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Based on record review and interview, staff failed to ensure patients are free from verbal and physical abuse and failed to report the abuse timely for one of one patients (Patient # 1) who were abused by staff in a sample of 1 reported abuse case.

Findings include:

1. Failure to ensure that patients were free from verbal and physical abuse and failure to report abuse timely for one of one patients (Patient #1). See A-0145


The cumulative effect of these failures has the potential to affect all 210 patients on census in this facility at the time of the survey.


An Immediate Jeopardy (IJ) was identified on 7/15/2019 at 2:42 PM regarding intensive care staff's failure to protect patients from verbal and physical abuse and failure to timely report such abuse. The immediate jeopardy was not removed at the time of the exit from the facility on 7/16/2019 at 9:00 AM.

Based on record review and interview, staff failed to ensure that patients were free from verbal and physical abuse and failed to report the abuse timely for one of one patients (Patient # 1) in a sample of 1 reported abuse case.

Findings include:

The facility's policy titled, "Reporting Allegations of Patient Abuse, Neglect, or Misappropriation of Patient Property," dated 6/27/2018, revealed in part, "3. In the interest of patient protection and compliance with federal and state laws, any allegation of an act of omission, or course of conduct that constitutes patient abuse, neglect or misappropriation of patient property by any person employed by or under contract with (health system) will be reported. Such reports will be made to the Department of Health and Family Services and to the Department of Regulation and Licensing (as applicable.)...3.1. Reports of Misconduct a. Employee, Provider, and Contractor obligations: Any employee, provider, or contractor who witnesses or becomes aware of alleged misconduct, as defined in this policy, by another employee, provider, or contractor, an injury of unknown source, or a unexplained loss of property must report the incident to Human Resources and/or Risk Management. b. Effect of Failure to Report: Employees, providers or contractors who fail to report incidents of alleged misconduct, injuries of unknown source or unexplained losses of property in a timely manner will be subject to progressive discipline, up to and including termination of their employment, contract or privileges...c. Response upon Learning of Allegation: Upon learning of alleged misconduct, (health system) will take necessary steps to ensure that patients are protected from subsequent episodes of misconduct while a determination on the matter is pending. Such steps may include, but are not limited to:...Training for all staff members or the staff member, provider, etc., involved in the incident, as appropriate. 3.2 c. Completion of the Investigation: Risk Management or the Medical Staff needs to complete its initial investigation within five calendar days from the date it received the allegation of misconduct...3.3 Reports of Misconduct a. Submission of Report(s): For all allegations that cannot be affirmatively ruled out as misconduct, Human Resources or the Medical Staff Coordinator will prepare an Incident Report of Caregiver Misconduct and Injuries of Unknown Source form and will submit it, within seven calendar days from the date it knew or should have known of the incident..."

The policy did not address reporting structures or time frames for staff to follow in the event Human Resources or Risk Management is closed when an incident should be reported.

The Department of Health Services, Division of Quality Assurance for the State of Wisconsin's Misconduct Incident Report revealed the following regarding mandatory reporting guidelines for non-long term care facilities: "Upon the completion of the entity's internal investigation of the incident, send the completed form, any available documentation, and the results of your investigation within SEVEN CALENDAR days of the date the entity knew or should have known of the incident." This form was completed and sent to the Department of Health Services, Division of Quality Assurance on 6/13/2019 following management date of awareness of 6/6/2019.

The facility policy titled, "Patient Bill of Rights and Responsibilities," dated 9/20/2018, revealed in part, "3.1 Patient Rights a. Patients have the following rights in accordance with the Patient Bill of Rights *Considerate Care: the right to receive considerate, respectful care from qualified personnel who respect the patient's dignity, personal values, spiritual values, belief system and culture, and the right to be free from all forms of abuse or harassment."

The facility's "Internal Investigation Report," which was not dated, regarding caregiver misconduct was reviewed on 7/15/2019 at 12:00 PM. The report outlines the events that took place on 6/2/2019 between Registered Nurse I and Patient #1 in the medical intensive care unit (ICU). The report revealed that on 6/2/2019 Certified Nursing Assistant J and ICU Charge Nurse H witnessed Nurse I forcibly holding Patient #1 down in the bed and yelling at Patient #1 while Patient #1 was being uncooperative and combative around 11:30 AM on 6/2/2019.

Further review of undated occurrence reports from Nurse H and Aide J revealed that both entered Patient #1's ICU room on 6/2/2019 after hearing a loud noise and discovered Nurse I holding Patient #1 down with both hands yelling, "You're a (expletive expletive) and "How do you like drinking now." According to Nurse H's account of the events, "The patient was combative and (Nurse I) continued to slam the patient down with both arms aggressively at the chest each time the patient attempted to sit up. (Nurse I) also took (I's) finger and tapped into (Patient #1's) chest over and over again while continuing to call (Patient #1) an "(expletive)."

A review of Charge Nurse H's account on the undated occurrence report of the event also revealed that H asked Nurse I to "step out and go for a walk," but Nurse I refused stating it was I's patient. Nurse I was allowed to continue to care for Patient #1 for the remainder of the shift. Nurse H did not report the incident to a supervisor or manager until 6/6/2019.

A review of Certified Nursing Assistant J's account on the undated occurrence report of the incident revealed that after Aide J entered the room Nurse I informed Aide J that Patient #1 had kicked Nurse I in the face and Nurse I had a red mark on the face where he/she said he/she was kicked. While helping to secure leg restraints to Patient #1, Aide J was also kicked in the face/shoulder and Nurse I, "Came across the room with both open hands and slammed his/her patient down to the bed. (Nurse I) then started calling his/her patient "(expletive expletive) and tap in the patient's chest vigorously with his/her finger."

In an interview with Medical ICU Manager D on 7/15/2019 at 1:00 PM, Manager D confirmed that D was informed of the incident on 6/6/2019 by Charge Nurse H by phone early in the morning on 6/6/2019, prior to Manager D's arrival to the facility. Manager D started an investigation by conducting employee interviews with Nurses H and L and Aide J on 6/6/2019, and reviewing medical records, and reported to human resources staff E on 6/6/2019 at 9:19 AM by a comprehensive e-mail.

The outcome of the facility's internal investigation was to terminate Nurse I. In the interview with Medical ICU Manager D on 7/15/2019 at 1:00 PM, in response to education provided to the remainder of the staff regarding reporting employee misconduct, Manager D stated, "We looked for a pattern and at the process and felt it was an isolated incident involving one individual and we chose to terminate."

In a follow up interview with Manager D on 7/15/2019 at 2:51 PM in regards to reporting of caregiver misconduct and why Charge Nurse H did not report the incident for 4 days, Manager D said, "I don't know. The expectation should have been to report it right away because (Nurse I) would have been sent home on leave pending an investigation."

Manager D also stated in the interview on 7/15/2019 at 2:51 PM, that Nurse I was allowed to continue to care for Patient #1 for the remainder of the shift on 6/2/2019 (shift ended at 7:30 PM), and then went on vacation. Nurse I provided no further care at this facility after 6/2/2019.