1 Disorder, most recent episode manic - moderate and had not been compliant with his/her medication. Notations made on 07/09/13, regarding the 07/08/13 incident, stated Patient #1 got into an altercation with a staff member resulting in some elbow pain and scratches on his/her left upper arm.

Review of PA #1, the alleged perpetrator, employee's file revealed he was re-hired on 08/16/09, criminal record checks were completed as required, and all required facility training had been completed to include Crisis Prevention Intervention Management Training (CPSI). PA #1 had corrective actions/performance improvement plans for poor attendance, tardiness, poor communication with patients, and unsatisfactory performance of duty. PA #1 was notified of an MDA on 07/02/13 for falsification of documentation on 06/23/13 when he made an illegible entry on a 24 hour monitor sheet, on 06/30/13 he made entries at 6:30 AM indicating the 7:00 AM hallway checks had been completed and he snatched a coloring sheet intended for patient therapy out of the patient's hand and threw it in the trash can.

Interview with Investigator #1 (the facility's investigator), on 07/15/13 at approximately 12:25 PM, revealed an alleged incident of snatching a coloring page did not meet the definition of abuse and was not investigated. It was referred to nursing for investigation at the department level. She additionally reported she believed this incident was a contributing factor leading to the MDA.

Interview with the Director of Quality Support Service (QSS)/Risk Management, on 07/15/13 at approximately 2:30 PM, revealed the alleged coloring page snatching incident involving PA #1 did not meet the definition of abuse and was therefore turned over to nursing services to handle on a departmental level.

Interview with Patient Aide II (PAII) #4, on 07/16/13 at approximately 10:02 AM, revealed she was in the hallway, heard voices and saw the altercation between PA #1 and Patient #1. Patient #1 had a notebook and struck PA #1 across the face one time. PA #1 wrestled the patient up against the wall using his arms around the patient's neck to spin the patient around and push Patient #1 against the wall. Patient #1 was not physically fighting back. Additionally PAII #4 stated, Registered Nurse (RN) #4 and Therapeutic Program Supervisory Assistant (TPSA) #5 pulled PA #1 off of the patient and asked him numerous times to please let go of the patient and go to the office. PA #1 went to the nurse's office. This occurred around 1:05 AM on 07/09/13. TPSA #3 came to the unit and removed PA #1 from direct patient care. PAII #4 stated she did not know if the verbal altercation between PA #1 and Patient #1 occurred the same night, she stated she remembered a time when PA #1 and Patient #1 had a verbal altercation but did not remember when this occurred. Staff from other units came over to the unit that night. She further reported it had been her experience in an incident like this, the RN would notify the Coordinator immediately, but she was not sure RN #4 had the chance to call the Coordinator.

Interview with TPSA #5, on 07/18/13 at approximately 9:14 AM, revealed after the first incident she took Patient #1 down the hallway and was sitting with him/her talking about the incident when PA #1 came out of the nurse's office and told Patient #1 to go to his/her room. Patient #1 went back to his/her room and PA #1 stood in the patient's doorway in an intimidating manner. She asked PA #1 to back away but he just stood there while the patient got an intramuscular injection (IM). She stated she called for help from other units and remained with the patient until additional staff arrived. She left the unit and walked to the coordinator's office to report the incident. After explaining what had happened the Coordinator sent TPSA #3 to the unit to pull PA #1 from direct patient care. She also reported she was in the Coordinator's Office when PA #1 got there and she returned to the unit.

Interview with RN #4, on 07/17/13 at approximately 8:02 AM, revealed she was the RN on the unit for the 11:00 PM to 7:00 AM shift on 07/08/13. She stated she and TPSA #5 pulled PA #1 off of Patient #1. She further stated she did not call the Coordinator but TPSA #5 went to the Coordinator's Office. There were approximately ten (10) staff there from other units. RN #4 stated PA #1 went back to the unit because no one was watching him to ensure he stayed in the office, but staff didn't let him near the patient. She stated she did not recall a verbal altercation but did recall the patient yelling about PA #1 and at this point she and other staff were trying to get PA #1 back into the office. She reiterated "at no time did I call the Coordinator's Office". She also stated she was aware of the policy stating the RN is to call the Coordinator's Office. RN #4 stated she did recall PA #1 returning to the hall and doing his rounds at approximately 1:15 AM and she redirected him to go back to the office. PA #1 went back to the office. She reported she assessed the patient and found a small scratch on his/her upper right arm and the patient stated his/her elbow was sore from being pulled on but he/she had full range of motion, no swelling and a little redness on his/her neck but it was fading quickly. RN #4 revealed she did not make any Nurse's Notes in the patient's chart regarding this incident.

Interview with TPSA #3, on 07/16/13 at approximately 8:10 AM, revealed she did not usually cover acute services. TPSA #3 reported TPSA #5 came to the Coordinator's Office and reported to RN #3, the coordinator, that PA #1 needed to be pulled from direct patient care due to the incident that occurred between PA#1 and Patient #1. TPSA #3 further stated PA #1 was told to go to the nurse's office and to leave the unit but he refused. TPSA #3 stated she was told by RN #3 to go upstairs and escort PA #1 to the coordinator's office. Further interview revealed TPSA #3 stated as she arrived at the unit she found PA #1 at the door between the two units, told PA #1 to make sure he had everything and escorted him to the coordinator's office. When they got to the Coordinator's Office the door was shut. TPSA #3 stated she told PA #1 to be seated and then RN #3, came out with the paperwork to send PA #1 home. RN #3 walked PA #1 into the TPSA office and told him to clock out which he did not do. TPSA #3 stated she was told by RN #3 to listen for the phone in case Quality Support Services (QSS) called. TPSA #3 stated she heard PA #1 say he didn't know why he was being pulled out. PA #1 finally completed the required paperwork pulling him from direct patient care and clocked out.

Interview with PA #1, the alleged perpetrator, on 07/19/13 at approximately 9:00 AM, revealed he saw Patient #1 pacing in the hall and waking other patients and he/she kept escalating. He stated he was at the desk when Patient #1 grabbed his pen and put the pen to his throat. PA #1 stated he believed he was in danger and reacted by using a crisis prevention intervention (CPI), a one (1) person hold technique then he and other staff members were trying to get Patient #1 to go to his/her room. The patient dropped to the ground, went to his/her room and got shots in the room. PA #1 stated he was not sure why he was pulled to the office, and at no time did he have his hands around the neck of Patient #1. He reported having the patient's wrist and under his/her arm and thought it was on his/her left side. He did not recall having his arms around the patient's neck. Additionally, he stated he did not recall anyone telling him to let go. Further interview revealed he believed the hold he used was appropriate, that he was not choking the patient and did not restrict the patient's movement. He stated he did recall staff from other units during the incident, that he had done rounds at 1:00 AM, he was up to date on Crisis Prevention Intervention (CPI) training, and he stated there was no one (1) person hold taught in CPI, it is a team hold. PA #1 admitted being pulled from care in the past due to being aggressive toward a patient but he did not believe he was aggressive. PA #1 acknowledged he was on a MDA.

Interview with the Director of Human Resources (HR), on 07/15/13 at approximately 12:30 PM, revealed PA #1 had several corrective actions and PA #1 was made aware of the MDA on 07/02/13. He additionally reported they had been waiting on approval from Personnel to remove PA #1 from direct patient care. The HR confirmed there was no policy to pull an employee from direct patient care if the employee was under an MDA other than in an instance of alleged abuse. The decision to pull this employee was made and communicated to the facility on 07/08/13 at 10:54 AM. HR sent an e-mail, stating PA #1 must be pulled from direct care on 07/08/13 at 10:57 AM, to the two (2) coordinators and copied the Director of Nursing Services (DON) and Assistant Director of Nursing (ADON).

Interview with the Director of Nursing Services (DON), on 07/16/13 at approximately 8:30 AM, revealed she was not at work during the time the alleged incidents between PA #1 and Patient #1 occurred or on 07/08/13 when the e-mails were sent by HR. She was not aware of this information until 07/09/13 when she returned to work. Additionally she reported HR had sent an e-mail to the Coordinator and copied the ADON on 07/08/13 at 10:59 AM stating HR would be in early the next morning to talk about the situation and that she was not copied on this e-mail. The DON stated she was told about the e-mail and got a copy from the Coordinator, RN #3, who told her based on this e-mail PA #1 would not have to be pulled until after she talked with HR the next morning. The e-mail sent at 10:59 AM by HR was not the same e-mail stream as his previous e-mail where he stated PA #1 was to be pulled from direct care. The DON reported she was present during the conversation with RN #3 and HR but did not remember what was said.

Interview with RN #3, on 07/17/13 at approximately 9:47 AM, revealed she was the Coordinator on 07/08/13 for the 11:00 PM to 7:00 AM shift. RN #3 stated she was in the Coordinator's office at approximately 1:15 AM when TPSA #5 came to the office to report the incident between PA #1 and Patient #1. Further interview revealed she sent TPSA #3 to the unit to escort PA #1 to the Coordinator's office. She stated she had PA #1 complete the required paperwork; removed him from direct patient care due to the incident; and, had him clock out. Additionally she reported, she opened the 07/08/13 e-mail from HR with the 10:59 AM time stamp at approximately 12:50 AM on 07/09/13, and this e-mail stream did not include the e-mail sent by HR on 07/08/13 at 10:57 AM. She also stated, based on the e-mail from HR on 07/08/13 at 10:59 AM, it was her understanding not to pull PA #1 from direct care that night and they would discuss what would be done with PA #1 when she, the ADON, and HR talked the next morning.

Interview with the ADON, on 07/16/13 at approximately 9:05 AM, revealed she had been on vacation and returned on 07/08/13. She stated she was unaware PA #1 was on an MDA and the incidents leading to it. She confirmed she had received both e-mail streams from HR. The ADON stated HR called her on 07/08/13 after he sent the e-mail stating PA #1 was to be pulled from direct care due to PA #1's MDA for falsification of a document. She stated she told him in the past they had never pulled anyone from patient care for falsification. She further stated they had only pulled, per policy, for allegations of abuse, neglect, or exploitation. HR stated ok, and that he would be in early the next morning to talk about this. He sent an e-mail on 07/08/13 at 10:59 AM confirming this. The ADON stated it was her understanding they would talk about what would be done the next morning and not to pull PA #1 that night because this was not an allegation of abuse.

Interview with HR, on 07/17/13 at approximately 8:15 AM, revealed he confirmed he sent the 10:59 AM e-mail on 07/08/13 and that he told the ADON PA #1 was to be pulled from direct patient care. He stated the e-mail he sent about the meeting was to discuss the falsification incident. He confirmed that he called the ADON and they discussed they had not in the past pulled staff unless it was an abuse related issue. He stated he was confident she understood to pull PA #1 from direct care that night. He further stated he could not say that he specifically stated to pull PA #1 from direct care that night.

Interview with the ADON, on 07/17/13 at approximately 12:54 PM, revealed it was her understanding of the conversation between she and HR on 07/08/13 time unknown, and the follow up e-mail on 07/08/13 at 10:59 AM from HR that they were going to discuss the situation in the morning and not to pull PA #1. Additionally she stated HR did not reiterate or make it clear PA #1 was to be pulled that night. "I believed action would be taken after out meeting the next morning".

The facility failed to ensure a safe environment for their patients. This failure placed patients at risk for injury, harm, impairment or death. On 07/17/13, Immediate Jeopardy was determined to exist. The facility initiated corrective actions as follows: through the Quality Support Services (QSS)/Risk Management office, the following policies and procedures were updated/modified: 1P, Disciplinary Measures now states upon employee notification of an MDA the employee will be removed from direct patient care pending the outcome of the MDA by their supervisor making this notification and the same supervisor is to ensure the facility director or designee is notified the employee has been removed from direct patient care; and 12A, Incident Investigations was modified to state, the supervisor will ensure that the facility director has been notified that the employee has been pulled from direct patient care. Training on the new policies for all staff was conducted on 07/18/13 at 7:00 AM, 8:00 AM, 9:00 AM, 10:00 AM, 11:00 PM. 12:15 PM, 07/19/13 at 8:40 AM,10:30 AM, 9:15 AM,and on 7/21/13 no times listed and to include a signed attestation from each employee to verify they had been trained and the attestation had questions to be answered by the employee to verify competency. Any staff who did not answer the questions correctly was retrained and had to answer the questions again. An e-mail was sent to all supervisors through the Administrator's Office stating employees who were not trained must complete the required training immediately upon returning to work.
Interviews with RN #13, RN #15, ADON, LPN #2, PA #10, RN #15, Environmental Services Lead Technician, Institutional Recreational Leader, RN #11, RN #12, LPN #4, and PA #11, on 07/24/13 at 8:10 AM, 8:45 AM, 9:25 AM, 9:30 AM, 9:35 AM, 9:40 AM, 9:43 AM, 9:47 AM, 9:56 AM, 10:02 AM, and 10:11 AM, respectively, revealed all had been trained on the revised policies and stated the policy changes were: when an employee is notified he or she has a Major Disciplinary Action pending the employee would be removed from direct patient care, if an employee is pulled from direct patient care it is the responsibility of that employee's supervisor to notify the facility director or designee.

Based on interviews and review of patient records, facility investigative reports, and policies and procedures, it was determined the facility failed to ensure the safety of one (1) of ten (10) sampled patients (Patient #1), due to the facility's failure to have a system in place to address employees with a Major Disciplinary Action (MDA) pending, an ineffective communication system, and failure to adhere to their policies and procedures as related to abuse.

The facility failed to remove Patient Aide (PA) #1 from direct patient care as directed in an e-mail dated 07/08/13 from Personnel due to a pending MDA. Additionally, after an altercation between Patient #1 and PA #1 on 07/08/13 where PA #1 put Patient #1 in a choke hold causing Patient #1 to sustain a scratch to his/her upper left arm and redness to his/her neck, the facility failed to adhere to their policy regarding staff to patient abuse. PA #1 was not removed from the unit after this altercation and the Coordinator's Office was not immediately notified. PA #1 was told to go to the nurse's office, however, he returned to the unit and had a verbal altercation with Patient #1.

These failures placed patients at risk for injury, harm, impairment or death. On 07/17/13, Immediate Jeopardy was identified and determined to exist related to Patient Rights. The facility initiated corrective actions on 07/19/13. It was determined the Immediate Jeopardy was abated on 07/24/13 prior to the survey exit.

Refer to A-395

Based on interview, review of facility policies, Patient Aide (PA) #1's personnel file, the facility's investigation, and review of patient records, it was determined the facility failed to provide patients with nursing care which ensured patient safety for one (1) of ten (10) sampled patients (Patient #1), due to the facility's failure to adhere to the facility's policies regarding abuse and nursing investigative process as they pertain to removal of staff from direct patient care following an incident of suspected patient abuse.

The findings include:

Review of the facility's policy on Abuse, Standard Operating Procedure No. 10 P dated, April 2013, revealed "In accordance with SOP 35 A, "Reporting Patient Abuse, Neglect, and Exploitation", any employee (state or contract) of the Hospital who is accused of patient abuse, neglect, or exploitation shall be removed from direct patient care pending the outcome of the facility's internal investigation".

Review of the facility's policy titled, Standard Operating Procedure No. 35 A, Reporting Patient Abuse, Neglect, and Exploitation, dated 07/01/1996, revealed it states, "If any employee (state or contract) of the Hospital who is accused of patient abuse, neglect, or exploitation shall be removed from direct patient care pending the outcome of the facility's internal investigation".

Review of the facility's policy titled, "Nursing Standard Operating Policy No. VII-N, Nursing Investigation Process", dated 12/2001, revealed the policy states "for the protection of all patients, staff shall IMMEDIATELY upon witnessing abuse, neglect, or exploitation of any form whether from staff or other individuals (peer-to-peer), visitors or other persons. "Intervene" is defined as immediately ensuring patient safety and reporting the incident to his/her immediate supervisor, or designee. If the immediate supervisor is involved in the incident, or takes no action, then staff shall follow their chain of command to report. If a staff member observes any form of non-therapeutic behaviors by staff towards a patient, such as exhibiting any angry demeanor, raising their voice, arguing with a patient and/or using threatening gestures, as well as using non-approved restraint techniques they shall intervene immediately to ensure patient safety." It also states the Nursing Coordinator shall be notified immediately and if the allegation involves an employee (state or contract) of the Hospital, the first line supervisor on the unit is to immediately remove the staff member from direct patient care areas.

Review of Patient #1's medical record revealed, he/she was admitted on 07/13/13 after a medication appointment when the psychiatrist requested an evaluation for hospitalization as the patient was considered manic, hyperactive, not sleeping adequately, reported voices and was paranoid. The patient had been medication non-compliant. Patient #1's diagnosis upon admission was Bipolar 1 Disorder, most recent episode manic - moderate and had not been compliant with his/her medication. Notations made on 07/09/13, regarding the 07/08/13 incident, stated Patient #1 got into an altercation with a staff member resulting in some elbow pain and scratches on his/her left upper arm.

Review of the facility's investigation, revealed an allegation of staff to patient abuse was reported on 07/09/13 by Patient Aide II (PAII) #4. It was reported Patient Aide (PA) #1 and Patient #1 were in an argumentative situation. Patient #1 slapped PA#1 then PA #1 wrestled Patient #1 into the wall and proceeded to place the patient into a chock hold. Four (4) staff intervened to get PA #1 off of Patient #1. RN #3 told PA #1 to go to the nurse's office, however, PA #1 returned to the unit a few minutes later and started arguing with Patient #1 again. Patient #1 sustained a small scratch to his/her upper left arm and redness to the left side of his/her neck.

Review of the employee file for PA #1, the alleged perpetrator, revealed he was re-hired on 08/16/09, criminal record checks were completed as required, and all required facility training had been completed to include Crisis Prevention Intervention Management Training (CPSI). PA #1 had corrective actions/performance improvement plans for poor attendance, tardiness, poor communication with patients, and unsatisfactory performance of duty. PA #1 was notified of an MDA on 07/02/13 for falsification of documentation on 06/23/13 when he made an illegible entry on a 24 hour monitor sheet; on 06/30/13, when he made entries at 6:30 AM indicating the 7:00 AM hallway checks had been completed; and for snatching a coloring sheet intended for patient therapy out of the patient's hand and throwing it in the trash can.

Interview with PAII #4, on 07/16/13 at approximately 10:02 AM, revealed she was in the hallway, heard voices and saw the altercation between PA #1 and Patient #1. Patient #1 had a notebook and struck PA #1 across the face one time. PA #1 wrestled the patient up against the wall placing his arms around the patient's neck to spin the patient around and push Patient #1 against the wall. PAII #4 stated Patient #1 was not physically fighting back. Additionally she stated, Registered Nurse (RN) #4 and Therapeutic Program Supervisory Assistant (TPSA) #5 pulled PA #1 off of the patient and asked him numerous times to please let go of the patient and go to the office. PA #1 went to the nurse's office. This occurred around 1:05 AM on 07/09/13. TPSA #3 came to the unit and removed PA #1 from direct patient care. PAII #4 stated she did not know if the verbal altercation between PA #1 and Patient #1 occurred the same night, but did remember a time when PA #1 and Patient #1 had a verbal altercation but did not remember when that was. She further reported it had been her experience in an incident like this that the Coordinator had been called immediately but she was not sure RN #4 had the chance to call the coordinator.

Interview with TPSA #5, on 07/18/13 at approximately 9:14 AM, revealed after the first incident she took Patient #1 down the hallway and was sitting with him/her talking about the incident when PA #1 came out of the nurse's office and told Patient #1 to go to his/her room. Patient #1 went back to his/her room and PA #1 stood in the patient's doorway in an intimidating manner. She asked PA #1 to back away but he just stood there while the patient got an intramuscular injection (IM). She stated she called for help from other units and remained with the patient until additional staff arrived then she left the unit and walked to the Coordinator's office to report the incident. After explaining what had happened, the Coordinator sent TPSA #3 to the unit to pull PA #1 from direct patient care. She also reported she was in the Coordinator's office when PA #1 got there and she returned to the unit.

Interview with RN #4, on 07/17/13 at approximately 8:02 AM, revealed she was the RN on the unit for the 11:00 PM to 7:00 AM shift on 07/08/13. She stated she and TPSA #5 pulled PA #1 off of Patient #1 and she did not call the Coordinator but TPSA #5 went to the Coordinator's office and there were approximately ten(10) staff there from other units. The RN stated PA #1 did come back on the unit because no one was watching him to ensure he stayed in the office, but staff did not let him near the patient. She stated she did not recall a verbal altercation but did recall the patient yelling about PA #1 and at this point she and other staff were trying to get PA #1 back into the office. She reiterated "at no time did I call the Coordinator's office". She also stated she was aware of the policy stating the RN is to call the Coordinator's office. RN #4 stated she did recall PA #1 returning to the hall and doing his rounds at approximately 1:15 AM and she redirected him to go back to the office and PA #1 went back to the office. She reported she assessed the patient and found a small scratch on his/her upper right arm and the patient stated his/her elbow was sore from being pulled on but he/she had full range of motion, no swelling and a little redness on his/her neck but it was fading quickly. RN #4 revealed she did not make any Nurse's Notes in the patient's chart regarding this incident.

Interview with TPSA #3, on 07/16/13 at approximately 8:10 AM, revealed she did not usually cover acute services, she covered admissions. TPSA # 5 came to the Coordinator's office and reported to RN #3, the Coordinator, she needed to pull PA #1 from direct patient care due to the incident that occurred between PA #1 and Patient #1, and stated RN #4 told PA #1 to go to the nurse's office and to leave the unit but he refused. RN #3 told me to go upstairs and escort PA #1 to the Coordinator's office. TPSA #3 stated when she arrived she found PA #1 at the door between the two units, told him to make sure he had everything and escorted him to the coordinator's office. Upon arrival to the coordinator's office, the door was shut, she told PA #1 to be seated and the coordinator, RN #3, came out with the paperwork to send PA #1 home, walked him into the TPSA office and told him to clock out which he did not do. She was told by RN #3 to listen for the phone in case Quality Support Services (QSS) called. TPSA #3 stated she heard PA #1 say he didn't know why he was being pulled out. He finally completed the required paperwork pulling him from direct patient care and clocked out.

Interview with PA #1, on 07/19/13 at approximately 9:00 AM, revealed he saw Patient #1 was pacing in the hall and waking other patients and he/she kept escalating. He stated he was at the desk when Patient #1 grabbed his pen and put the pen to PA #1 throat. PA #1 stated he believed he was in danger and reacted by using a Crisis Prevention Intervention (CPI), one person hold technique, then he and other staff members were trying to get Patient #1 to go to his/her room. The patient then dropped to the ground and then went to his/her room and received shots in his/her room. PA #1 stated he was not sure why he was pulled to the office, at no time did he have his hands around the neck of Patient #1. He reported having the patient's wrist and under his/her arm and thought it was on his/her left side and did not recall having his arms around the patient's neck. Additionally, he stated he did not recall anyone telling him to let go and he believed the hold he used was appropriate, he was not choking the patient and did not restrict the patient's movement. He stated he had completed rounds at 1:00 AM and a one (1) person hold is not taught in CPI. CPI teaches a team hold. PA #1 admitted being pulled from care in the past due to being aggressive toward a patient but he did not believe he was aggressive and he acknowledged he was on an MDA.

The facility failed to to provide patients with nursing care which ensured a safe environment for their patients. This failure placed placed patients at risk for injury, harm, impairment or death. On 07/17/13, Immediate Jeopardy was determined to exist. The facility initiated corrective actions as follows: through the QSS/Risk Management office, the following policies and procedures were updated/modified: 1P, Disciplinary Measures now states upon employee notification of an MDA the employee will be removed from direct patient care pending the outcome of the MDA by their supervisor making this notification and the same supervisor is to ensure the facility director or designee is notified the employee has been removed from direct patient care, and 12A, Incident Investigations has been modified to state, the supervisor will ensure that the facility director has been notified that the employee has been pulled from direct patient care. Training on the new policies for all staff was conducted to include a signed attestation from each employee to verify they had been trained and the attestation had questions to be answered by the employee to verify competency. Any staff who did not answer the questions correctly was retrained and had to answer the questions again. An e-mail was sent to all supervisors through the Administrator's Office stating employees who were not trained must complete the required training immediately upon returning to work.
The facility failed to ensure a safe environment for their patients. This failure placed patients at risk for injury, harm, impairment or death. On 07/17/13, Immediate Jeopardy was determined to exist. The facility initiated corrective actions as follows: through the Quality Support Services (QSS)/Risk Management office, the following policies and procedures were updated/modified: 1P, Disciplinary Measures now states upon employee notification of an MDA the employee will be removed from direct patient care pending the outcome of the MDA by their supervisor making this notification and the same supervisor is to ensure the facility director or designee is notified the employee has been removed from direct patient care; and 12A, Incident Investigations was modified to state, the supervisor will ensure that the facility director has been notified that the employee has been pulled from direct patient care. Training on the new policies for all staff was conducted on 07/18/13 at 7:00 AM, 8:00 AM, 9:00 AM, 10:00 AM, 11:00 PM. 12:15 PM, 07/19/13 at 8:40 AM,10:30 AM, 9:15 AM,and on 7/21/13 no times listed and to include a signed attestation from each employee to verify they had been trained and the attestation had questions to be answered by the employee to verify competency. Any staff who did not answer the questions correctly was retrained and had to answer the questions again. An e-mail was sent to all supervisors through the Administrator's Office stating employees who were not trained must complete the required training immediately upon returning to work.
Interviews with RN #13, RN #15, ADON, LPN #2, PA #10, RN #15, Environmental Services Lead Technician, Institutional Recreational Leader, RN #11, RN #12, LPN #4, and PA #11, on 07/24/13 at 8:10 AM, 8:45 AM, 9:25 AM, 9:30 AM, 9:35 AM, 9:40 AM, 9:43 AM, 9:47 AM, 9:56 AM, 10:02 AM, and 10:11 AM, respectively, revealed all had been trained on the revised policies and stated the policy changes were: when an employee is notified he or she has a Major Disciplinary Action pending the employee would be removed from direct patient care, if an employee is pulled from direct patient care it is the responsibility of that employee's supervisor to notify the facility director or designee.