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The condition of Patient Rights has not been met. Based on observation, tour of the hospital's video monitored bedrooms and monitor viewing area, review of hospital policies and procedures and interviews for one of ten patients reviewed for abuse (Patient #10) the hospital failed to ensure that Patient #10 was free of abuse, failed to ensure that the incident was reported through to administration and acted upon immediately to ensure that the patient remained free from further abuse, failed to ensure that a comprehensive plan of care was developed, documented and implemented and to ensure the patient's continued safety, failed to ensure that all staff received comprehensive abuse training, and failed to ensure that the incident was reported to regulating agencies per policy.

Please refer to A145, A385, A395 and A396.

Based on observation, tour of the hospital's video monitored bedrooms and monitor viewing area, review of hospital policies and procedures and interviews for one of ten patients reviewed for abuse (Patient #10) the hospital failed to ensure that Patient #10 was free of abuse, failed to ensure that the incident was reported through to administration and acted upon immediately to ensure that the patient remained free from further abuse, failed to ensure that a comprehensive plan of care was developed, documented and implemented and to ensure the patient's continued safety, failed to ensure that all staff received comprehensive abuse training, and failed to ensure that the incident was reported to regulating agencies per policy. The findings include:



Patient #10 was admitted to the hospital on 09/10/16 with diagnoses that included supraventricular tachycardia (SVT), diabetes mellitus (DM), major depression, anxiety, and chronic obstructive pulmonary disease (COPD). On 09/12/16, Patient #10 was transferred to the intermediate care unit (ICU) for closer cardiac monitoring. Patient #10 was placed in a room with continuous video monitoring due to high fall risk with disorientation to person, place, time, and situation.

Review of a nursing progress noted dated 09/13/16 at 10:29 AM by RN #8 (7 AM through 7 PM) identified that Patient #10 was disoriented times four and was non- English speaking. Fall safety rounds were performed hourly and the patient was kept in a video monitored bedroom with continuous video monitoring as part of the fall prevention plan.

Interview with NA #10 on 09/26/16 at 2:00 PM identified that on 09/13/16 he/she was assigned to the video monitoring room beginning at 5:00 PM. At that time, NA #10 witnessed Patient #10 and visiting Family Member #1 exhibiting agitated behavior towards each other including pacing (family member) and talking loudly. NA #10 communicated this observation to the unit staff member assigned to conduct the hourly safety rounds (NA #2) and also to RN #8. NA #2 responded to the room, identified that the agitation was in part related to the dinner meal and NA #2 provided assistance with the meal.

Additional interview with NA #10 identified that about 7:00 PM, NA #10 observed Family Member #1 "get rough" with Patient #10 by attempting to take Patient #10's nasal oxygen tubing off in a rough manner. NA #10 identified that at that time, he/she witnessed Family Member #1 motion in a manner that appeared to be a slap on Patient #10's face. NA #10 identified that he/she was worried that Family Member #1's rough actions could cause bruising. NA #10 immediately notified RN #8 about his/her observation. NA #10 did not observe RN #8 enter Patient #10's room following this notification. NA #10 was concerned that RN #8 did not notify the on-coming 7:00 PM nurse (RN #2) about Patient #10 being slapped by Family Member #1, prompting NA #10 to notify RN #2 about the observation.


Review of Patient #10's clinical record identified that RN #8 failed to document that NA #10 witnessed Patient #10 being slapped by Family Member #1, failed to identify that the supervisor and the oncoming nurse were notified of the observation, failed to identify that an investigation was initiated, and failed to include a plan to ensure Patient #10's safety from further abuse by Family Member #1. From the time of occurrence (between 5:00 PM and 7:00 PM) until approximately 8:20 PM, there was a delay in insuring Patient #10 remained safe and free from abuse by Family Member #1.


Review of RN #2's nursing progress note dated 09/14/16 at 1:05 AM identified that during his/her shift, Patient #10 was awake, alert and disoriented per base-line. However, Patient #10 exhibited a new behavior of being intermittently anxious and inconsolable (in part due to discharge plans) during a visit with his/her adult child. Documentation identified that about 8:20 PM, NA #10 notified RN #2 that he/she had observed family member #1 slap the patient multiple times earlier in the shift. At that time, RN #1 notified MD #1, the patient's adult child #1 (still visiting), and requested a social work consult for the following day. At that time, the adult child reported that Family Member #1 had "done this before."


Interview with RN #2 on 09/27/16 at 2:00 PM and 09/30/16 at 9:00 AM identified that RN #8 did not report that Patient #10 had been slapped. Once notified RN #2 immediately reported the incident to his/her supervisor (RN #5) as well as all video monitor staff and unit staff responsible for safety rounds. Although Family Member #1 had left prior to 8:20 PM, RN #2 instructed all monitoring staff to observe Patient #10 and notify the nurse right away if Family Member #1 returned.


Interview with the supervisor (RN #5) on 9/26/16 at 2:00 PM identified that although he/she was notified by RN #2 of the incident involving P#10, he/she did not notify administration.


Review of Patient #10's computerized plan of care failed to include the incident of abuse by the family member and failed to identify immediate interventions to prevent further abuse to include: problem statement, goals, and outcomes as per policy.


Interview with MD #1 on 09/29/16 at 3:00 PM identified that he/she had been notified that Patient #10 was agitated and that the patient had been slapped by Family Member #1. MD #1 further identified that he/she had assessed the patient for the agitation but did not assess for possible physical injury, mental anguish, or patient response to being slapped. Review of the clinical record identified that MD #1 failed to document his/her assessment of Patient #10's agitation.


Review of Patient #10's clinical record and review of hospital documentation between 9/14/16 from 7:00 AM to 7:00 AM failed to identify that measures to prevent further abuse were documented


Clinical record review of a Social Work (SW) Plan of care note dated 09/15/16 at 2:53 PM identified that SW #1 had received a request for consult on Patient #10 from an MD and RN regarding the incident of Patient #10 being slapped by Family Member #1. The social work plan identified that Patient #10 and his/her visitors would be closely observed via video monitor. If Family Member #1 visited and displayed any aggression, security would be notified and further visits would be with supervision only. SW #1 met with Patient #10's adult child to discuss the hospital's plan to ensure that Patient #10 remained free from abuse. In addition, the SW documented that staff raised a concern that Family Member #1 had been known to bring in inappropriate, high sugar foods to feed to patient.


Interview and record review with SW #1 on 09/27/16 at 12:45 PM identified that on 9/15/16 he/she had been notified of the incident and updated on the safety interventions that were in place. SW #1 contacted Patient #10's adult child and discussed the abuse incident. In addition, Patient #10's plan was to be discharge to an out-of-state home. On 09/19/16 (6 days after event) SW #1 notified an out-of-state agency about Family Member #1's abusive act towards Patient #10. However, SW #1 failed to report the abusive act to the appropriate state agency in the state where the abuse occurred.


The hospital policy on abuse identified to report abuse immediately to the patient care team or to their supervisor. The policy failed to include how and when to notify hospital administration when abuse occurs. In addition, the policy directed that the hospital had 72 hours to report incidents of abuse to appropriate state agencies.


Interview with the Education Specialist on 9/29/16 at 11:50 AM identified that the hospital has an abuse learning module that all nurses reviewed annually. Interview and review of annual training information identified that RN's received annual training that included abuse. The training identified to notify the Nurse Manager or Administrative Coordinator when abuse is suspected. Nurse aides received general training regarding care of the patient, what to report and who to report to. However, the Education Specialist identified that there was no learning module or specific abuse education for nurse aides.

The condition of Nursing Services has not been met. Based on observation, tour of the hospital's video monitored bedrooms and monitor viewing area, review of hospital policies and procedures and interviews for one of ten patients reviewed for abuse (Patient #10) the hospital failed to ensure an incident of abuse was reported through to administration and acted upon immediately to ensure that the patient remained free from further abuse, failed to ensure that a comprehensive plan of care was developed, documented and implemented and to ensure the patient's continued safety, failed to ensure that all staff received comprehensive abuse training, and failed to ensure that the incident was reported to regulating agencies per policy.

Please refer to A395 and A396.

Based on observation, tour of the hospital's video monitored bedrooms and monitor viewing area, review of hospital policies and procedures and interviews for one of ten patients reviewed for abuse (Patient #10) the hospital failed to ensure that nursing staff evaluated and supervised Patient #10's care when the patient was witness to be abused. Nursing staff failed to ensure that the incident was reported through to administration and acted upon immediately to ensure that the patient remained free from further abuse, failed to ensure that a comprehensive plan of care was developed, documented and implemented and to ensure the patient's continued safety, failed to ensure that all staff received comprehensive abuse training. The findings include:



Patient #10 was admitted to the hospital on 09/10/16 with diagnoses that included supraventricular tachycardia (SVT), diabetes mellitus (DM), major depression, anxiety, and chronic obstructive pulmonary disease (COPD). On 09/12/16, Patient #10 was transferred to the intermediate care unit (ICU) for closer cardiac monitoring. Patient #10 was placed in a room with continuous video monitoring due to high fall risk with disorientation to person, place, time, and situation.

Review of a nursing progress noted dated 09/13/16 at 10:29 AM by RN #8 (7 AM through 7 PM) identified that Patient #10 was disoriented times four and was non- English speaking. Fall safety rounds were performed hourly and the patient was kept in a video monitored bedroom with continuous video monitoring as part of the fall prevention plan.

Interview with NA #10 on 09/26/16 at 2:00 PM identified that on 09/13/16 he/she was assigned to the video monitoring room beginning at 5:00 PM. At that time, NA #10 witnessed Patient #10 and visiting Family Member #1 exhibiting agitated behavior towards each other including pacing (family member) and talking loudly. NA #10 communicated this observation to the unit staff member assigned to conduct the hourly safety rounds (NA #2) and also to RN #8. NA #2 responded to the room, identified that the agitation was in part related to the dinner meal and NA #2 provided assistance with the meal.

Additional interview with NA #10 identified that about 7:00 PM, NA #10 observed Family Member #1 "get rough" with Patient #10 by attempting to take Patient #10's nasal oxygen tubing off in a rough manner. NA #10 identified that at that time, he/she witnessed Family Member #1 motion in a manner that appeared to be a slap on Patient #10's face. NA #10 identified that he/she was worried that Family Member #1's rough actions could cause bruising. NA #10 immediately notified RN #8 about his/her observation. NA #10 did not observe RN #8 enter Patient #10's room following this notification. NA #10 was concerned that RN #8 did not notify the on-coming 7:00 PM nurse (RN #2) about Patient #10 being slapped by Family Member #1, prompting NA #10 to notify RN #2 about the observation.


Review of Patient #10's clinical record identified that RN #8 failed to document that NA #10 witnessed Patient #10 being slapped by Family Member #1, failed to identify that the supervisor and the oncoming nurse were notified of the observation, failed to identify that an investigation was initiated, and failed to include a plan to ensure Patient #10's safety from further abuse by Family Member #1. From the time of occurrence (between 5:00 PM and 7:00 PM) until approximately 8:20 PM, there was a delay in insuring Patient #10 remained safe and free from abuse by Family Member #1.


Review of RN #2's nursing progress note dated 09/14/16 at 1:05 AM identified that during his/her shift, Patient #10 was awake, alert and disoriented per base-line. However, Patient #10 exhibited a new behavior of being intermittently anxious and inconsolable (in part due to discharge plans) during a visit with his/her adult child. Documentation identified that about 8:20 PM, NA #10 notified RN #2 that he/she had observed family member #1 slap the patient multiple times earlier in the shift. At that time, RN #1 notified MD #1, the patient's adult child #1 (still visiting), and requested a social work consult for the following day. At that time, the adult child reported that Family Member #1 had "done this before."


Interview with RN #2 on 09/27/16 at 2:00 PM and 09/30/16 at 9:00 AM identified that RN #8 did not report that Patient #10 had been slapped. Once notified RN #2 immediately reported the incident to his/her supervisor (RN #5) as well as all video monitor staff and unit staff responsible for safety rounds. Although Family Member #1 had left prior to 8:20 PM, RN #2 instructed all monitoring staff to observe Patient #10 and notify the nurse right away if Family Member #1 returned.


Interview with the supervisor (RN #5) on 9/26/16 at 2:00 PM identified that although he/she was notified by RN #2 of the incident involving P#10, he/she did not notify hospital administration (per policy).


Review of Patient #10's computerized plan of care failed to include the incident of abuse by the family member and failed to identify immediate interventions to prevent further abuse to include: problem statement, goals, and outcomes as per policy.


Review of Patient #10's clinical record and review of hospital documentation between 9/14/16 from 7:00 AM to 7:00 AM failed to identify that measures to prevent further abuse were documented


Clinical record review of a Social Work (SW) Plan of care note dated 09/15/16 at 2:53 PM identified that SW #1 had received a request for consult on Patient #10 from an MD and RN regarding the incident of Patient #10 being slapped by Family Member #1. The social work plan identified that Patient #10 and his/her visitors would be closely observed via video monitor. If Family Member #1 visited and displayed any aggression, security would be notified and further visits would be with supervision only. SW #1 met with Patient #10's adult child to discuss the hospital's plan to ensure that Patient #10 remained free from abuse.


The hospital policy on abuse identified to report abuse immediately to the patient care team or to their supervisor. The policy failed to include how and when to notify hospital administration when abuse occurs.


Interview with the Education Specialist on 9/29/16 at 11:50 AM identified that the hospital has an abuse learning module that all nurses reviewed annually. Interview and review of annual training information identified that RN's received annual training that included abuse. The training identified to notify the Nurse Manager or Administrative Coordinator when abuse is suspected. Nurse aides received general training regarding care of the patient, what to report and who to report to. However, the Education Specialist identified that there was no learning module or specific abuse education for nurse aides.

Based on observation, tour of the hospital's video monitored bedrooms and monitor viewing area, review of hospital policies and procedures and interviews for one of ten patients reviewed for abuse (Patient #10) the hospital failed to ensure that nursing staff developed a plan of care to ensure Patient #10's safety when the patient was witness to be abused. Nursing staff failed to ensure that a comprehensive plan of care was developed, documented and implemented and to ensure the patient's continued safety. The findings include:



Patient #10 was admitted to the hospital on 09/10/16 with diagnoses that included supraventricular tachycardia (SVT), diabetes mellitus (DM), major depression, anxiety, and chronic obstructive pulmonary disease (COPD). On 09/12/16, Patient #10 was transferred to the intermediate care unit (ICU) for closer cardiac monitoring. Patient #10 was placed in a room with continuous video monitoring due to high fall risk with disorientation to person, place, time, and situation.

Review of a nursing progress noted dated 09/13/16 at 10:29 AM by RN #8 (7 AM through 7 PM) identified that Patient #10 was disoriented times four and was non- English speaking. Fall safety rounds were performed hourly and the patient was kept in a video monitored bedroom with continuous video monitoring as part of the fall prevention plan.


Interview with NA #10 on 09/26/16 at 2:00 PM identified that on 09/13/16 he/she was assigned to the video monitoring room beginning at 5:00 PM. At that time, NA #10 witnessed Patient #10 and visiting Family Member #1 exhibiting agitated behavior towards each other including pacing (family member) and talking loudly. NA #10 communicated this observation to the unit staff member assigned to conduct the hourly safety rounds (NA #2) and also to RN #8. NA #2 responded to the room, identified that the agitation was in part related to the dinner meal and NA #2 provided assistance with the meal.


Additional interview with NA #10 identified that about 7:00 PM, NA #10 observed Family Member #1 "get rough" with Patient #10 by attempting to take Patient #10's nasal oxygen tubing off in a rough manner. NA #10 identified that at that time, he/she witnessed Family Member #1 motion in a manner that appeared to be a slap on Patient #10's face. NA #10 identified that he/she was worried that Family Member #1's rough actions could cause bruising. NA #10 immediately notified RN #8 about his/her observation. NA #10 did not observe RN #8 enter Patient #10's room following this notification. NA #10 was concerned that RN #8 did not notify the on-coming 7:00 PM nurse (RN #2) about Patient #10 being slapped by Family Member #1, prompting NA #10 to notify RN #2 about the observation.


Review of Patient #10's clinical record identified that RN #8 failed to document that NA #10 witnessed Patient #10 being slapped by Family Member #1, failed to identify that the supervisor and the oncoming nurse were notified of the observation, failed to identify that an investigation was initiated, and failed to include a plan to ensure Patient #10's safety from further abuse by Family Member #1. From the time of occurrence (between 5:00 PM and 7:00 PM) until approximately 8:20 PM, there was a delay in insuring Patient #10 remained safe and free from abuse by Family Member #1.


Review of RN #2's nursing progress note dated 09/14/16 at 1:05 AM identified that during his/her shift, Patient #10 was awake, alert and disoriented per base-line. However, Patient #10 exhibited a new behavior of being intermittently anxious and inconsolable (in part due to discharge plans) during a visit with his/her adult child. Documentation identified that about 8:20 PM, NA #10 notified RN #2 that he/she had observed family member #1 slap the patient multiple times earlier in the shift. At that time, RN #1 notified MD #1, the patient's adult child #1 (still visiting), and requested a social work consult for the following day. At that time, the adult child reported that Family Member #1 had "done this before."


Interview with RN #2 on 09/27/16 at 2:00 PM and 09/30/16 at 9:00 AM identified that RN #8 did not report that Patient #10 had been slapped. Once notified RN #2 immediately reported the incident to his/her supervisor (RN #5) as well as all video monitor staff and unit staff responsible for safety rounds. Although Family Member #1 had left prior to 8:20 PM, RN #2 instructed all monitoring staff to observe Patient #10 and notify the nurse right away if Family Member #1 returned.


Interview with the supervisor (RN #5) on 9/26/16 at 2:00 PM identified that although he/she was notified by RN #2 of the incident involving P#10, he/she did not notify hospital administration (per policy).


Review of Patient #10's computerized plan of care failed to include the incident of abuse by the family member and failed to identify immediate interventions to prevent further abuse to include: problem statement, goals, and outcomes as per policy.


Review of Patient #10's clinical record and review of hospital documentation between 9/14/16 from 7:00 AM to 7:00 AM failed to identify that measures to prevent further abuse were documented


Clinical record review of a Social Work (SW) Plan of care note dated 09/15/16 at 2:53 PM identified that SW #1 had received a request for consult on Patient #10 from an MD and RN regarding the incident of Patient #10 being slapped by Family Member #1. The social work plan identified that Patient #10 and his/her visitors would be closely observed via video monitor. If Family Member #1 visited and displayed any aggression, security would be notified and further visits would be with supervision only. SW #1 met with Patient #10's adult child to discuss the hospital's plan to ensure that Patient #10 remained free from abuse.


The hospital policy for the plan for provision of care identified that it is an organized and systematic process designed to ensure the delivery of safe, effective, and timely care and treatment that includes patient safety needs.