HospitalInspections.org

Based on observation, interview, record review, policy review and video review, the hospital failed to provide care in a safe setting when they failed to:
- Ensure staff members were immediately removed from patient care after allegations of staff-to-patient physical and verbal abuse for two patients (#17 and #28) of three allegations investigated. (A-0144)
- Ensure that proper assessments and safety interventions were implemented for one patient (#18) of one altercation investigated. (A-0144)
- Ensure immediate and thorough investigations were performed, along with education provided to staff, after staff-to-patient abuse allegations and patient-to-patient altercations. (A-0145)

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient's Rights.

Based on observation, interview, record review, policy review and video review the hospital failed to provide care in a safe setting when they failed to immediately remove two staff members from patient care after allegations of physical and verbal abuse were reported for two discharged patients (#17 and #28) of three abuse allegations reviewed and failed to implement safety interventions and properly assess one discharged patient (#18) after two separate assaults. These failed practices placed all patients admitted to the hospital at increased risk for their safety.

Findings Included:

Review of the hospital's policy titled, "Abuse, Neglect, Exploitation, Unethical or Unprofessional Conduct," revised 05/2024, showed physical abuse was defined as an employee purposefully beating, striking, wounding or injuring any consumer. In any manner whatsoever, an employee mistreating or maltreating a consumer in a brutal or inhumane manner. An employee handling a consumer with any more force than is reasonable for proper control, treatment or management.
Verbal abuse was defined as an employee making a threat of physical violence to a consumer when such threats are made directly to a consumer or about a consumer in the presence of a consumer.

Review of the hospital's policy titled, "Patient Complaint and Grievance Process," revised 04/2024, showed a grievance was defined as a written or verbal complaint by the patient or the patient's representative regarding patient's care, abuse or neglect, hospital compliance with regulations and or billing complaints. Written complaints concerning the hospital's care provided, Medicare Condition of Participation (CoP) and abuse and neglect were reviewed and responded to through the formal grievance process.

Review of the hospital's policy titled, "Incident Reporting," revised 07/10/2024 showed:
- An incident was defined as any happening that is not consistent with the normal or usual operations of the hospital and/or department.
- Only the employee directly involved in the occurrence or incident should initiate and document on the Incident Report Form. This should be done immediately after an incident occurs or as soon as one becomes of aware of such an occurrence.
- The description of the incident is to be documented in the medical record. Include a detailed description of the incident, date, time, location, individuals involved and actions taken.
- The documentation should never include the names of patients or staff involved.
- Never document in the medical record that an incident report was completed.
- An incident report shall be completed for all patient incidents including, but not limited to, abuse, neglect, exploitation, accidents and injuries to patients, illegal or violent behavior, elopements or elopement attempts.
- Staff will inform the House Supervisor of all critical incidents as soon as possible. Critical incidents are any incident that causes, or has the possibility of causing, serious injury such as acts of suspected abuse, neglect or exploitation.
- The House Supervisor will notify the Administrator-on-Call (AOC), Director of Nursing (DON) and the Quality/Risk Director as soon as possible of all critical incidents.
- Patient Safety Work Products (PSWP) are information protected by the privilege and confidentiality protections of the Patient Safety Act and Patient Safety Rule. Incident reports and documents produced as part of the incident investigation are considered PSWP and are therefore privileged. Incident reports should not be shared with any outside agency without the appropriate approvals.

Review of the hospital's undated document titled, "Decision Matrix," showed:
- Steps for the AOC to take after being notified of an abuse or neglect allegation.
- The AOC would contact the Abuse/Neglect hotline in a timely manner.
- The AOC would notify the Department of Social Services Children's Division.
- The Chief Executive Officer (CEO), Physician, DON and Quality/Risk Director would be notified.
- If the alleged perpetrator is a staff member immediately notify the Quality/Risk Director and Human Resources (HR) and send the staff home until the investigation is completed.

Review of the hospital's undated, untitled, documented showed:
- An incident involving Staff P, Mental Health Technician (MHT), and Patient #17 on 08/18/24.
- An Incident Statement Form from Patient #17, written by Staff J, Registered Nurse (RN), alleged that Staff P physically assaulted her. The patient admitted that she had been bothering Staff P throughout his shift and that she may have "made him mad because I am annoying." She reported that Staff P grabbed her shirt, threw her against the corner of a door and said, "If you don't leave me alone, I will fucking kill you." She hadn't reported it earlier in the shift because she didn't think that anyone would believe her.
- There was no documentation of when Staff J, RN, notified the AOC of the allegations made against Staff P.
- An Incident Statement Form from Patient #30 alleged that she witnessed Patient #17 and Staff P "playing around and that staff around them knew that they were playing around" then she "looked over" and Staff P pushed Patient #17 into the corner. Patient #17 told her afterward that Staff P said, "if she did it again, he would kill her."
- On 08/19/24, Staff A, Quality/Risk Director, reviewed video footage from 08/18/24 between 6:05:49 PM and 6:06:30 PM. Patient #17 and Staff P were seen in the hallway in a physical confrontation. Staff P was seen "placing his hands on Patient #17, grabbing her shirt and pulling her down the hallway to an alcove in the wall out of sight of the camera."
- Staff P continued to work the remainder of his shift on 08/18/24.
- Staff P returned to work on 08/19/24 and worked from 6:45 AM until 8:30 AM.

Although requested, the hospital failed to provide a copy of the video camera footage of the incident citing that they only keep recorded video for 30 days.

Although requested, the hospital failed to provide any incident reports or investigative documentation, citing it was a PSWP.

Verbal Review of the PSWP with Staff A, Quality/Risk Director, on 10/01/24 at 4:09 PM, showed:
- Staff J, RN, filled out an incident report but that she did not document the time that she notified the AOC.
- Staff A was determined to be the AOC on-call for 08/18/24.
- Staff P was not sent home from his shift on 08/18/24 "because his shift ended at 7:00 PM and by the time the AOC was notified he had already left for the day."
- She wasn't sure if Staff P "was on the schedule and did not notify him not to come in the next day".
- The only education provided to staff after this incident was "not to take patients into alcoves outside of camera view."

Review of the document titled, "Employee Timesheet," dated 08/18/24 through 08/31/24, showed Staff P, MHT, worked on 08/19/24 from 6:45 AM until 8:30 AM.

During an interview on 10/02/24 at 10:35 AM, Staff J, RN, stated that Patient #17 approached her while she was doing a medication pass and reported that Staff P, MHT, held her up against a door and threatened her and that another patient witnessed the incident. She completed an incident report and notified the AOC. If the patient reports abuse or neglect while the staff member is present, they are to be sent home immediately but by the time she had notified the AOC, Staff P had already left for the day. She was unsure if he was notified to not come in for his next shift.

Review of two hospital documents titled, "Patient Grievance Form," dated 06/15/24, showed:
- Patient #13 did not complete the Patient Grievance Form in its entirety, but did write down the name of Staff O, Agency MHT, and marked "yes" in a box that she, "attempted to process with staff" on 06/15/21 at 3:41 PM.
- Patient #14 documented that Staff O, MHT, went into Patient #28's room and choked him and that she used racial slurs toward patients.
- Staff O continued to work the remainder of her shift, until 11:05 PM, on 06/15/24.
- On 06/17/24, Staff A, Quality/Risk Director reviewed video footage from 06/15/24 between 7:30 PM and 9:00 PM. She documented that Staff O was in view of the camera throughout the time in question and that she was not viewed entering the patient's room or having any physical contact with Patient #28.
- There was no documentation of this incident in Patient #13, Patient #14 or Patient #28's medical record.
- There was no documentation of any staff education after this incident.

During an interview on 10/01/24 at 12:10 PM, Staff B, Patient Advocate, stated that this allegation was not made by the patient himself, but by other patients. If the patient had made the allegation, she would speak with the staff member in question but since the allegation was made by the patient's peers, she just spoke with the patient who denied that the incident occurred. The investigative process for allegations was only for hospital staff, not agency. If the allegation was against an agency staff member, they would just call the agency and say that they won't be using that person anymore.

During an interview on 10/01/24 at 12:50 PM, Staff D, DON, stated that after a staff-to-patient allegation she would "talk to the child that alleged the harm, talk to several of the kids, interview the staff member involved and any other witnesses." Anytime there was a staff allegation that staff member would immediately be removed, until an investigation was completed. The AOC would come in for all allegations in the evenings or on weekends. Staff A, Quality/Risk Director, would be responsible for reviewing any video, informing therapy, immediately removing the staff member from patient care and making all appropriate notifications. The investigative process for agency staff was the same but "it is just easier for me to call the agency and say we don't want them back."

During an interview on 10/01/24 at 12:50 PM, Staff A, Quality/Risk Director, stated that for any staff-to-patient allegation she would pull that staff member off the floor and notify the proper team. If an incident happened during the evening or weekend hours the AOC would be notified and that person would be sent home.

Review of Patient #18's medical record showed:
- She was a 15-year-old-female who was admitted on 09/12/24 and placed on C-Pod.
- On 09/15/24, nursing documentation showed the patient was in an altercation with another peer. No injuries were noted. The patient was moved to D-Pod without incident and had no further issues. There was documentation of a physical assessment.
- On 09/16/24, a Morning Check-In Form showed that the patient requested to talk to the Patient Advocate.
- On 09/16/24 at 10:20 AM, a Psychiatric Progress Note showed "Patient reports high anxiety due to a peer who attacked her yesterday."
- On 09/16/24 at 6:48 PM, nursing documentation showed the patient got into an altercation with two other peers which resulted in her hair being pulled. The patient had a small amount of hair pulled out of her head. She was moved to a D-Pod and had no further issues. There was no documentation of a physical assessment.
- On 09/17/24, nursing documentation showed the patient reported feeling tired and having trouble falling asleep and staying asleep. She was withdrawn and not interacting with her peers. She complained of scalp pain at the area where her hair was pulled out.
- On 09/20/24, nursing documentation showed Patient #18 complained of a "weird pressure in her head behind eyes that does not feel like a headache."

Review of a video recording, without audio, dated 09/15/24, 9:11 AM through 9:32 AM showed:
- Patient #18 was seen leaving the C-Pod dayroom and going into her bedroom.
- Patient #11 was seen entering Patient #18's bedroom with Staff F, Mental Health Technician (MHT), following behind her.
- Patient #11 was seen leaving Patient #18's bedroom.
- Staff U, Registered Nurse (RN), entered Patient #18's bedroom.

Review of a video recording, without audio, dated 09/16/24, 4:30 PM through 4:50 PM showed:
- Patient #18 was sitting in dayroom at a table with Patient #11, Patient # 23, and other unidentified patients. Staff V, MHT, was sitting in day room doorway observing patients in day room and hallway.
- A physical altercation occurred involving Patients #11, #18 and #23 with Staff V attempting to intervene.
- Patient #18 was observed being punched, kicked and having her hair pulled by Patient #11 and Patient #23.
- Staff V, MHT, and Staff W, MHT, were able to remove Patient #11 and Patient #23 after approximately three minutes. Staff E, RN, entered the dayroom after approximately six minutes.
- The video review failed to show that the RN completed a physical assessment of Patient #18.

Review the hospital's investigate documentation and incident statements provided for the altercations on 09/15/24 and 09/16/24 showed:
- After the incident on 09/15/24, Patient #18 was moved to D-Pod only for groups. She returned to C-Pod to sleep. On 09/16/24, she remained on C-Pod and did not return to D-Pod.
- There was no documentation of a physical assessment after either altercation.
- There was no follow-up to Patient #18's complaint of head pain following the physical altercation.

During an interview on 10/02/24 at 11:41 AM, Staff F, MHT, stated that on 9/15/24 he was putting away laundry when he heard "a smack and yelling" so he went into the room and pulled Patient #11 away from Patient #18. He didn't "see anything actually happen other than them pulling on each other." The patient did not complain to him of pain or any head injury.

During an interview on 10/02/24 at 4:11 PM, Staff V, MHT, stated that on 9/16/24 Patient #18 and Patient #23 were arguing back and forth when Patient #23 came across the table and picked up Patient #18 by the hair. He was on the other side of the room, and he was trying to verbally de-escalate then before Patient #23 stood up. As soon as Patient #23 stood up, he stood up, and called on the radio for a staff assist and attempted to step in. Patient #11 then joined in the physical altercation. He did witness Patient #18 get hit in the face. When other staff arrived to assist Patient #23 was removed from the room, and he stayed with Patient #18. The RN came in asked what happened, assessed Patient #18 and moved her to a different pod. He did not recall talking to any leadership after this incident or receiving any education.

During an interview on 10/2/24 at 11:31 AM, Staff E, RN, stated that on 9/15/24 she was called to the unit and Patient #11 and Patient #18 had already been separated. She performed an assessment on both girls and did not find any physical injuries or bruising. She filed the incident report and the daily nursing documentation. She would have documented in the medical record any physical assessment and that there was an altercation. The provider made the determination to move Patient #18 to a different pod program for the day. On 9/16/24, she responded to a staff assist call and when she arrived on the unit Patient #18 was already separated from the other patients in the dayroom. She was told by Staff V, MHT, that Patient #18 was name calling, Patient #23 got upset and began pulling at Patient #18's hair. She spoke with both patients separately but was unaware if anyone else talked to them after the event. Patient #18 did have an area on top of her head that was missing hair. She talked to Patient #18's mother "a couple of times and did notify her of missing hair." She moved Patient #18 to another pod and then called the provider to get an order to move the patient to that pod permanently. It was common to move a patient to a different pod "to program for a day, to give them a break in response to an incident."

During interviews on 10/01/24 at 12:50 PM and 10/03/24 at 11:57 AM, Staff D, DON, stated a nursing physical assessment should be completed after an incident "if the child is willing but most of the time they refuse." She would expect the RN to document the that the child was offered an assessment but refused. Nurses "chart by exception" so only assessment findings not within normal limits need to be documented. She would not expect to see a skin assessment sheet completed after a physical altercation. When parent or physicians were notified, it would not be documented in the chart, but on the incident report form. Interventions after an incident may include moving patients to a different pod, a one-on-one with a staff member, or they might block a room so the patient could have some time alone.

During interviews on 10/01/24 at 12:35 PM, and 10/03/24 at 12:15 PM, Staff C, CEO, stated that an incident report should be completed for any allegation of abuse or neglect and for any altercation. The person who witnessed the incident, or who the incident was reported to, would be responsible for filling out the incident report form. A nurse summary of any event should be documented in the medical record but not documented on the incident form. If a complaint or grievance had an allegation of abuse they would "hotline" it. For patient-to-patient altercations they look at the safety of every patient, which could include discharging a child. For staff-to-patient allegations the DON or Quality/Risk Director should be notified, and the staff member would be immediately suspended, pending an investigation. If the event happened after hours or on the weekend the AOC would be responsible for ensuring the staff member was suspended.

Based on interview, record review and policy review, the hospital failed to appropriately and thoroughly investigate allegations of abuse and neglect related to three patients (#5, #18 and #28). They failed to determine whether abuse had occurred and to provide education to all staff. These failed practices placed all patients admitted to the hospital at increased risk for their safety.

Findings Included:

Review of the hospital's policy titled, "Abuse, Neglect, Exploitation, Unethical or Unprofessional Conduct," revised 05/2024 showed:
- Physical abuse was defined as an employee purposefully beating, striking, wounding or injuring any consumer. In any manner whatsoever, an employee mistreating or maltreating a consumer in a brutal or inhumane manner. An employee handing a consumer with any more force than is reasonable for proper control, treatment or management.
- Verbal abuse was defined as an employee making a threat of physical violence to a consumer when such threats are made directly to a consumer or about a consumer in the presence of a consumer.
- The Grievance Committee would investigate each allegation and provide follow-up reports to the appropriate state health care regulatory agency and/or legal authority.

Review of the hospital's policy titled, "Incident Reporting," revised 07/10/2024 showed:
- An incident was defined as any happening that was not consistent with the normal or usual operations of the hospital and/or department.
- An incident report shall be completed for all patient incidents including, but not limited to, abuse, neglect, exploitation, accidents and injuries to patients, illegal or violent behavior, elopements or elopement attempts.
- Only the employee directly involved in the occurrence or incident should initiate and document on the Incident Report Form. This should be done immediately after an incident occurs or as soon as one becomes of aware of such an occurrence.
- The description of the incident was to be documented in the medical record. Include detailed description of the incident, date, time, location, individuals involved and actions taken.
- The documentation should never include the names of patients or staff involved.
- Never document in the medical record that an incident report was completed.
- Staff will inform the House Supervisor of all critical incidents as soon as possible. Critical incidents were any incident that caused, or had the possibility of causing, serious injury such as acts of suspected abuse, neglect or exploitation.
- The Supervisor or House Supervisor was responsible for make sure all incidents were initially investigated and that appropriate follow-up actions were in place.
- The House Supervisor would notify the Administrator-on-Call (AOC), Director of Nursing (DON) and the Quality/Risk Director as soon as possible of all critical incidents.
- All reports were to be turned into the incident report box for the same day pick up by the Quality/Risk Director or designee.
- The Quality/Risk Director was responsible for ensuring that all follow-up actions were completed and a formal investigation was conducted as indicated.
- Patient Safety Work Products (PSWP) were information protected by the privilege and confidentiality protections of the Patient Safety Act and Patient Safety Rule. Incident reports and documents produced as part of the incident investigation are considered PSWP and are therefore privileged. Incident reports should not be shared with any outside agency without the appropriate approvals.

Review of the hospital's policy titled, "Patient Complaint and Grievance Process," revised 04/2024 showed:
- A grievance was defined as a written or verbal complaint by the patient or the patient's representative regarding patient's care, abuse or neglect, hospital compliance with regulations and or billing complaints.
- The following were considered grievances; all written complaints pertaining to hospital services, including complaints about staff attitude and customer service. Those would be evaluated by the Patient Advocate, if not resolved by hospital leadership, prior to receipt. The Patient Advocate would determine if a complaint resolution fell within the parameters of a complaint or grievance.
- Written complaints concerning the hospital's care provided, Medicare Conditions of Participation (CoP), and abuse and neglect were reviewed and responded to through the formal grievance process as outlined in the procedures.
- The Patient Advocate would conduct Grievance Review and Response as follows; send a written acknowledgment to the patient or the patient's representatives within 72 hours of receipt of the written grievance and or conversation with patient or representative. Date of receipt was considered next business day if the incident/allegation was made on a weekend or holiday. Collaborates with appropriate departments to complete a thorough review. Reviews the grievance responses with Quality/Risk leadership and provide a written response to the patient or their representative within seven business days from the date of receipt.

Review of the hospital's undated document titled, "Patient Grievance Form," showed that patients could complete a grievance form after they have attempted to resolve the issue with informally with the staff member(s) involved before the end of the shift. If they were not satisfied with the outcome, they would complete the grievance form and place it in the grievance box.

Review of the hospital's undated document titled, "Decision Matrix," showed:
- Steps for the AOC to take after being notified of an abuse or neglect allegation included contacting the Abuse/Neglect hotline in a timely manner, notifying the Department of Social Services Children's Division, the Chief Executive Officer (CEO), Physician, DON and Quality/Risk Manager.
- If the alleged perpetrator was a staff member immediately notify the Quality/Risk Manager and Human Resources (HR) and send the staff member home until the investigation is completed.
- If the alleged perpetrator is a peer, the alleged victim and alleged perpetrator are to be immediately separated onto different units.
- Steps for the AOC to take after being notified of an injury to a patient included a nursing assessment and all markings/injuries are to be documented to compare to the initial skin assessment. If any markings/injuries require medical attention, or there is redness, swelling or pain, the patient should have an x-ray (test that creates pictures of the structures inside the body-particularly bones). If an x-ray cannot occur withing one hour, the patient is to be sent to the local ED. Any injuries are to be reassessed every two hours times three, until symptoms resolve.
Assessments/reassessments should be documented in the medical record.
- Notify the physician and the patient's guardian.

Review of Patient #18's medical record showed:
- On 09/12/24, a 15-year-old-female was admitted and placed on C-Pod.
- On 09/15/24, nursing documentation showed the patient was in an altercation with another peer. A physical assessment was completed, no injuries were noted. She was moved to D-Pod without incident.
- On 09/16/24, a Morning Check-In Form indicated she requested to talk to the Patient Advocate.
- On 09/16/24 at 10:20 AM, a Psychiatric Progress Note indicated she reported high anxiety due to being attacked by a peer the previous day.
- On 09/16/24 at 6:48 PM, nursing documentation indicated there was an altercation with two other peers which resulted in her hair being pulled. An area on her scalp was identified a small amount of hair was pulled out of her head. There was no documentation of a physical assessment. She was moved to a D-Pod.
- On 09/17/24, nursing documentation indicated that she was feeling tired, having trouble falling asleep and staying asleep. She was withdrawn and complained of scalp pain at the area where her hair was pulled out.
- On 09/20/24, nursing documentation indicated that Patient #18 complained of a "weird pressure in her head behind eyes that does not feel like a headache."

Review of a video recording, without audio, dated 09/15/24, 9:11 AM through 9:32 AM showed:
- Patient #18 was seen leaving the C-Pod dayroom and entering her assigned room.
- Patient #11 follows Patient #18 into her assigned room, along with Staff F, Mental Health Technician (MHT) immediately behind her.
- Patient #11 exits Patient #18's room and Staff U, Registered Nurse (RN), enters. No video was available from inside Patient #18's room.

Review of a video recording, without audio, dated 09/16/24, 4:30 PM through 4:50 PM showed:
- Patient #18 sitting in the dayroom at a table with Patient #11, Patient # 23, and other unidentified patients. Staff V, MHT, sitting in the dayroom doorway, observing patients in the dayroom and the hallway.
- A physical altercation occurs involving three patients (#11, #18 and #23). Staff V attempts to intervene.
- Patient #11 and Patient #23 proceed punch, kick and pull Patient #18's hair.
- Staff W, MHT, enters the room to assist Staff V with separating and removing Patient #11 and Patient #23, approximately three minutes later.
- Staff E, RN, enters the dayroom after approximately six minutes, she does not complete any type of physical assessment.

Review the hospital's investigation documentation related to the altercations, involving Patient #18, on 09/15/24 and 09/16/24 showed:
- On 09/15/24, after the altercation Patient #18 was moved to D-Pod for group activities only, she returned to C-Pod to sleep.
- On 09/16/24, after the altercation, she remained on C-Pod and was not moved.
- There was no documentation of a physical assessment after either altercation.
- There was no documentation related to notification of the altercations with her family/guardian or her physician.
- No statements regarding the either incident were obtained from staff or patients that may have observed the incidents.
- No education was provided to staff after the physical altercations.
- There was no follow-up to Patient #18's complaint of head pain following the physical altercation.

During an interview on 10/02/24 at 11:41 AM, Staff F, MHT, stated that on 9/15/24 he was putting away laundry when he heard "a smack and yelling" so he went into the room and pulled Patient #11 away from Patient #18. He didn't "see anything actually happen, other than them pulling on each other." Nursing staff asked him "for a rundown of what happened" but could not remember if they wrote it down or not. No one from administration reached out to him about this event until 10/01/24 to discuss what happened, after the survey team made inquiries.

During an interview on 10/02/24 at 4:11 PM, Staff V, MHT, stated that on 9/16/24 Patient #18 and Patient #23 were arguing back and forth when Patient #23 came across the table and picked up Patient #18 by the hair. He was on the other side of the dayroom and he was tried to verbally de-escalate them before Patient #23 stood up. As soon as Patient #23 stood up, he stood up, and called on the radio for a staff assist and attempted intervene. Patient #11 then joined in the physical altercation. He witnessed Patient #18 get hit in the face. He did not recall talking to any leadership after this incident or receiving any education.

During an interview on 10/2/24 at 11:31 AM, Staff E, RN, stated that on 9/15/24 she was called to the unit for an altercation. Patient #11 and Patient #18 had already been separated. She filled out the incident report and the nursing documentation. If she had completed a physical assessment, she would have documented it in the medical record, along with the fact that there was an altercation. She spoke with both patients separately but was unaware if anyone else talked to them after the event. She spoke with Patient #18's mother "a couple of times and did notify her of the missing hair."

Review of the hospital's document titled, "Patient Grievance Form," related to Patient #5, dated 04/23/24, showed:
- On 04/22/24, Staff K, MHT, documented that female patients were complaining about Staff N, MHT, from the night shift of 04/21/24. The patients reported that she was using the word "fuck" all shift and had told them that "no man is going to make my pussy wet for free." The patients were requesting that Staff N not be allowed to work on their pod.
- On 04/23/24, at 2:30 PM, a complaint investigation was initiated and was completed by 4:00PM.
- Patient #5, alleged that on 04/21/24, Staff N, MHT, was "getting in patient's faces, stating that they were bitches", they "don't need to be here, you're rich and your life is perfect". She was telling patients to "shut your bitch ass up" and "I don't get me pussy wet for free." Staff N told the patients she had more trauma than them.
- There was no documentation of this incident in the patient's medical record.
- There were no written statements regarding the incident from any of the staff or patients present on the evening shift of 04/21/24.
- There was no documentation of a video review or staff education related to the incident.
- The resolution indicated that the DON was notified along with Staff N's agency, and the hospital would no longer be using her as a MHT.

Although requested, the hospital failed to provide any incident reports or investigation documentation, citing it was a PSWP.

Although requested, the hospital failed to provide a copy of the video footage of this incident citing that they only keep recorded video for 30 days.

During an interview on 10/01/24 at 12:50 PM, Staff D, DON, stated that patients could ask for a Patient Grievance Form to fill out and stick them in a box that Staff B, Patient Advocate, checked daily, Monday through Friday. This process was in place so that the patient did not have to confront the person in question. The allegation against Staff N, MHT, was not "something she knew about in the moment" and she was not involved in the investigation. Staff B, Patient Advocate, received the grievance, notified her and the decision was made to not have Staff N return to patient care.

Review of the hospital's document titled, "Patient Grievance Form," related to Patient #28, dated 06/15/24, showed:
- Patient #13 started a form but did not complete it in its entirety.
- Staff O, MHT, was indicated by name on the form as the staff member that had choked another patient (#28) and used racial slurs towards the patients.
- Staff O, MHT, worked 06/15/24 from 2:15 PM through 11:05 PM.
- Patient #13 marked "yes" indicating that she "attempted to process with staff" at 3:41 PM.
- On 06/17/24, 46 hours after the incident, an investigation was initiated at 1:00 PM, and resolved at 2:00 PM.
- Patient #28 was interviewed and did not report any verbal or physical abuse from Staff O, so the complaint was unsubstantiated.
- Video footage from 7:30 PM till 9:00 PM on 06/15/24 was reviewed. Staff O was visible on camera during the time in questions, she did not enter Patient #28's room or have any contact with him.
- No statements were obtained from other patients or staff present on 06/15/24.
- No staff education was completed.
- The resolution was documented as "patient discharged".

Review of Patient #13's medical record showed no mention of the incident involving Staff O, MHT, or Patient #28.

Review of the hospital's document titled, "Patient Grievance Form," related to Patient #28, dated 06/15/24, showed:
- Patient #14 completed a form indicating that Staff O, MHT, went into Patient #28's room and choked him. Staff O also used racial slurs toward patients.
- Staff O, MHT, worked 06/15/24 from 2:15 PM through 11:05 PM.
- On 06/17/24, 46 hours after the incident, an investigation was initiated at 1:00 PM, and resolved at 2:00 PM.
- Patient #28 was interviewed and did not report any verbal or physical abuse from Staff O, so the complaint was unsubstantiated.
- Video footage from 7:30 PM till 9:00 PM on 06/15/24 was reviewed. Staff O was visible on camera during the time in questions, she did not enter Patient #28's room or have any contact with him.
- No statements were obtained from other patients or staff present on 06/15/24.
- No staff education was completed.
- The resolution indicated that the DON and Quality/Risk Director were notified along with Staff O's agency. The agency was told the hospital would no longer use Staff O due her unprofessionalism.

Review of Patient #14's medical record showed no mention of the incident involving Staff O, MHT, or Patient #28.

Review of Patient #28's medical record showed no mention of the incident involving Staff O, MHT, or Patient #28.

Although requested, the hospital failed to provide any incident reports or investigation documentation, citing it was a PSWP.

Although requested, the hospital failed to provide a copy of the video camera footage of this incident citing that they only keep recorded video for 30 days.

During an interview on 10/01/24 at 2:10 PM, Staff B, Patient Advocate, stated that after a complaint/grievance was filled out, she would read it over and go back to the patient, or their family, to speak with them and reach a resolution. If the issue was resolved the patient would sign the bottom of the form. If it was not resolved the process with the hospital ends and they would be told that they could file a complaint with the Missouri Abuse/Neglect Hotline, Joint Commission or the Missouri Department of Health & Senior Services (DHSS). If it was an allegation of abuse or neglect the patient would be interviewed and if the issue was clinical the DON would get involved. Staff A, Quality/Risk Director, would review any video, if necessary, then the grievance committee would come together and make a determination. The investigative process for allegations only applied to hospital staff, not agency. If the allegation was against an agency staff member, they would just call the agency and say that they won't be using that person anymore.

During an interview on 10/01/24 at 12:50 PM, Staff D, DON, stated that after she learned of the allegation against Staff O, she spoke with Patient #28 and that he denied being choked by her. Even though he denied the abuse, the hospital decided to not bring her back. Staff encourage the patients to report any concerns of abuse or neglect, but they can't make them report it. If a patient makes an allegation and completes the form, at night or on the weekends, the hospital would not know until Monday morning. There is no patient advocate available at those times.

During an interview on 10/01/24 at 12:50 PM, Staff A, Quality/Risk Director, stated that she and Staff B, Patient Advocate, would collaborate on any complaints/grievances that came in. Any patient-to-patient incidents would be sent to her to investigate. She would complete a camera and document review. Anyone reported to have been involved would be interviewed. With staff-to-patient allegations, the staff member would be pulled off the floor and appropriate team members would be notified. She would complete a camera review and interview anyone involved or present at the time of the incident. During evening or weekend hours the AOC would be notified and the staff member would be sent home. Verbal abuse was any verbal indication of violence or threat of violence. The context of the statements would be taken into consideration for any verbal abuse allegation.

During interviews on 10/01/24 at 12:35 PM, and 10/03/24 at 12:15 PM, Staff C, CEO, stated that an incident report should be completed for any allegation of abuse or neglect and for any altercation. The person who witnessed the incident, or who the incident was reported to, would be responsible for filling out the incident report form. A nurse summary of the event should be documented in the medical record but should not include the documentation that an incident form was completed. Complaint or grievances with an allegation of abuse would be hot lined. Any staff member accused of abuse should be suspended immediately. For incidents that happen after hours or on weekends, the AOC would be responsible for ensuring the staff member was suspended. All parties and witnesses involved would be interviewed. The hospital would complete the hotline notification within 24 hours. The patient's guardian and physician would be notified.