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Based on interview, record review and policy review, the hospital's Governing Body failed to ensure that patients were free from abuse and neglect when the Chief Executive Officer (CEO) failed to effectively manage the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.13 Condition of Participation (COP): Patient's Rights. These failures had the potential to adversely affect the quality of care and safety to all patients in the hospital.

This failed practice resulted in a systemic failure and non-compliance with 42 CFR 482.12 COP: Governing Body.

Please refer to tag A-0057, A-0115 and A-0145.

Based on interview, record review and policy review, the hospital's Governing Body failed to ensure that the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including the accountability for the effective oversight of staff to comply with the requirements under 42 CFR 482.12 Condition of Participation (COP): Governing Body and 482.13 COP: Patient's Rights. These failed practices had the potential to adversely affect the quality of care and safety of all patients in the hospital.

Findings included:

Review of the hospital's document titled, "Medical Staff Bylaws," dated 07/31/24, showed that the CEO was appointed by the Department of Mental Health (DMH) to be responsible for the administration of Northwest Missouri Psychiatric Rehabilitation Center (NMPRC) and Governing Body to act in its behalf in the overall management of NMPRC. The medical staff is dedicated to the recognition and resolution of problems related to the delivery of quality patient care.

During a telephone interview on 11/05/24 at 2:00 PM, Staff Q, CEO, stated that she was responsible for the oversight and management of the entire hospital.

Based on interview, record review, policy review and video review, the hospital failed to ensure patients were free from all forms of abuse, neglect or harassment when:
- One patient (#6) was verbally abused, not allowed food or bathroom privileges and treated in ways to make him uncomfortable, until he complied with staff wishes.
- The hospital failed to ensure a thorough investigation was performed following an event report with allegations of abuse and neglect.
- The hospital failed to recognize patient abuse and provide education to staff related to abuse and neglect.

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

Based on interview, record review and policy review, the hospital failed to ensure patients were free from all forms of abuse, neglect or harassment when:
- One patient (#6) was verbally abused, denied food and bathroom privileges and treated in ways to make him uncomfortable until he complied with staff wishes.
- The hospital failed to ensure a thorough investigation was performed following an event report with allegations of abuse and neglect.
- The hospital failed to recognize patient abuse and provide education to staff related to abuse and neglect.

These failed practices had the potential to adversely affect the quality of care and safety of all patients in the hospital.

Findings included:

Review of the hospital's document titled, "Patient Rights," dated 04/03/24, showed:
- Patient rights that could not be limited included humane care and treatment; to be treated with dignity as a human being; to a nourishing, well balanced and varied diet; and to be free from verbal, physical and sexual abuse.
- Patients had the right to personal dignity and services considerate and respectful of personal values and beliefs.
- Patients had the right to receive care in a safe setting.
- Patients had the right to be free from harassment, physical abuse, mental abuse and corporal punishment.
- Patients had the right to be free from restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) or seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) of any form imposed as a means of coercion, discipline, convenience or retaliation by staff.
- Each patient has the right to a timely and impartial administrative review of alleged violations of rights.

Review of the hospitals policy titled, "Investigation Procedures," dated 06/22/22, showed:
- Neglect was defined as the failure of an employee to provide reasonable or necessary services to maintain the physical and mental health, safety or welfare of a patient.
- Physical abuse included any manner whatsoever, an employee mistreating or maltreating a patient in a brutal or inhumane manner.
- If there is reasonable cause to believe that physical, or verbal abuse or neglect has occurred, the head of the hospital or designee shall immediately refer the complaint to the investigations unit (IU) on the department approved form for initiating an investigation.

Review of the hospital's policy titled, "Misconduct Procedures," dated 03/02/23, showed:
- A complaint was an allegation that employee misconduct has occurred.
- Employee misconduct is when an employee fails to comply with acceptable standards of care, the requirements of hospital policy related to patient care, the requirements of treatment or rehabilitation plan, fails to report employee misconduct, or is verbally disrespectful to a patient or in the presence of a patient.
- Verbal disrespect was an employee using profanity or speaking in a demeaning, non-therapeutic, undignified or derogatory manner to a patient or in the presence of a patient.
- Complaints of employee misconduct shall be immediately reported to the head of the hospital by department employees and contract employees who know through direct or indirect means that employee misconduct has occurred, or suspect that employee misconduct has occurred or receive a complaint that employee misconduct has occurred.

Review of the hospital's undated education titled, "Abuse, Neglect, Exploitation," showed:
- The leading cause of abuse is attempting to gain control through compliance.
- Abuse is defined and includes the threat of physical violence from an employee to a patient, verbal abuse and/or neglect of a patient.
- Employees are mandated reporters for abuse and neglect. Staff should address suspected abuse and neglect by checking on the patient, reporting the event and any consequences of the abuse being reported.
- Retaliation against a patient, a patient's family, or another employee is subject to disciplinary action, including dismissal.

Review of the hospital's undated education titled, "Employee Conduct and Misconduct," showed:
- Cursing, condescension, and retaliation are unacceptable behaviors.
- Verbal disrespect is a category of employee misconduct.
- Failure to report misconduct could be considered neglect.

Review of the hospital's undated education titled, "SMART Training, Introduction to Situation Management and Response Techniques," showed:
- Employees are trained to treat all patients with kindness and respect regardless of the patient's behavior.
- Patient behaviors can escalate when they have little control over their environment. Employees are trained to understand the patient's cognitive and emotional experience to de-escalate a situation.
- Staff must use the crisis management techniques every day to avoid patient confrontation, including self-awareness. Employees should step aside if they are not working well with a patient and let someone else care for them.

Review of the hospital's document titled, "Event Report Form," dated 09/15/24, showed Staff G, Registered Nurse (RN), completed an event report at 4:03 PM. Documentation indicated that around 8:00 AM, Patient #6 took a metal clip off of another patient's name badge. He was asked to return the clip to the nurse and he refused. Patient #6 carried around a brown paper sack containing several unknown items. When Staff G asked him to give the sack to her, he refused. At 12:20 PM, Security was contacted and responded to the unit to retrieve the bag. Staff AA, Security Officer and Staff V, Security Officer, used the seclusion room to speak with Patient #6 about returning the items he was not allowed to have. Patient #6 gave the security officers a few of the items but refused to give up his brown paper sack and then refused to leave the seclusion room. Staff tried to get him to leave the seclusion room, but he refused to leave until all of his items were returned. Staff H, Advanced Practice Registered Nurse (APRN), was notified and she ordered oral Ativan (a medication used to trat anxiety or sleep difficulty). He refused the Ativan. Staff H also told Staff G that if Patient #6 needed to eat he had to go to the dayroom. If he needed to use the restroom, he had to use the one in his assigned room. Patient #6 was allowed to use the restroom near the seclusion room once, after that, he urinated on the floor. Staff continued to encourage him to eat in the dining room, but he refused. Staff G indicated on the form that there was no suspicions of abuse, neglect, or employee misconduct. Staff Q, Chief Executive Officer (CEO), signed the event report on 09/26/24 and indicated the event was an employee misconduct allegation.

Review of the hospital's document titled, "Event Report Form," dated 09/16/24, showed Staff E, Program Director, completed an event report at 10:21 AM. Staff E documented that on 09/16/24 around 8:05 AM, she spoke with Staff C, RN, about Patient #6 being in the quiet room (seclusion room). Staff C was visibly upset as evidenced by a slightly raised voice and tense eyebrows. He stated that when Patient #6 appeared tired or ready to fall asleep, staff were instructed to interact with him to prevent him from falling asleep and to make the room "as uncomfortable as possible" for him so he would return to his assigned room. Staff C then asked for an order for a manual hold to remove the patient from the seclusion room because they did not have enough staff available to sit with him in seclusion. On 09/16/24 around 9:00 AM, Staff E and Staff U, Medical Director, went to speak with administration regarding the allegations and to discuss the situation further. At 9:45 AM, Staff E spoke with Staff C to obtain additional information. Staff C reported that the night shift nurse Staff I, RN, told him in hand off that anytime Patient #6 started to fall asleep staff were to speak with him and encourage him to return to his assigned room. Staff C was unsure if Patient #6 was offered food, fluids, to use the restroom near the seclusion room, a urinal, or if staff only encouraged him to return to his assigned room. At 9:52 AM, Staff E contacted Staff H, APRN, to obtain additional information. Staff H reported that Patient #6 planned to stay in the quiet room and to eat his meals there. He was encouraged to eat in the day hall. At one point the patient needed to use the restroom and was allowed to use the one near the seclusion room. Later when he needed to use the restroom, and he lowered his pants and urinated on the floor in the seclusion room. Staff H instructed staff to offer the patient peanut butter to get him to leave the seclusion room. Staff offered to return the items that had been taken by security, but he continued to refuse to leave the seclusion room and to return to his assigned room. Patient #6 then requested a pardon from the Governor and to call his wife. When staff agreed to allow him to call his wife from the dayroom, he refused. Staff H indicated that she had not been contacted or updated during the night by the staff. Staff Y, House Supervisor, reported to Staff E that she had a conversation with Staff I, RN, who had a "meltdown" over the situation. Staff I told Staff Y, House Supervisor, that Patient #6 "should not be allowed to act like that." Staff I did not want to let the patient sleep in the seclusion room and stated, "he's not going to sleep back there, it's not okay. "The areas for suspicion or allegation of abuse, neglect or employee misconduct were left blank. There was no review signature or incident type indicated.

Review of the hospital's document titled, "Event Report," dated 09/17/24, showed Staff X, Nurse Manager, completed an event report at 3:21 PM. She documented that she had a discussion with nursing staff regarding the seclusion room being used as an alternative room/quiet room. When a patient used the seclusion room as a quiet room they were to be allowed to eat, sleep, drink and use the restroom in that area. It was reported that Patient #6 was not allowed to use the restroom near the seclusion room and was required to go back to his assigned room if he wanted to use the restroom. Staff CC, Patient Care Technician (PCT), assisted Patient #6 to the restroom near the seclusion room. Staff G, RN, told PCT's that if he wanted to use the restroom, he needed to use the one in his assigned room because he needed to leave the seclusion room. When Staff CC switched with Staff Z, PCT, the patient asked to use the restroom. Staff Z told him that he could not do that anymore, he had to go to his assigned room if he wanted to use the bathroom. Patient #6 then urinated in the corner of the room. The areas for suspicion or allegation of abuse, neglect or employee misconduct were left blank. The event report was reviewed on 09/18/24 by Staff Q, CEO, who marked the incident type as employee misconduct.

Review of the hospital's document titled, "Employee Misconduct Inquiry Report," dated 09/18/24, showed:
- Staff DD, Investigator 1, was assigned the inquiry. Allegations showed that on 09/15/24, Staff H, APRN; Staff G, RN; Staff I, RN; and Staff C, RN, failed to treat Patient #6 with dignity and respect while he was in the seclusion/quiet room.
- Event reports were reviewed along with Patient #6's medical record and progress notes from 09/15/24 through 09/16/24.
- An email sent from Staff Y, House Supervisor, to Staff X, Nurse Manager, dated 09/16/24, was included in the investigation. The email showed Staff Y reported that when she was on the Twain unit, she spoke with Staff I, RN, about Patient #6. Staff I told her that the patient wanted to sleep in the seclusion room and she would not let him. If the patient wanted to sleep, he needed to go to his assigned room. Staff Y spoke with Patient #6 and he refused to leave the seclusion room. Later Staff Y received a call from Staff I who reported Patient #6 became verbally aggressive (behavior that is intended to harm another individual) and almost threw a chair at staff when they tried to talk to him. Staff I felt that the patient needed Ativan, but he refused to take it orally. Staff Y asked if Patient #6 was calm when staff didn't speak to him. Staff I did not respond. Staff Y asked Staff I again if the patient was calm if staff didn't talk to him. Again, Staff I did not answer her question. Staff Y told Staff I that she should just let the patient go to sleep, she would rather they let him sleep than someone get hurt trying to give the patient a shot. If he was not aggressive when left alone, then don't talk to him. Staff I replied, "whatever, you are the boss." Staff Y then asked Staff I's opinion on what should be done. Staff I responded that it was fine. Staff Y told Staff I that if she truly felt the patient needed an injection, she could call the on-call physician for an order. Staff I told her that it was fine and hung up the telephone. Staff Y tried to call back, but no one answered the telephone. She called a second time and was told that Staff I went on a break. Staff Y then went to the unit breakroom to speak with Staff I. Staff Y explained that Staff I was the Charge Nurse on the unit and in the situation. If she, as a charge nurse, had a concern she should call the provider and ask their opinion. Staff Y told Staff I that she could not order medications. Staff I then stated there was already an order for an Ativan injection. Staff Y asked her if there was already an order for an injection. Staff I responded yes in an agitated tone with tears in her eyes. Staff Y then told Staff I that even though there was already an order for an injection, the provider liked to be notified prior to administration due to the increased risk for falls. Staff I had tears streaming down her face and said, "I do not understand why they let him get away with everything." Staff Y asked her why it affected her so much and she replied, "you don't understand what I have gone through with that man just in the past couple days. He has called me about every name and has been very hateful to me all weekend." Staff Y explained that Patient #6 was a very sick man and she was sorry that Staff I had so much to deal with. If she needed a break from the Twain Unit she should let her know. Staff Y told Staff I that her opinion of the situation was to let the patient sleep. She did not want anyone to get hurt. If letting the patient sleep a few hours would prevent a behavior that would be the less invasive approach. Staff Y sent the email because she felt Staff I may have been feeling overwhelmed.
- On 09/24/24, Staff X, Nurse Manager, was interviewed and stated that when she entered the unit on the morning of 09/16/24, Patient #6 was sitting in the seclusion/quiet room singing. Staff C, RN, told Staff X that the patient had urinated on the floor of the seclusion room. She asked him why he did not use the one near the seclusion room and he told her that Staff I, RN, would not let him use it. He also informed her that he was not allowed to eat or sleep in the seclusion room. Staff I told him that she was just passing on what Staff G, RN, told her. Staff C stated that "they" wanted Patient #6 to be uncomfortable so he would leave the seclusion room.
- On 09/24/24, Staff CC, PCT, was interviewed regarding the incident. He stated that he sat with Patient #6 and allowed him to use the restroom near the seclusion room. Staff G, RN, then told Staff CC not to let the patient use that restroom again. If he needed the restroom he had to go to his assigned room. Patient #6 told Staff CC that he wanted to have his dinner meal in the seclusion room. Staff Z, PCT, took over the sitting assignment prior to dinner. Staff CC then called Staff H, APRN, to speak about the situation. Staff H told Staff CC that if Patient #6 wanted to eat dinner, he needed to come out of the seclusion/quiet room and eat in the dayroom or in his own room. Staff CC reported in his interview that staff were trying to get the patient to come out of the seclusion room because there wasn't enough staff available to sit with him.
- On 09/27/24, Staff Z, PCT, was interviewed and reported she was told that Patient #6 was not allowed to use the restroom by the seclusion/quiet room. If he wanted to use the restroom he had to go to his assigned room. Patient #6 did ask her to use the restroom and she told him that he had to use the one in his room. Patient #6 told her that he would just go in the floor. He then urinated on the floor in the seclusion room. Another staff member told Patient #6 that he could not eat in the seclusion room. The patient told her that he would just survive on candy he had in his brown paper sack.
- On 09/27/24, Staff Y, House Supervisor, was interviewed and reported that she did not know staff were not allowing Patient #6 to use the restroom by the seclusion room, nor that they were not allowing him to have food. Staff Y felt it was inhumane to not allow Patient #6 to use the restroom, he was not aggressive at the time, just psychotic (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature).
- On 09/30/24, Staff G, RN, was interviewed and stated that Patient #6 had been taken into the seclusion room so he could be searched for a metal badge clip he had taken. After the patient went to the seclusion room he refused to leave. She called Staff H, APRN, and was told to offer the patient oral Ativan and he refused to take it. She called Staff H a second time to update her on the situation. Staff H told her that if the patient wanted to use the restroom or eat, he had to leave the seclusion room to do it. Staff G then reported to the PCT sitting with the patient that he could not use the restroom in that area or eat while he remained in the seclusion room. A little while later it was reported to her that the patient had urinated on the floor. She just did what the on-call provider instructed her to do and she would not deprive a patient of his basic needs. It was noted that Staff G was very tearful during her interview and felt bad for not questioning Staff H's orders or confirming the order with the Administrator on Duty (AOD).
- On 09/30/24, Staff I, RN, was interviewed and stated that in the hand off report, Staff G, RN, told her that the staff's main goal was to get Patient #6 to leave the seclusion area. Staff G told her that if the patient wanted to eat or use the restroom, he had to leave the seclusion room. When Staff I tried to talk with the patient, he just yelled at her. There wasn't a written order of any kind for staff and she did not know how to handle the situation. She instructed the PCT's that the patient could not use the restroom or eat in the seclusion area. She also instructed them to make the room uncomfortable for the patient by talking to him when he started to fall asleep. She did not think the patient should be allowed to sleep in there because that wasn't what the room was used for. She passed the information along to Staff C, RN, in the morning hand off on 09/16/24.
- On 09/30/24, Staff C, RN, was interviewed and stated that no one told him Patient #6 could not eat, sleep or use the restroom in the seclusion room. Staff on his shift offered the patient breakfast and drinks, but he refused. About four hours into his shift, Patient #6 left the seclusion room when another staff member invited him to book club.
- On 10/02/24, Staff W, PCT, was interviewed and reported that she was told by Staff G, RN, and Staff I, RN, to tell Patient #6 that if he needed to use the restroom, he had to use the one in his room and if he wanted to eat, he had to leave the seclusion area. Staff I, RN, told her that if Patient #6 started to fall asleep, she needed to wake him up and encourage him to sleep in his assigned room. When Staff W tried to keep the patient awake, he became agitated and raised his fist at her, so she let him sleep. Staff W told the patient that he could have his therapeutic snacks if he left the seclusion room, but he refused and said he was on a hunger strike.
- On 10/02/24, Staff H, APRN, was interviewed and stated that she received a phone call from Staff G, RN, who reported Patient #6 had been taken to the seclusion room by security to search him. He became agitated and refused to leave the area. She gave an order for oral Ativan. They had a discussion regarding patients using the seclusion room as a quiet room and Staff H was under the impression that patients were not supposed to use the room in that way. She was told that the patient refused to leave the seclusion room until he got his belongings back. Staff H called the AOD and security staff to see if it was ok to give the patient back his things. When staff attempted to give his items back to him the patient still refused to leave the seclusion area. Staff H told Staff G to continue to encourage the patient to come out of the room. She told Staff G to encourage the patient to leave the seclusion room to eat and she was not sure if he should have a meal tray in there or plastic utensils. She never told Staff G that the patient wasn't allowed to eat in the seclusion room. Staff H was later informed by Staff G that the patient had urinated on the floor in the seclusion room and that he often did that in his assigned room.
- Staff training records were reviewed and they indicated Staff I, RN; Staff G, RN; and Staff C, RN, had completed training related to abuse and neglect. Staff H, APRN, had not completed any training.
- A summary of the investigation showed that Patient #6 had not received any meals while he was in the seclusion room. He spent approximately 22 hours in the seclusion room, eating some candy and condiments from his brown paper sack. Staff H, APRN, instructed Staff G, RN, to encourage Patient #6 to leave the seclusion area to eat and use the restroom. but She never told her not to allow him to eat in the room or to use the restroom near the seclusion area.
- A plan of action showed Staff C, RN; Staff G, RN; Staff H, APRN; and Staff I, RN, failed to comply with acceptable standards of care.
- The investigation was sent to the IU, where they determined the request did not include an allegation of abuse/neglect nor did the event narrative support reasonable suspicion of an abuse/neglect type.
- Education to staff after the event included when to contact the AOD.
- Staff I, RN, received a written reprimand for failure to comply with the Code of Conduct Policy; Patient's Rights policy; Expected staff Behavioral/Conflict Resolution; Code of Expected Employee Behavior; Respect; and the employee handbook.

Review of Patient #6's medical record, showed:
- On 07/26/23, he was admitted to the hospital with a long-standing history of mental illness and multiple, previous psychiatric hospitalizations. His mental state consisted of episodes of mood elevation, tangential thoughts (a type of thought disorder in which each of a series of thoughts seems less closely related to the original thought than the one before it), delusions (false ideas about what is taking place or who one is) of persecution and grandiosity (over-inflated sense of worth, power, knowledge, or identify), episodes of irritability and depressive episodes (long period of extreme sadness that doesn't go away).
- Past medical history included bipolar disorder-manic type (characterized by clear changes in mood, energy, and activity levels with periods of extremely energized behavior) with psychotic features (characterized by defective or lost contact with reality). He was committed to the Department of Mental Health (DMH) as it was determined he was permanently incompetent to stand trial.
-On 07/17/24, an annual assessment was performed. It was reported that he was poorly groomed and smelled of urine and excrement. He carried a bag around with him that was full of condiment packets. He had disorganized thinking (unable to connect thoughts and appropriately process problems) with distorted and grandiose ideals. He lacked attention, concentration and insight to his illness. His judgement was impaired because he refused to take the recommended medications. His mood fluctuated from being elevated without defined depressed periods to episodes when he was irritable that alternated with episodes of euphoria (feeling of intense excitement and happiness). The provider determined, the patient's long-term risk of suicide (to cause one's own death) and risk to become violent towards others, was moderate. It was determined the patient's treatment would be continued on the locked Twain Unit of the hospital. Medications were provided and adjusted when needed. Re-direction and education were provided accordingly.
- On 09/15/24 at 4:41 PM, Staff G, RN, documented that the patient had taken a metal piece, from another patient's name badge. The patient refused to give the metal piece back to the RN. The RN requested to search a brown paper bag he Patient #6 was carrying around with him for the metal piece. The patient refused. Security was called. Two security officers spoke to the patient in the seclusion room. He gave up a few items he had with him but refused to allow them to search his brown paper bag. The patient then refused to leave the seclusion room until he was given all his items back. The RN notified Staff H, APRN, of the situation. It was noted the patient was informed he could not eat while in the seclusion room and would need to return to the dayroom.
- On 09/16/24 at 2:56 AM, it was documented in a progress note that the patient was sitting on the bed in the seclusion room. He had urinated in the corner of the seclusion room and was willing to mop it up. The patient mopped up the urine on the floor and commented that the cereal carton in the corner was his toilet. He stated that he was willing to flush the urine in the cereal carton, but he was not going to throw it away.
- On 09/16/24 at 3:17 AM, Staff W, PCT, documented that the patient continued to refuse to leave the seclusion room. While she observed the patient, she noted the patient was falling asleep and she asked him to return to his room if he wanted to sleep. He became aggressive and charged at Staff W, as she stepped into the seclusion room. He kicked a chair towards her and attempted to hit her with his fist.
- On 09/16/24 at 5:29 AM, Staff I, RN, documented that the patient had remained in the seclusion room during her shift, of his own free will. When requested, he refused to leave. He had a staff member assigned to sit with him while he remained in the seclusion room. During her shift, he urinated on the floor multiple times, ate pieces of paper and charged at the staff assigned to sit with him. He demanded to speak to his lawyer before he would leave the seclusion room. Staff attempted to speak with him to get him leave the seclusion room but were not successful.
- On 09/16/24 at 9:00 AM, documentation showed that the patient was encouraged multiple times to attend breakfast. He declined.
- On 09/16/24 at 10:03 AM, documentation showed that the patient sang loudly, was hateful and rude to staff. He was offered a drink of water but refused. The patient mumbled incoherently, at times.
- On 09/16/24 at 10:24 AM, Staff C, RN, documented that the patient's social worker invited the patient to book club and the patient agreed. He was offered water and to use the restroom, but he refused. The patient left the seclusion room and was escorted to the dayroom.
- On 09/16/24 at 12:29 PM, nursing documentation showed that the patient was laying on his bed whenever his lunch arrived. Several staff attempted to wake him but were not successful. Staff informed him that, "His lunch was here and would be sent back if he didn't eat." The patient refused to get up.
- On 09/16/24 at 2:07 PM, documentation showed that the patient was in the seclusion room. He discussed religious beliefs and recited bible verses. He reported that he was not able to eat or drink in the seclusion room. He was calm and spoke with staff.

During a telephone interview on 10/30/24 at 4:45 PM, Staff H, APRN, stated that she told Staff G, RN, to make sure the patient knew that he was not in seclusion and to leave the door open. She never gave any orders for him to be in seclusion. She instructed Staff G to encourage the patient to leave the seclusion room by offering him some of his favorite foods, returning some of his things back or letting him call his wife. Patient #6 was going through some medication changes at the time that were affecting him and he was struggling. Staff I, RN, called her for an order for an injection. Staff I stated, "he is irritated because I won't let him sleep, I am irritating him to the point that he needs an injection." She refused the request for an injection. At one point Staff I tried to shut the door between the seclusion room and the nursing station. She did not hear from staff again that night. No orders were given to Staff G, RN, for anything other than to offer him his oral Ativan. She never told staff to withhold food, water or the restroom and never imagined that encouraging him to come out for those things would be interpreted as withholding food or the use of the restroom. She felt staff did that to get him to do what they wanted him to do. She felt that withholding food or use of the restroom would absolutely be a form of abuse and neglect, especially due to the vulnerable population at that hospital.

During an interview on 10/30/24 at 1:55 PM, Staff G, RN, stated that Staff H, APRN, told her "if he needed to eat or use the restroom he had to go to the dayroom or his assigned room to do it." She never wanted to violate Patient #6's rights and was just doing what she was told to do. There was no physician's order to withhold food and/or to refuse to let him use the restroom. She did not complete a verbal order. She reported to Staff I, RN, during the shift report what Staff H had instructed her to do. She never thought withholding food was a violation of a basic human rights. She was just following orders and would never want to neglect a patient. She did not know why there were no orders to withhold food or allow him to use the restroom. She wanted the patient to leave the seclusion room so he could go back out and socialize and take part in the canteen. It was fine that Staff CC, PCT, allowed Patient #6 to use the restroom near the seclusion room, she wasn't upset about that.

During a telephone interview on 11/05/24 at 11:50 AM, Staff CC, PCT, stated that he had great interaction with Patient #6, so he volunteered to be the first person to sit with him in the seclusion room. He felt that he would be able to get him calmed down. When he got to the seclusion room, he removed the sheet from the bed and the restraints from the room. Patient #6 asked to use the restroom and Staff G, RN, told him no, he had to use the one in his assigned room. Staff CC let Patient #6 use the restroom near the seclusion room and Staff G got mad and yelled at him. He thought it upset Patient #6 when Staff G yelled at him, as he had been calm, prior to her yelling at him. Staff G changed his assignment and had another PCT sit with the patient. Staff had asked Patient #6 if he wanted dinner and he said he did, then Staff G told him he couldn't have it unless he left the seclusion room. Staff CC "threw a fit" when he heard that and reported it to Staff X, Nurse Manager. Patient #6 ate candy and butter packets from his brown paper sack. He felt sorry for Patient #6. He believed that staff wanted the patient out of the seclusion room because they were short staffed and everyone wanted to watch the football game on tv.

During a telephone interview on 11/04/24 at 11:15 AM, Staff Z, PCT, stated that Staff CC, PCT, sat with the patient earlier and let him use the restroom near the seclusion room. Staff G, RN, got upset with Staff CC and, "bitched him out for it." Staff G told her that the patient was not allowed to do that again and to make the patient uncomfortable. When Patient #6 asked Staff Z to use the restroom, she told him that he was supposed to use the one in his assigned room. He then urinated on the floor of the seclusion room. Staff G told her that the patient could not have any food in the seclusion room. She was uncomfortable with the whole situation, but she was afraid of getting in trouble with her supervisors.

During a telephone interview on 11/06/24 at 8:30 AM, Staff EE, PCT, stated that while she was sitting with Pa