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Based on observations, interviews, record review, and policy review, it was determined the facility failed to have an effective Governing Body responsible for the conduct of the facility. The facility's Governing Body and Chief Executive Officer (CEO) failed to ensure the facility's policies and procedures prohibiting abuse were implemented. The Governing Body failed to ensure contract employees (Security staff) were trained and knowledgeable of the facility's policy/procedure related to abuse/neglect and reporting.

On 04/30/16, Security Guard #1 observed Patient Care Assistant (PCA) #1 abuse Patient #1. Security Guard #1 failed to report the abuse and PCA #1 continued to provide care to Patient #1. On 05/02/16, Security Guard #8 witnessed PCA #1 abuse Patient #1. Security Guard #8 also failed to immediately report the abuse and PCA #1 continued to provide patient care. The security guards reported the abuse to their supervisors (contracted service) on 05/04/16; however, the abuse allegations were not reported to the facility until 05/06/16. The facility initiated an investigation but failed to assess Patient #1 for injuries and failed to ensure all staff who allegedly failed to report abuse was suspended per the facility's procedure. In addition, the Governing Body failed to ensure the facility's policies and procedures related to restraints were implemented. Security Guards/staff restrained patients (held patients down) without a physician's order and Security staff was not trained on how to physically restrain a patient while the patient was lying down.

Review of the facility's investigation revealed on 04/30/16 at approximately 12:00 AM and 4:00 AM, Security Guard #1 witnessed PCA #1 slap Patient #1 while PCA #1 and Security Guard #2 were physically restraining the patient, without evidence of a Physician's Order to restrain the patient. Security Guard #1 failed to report the abuse and PCA #1 continued to provide care to Patient #1. On 05/02/16 at approximately 2:35 AM, Security Guard #8 witnessed PCA #1 hit Patient #1 in the face, drag the patient across the floor, and kick the patient in "the ribs." Security Guard #1 also failed to report the abuse and PCA #1 continued to provide patient care. On 05/04/16, Security Guards #1 and #8 reported the allegations of abuse to their security supervisors. Security staff failed to ensure the allegations were reported to the facility and no action was taken to protect patients from abuse until 05/06/16. In addition, as of 05/18/16, the facility failed to medically assess Patient #1 for possible injuries as a result of being abused. Refer to A0057.

Based on observations, interviews, record review, and policy review, it was determined the facility failed to have an effective Governing Body responsible for the conduct of the facility. The facility's Governing Body and Chief Executive Officer (CEO) failed to ensure the facility's policies and procedures prohibiting abuse were implemented. The Governing Body failed to ensure contract employees (security staff) were trained and knowledgeable of the facility's policy/procedure related to abuse/neglect and reporting.

On 04/30/16 and 05/02/16, Security Guards #1 and #8 witnessed Patient Care Assistant (PCA) #1 abuse Patient #1. The Security Guards failed to immediately report the abuse and PCA #1 continued to provide patient care until 05/06/16. The facility initiated an investigation but failed to assess Patient #1 for injuries and failed to ensure all staff, who allegedly had knowledge of the abuse and failed to report the abuse, was suspended per the facility's procedure. Also, the Governing Body failed to ensure the facility's policies and procedures related to restraints were implemented. Security Guards/staff restrained patients (held patients down) without a physician's order and Security staff was not trained on how to physically restrain a patient while the patient was lying down.

The findings include:

Review of the policy, titled "Board of Trustees, Policies and Procedures, Corporate Objectives," not dated, revealed the President and Chief Executive Officer (CEO) under the policies and directives of the Board of Trustees was accountable for planning, executing, controlling, and monitoring the programs and activities of the facility.

Review of the facility's policy, titled "Suspected Abuse, Neglect, Exploitation of Patients and Reporting," approved March 2016, revealed the purpose of the policy was to ensure all patients were free of all types of abuse and neglect from staff, volunteers, other patients, and visitors. The policy stated that as a condition of employment any person that had reasonable cause to suspect that any patient had suffered abuse or neglect, should immediately report the incident to their supervisor or the House Supervisor.

Review of a staffing services contract, dated 07/01/11, between the Security Company (agency) and facility (client) revealed the client would be responsible for conducting site-specific training required for the employee to perform the job safely and effectively.

Review of the "Nonviolent Crisis Intervention (NVCI)" workbook utilized by facility Security Guards, dated 2005 and revised in 2014, emphasized physical restraint was recommended when all other less restrictive methods had been exhausted. Further, any physical intervention was potentially dangerous and should be looked at as an emergency response procedure. Review of the NVCI workbook revealed Security staff was not trained to hold a patient in a lying position.

Observation of Patient #1 on 05/18/16 at 11:10 AM revealed Patient #1 was sitting in the facility group room with a PCA and a Security Guard. Patient #1 became agitated when state surveyors walked into the room; however, the patient did not appear to have visible injuries.

Review of Patient #1's medical record revealed the facility admitted the patient to the Behavioral Health Center on 04/26/16 on an involuntary 72-hour hold for delusional behavior. Staff interviews and nursing assessments revealed the patient was irritable, delusional, and in an agitated state. Review of the facility's investigation revealed on 04/30/16 at approximately 12:00 AM and 4:00 AM, Security Guard #1 witnessed PCA #1 slap Patient #1 while PCA #1 and Security Guard #2 were holding the patient for the administration of an injectable medication by Licensed Practical Nurse (LPN) #1, without a physician's order to physically restrain the patient. On 05/02/16 at approximately 2:35 AM, Security Guard #8 witnessed PCA #1 hit Patient #1 in the face, drag the patient across the floor, and kick the patient in "the ribs." Security Guards #1 and #8 failed to report the allegations of abuse until 05/04/16 to their security supervisors. Security staff failed to ensure the allegations were reported to the facility and no action was taken to protect patients from abuse until 05/06/16. In addition, as of 05/18/16, the facility failed to medically assess Patient #1 for possible injuries as a result of being abused.

Interview on 05/09/16 at 4:00 PM with the Corporate Director of Security revealed Security Guards were trained on the Security Company's "Speak Out" policy regarding abuse. He stated the policy required the security officers to report incidents of abuse to the Security Company's supervisors and did not train security officers to report allegations of abuse immediately to the facility or local state agencies.

Interview with the CEO on 05/18/16 at 11:00 AM revealed he was responsible to oversee that all policies and procedures were implemented for the facility. He stated he was unaware that the Security Company's training on abuse/neglect and reporting did not meet the standards of the facility. Continued interview with the CEO revealed that he was unaware staff was physically restraining patients without an order and that he felt that Nursing staff was "therapeutically holding" patients to keep them safe.

Based on observation, interviews, record review, review of the facility's policies, and review of security staff's contract, training, and logs, it was determined the facility failed to protect the rights of their patients. The facility failed to ensure one (1) of twelve (12) sampled patients (Patient #1) was free from abuse.

The facility failed to ensure security staff (contracted service) was trained on the facility's abuse reporting policy. As a result, two (2) Security Guards failed to report abuse allegations to the facility until four (4) and six (6) days after they observed abusive incidents.

Patient #1 was admitted to the Behavioral Health Center on 04/26/16 on an involuntary 72-hour hold for delusional behavior. Staff interviews and nursing assessments revealed the patient was irritable, delusional, and in an agitated state. On 04/30/16 at approximately 12:00 AM and 4:00 AM, Security Guard #1 witnessed Patient Care Assistant (PCA) #1 slap Patient #1 while PCA #1 and Security Guard #2 were holding the patient for the administration of an injectable medication by Licensed Practical Nurse (LPN) #1. Security Guard #1 failed to report the abuse and PCA #1 continued to provide patient care; patients were not protected from further abuse/potential abuse.

On 05/02/16 at approximately 2:35 AM, Security Guard #8 witnessed PCA #1 hit Patient #1 in the face, kick Patient #1 in the ribs, and drag the patient across the floor. However, Security Guard #8 failed to immediately report the abuse of Patient #1, and PCA #1 continued to provide care to Patient #1. Security Guards #1 and #8 failed to report the allegations of abuse until 05/04/16, when they reported the allegations to their security supervisors. However, the Security Supervisors were also a contracted service and did not report the allegations to the facility; no action was taken to protect Patient #1 and other patients of the facility until 05/06/16, when Security staff reported the allegations to the facility's Risk Manager. Even though the facility's investigation revealed the facility was not neglectful in dealing with the abuse allegations once they became aware, the facility failed to identify that two (2) nurses allegedly were present on 04/30/16 when Patient #1 was abused and allegedly failed to report patient abuse. In addition, the facility failed to ensure their policies and procedures were followed when they failed to medically assess Patient #1 for possible injuries after the facility became aware of the allegations of abuse.

It was also determined the facility failed to ensure three (3) of twelve (12) sampled patients (Patient #1, Patient #2, and Patient #3) were free from physical restraints used without a physician's order. Interviews and review of facility documentation revealed Patient #1, Patient #2, and Patient #3 were physically restrained by Security Guards and facility staff. On 04/29/16, a Registered Nurse (RN) witnessed two (2) Security Guards "physically restrain" Patient #3 and dress the patient in a hospital gown; however, the "physical restraint" was not documented in the medical record and an order for the physical restraint was not obtained. On 04/30/16 and 05/01/16, staff physically restrained Patient #1 and the incident was not documented in the medical record and an order for the physical restraint was not obtained. On 05/01/16, an RN witnessed a Security Guard physically restrain Patient #2 after an altercation with another patient. Although the incidents were witnessed by facility staff, the facility failed to document the physical restraints and obtain a physician's order for the restraints. Refer to A0145 and A0161.

Based on observation, interviews, record review, and review of the facility's policies and Security documentation, it was determined the facility failed to ensure one (1) of twelve (12) sampled patients (Patient #1) was free from abuse.

The facility failed to ensure Security staff (a contracted service) was trained on the facility's abuse reporting policy. As a result, two (2) Security Guards failed to report abuse allegations to the facility until four (4) and six (6) days after they observed abusive incidents. Patient #1 was admitted to the Behavioral Health Center on 04/26/16 on an involuntary 72-hour hold for delusional behavior. Staff interviews and nursing assessments revealed the patient was irritable, delusional, and in an agitated state. On 04/30/16 at approximately 8:40 PM, Security Guard #1 witnessed Patient Care Assistant (PCA) #1 slap Patient #1 while PCA #1 and Security Guard #2 were holding the patient for the administration of an injectable medication by Licensed Practical Nurse (LPN) #1. Security Guard #1 failed to immediately report the abuse and PCA #1 continued to provide care to the patient and other patients of the facility.

On 05/02/16, Security Guard #8 witnessed PCA #1 hit Patient #1 in the face. Security Guard #8 witnessed PCA #1 kick the patient in "the ribs," and drag the patient across the floor. However, Security Guard #8 failed to immediately report the abuse.

On 05/04/16, Security Guards #1 and #8 reported the patient abuse to their security supervisors (a contracted service for the facility); however, the abuse was not reported to the facility and action was not taken to protect patients until 05/06/16.

Further, even though the facility's investigation revealed the facility was not neglectful in dealing with the abuse allegations once they became aware, the facility failed to identify that two (2) nurses allegedly were present on 04/30/16 when Patient #1 was abused and allegedly failed to report patient abuse. In addition, the facility failed to ensure their policies and procedures were followed when they failed to assess Patient #1 for possible injuries after the facility became aware of the allegations of abuse as of 05/18/16.

The findings include:

Review of the facility's policy, titled "Suspected Abuse, Neglect, Exploitation of Patients, and Reporting," approved March 2016, revealed the purpose of the policy was to ensure all patients were free of all types of abuse and neglect from staff, volunteers, other patients, and visitors. Furthermore, any person who knows or has reasonable cause to believe abuse and neglect of a child or adult exists shall immediately report the incident. Staff discovering the incident shall immediately ensure first aid is provided and medical services are contacted. If a staff member is identified for an act of abuse, the employee will be placed in a non-patient care area or placed on leave.

Further review of the policy revealed allegations of abuse and neglect that were reported to have occurred while the patient was under care of the facility were considered unusual incidents and the policy for reports of unusual incidents was to be followed. As a condition of employment, any person that has reasonable cause to suspect that any patient has suffered abuse or neglect shall immediately report the incident to their supervisor or the House Supervisor. Upon receipt of the report, the facility should report to the appropriate state agencies. The facility's policy defined abuse as the willful infliction, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This included staff neglect or indifference to infliction of injury.

Review of the facility's policy titled "Patient Rights and Responsibilities," adopted 04/27/11, revealed the patient has the right to be free from verbal or physical abuse, negligence, or harassment while hospitalized.

Review of the facility's policy titled "Reporting and Investigating of Unusual Incidents," approved March 2016, revealed it was the facility's responsibility to have a process in place to report, investigate, and manage incidents related to the protection of the patients.

Review of the staffing services contract, dated 07/01/11, between the Security Company (agency) and the facility (client) revealed the client would be responsible for conducting site-specific training required for the employee to perform the job safely and effectively. However, interview on 05/09/16 at 4:00 PM with the Corporate Director of Security revealed Security Guards were trained on the Security Company's "Speak Out" policy regarding abuse. He stated the policy required the security guards to report incidents of abuse to the Security Company's supervisors which did not train security guards to report allegations of abuse immediately to the facility or local state agencies.

Review of the facility's Final Expanded Investigative Report, dated 05/12/16, revealed Security Guard #1 and Security Guard #8 reported they witnessed PCA #1 abuse Patient #1 on two (2) separate occasions. Security Guard #1 reported PCA #1 slapped Patient #1 while staff was attempting to administer an "as needed" medication on 04/30/16. Security Guard #1 also stated on an unknown date she observed PCA #1 "slap" Patient #1 while the patient was lying on the floor. The report further revealed Security Guard #8 reported Patient #1 was "kicked in the ribs" and pulled across the patient's room by PCA #1.

Further review of the facility's Investigative Report revealed there was inconclusive evidence that the allegation on 04/30/16 occurred. However, according to the report of the allegation on 05/03/16 (interviews and review of security logs revealed the date was 05/02/16), "more likely than not, the incident occurred as alleged." Continued review revealed the Security Guards were neglectful when they failed to report the incidents of alleged abuse. The facility's investigation stated they took the appropriate steps to ensure the safety of the patient; however, there was no documented evidence the facility assessed the resident for injury or suspended the two (2) nurses who allegedly had knowledge of the abuse but failed to report and protect patients.

Review of the medical record for Patient #1 revealed the facility admitted the patient on 04/26/16, with diagnoses that included Unspecified Psychotic Disorder, Polysubstance Use, and Urinary Tract Infection (UTI).

Observation of Patient #1 on 05/18/16 at 11:10 AM revealed the patient was sitting in the facility group room with a PCA and a Security Guard. The patient did not appear to have visible injuries. Patient #1 was not interviewed, as he/she became agitated when he/she saw the surveyor.

Review of Patient #1's Progress Note/Nursing Reassessment, dated 05/06/16, revealed there was no documented evidence that Patient #1's Registered Nurse (RN) had been notified of the allegations of abuse and no evidence an assessment was conducted to rule out possible injuries related to the allegations of abuse.

Interview on 05/10/16 at 10:40 AM and 3:00 PM with Security Guard #1 revealed she was "roaming" on 04/30/16, time unknown, and observed PCA #1 cursing Patient #1. The interview further revealed she then observed Security Guard #2 and PCA #1 "hold down" Patient #1 while two (2) nurses (names unknown) administered an injection to Patient #1. Continued interview revealed she observed PCA #1, while holding Patient #1's shoulder for the injection, "slap" the patient in the face. She stated she heard the two (2) nurses talking about "the slap" at the nurses' station after the incident. In addition, Security Guard #1 stated she witnessed PCA #1 hit Patient #1 on the head on 05/02/16 while Security Guard #8 was sitting with the patient. Security Guard #1 stated she reported the incidents to Security Guard #3 and Security Guard #11 on 05/04/16. The interview further revealed Security Guard #1 was unsure to whom to report the allegations of abuse and she was unaware that she should have intervened, protected the patient from staff, and reported the abuse immediately.

Interview on 05/10/16 at 11:40 AM with Security Guard #8 revealed on 05/02/16 at an unknown time, PCA #1 "got mad" at Patient #1. While the patient was lying on the floor, PCA #1 hit the patient in the face two to three times. Security Guard #8 stated Security Guard #1 was "roaming" (making walking rounds of the facility) at the time of the incident and witnessed the incident. Security Guard #8 stated Patient #1 went into the bathroom and was attempting to drink from the toilet and PCA #1 went into the bathroom and kicked the patient in the ribs. Security Guard #8 stated he told PCA #1 to stop. He stated he reported the incident to his supervisor the next time he saw his supervisor which was on 05/04/16. Continued interview with Security Guard #8 revealed that he was unaware that he was supposed to report the allegations of abuse immediately and was not aware that allegations should be reported to the local state agencies.

Interview on 05/10/16 at 11:50 AM with PCA #1 revealed he sat with Patient #1 every time he worked. PCA #1 stated at no time did he hit, slap, kick, curse, or drag Patient #1 across the floor. Continued interview with PCA #1 revealed that he had worked in the facility after 04/30/16, but he was unaware of how many days.

Review of Patient #1's Patient Monitoring/Daily Patient Care Summary revealed PCA #1 worked with Patient #1 on 04/30/16, 05/01/16, 05/02/16, 05/03/16, 05/05/16, and 05/06/16.

Interview on 05/11/16 at 1:15 PM with Security Guard #4 (on-site Director of Security) revealed Security Guard #11 and Security Guard #3 reported to him on 05/05/16, the allegations of abuse that Security Guard #1 and Security Guard #8 had reported to them. Security Guard #4 stated he informed his supervisor on 05/05/16 of the allegations. He stated he had never been trained to report allegations of abuse to any facility staff members or to the state agencies.

Interview on 05/09/16 at 4:00 PM with the Corporate Director of Security revealed Security Guards at the facility were employees of the Security Company and contracted to provide security services to the facility. The interview further revealed Security Guards were supposed to intervene when abuse was witnessed and report the allegations to their supervisor. He stated his agency's policy was to report the allegation of abuse to the on-site Supervisor and the on-site Supervisor would report to the Corporate Office. The Corporate Director of Security revealed the Security Guard's primary role was to provide safety and security to the patients and staff of the facility. Further interview with the Corporate Director of Security revealed that to his knowledge the Security Guards were not trained on the facility's policy regarding abuse/neglect and reporting.

Interview on 05/09/16 at 3:20 PM with the Risk Manager of Behavioral Health revealed Security Guard #4 reported to her the allegations of abuse involving Patient #1 and PCA #1 on 05/06/16. She stated she immediately began an internal investigation of the allegations and removed PCA #1, Security Guard #1, and Security Guard #8 from any direct patient contact. Continued interview with the Risk Manager revealed that she became aware the Security Guards had not been trained on the facility's policy regarding abuse/neglect and reporting after she began investigating this incident.

Interview on 05/09/16 at 2:20 PM and on 05/18/16 at 11:00 AM with the Director of Nursing (DON) of the Behavioral Health Center revealed the facility, through their investigation, did not identify that two (2) nurses who worked on 04/30/16 and were mentioned in Security Guard #1's statement possibly did not report alleged abuse. Even though the facility's policy states that as a condition of employment staff who suspects abuse "shall immediately report" abuse allegations, the nurses were not removed from direct patient contact until 05/09/16. In addition, the interview further revealed Patient #1 did not receive a medical assessment after the allegations of abuse were made to rule out any injuries and she gave no explanation why the patient was not assessed for injuries. The DON was unaware Security Guards were not trained on the facility's abuse/neglect reporting policies.

Based on interviews, record review, and review of the facility's restraint policy, it was determined the facility failed to ensure three (3) of twelve (12) sampled patients (Patient #1, Patient #2, and Patient #3) were free from physical restraints used without a physician's order. Interviews and review of facility's documentation revealed Patient #1, Patient #2, and Patient #3 were physically restrained by Security Guards and facility staff. Although the incidents were witnessed by facility staff the facility failed to document the physical restraints and obtain a physician's order.

On 04/30/16 and 05/01/16, staff physically restrained Patient #1 and the incident was not documented in the medical record and an order for the physical restraint was not obtained.

On 04/29/16, a Registered Nurse (RN) witnessed two (2) Security Guards physically restrain Patient #3 and dress the patient in a hospital gown; however, the "physical restraint" was not documented in the medical record and an order for the physical restraint was not obtained. On 05/01/16, an RN witnessed a Security Guard physically restrain Patient #2 after an altercation with another patient.

The findings include:

Review of the policy titled "Seclusion and/or Restraint-Behavioral," approved February 2016, revealed a physical restraint was defined as any manual method, physical or mechanical, material or equipment, that immobilizes or reduces the ability of the patient to move his/her arms, legs, body, or head freely. Manually holding a patient is considered a restraint regardless of duration. The policy further revealed a verbal or telephone order from the physician or other independent licensed practitioner to order seclusion or restraint must be obtained within fifteen (15) minutes of initiating either procedure.

Review of the "Nonviolent Crisis Intervention (NVCI)" workbook utilized by the facility's Security Guards, dated 2005 and revised in 2014, revealed the program was to provide the best care, welfare, safety, and security for the patients in the facility's care even in violent moments. Continued review of the workbook revealed NVCI emphasized physical restraint was recommended when all other less restrictive methods had been exhausted. Further, any physical intervention was potentially dangerous and should be looked at as an emergency response procedure. Continued review of the NVCI workbook revealed the physical restraints are the "Team Control Position" which was used to manage patients who have become dangerous to themselves or others. This approach utilizes two (2) staff members to hold the patient in an upright/standing position as another staff member continually assesses the safety of all individuals involved in the restraint. The second physical restraint taught was the transport position. This approach is where two (2) staff members assist a patient who is not struggling from one area to another. Review of the NVCI workbook revealed Security staff was not trained to hold a patient in a lying position.

1. Review of the medical record for Patient #1 revealed the facility admitted the patient on 04/26/16 with diagnoses that included Unspecified Psychotic Disorder, Polysubstance Use, and Urinary Tract Infection (UTI).

Review of Patient #1's Progress Note/Reassessment form, dated 04/30/16 at 9:30 PM, revealed the patient was agitated and aggressive and injectable medications were administered.

Review of the Security Guard Service Request Sheets dated 04/30/16 for Security Guard #2 revealed at 9:15 PM, he was called to Patient #1's room and the patient was physically restrained while "as needed" medications were administered. However, there is no physical restraint taught in the NVCI workbook that would allow the Security Guards to physically restrain a patient on the bed while having injectable mediation administered.

Interview on 05/10/16 at 11:50 AM with Patient Care Assistant (PCA) #1 revealed on 04/30/16 PCA #1 and Security Guard #2 "held" Patient #1 while Nursing staff (he thought Licensed Practical Nurse #1) administered an injectable as needed medication.

Interview on 05/10/16 at 10:40 AM and 3:00 PM with Security Guard #1 revealed she stated she was "roaming" on 04/30/16 (time unknown) and observed Security Guard #2 and PCA #1 "hold down" Patient #1 while Nursing staff administered an injection to Patient #1.

Interview on 05/10/16 at 2:40 PM with Security Guard #2 revealed Security Guard #2 and PCA #1 "restrained" Patient #1 in the patient's room while the Nursing staff administered an injectable medication.

However, further review of Patient #1's medical record revealed no documentation that the patient was physically restrained. Review of the Physician's Orders, dated 04/30/16, revealed no documented evidence an order was obtained for a physical restraint.

Review of Patient #1's multiple disciplinary Progress Notes, dated 05/01/16 from 2:00 AM through 4:00 AM, revealed the patient was awake, cursing staff, was very hard to redirect, very psychotic, and appeared to be responding to psychosis. Further review of the Notes revealed no documented evidence Patient #1 was physically restrained and review of the Physician's Orders, dated 05/01/16, revealed no documented evidence of an order to restrain the patient. However, review of the Security Guard Service Request Sheets for Security Guard #10, dated 05/01/16 at 2:00 AM to 4:00 AM, revealed the guard was sitting one on one with Patient #1 and NVCI (physical restraint) was used multiple times.

Interview on 05/17/16 at 2:15 PM with Security Guard #10 revealed he sat with Patient #1 on 05/01/16 and any time he documented that he used NVCI on a patient it meant he had to physically restrain a patient.

Interview on 05/16/16 at 2:55 PM with RN #1 revealed she was working on 05/01/16 and was responsible for Patient #1's care; however, she was not in the patient's room during that time and stated she was unaware the Security Guard physically restrained Patient #1 multiple times. RN #1 stated she documented the information that other Nursing staff reported to her about Patient #1.

2. Medical record review revealed Patient #3 was admitted to the Behavioral Health evaluation area in the Emergency Department on 04/29/16 on an involuntary 72-hour hold due to psychotic behavior and possible drug use. Patient #3 was later diagnosed with Mood Disorder on the Behavioral Health Unit. Review of Patient #3's Integrated Assessment Initial Evaluation, dated 04/29/16 at 10:00 PM, revealed Security Guard #13 searched the patient's belongings. There was no documentation that Security Guard #5 and Security Guard #13 physically restrained Patient #3.

However, review of the Security Guard Service Request Sheets dated 04/29/16 revealed Security Guard #5 documented "assist with one (1) patient in behavioral health evaluation, patient acting out, Nonviolent Crisis Intervention (NVCI) used and dressed patient in hospital attire." Review of the Security Guard Service Request Sheets revealed Security Guard #13 documented "assist with helping change patient clothes into gown, NVCI used."

Review of the Physician's Orders, dated 04/29/16, revealed no documented evidence an order was obtained for the restraint. In addition, there was no documentation found that Security Guard #5 and Security Guard #13 dressed Patient #3 in a hospital gown.

Interview on 05/11/16 at 1:30 PM with Security Guard #5 revealed any time the guard "laid hands" on a patient, they documented it on the Service Request Sheets. The interview further revealed on 04/29/16, he and Security Guard #13 had to physically restrain Patient #3 and dress the patient in a hospital gown.

Interview on 05/16/16 at 4:15 PM, with RN #5 revealed the RN was working the evaluation area on 04/29/16 and the Security Guards had to help her dress a "high risk" patient. RN #5 stated Security Guards had to help her at times because there was not enough staff. Further, RN #5 stated Patient #3 was very aggressive and could not be changed without the Security Guards putting their "hands on the patient." RN #5 stated the Security Guards did limit Patient #3's movement and she did not think at the time they were "restraining the patient." However, now that she thought about it the guards did limit the patient's movement and had to "fight" Patient #3 "some" to get the hospital gown on the patient. RN #4 stated she did not obtain a physician's order to restrain the patient. However, there was no physical restraint taught in the NVCI workbook where Security Guards would physically restrain a patient to dress them.

3. Review of Patient #2's medical record revealed the facility admitted the patient on 04/02/16 with a diagnosis of Unspecified Psychosis.

Review of Patient #2's multiple disciplinary Progress Notes, dated 05/01/16 at 6:00 PM, documented by RN #7 revealed Patient #2 struck another patient, a "Code Green" was called, and the patient was escorted to his/her room per staff.

Review of the Security Guard Service Request Form for Security Guard #10, dated 05/01/16, revealed at 5:45 PM to 6:00 PM the Security Guard was called to assist with Patient #2 and NVCI was used.

Interview on 05/17/16 at 2:15 PM with Security Guard #10 revealed the guard responded to a "Code Green" and observed Patient #2 fighting with another patient. The interview further revealed Security Guard #10 had to place his hands on Patient #2 and "pull [Patient #2] back" off of the other patient. The incident was witnessed by Nursing staff.

Interview on 05/17/16 at 1:25 PM with RN #7 revealed on 05/01/16, Patient #2 was fighting with another patient and the Security Guard "grabbed" Patient #2 and physically restrained the patient. RN #7 stated he did not obtain an order for a physical restraint because he was unaware an order was needed for that type of physical restraint.

Interview on 05/09/16 at 2:20 PM and 05/18/16 at 11:00 AM with the Director of Nursing (DON) of the Behavioral Health Center revealed staff had been trained on physical restraints and the need to obtain an order for a physical restraint. Continued interview revealed the DON stated Nursing staff felt the utilization of the types of physical restraints used by the Security Guards did not warrant Nursing staff obtaining an order for the physical restraint.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure a Registered Nurse (RN) supervised and/or evaluated the nursing care for one (1) of twelve (12) sampled patients (Patient #1). The facility failed to ensure Patient #1's level of supervision was maintained as ordered, while awake, resulting in a fall with injuries at approximately 4:30 AM on 05/01/16.

In addition, on 04/30/16 and 05/02/16, the facility failed to protect Patient #1 from abuse while the patient was on one to one supervision. Interviews with Security Guards revealed Patient Care Assistant (PCA) #1 hit, slapped, and/or kicked Patient #1 on 04/30/16 and 05/02/16; however, staff failed to assess Patient #1 for injuries. Refer to A0395.

Based on interview, record review, documentation and review of facility policy it was determined the facility failed to ensure a Registered Nurse (RN) supervised and/or evaluated the nursing care for one (1) of twelve (12) sampled patients (Patient #1).

The facility failed to ensure Patient #1's level of supervision was provided as ordered, while awake, resulting in a fall with injuries at approximately 4:30 AM on 05/01/16. In addition, on 04/30/16 and 05/02/16, the facility failed to protect Patient #1 from abuse while the patient was on one to one supervision. Interviews with facility Security Guards revealed Patient Care Assistant (PCA) #1 hit, slapped, and/or kicked Patient #1 on 04/30/16 and 05/02/16. The facility failed to ensure staff assessed the patient for injuries.

The findings include:

Review of the facility's policy titled "Suspected Abuse, Neglect, Exploitation of Patients and Reporting," approved March 2016, revealed the purpose of the policy was to ensure all patients are free of all types of abuse and neglect from staff, volunteers, other patients, and visitors. The policy further stated staff discovering the incident should immediately ensure first aid was provided and medical services were contacted.

Review of the policy titled "Documentation of Medication Effectiveness," reviewed February 2015, revealed the RN or Licensed Practical Nurse (LPN) who administered medication should document the indication for and the response to as needed (PRN) medications.

Review of the medical record for Patient #1 revealed the facility admitted the patient on 04/26/16 with diagnoses that included Unspecified Psychotic Disorder, Polysubstance Use, and Urinary Tract Infection (UTI).

1. Review of the facility's Final Expanded Investigative Report, dated 05/12/16, revealed Security Guard #1 and Security Guard #8 reported they witnessed PCA #1 abuse Patient #1 on two (2) separate occasions. Security Guard #1 reported PCA #1 slapped Patient #1 while staff was attempting to administer "as needed" medication. Security Guard #1 also stated on an unknown date she observed PCA #1 "slap" Patient #1 while the patient was lying on the floor. The report further revealed Security Guard #8 reported Patient #1 was "kicked in the ribs" and pulled across the patient's room by PCA #1.

Interview on 05/10/16 at 10:40 AM and 3:00 PM, with Security Guard #1 revealed she was "roaming" on 04/30/16, time unknown, and observed PCA #1 cursing Patient #1. The interview further revealed she then observed Security Guard #2 and PCA #1 "hold down" Patient #1 while two (2) nurses (names unknown) administered an injection to Patient #1.

Continued interview revealed she observed PCA #1 "slap" the patient in the face while the PCA was holding the patient's shoulders for the injection. In addition, Security Guard #1 stated she witnessed PCA #1 hit Patient #1 on the head on 05/02/16 while Security Guard #8 was sitting with the patient.

Interview on 05/10/16 at 11:40 AM with Security Guard #8 revealed on 05/02/16, at an unknown time, PCA #1 "got mad" at Patient #1 and while the patient was lying on the floor, PCA #1 hit the patient in the face two to three times. Security Guard #8 stated Security #1 was roaming at the time of the incident and also witnessed the incident. Security Guard #8 stated Patient #1 then went into the bathroom and was attempting to drink from the toilet when PCA #1 went into the bathroom and kicked the patient in the ribs. Security Guard #8 stated he told PCA #1 to stop.

Review of Patient #1's Progress Note/Nursing Reassessment, dated 05/02/16 at 9:45 PM through 05/03/16 at 3:00 AM, documented by RN #3 revealed the patient was agitated, kicking and fighting with staff, unable to be redirected, and injectable medications were given.

Review of Patient #1's Progress Note/Nursing Reassessment, dated 05/06/16, revealed there was no documented evidence that Patient #1's Registered Nurse (RN) had been notified of allegations that the patient was abused and no evidence an assessment was conducted to rule out possible injuries related to the allegations of abuse.

Interviews on 05/10/16 at 1:15 PM, with Licensed Practical Nurse (LPN) #1 and on 05/17/16 at 2:55 PM with RN #1 revealed they were working on the night of 04/30/16 and RN #1 was assigned as Patient #1's primary nurse. However, even though RN #1 documented in Patient #1's medical record regarding the incident, she was not in the room at the time of the alleged abuse. LPN #1 stated she administered medication when the alleged abuse occurred; however, she denied witnessing abuse and neither assessed the patient for injuries after the patient was abused.

Interview with the DON on 05/18/16 at 10:00 AM revealed that she had never formally informed the nursing staff of the allegation that Patient #1 was abused and had never had them request a medical consultation to assess the patient for injuries; however, it was the policy of the facility for the nursing staff to assess injuries after and inform medical staff when an allegation of abuse was made.

2. Review of the policy titled "Supervision of Patients," revised June 2014, revealed the patient should be placed on the appropriate level of supervision to assure the safety and well-being of the patient and others. The policy further revealed the level of supervision would determine the frequency and proximity of the patient observation.

Review of the policy titled "One to One Intervention," revised January 2013, revealed Security Guards did not provide one to one observation as outlined in the policy. One to one supervision was accomplished by face-to-face monitoring with staff close enough to intervene quickly at all times. The policy further revealed PCAs should document every fifteen (15) minutes for patients one to one and should document changes in mental status, physical status, and behavior and report the changes to the patient's assigned nurse. Continued review of the policy revealed PCAs should provide any "hands on" patient care.

Interviews on 05/09/16 with the Director of Nursing (DON) at 2:20 PM and Risk Manager for Behavioral Health at 3:00 PM, revealed staff providing one to one supervision should be within "arm's reach" of the patient at all times while the patient was awake.

Review of Patient #1's Physician Orders, dated 04/29/16 at 9:49 PM revealed an order for the patient to be one on one with staff with a guard on the unit at all times.

Review of a Patient Safety Event Report, dated 05/01/16 at 4:30 AM, revealed Patient #1 had a fall. Continued review of the report revealed Patient #1's level of supervision was one to one with a PCA in the room. Further review of the report revealed the patient sustained a laceration to the left eye and an abrasion to the left side of the head.

Review of photographs of Patient #1 taken on 05/01/16 at 9:05 AM, revealed the patient had a two (2) centimeter laceration over the left eye with bruising around the eye area. Patient #1 also had a reddish purple discolored area approximately four (4) centimeters long behind the right ear.

Review of Patient #1's Emergency Room record, dated 05/01/16 at 6:11 AM, revealed the patient was evaluated in the Emergency Room after a fall on the Behavioral Health Unit for a single laceration over the left eyebrow, a soft contusion injury to the face, and complaints of a headache. Further review of the Emergency Room record revealed the patient was diagnosed with a contusion of the face, injury of forehead, history of falls, post-traumatic headache, and facial laceration.

Interview on 05/16/16 at 5:00 PM with PCA #2 revealed he was not aware if Patient #1's supervision at the time of the fall was supposed to be within arm's reach or within line of sight. PCA #2 stated while he was sitting in the doorway with the Security Guard, the patient fell, and his/her eye hit the window seal. PCA #2 stated he was not within arm's reach of the patient when the fall occurred. When the PCA went to assist the patient, the patient fell backward and hit his/her head on the dresser. The interview further revealed PCA #2 saw blood on the floor, picked the patient up off the floor, and assisted the patient back to bed prior to notifying the nurse of the patient's fall.

Interview on 05/17/16 at 2:55 PM with RN #1 revealed the RN was assigned to provide care to Patient #1 the night the patient fell. RN #1 stated the patient's level of supervision required staff to be one on one within arm's reach of the patient. The interview further revealed RN #1 did not witness the fall and the patient had been placed back in bed by the PCA prior to the nurse being able to assess the patient after the fall.

Interview on 05/09/16 at 2:20 PM and on 05/18/16 at 11:00 AM with the Director of Nursing (DON) of the Behavioral Health Center revealed Patient #1 did not receive a medical assessment after the allegations of abuse were made to rule out any injuries. She had no explanation why the patient was not assessed for injuries. The interview further revealed the Behavioral Health Units used a team nursing approach with a primary nurse and a medication nurse. However, the Nursing staff that administered a medication should document the reasons a medication was administered. Continued interview revealed the primary nurse should also supervise all care provided to the patients.

Based on interview, record review, and review of Patient #4's History and Physical, it was determined the facility failed to ensure Patient #4's medical record was accurately written and maintained.

The findings include:

Interview with the Risk Manager on 05/09/16 at 3:00 PM revealed the facility had no policy or procedure in place related to ensuring patients' medical records including History and Physicals were accurately maintained.

Review of Patient #4's medical record revealed the facility admitted the patient on 02/29/16, with diagnoses including Mood Disorder, Dementia, and Hypothyroidism. Review of Patient #4's History and Physical dated 04/19/16, revealed the facility had documented that the patient's medical history included documentation that the patient had been previously discharged from a "psychiatric center" earlier in the day on 04/19/16, and returned to the patient's residence in a long term care facility. The History and Physical stated the patient was exhibiting "psychosis," and was subsequently admitted to the facility for further evaluation, treatment, and management. Patient #4's "Social History" detailed on the History and Physical stated the patient was a "long term resident at another facility" and in recent months had several admissions to "psychiatric facilities."

Interview on 05/09/16 at 11:00 AM with Patient #4's Guardian revealed the information contained in the History and Physical dated 04/19/16 was inaccurate. The Guardian stated that Patient #4 had been admitted from home, never been in a long term care facility, never had any psychiatric diagnoses, nor ever been in a psychiatric facility, until the patient's current admission to the facility for management of behavioral episodes related to increasing dementia. The Guardian stated Patient #4 had been admitted to the facility for treatment and to provide assistance in finding placement for the patient in a facility that could meet the patient's needs. However, the Guardian stated she had spoken with facility staff on several occasions about finding placement for the patient, but was repeatedly told that the facility "was having trouble" finding placement for Patient #4, and had been unable to find a facility that would admit the patient. The Guardian stated she requested a copy of Patient #4's medical record and when provided the record, discovered the Patient's History and Physical was incorrect and was most likely the cause of the facility being unable to find placement for Patient #4 in a long term care facility. The interview further revealed the Guardian notified the facility of the incorrect information in the History and Physical on 04/29/16, and requested the History and Physical be corrected. However, the Guardian stated as of 05/09/16, she had not received the corrected medical record for Patient #4.

Interview on 05/16/16 at 3:49 PM, with the Practitioner who had made the incorrect documentation in Patient #4's medical record revealed he had "mixed up" Patient #4's medical history with his/her roommate's medical history. The interview further revealed that although the Practitioner and administrative staff had been notified of the error during the week of 05/09/16 (exact date unknown), Resident #4's medical record had not been corrected as of 05/16/16.

Interview on 05/16/16 at 2:47 PM, with Physician #1 revealed he authenticated the History and Physical dictated by the Practitioner for Patient #4 on 04/19/16. However, the Physician stated that his "authentication" of the documentation was for timeframe standards and to ensure there were no "blanks" in the History and Physical, and was not to ensure the "content" of the documentation was correct.

Interview on 05/09/16 at 3:20 PM, with the Risk Manager for the facility revealed she was unaware of any mechanism in place at the facility to ensure documentation made in a patient's medical record was accurate, including patient History and Physicals.