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Based on interview, record review and review of the facility's policy, it was determined failed to have an effective system in place to ensure the facility's policies and procedures related to identifying and reporting alleged abuse were implemented for two (2) of ten (10) sampled patients (Patients #4 and #10).

Facility staff and facility contracted staff failed to report potential physical abuse of Patient #4, and possible verbal abuse of Patient #10 by Registered Nurse (RN) #6. However, the facility's staff and contracted staff failed to report the alleged abuse, as per the facility's policy. Additionally, a Cardiovascular Technician (CVT) heard Patient #10 being allegedly verbally abused by a facility contracted staff which she reported to the Charge Nurse. However, the Charge Nurse failed to implement the facility's abuse policies and procedures and report the alleged abuse.

The findings include:

Review of the facility's policy titled, "Identification, Assessment, Reporting, and Investigation of Suspected/Alleged Victims of Abuse, Neglect or Exploitation", dated May 2014, revealed the facility must ensure any incidence of abuse, neglect, or harassment was reported and analyzed, and the appropriate corrective, remedial, disciplinary action occurred, in accordance with the applicable local, State or Federal Laws. The Policy revealed it was its policy to refer to Kentucky Law which mandated it was the responsibility of any person who knew or who had reasonable cause to believe an adult or a child who was dependent, had been abused, neglected or exploited to report it immediately to a local law enforcement agency, Kentucky State Police or the State Adult or Child Protective Services Agency, as per the Kentucky Revised Statute (KRS) 209 and 620. Continued review revealed the facility was required to report to the State Agency for Adult Protective Services (APS) any alleged abuse of an adult who was not able to care for them self. Per the Policy, a "Suspected Abuse/Neglect, Dependency, Exploitation Reporting Form" (MR-512) must be completed in its entirety on any patient suspected to be a victim of abuse or neglect, which was the responsibility of the primary caregiver in collaboration with the House Administrator. The Policy revealed the Administrator and Director of Nursing (DON) would be notified at the time the incident was recognized, and APS would be notified verbally or via electronic notification. The original copy of MR-512 form was to be scanned into the patient's medical record and the second copy sent to the Case Management (CM) Director. According to the Policy, the staff member who identified the suspected abuse/neglect/exploitation was to report the situation as soon as possible to APS, with all information documented in the patient's medical record.

1. Review of Patient #4's record revealed the facility admitted the patient on 06/05/15, with diagnoses which included Acute Heart Failure and Difficulty Breathing. Continued record review revealed the facility assessed Patient #4 to be alert and oriented to person, place and time.

Interview with Patient #4, on 06/10/15 at approximately 11:45 AM, revealed RN #6 was "rough" during his/her care when the patient was hospitalized during a previous visit to the facility. Patient #4 revealed he/she reported RN #6's behavior towards him/her to staff, and requested the RN not care for him/her anymore.

Interview with RN #1, on 06/10/15 at 3:28 PM, revealed he had heard about RN #6 being "rough" with Patient #4 when the incident occurred. RN #1 stated however, since he was not directly involved and had not witnessed the incident, he did not report it, as other nurses were also aware of the incident.

2. Review of Patient #10's closed medical record revealed the facility admitted the patient on 04/09/15, with diagnoses which included Congestive Heart Failure, Pulmonary Congestion, Bacterial Pneumonia and Dementia. Continued review revealed the facility care planned Patient #10 for Mental Impairment.

Interview with Sitter #1, Patient #10's facility contracted sitter, on 06/11/15 at 12:10 PM, revealed on 04/26/15, on second (2nd) shift, she had provided sitter services for the patient who was obviously very confused. Per interview, she had not provided sitter services for Patient #10 before, and was not familiar with the patient's medical diagnoses; however, she stated Patient #10 was a difficult patient. She revealed Patient #10 would often ask staff to raise the head of the bed, then turn around and ask staff to lower the head of the bed. Continued interview revealed on the night of 04/26/15, RN #6 came into Patient #10's room and was talking to the patient as if he/she was not confused. Sitter #1 reported Patient #10 was not agitated at first, but became agitated when RN #6 spoke to the patient "sternly". Per Sitter #1, Patient #10 hit RN #6 on the back side, and RN #6 told Patient #10, in a stern voice, "Don't hit me again". She revealed she was glad she was with Patient #10 when this occurred, as she thought she prevented RN #6 from physically abusing the patient. Further interview revealed she thought RN #6's tone was threatening towards Patient #10 and stated, "it scared me". She revealed RN #6 told Patient #10 he was going to get "Billy" and Sitter #1 did not know who "Billy", but the tone of the RN's voice scared her. Additionally, Sitter #1 revealed she did not tell anyone about this incident however, because she was new to the contracted sitter service agency. Sitter #1 stated she asked the person who was on call at the sitter service agency the next day about what she should have done when RN #6 acted like he did towards Patient #10. Per interview, she was advised she should have reported the incident, which she contacted after the discussion with the on call person.

Interview with Cardiovascular Technician (CVT) #4, on 06/12/15 at 7:45 AM, revealed she was familiar with Patient #10. She stated Patient #10 was a difficult patient with a Dementia diagnosis and often repeated his/her needs to staff over and over. Per interview, even though she thought RN #6 was a good nurse, she had observed the RN had difficulty working with patients who had a Dementia diagnosis. She reported she did not know if RN #6 had ever worked with Patient #10, but had advised the nursing staff to refrain from assigning RN #6 with the patient as he/she would drive the RN "crazy".

Interview with CVT #1, on 06/11/15 at 9:57 AM, revealed she knew RN #6 and was aware of how he provided care for his patients. She stated RN #6 had some difficulty working with patients with a Dementia diagnosis because he would often try to explain things to them, not knowing the demented patients might not always comprehend what he was telling them. Per interview, this frequently would agitate patients who had Dementia; and she stated a lot of patients called the desk and reported RN #6 was "yelling" at them. She stated however, the patients statements regarding RN #6 "yelling" at them was not investigated. Further interview revealed she heard RN #6 talking to patients when she was in the hallway, and it did not sound like the RN was verbally abusive to patients. Per CVT #1, RN #6 was from Bulgaria and it was often difficult to understand him.

Interview with CVT #3, on 06/11/15 at 5:30 PM, revealed she was familiar with Patient #10, and that the patient was very confused and repetitive in speech. Per interview, Patient #10 had a private sitter with him/her when hospitalized. Continued interview revealed she had never seen RN #6 work with Patient #10, but stated RN #6 got emotional easily and was not good at hiding it. She reported RN #6 would come across as "hard" and "rude" to patients, and his personality was different because he was from a different country. CVT #3 revealed she did not think RN #6 knew how to work with patients who had a diagnosis of Dementia, as he thought he could explain things to those patients as he did to patients who did not have Dementia. She stated she thought it was frustrating to him when he could not make the patients with Dementia understand what he was telling them.

Telephone interview was attempted on 06/12/15 at 11:54 AM, with RN #6; however, was unsuccessful and a message was left for him to return the Surveyor's call, but no return call was ever received.

Continued interview with CVT #4 on 06/12/15 at 7:45 AM, revealed she had also witnessed a contracted sitter, Sitter #2, being verbally abusive to Patient #10. CVT #4 revealed she was not certain of the date, but thought the incident occurred around 04/15/15 or 04/20/15. According to CVT #4, she recalled Sitter #2 having a "sharp tongue" and loud voice when sitting with Patient #10 which carried out into the hallway. She stated Sitter #2 told Patient #10 in a loud sharp voice, "You need to be quiet", which she thought was verbally abusive and so she told the Charge Nurse, RN #4. Further interview revealed RN #4 switched Sitter #2 to another patient's room, but did not remove the sitter from patient areas on the floor.

Interview with RN # 4, on 06/11/15 at 8:38 AM and on 06/12/15 at 11:45 AM, revealed when alleged abuse was identified, she was contacted as Charge Nurse, and also the Unit Manager, and the incident would then be written up. RN #4 revealed she recalled CVT #4 informing her of Sitter #2 being verbally abusive to Patient #10, however; she stated she listened to Sitter #2 speak with the patient and concluded Sitter #2 was not abusive to Patient #10. Per interview, she thought Sitter #2 was "short" with Patient #10, and "frustrated" with caring for the patient. Continued interview revealed she did not report the alleged abuse because she had not thought Sitter #2's actions were abusive; however, admitted it was not her roll to investigate alleged abuse. RN #4 reported she was the Charge Nurse when CVT #4 reported the alleged verbal abuse, and due to staffing on the unit, she explained to Sitter #2 she could not talk to Patient #10 in the way she had been doing. Further interview revealed RN #4 made the decision to switch Sitter #2 to another patient and away from Patient #10.

Interview, on 06/12/15 at 10:00 AM, with the Personal Service Agency's (PSA's) General Manager, the PSA the facility contracted sitter services through, revealed it was the PSA's policy to have their contractual staff providing sitter services in the facility to contact them, the service provider, if the contractural staff witnessed abuse. He reported his Agency would then notify the "higher ups" regarding the alleged abuse; however, he stated the role of the sitters was to "mind their own business" when in the facility. Per interview, he had informed the PSA staff they could always contact APS if they did not feel comfortable reporting the abuse to the Agency. Continued interview with the General Manager revealed he asked staff to notify him because they have a contract with the facility and he did not want the facility to "resent" the PSA. The General Manager revealed he was not certain who the sitter was who was involved in the incident involving Patient #10, but would check and call the Surveyor back with phone numbers for the sitters. who switched rooms the night from Patient #10, but call back with the sitters numbers and information for the date of 04/20/15. However, the Surveyor did not receive a return call from the General Manager with the sitter's contact information and was therefore unable to interview Sitter #2.

Interview with CVT #5, on 06/12/15 at 10:33 AM, revealed the facility's process for reporting abuse was for floor staff to tell their Charge Nurse and if the Charge Nurse did nothing about it, then staff should contact the Nurse Manager. Continued interview with CVT #5 revealed she would describe "yelling" at someone as abusive and something which should be reported.

Interview with the Unit Manager (UM), on 06/12/15 at 12:39 PM, revealed "yelling" was a form of verbal abuse. She stated if staff contacted her regarding an allegation of abuse she would contact the Human Resource (HR) business office. Per interview, she would not make a decision on her own regarding an allegation of abuse, as there might be certain bias which could come into play. The UM revealed therefore, HR would investigate the alleged abuse.

Interview with the Clinical Manager, on 06/11/15 at 5:55 PM, revealed she was familiar with Patient #10, who she described as being "confused" and "combative". Per interview, Patient #10 would often "pinch" the staff when they provided care. The Clinical Manager revealed she had not observed RN #6 working with Patient #10; however, stated RN #6 would become frustrated with some of the patients with Dementia because he could not talk them into calming down.

Interview with the Director of HR, on 06/11/15 at 2:45 PM, revealed the facility's process for reporting alleged abuse was for facility staff to follow the chain of command. The Director of HR revealed contracted staff were held to the same standards as the facility staff, and should report any alleged abuse immediately. Continued interview revealed the HR Department would conduct the allegations of abuse reported, and if an employee was suspected of abuse, the employee was suspended immediately, pending the results of the investigation. He stated this was important for patients' safety. The Director of HR revealed after an employee was suspected of abuse, APS was notified and Case Management would become involved with the investigation process. Further interview with the Director of HR revealed he had not been made aware of RN #6 being allegedly of verbally abusive, and therefore, the RN was not suspended.

Interview with the Social Worker (SW)/Case Manager Supervisor (CMS), on 06/11/15 at 10:47 AM, revealed APS contacted her regarding Patient #10 and investigating the staff for abuse. She revealed she contacted RN #10/UM to have the alleged perpetrator, RN #6, contact the APS worker. Per interview, the facility's process for reporting abuse was for anyone who observed alleged abuse to make a report to APS and/or make a report online. SW/CMS revealed when an aide observed abuse, they should report it to their Charge Nurse who would report to the UM, and it would go on up the chain of command. Continued interview revealed in the case of RN #6's alleged verbal abuse, the facility did not investigate and left it up to APS to investigate.

Interview with the Administrative Director, on 06/12/15 at 12:13 PM, revealed "yelling" was a form of abuse, and it was her expectation staff would follow their chain of command to report alleged abuse. She revealed it was important she was made aware of the information, as staff did not know what happened behind the scenes, all allegations of abuse should be reported for investigation.

Interview with the Vice President (V/P) of Patient Care, on 06/12/15 at 1:30 PM, revealed it was her expectation staff would report any alleged abuse immediately and if they did not know how, they should ask someone for assistance. Continued interview with the V/P of Patient Care revealed contracted staff should also report, as per the facility's policy. Per interview, anyone who worked in the facility "were bound by the same polices".

Based on observation, interview and review of the facility's policy, it was determined the facility failed to have adequate staffing to provide care for patients as they needed it, for two (2) of ten (10) sampled patients (Patients #4 and #6).

The findings include:

Review of the facility's policy titled, "Staffing", dated March 1988, revealed the staffing design should represent a balance among the needs of the patients, institution, and the employees.

1. Review of the the facility's policy titled, "Fall Prevention", dated January 1997, revealed staff would supervise patient's toileting as indicated.

Review of the facility's, "Fall and Injury Reduction Tip", dated January 2015 and March 2015, revealed staff were to remain within arm's length of a patient who had a mobility and or cognitive impairment when assisting the patient with toileting needs.

Review of Patient #6's record revealed the facility admitted the patient on 06/06/15 with diagnoses which included Post Stroke. Record review revealed the facility had assessed Patient #6 as alert and oriented, and as at risk for falls. Review of Patient #6's Nurse's Note, dated 06/09/15 at 12:16 AM, revealed the patient was found lying on the bathroom floor, and he/she reported calling out for assistance, but no one came. Per the Note, Patient #6 had reported pulling the bathroom alarm cord, and no one came to assist him/her. According to the Note, Patient #6 stated he/she had been concerned because the "potty hat" over the toilet was full of urine and the patient was "sitting" in his/her own "urine". Further review of the Note revealed Patient #6 told staff he/she stood up from the toilet, bent over to empty the "potty hat" and then sat down on the floor.

Interview with Patient #6, on 06/10/15 at approximately 11:35 AM, revealed he/she had experienced a fall on Monday, 06/08/15. Patient #6 revealed Cardiovascular Technician (CVT) #4 had assisted him/her to the bathroom, but had not emptied the "potty hat". Continued interview revealed when Patient #6 sat down on the toilet, his/her "butt" was wet after urinating due to the "potty hat" having urine still in it from previously. Patient #6 revealed he/she called for someone to come help empty the "potty hat" and assist with cleansing, but no one came. Further interview revealed Patient #6 tried to empty the "potty hat", and fell in the process. Patient #6 stated he/she did not believe the facility had enough staff to meet his/her or other patients' needs.

Interview with CVT #1, on 06/11/15 at 9:57 AM, revealed there was not a lot of staff to assist with patient care. She stated to be fully staffed, the unit would need five (5) or six (6) nurses, two (2) CVT's on the floor and one (1) person to monitor the desk. CVT #1 revealed however, the unit was only staffed with four (4) or five (5) nurses, usually only four (4) nurses on the unit, and one (1) technician. Continued interview revealed patients had often complained about it taking a long time for staff to answer their call lights. Per interview, on 06/08/15, the day of Patient #6's fall, the patient had fallen around shift change . She stated Patient #6 had called for assistance to the bathroom and she (CVT #1) had contacted CVT #4 who indicated she would respond to the patient's call light. Further interview revealed she had not heard anything else until Registered Nurse (RN) #3 came to the nurse's station and reported finding Patient #6 on the floor of the bathroom.

Interview with CVT #4, on 06/12/15 at 7:45 AM, revealed she was not aware of Patient #6's fall, as she had not worked the shift on which the fall had occurred. However, review of the staffing schedule for 06/08/15, revealed CVT #4 had worked that day at the time of the fall. Continued interview with CVT #4 on 06/12/15 at 7:45 AM, revealed she had heard about Patient #6's fall from another staff member. According to CVT #4, she did not know who had assisted Patient #6 to bathroom and left the patient there alone. Per interview, Patient #6 should not have left alone though. CVT #4 revealed there was not enough staff to meet the needs of the unit's patients. Further interview revealed with the limited number of staff to care for patients, it was dangerous. Per CVT #4, if a patient went into cardiac arrest, there would not be enough staff to assist if another patient went into cardiac arrest at the same time, as there was never enough staff on the unit.

Interview with RN #3, on 06/11/15 at 7:48 AM, revealed she had been sitting in shift change report on 06/08/15, and noticed Patient # 6's call light was going off. She revealed when she responded to Patient #6's call light she found the patient lying on the bathroom floor. Continued interview revealed Patient #6 told her a staff member had assisted him/her to the bathroom leaving the "potty hat" on the toilet and leaving the patient alone in the bathroom. According to RN #3, she had never clarified with Patient #6 who the staff member was who assisted her to the bathroom; however, she addressed leaving the 'potty hat" on the toilet with the two (2) CVT's working the unit the night of Patient #6's fall, who were CVT #4 and CVT #5. RN #3 stated Patient #6 was upset about there being urine in the "potty hat" when he/she sat down. Per interview, Patient #6 had every right to be upset about that, as the "potty hat" should have been emptied. Further interview revealed the facility was not staffed very well, and her unit was supposed to have six (6) nurses, but always had only five (5) nurses. She stated the unit was not staffed appropriately, and the patients didn't get the care they needed because the staff always had to be somewhere else. In addition, RN #3 revealed even though it was not intentional, being short staffed could lead to neglect of patients.

Interview with the Clinical Manager, on 06/11/15 at 5:55 PM, revealed she believed Patient #6 experienced the fall on 06/08/15, around shift change, which was somewhere around 8:00 PM. Per interview, from what she had been told about the fall incident, the patient was using the toilet and the urinal hat had not been emptied. Continued interview revealed she had been told Patient #6 had sat in the urine in the urinal had, then tried to empty it and fell. The Clinical Manager revealed RN #3 had been upset about the situation because she felt the fall could have been avoided if the patient had not been left alone. Further interview revealed the CVT who assisted Patient #6 to sit on the toilet should not have left him/her alone.

2. Record review revealed the facility admitted Patient #4 on 06/05/15, with diagnoses which included Difficulty Breathing, Dialysis and Acute Heart Failure. Record review revealed the facility assessed Patient #4 as alert and oriented to person, place and time.

Interview with Patient #4, on 06/10/15 at approximately 11:45 AM, revealed she felt there was not enough staff to meet his/her or other patients' needs. Patient #4 revealed on Monday, 06/08/15, he/she was transported to Dialysis late in the evening, even though he/she liked going earlier in the day. According to Patient #4, when he/she asked the Dialysis staff why it had taken so long for him/her to be taken to Dialysis, the staff there told the patient there had not been staff to take him/her. Patient #4 revealed he/she was not happy having to go so late, and had not liked returning from Dialysis so late.

Interview with Registered Nurse (RN) #1, on 06/10/15 at 3:28 PM, revealed he was aware Patient #4 was upset about having to go to Dialysis so late on 06/08/15. He revealed he had came in early that day, 06/10/15, to make sure Patient #4 got to go in early to Dialysis.

Interview with CVT #5, on 06/12/15 at 10:33 AM, revealed she had assisted Patient #4 back from Dialysis the day Patient #6 experienced the fall. She revealed she had picked Patient #4 up from Dialysis around 8:30 PM on Monday 06/08/15, which left only one (1) CVT on the floor, CVT #4. Continued interview with CVT #5 revealed Patient #4 was very vocally upset about how late she had gone to Dialysis and expressed how unhappy she was about the matter. CVT #5 revealed staffing was always a concern on the second floor Telemetry Unit, and patients had told her they had to wait quite awhile for staff to respond to their call lights. Further interview revealed she had worked on nights where she was the only CVT, and there were only four (4) nurses working the floor. She stated it was hard to care for and meet the needs of the patients when they worked short staffed.

Interview with RN #5, on 06/11/15 at 4:25 PM. revealed she worked in Dialysis and stated the department opened at 6:00 AM, and there was no designated time for each patient to come to Dialysis. Per interview, the Dialysis Department staff called the unit of the patient who had Dialysis scheduled on the day they were scheduled to have the patient brought down. She stated if the unit was busy at the time of their call and no one was available to bring that patient, they would call another patient to come instead. Continued interview revealed it was a problem in getting the Dialysis patients to the department for their Dialysis. RN #5 revealed even though the department opened at 6:00 AM, patients could not get brought down until about 8:00 AM. She stated she would have to call the unit three (3) or four (4) times before they could get someone to bring a patient. Further interview revealed staffing was an issue in all the facility's departments and stated it was important for the departments to be fully staffed for the safety of patients. She stated her department did not have enough staff to go get the patients, nor staff to provide the Dialysis service required if all the patients at one (1) time.

Interview with CVT #3, on 06/11/15 at 5:30 PM, revealed she did not believe the facility had enough staff to meet the needs of all the patients. She stated she had heard patients report having to wait a long time for staff to respond to their call lights. Continued interview revealed her unit had more patients which were total care. CVT #3 revealed normally the patients were asking for assistance to the bathroom and three (3) CVT's would be ideal, but only having one (1) on the floor to assist patients was nearly impossible.

Interview with RN #2, on 06/10/15 at 8:49 PM, revealed the facility was always short staffed, often having only four (4) nurses and one (1) CVT on her unit to provide care for the patients. She revealed one (1) CVT on her unit was on light duty and that spread the unit staffing thin. Continued interview revealed if the unit was fully staffed there would be five (5) nurses, two (2) technicians, and one (1) secretary to monitor the floor.

Interview with RN # 4, on 06/11/15 at 8:38 AM and on 06/12/15 at 11:45 AM, revealed based on the acuity of the patients on the second floor Telemetry Unit, there was not enough staff to make rounds and provide the care needed. She revealed the patients on the second floor required more assistance with their care. Per interview, the unit was staffed per a grid which was used to determine the number of staff needed to care for the patients. However, she stated the staffing grid was not reflective of the medical needs of the patients on the unit. Further interview revealed the shortage of staff put a strain on the staff working, and prohibited them from providing the care needed for the patients. According to RN #4, this was dangerous for the patients and the staff.

Interview with the Unit Manager (UM) of the Telemetry Unit, on 06/12/15 at 12:39 PM, revealed the grid for staffing did not reflect the acuity of the patients on the unit. She reported it was important for there to be adequate staff for the safety of patients.

Continued interview with the Clinical Manager, on 06/11/15 at 5:55 PM, revealed there was not enough staff to meet the needs of the patients. She stated the staff tried to meet patients' needs, but it was impossible. Per interview, the problem occurred on both shifts on the second floor Telemetry Unit. Consequently, the Clinical Manger revealed the night shift got the "crap" end of it, as the patients were often confused and the unit normally worked with only four (4) nurses. She stated the patients had to be turned and they were "needy" patients who required a great deal of assistance. Further interview revealed the staffing grid used did not reflect the acuity of the patients located on the second floor Telemetry Unit.

Interview with the Administrative Director, on 06/12/15 at 12:13 PM, revealed she could not comment on the staffing, as the unit managers would have that information. The Administrative Director stated however, in regards to Patient #6, it would have been her expectation that staff would have emptied Patient #6's "potty hat" before assisting the patient onto the toilet. She stated the person who assisted Patient #6 to the toilet should not have left the patient alone for safety reasons.

Based on observation, interview,and review of the facility's policy, it was determined the facility failed to supervise and evaluate nursing care for one (1) of ten (1) sampled patients (Patient #6). The facility assessed Patient #6 to be a fall risk; however, the patient was assisted to the bathroom by staff and left on the toilet without supervision. As a result of the lack of supervision, Patient #6 experienced a fall on 06/08/15.

The findings include:

Review of the facility's policy titled, "Fall Prevention", dated January 1997, revealed patients were assessed for fall risk factors on admission through the use of the Morse Fall Scale (MFS). Per the Policy, if a patient scored greater than forty-four (44) on the MFS assessment staff were to implement high fall risk prevention interventions. Further review revealed the high fall risk interventions included a "falling star" posted outside the patient's room, placement of yellow nonskid slippers, placement of an arm bracelet, elimination needs assessed and staff would supervise toileting of patients as indicated.

Review of the facility's, "Fall and Injury Reduction Tip", dated January 2015 and March 2015, revealed staff were to remain within an arm's length of a patient who had a mobility and/or cognitive impairment when assisted by staff to the bathroom for toileting.

Review of Patient #6's record revealed the patient was admitted by the facility on 06/06/15, with diagnoses which included being Post Stroke. Record review revealed the facility assessed Patient #6 as a high risk for falls on 06/06/15. Review of Patient #6's 06/08/15, 12:16 AM, Nurse's Note revealed staff found Patient #6 lying on the bathroom floor, with the patient stating he/she had pulled the bathroom alarm, but no staff responded. Per the Note, Patient #6's "potty hat" had urine already in it when he/she was assisted to the toilet, and the patient reported "sitting" in the urine. The Note revealed Patient #6 stood to empty the "potty hat" on his/her own and then experienced a fall.

Interview with Patient #6, on 06/10/15 at approximately 11:35 AM, revealed the patient had experienced a fall on Monday, 06/08/15. Per interview, Cardiovascular Technician (CVT) #4 had assisted Patient #6 to the bathroom, but did not empty the "potty hat" and helped the patient to sit on the toilet. According to Patient #6, the CVT left him/her to use the toilet, and the patient's "butt" was wet after urinating in the "potty hat" which already had urine in it. Continued interview revealed Patient #6 called for assistance; however, no one came. Per Patient #6, therefore, he/she tried emptying the "potty hat" on his/her own and fell while in the process of doing so.

Interview, on 06/11/15 at 9:57 AM, with CVT #1 revealed Patient #6's fall incident occurred around shift change on 06/08/15. Per interview, Patient #6 called for assistance to go to the bathroom, and CVT #1 contacted CVT #4 who stated she would respond to the patient's call light. She stated she had not heard anything else until RN #3 came to the nurse's station and reported finding Patient #6 on the floor of the bathroom.

Interview with CVT #4, on 06/12/15 at 7:45 AM, revealed she was not aware of Patient #6's fall, as she had not worked the shift the fall occurred on. However, interviews with other staff and Patient #6, revealed CVT #4 had worked that day on that shift and had assisted Patient #6 to the bathroom. Additionally review of the staffing information revealed CVT #4 had worked that day on that shift. Continued interview with CVT #4, on 06/12/15 at 7:45 AM, revealed she heard about Patient #6's fall from another staff person. CVT #4 revealed she did not know who had assisted Patient #6 to the bathroom, though whoever had done so, should not have left the patient unsupervised due to him/her being a fall risk. Further interview revealed she was not re-educated on assisting patients to the bathroom after Patient #6's fall.

Interview, on 06/11/15 at 7:48 AM, with RN #3 revealed on 06/08/15, she had been in shift change report when she noticed Patient #6's call light was going off. Per interview, she responded to the call light and found Patient #6 lying on the bathroom floor. Continued interview revealed Patient #6 told her a staff person had assisted him/her to the bathroom where the "potty hat" was on the toilet with urine already in it. RN #3 stated she never clarified who the staff person was who assisted Patient #6 to the bathroom, but did address with CVT #4 and CVT #5, who both had worked the night of the patient's fall, about leaving the "potty hat" on the toilet with urine in it. Additionally, she reported Patient #6 had been very upset about there being urine already in the "potty hat" when he/she sat down, and the patient had the right to be upset.

Interview with CVT #5, on 06/12/15 at 10:33 AM, revealed she was assisting another patient with care at the time of Patient #6's fall and therefore, had not witnessed any of the incident. Per interview, she and CVT #4 were the CVT's assigned to Patient #6's unit that night.

Interview with the Clinical Manager, on 06/11/15 at 5:55 PM, revealed she believed Patient #6 experienced the fall on 06/08/15 somewhere around 8:00 PM, around shift change. According to the Clinical Manager, from what she had been told Patient #6 was assisted to the bathroom where the urinal hat was on the toilet and it had not been emptied. Per interview, she had been told Patient #6 sat in the urine, stood and tried to empty the urinal had, then experience the fall. The Clinical Manager revealed RN #3 was upset about the situation because she felt the fall could have been avoided. Continued interview with the Clinical Manger revealed the CVT who sat Patient #6 on the toilet should not have left the patient sitting there alone.

Interview with the Clinical Nurse Specialist (CNS), on 06/12/15 at 11:15 AM, revealed she investigated Patient #6's fall. She stated the facility was working on revising its policy, and it should state staff could not be no more than an arm's length from the patient. Per interview, Patient #6 and RN #3 reported CVT #4 assisted the patient to the bathroom and the staff member was supposed to be re-educated. However, per the Clinical Nurse Specialist CVT #4 had not been re-educated as of the time of interview, but would be as soon as possible.

Interview with the Administrative Director, on 06/12/15 at 12:13 PM, revealed it was her expectation staff would have emptied Patient #6's "potty hat" prior to assisting the patient to sit down on the toilet. She stated the person who assisted Patient #6 to the toilet should not have left the patient alone for his/her safety.