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Based on interviews, record review, review of the facility investigation, and review of the facility's policies, it was determined the facility failed to ensure that an allegation of abuse for one (1) of three (3) sampled patients (Patient #1) was investigated timely, reported timely to required state agencies, and that patients were protected from further potential abuse. On 03/28/2021, prior to 1:00 PM, Registered Nurse (RN) #3 observed State Registered Nurse Aide (SRNA) #4 on camera monitors taunting Patient #1 by flicking a wash cloth at the patient when providing patient care. The RN failed to report the allegation of abuse to administrative staff until 03/29/2021. Administrative staff failed to report the allegation of abuse to the state survey agency until 04/05/2021 (eight days after the original report) and failed to report the allegation to Adult Protection Services (APS). In addition, the facility failed to protect residents from further potential abuse after the report and while investigating the abuse allegation. SRNA #4 worked providing direct patient care on 03/31/2021, 04/01/2021, and four (4) hours on 04/02/2021.

The findings include:

Review of a facility policy titled "Abuse and Neglect," with a revision date of 08/11/2014, revealed if abuse was reported or suspected staff should report any complaint of abuse, neglect, or patient harm immediately to the patient's nurse supervisor (the nurse in charge of that patient's care on that given day), if the nurse supervisor was not available report to the charge nurse. The nurse supervisor would assess the patient to ensure the patient was safe and free from injury, and report the complaint to the charge nurse who both had the responsibility to report this immediately to Administration. The policy stated the patient's physician and representative must also be notified, and the nurse supervisor must complete an incident report. Further review of the policy stated the charge nurse would assess the patient to ensure the patient was safe and free from abuse, report any complaint of abuse immediately to Administration, and oversee that an incident report was completed and if an incident report was not completed by the nurse supervisor, the charge nurse was obligated to complete an incident report. Continued review of the policy stated if the event occurred on the weekend to "report it immediately, do not wait." The investigation would begin immediately upon reporting of abuse or neglect. If allegations of abuse were determined or made, the employee alleged would be suspended until completion of the investigation and the patient would be protected and removed from harm during the investigation. The policy stated all alleged violations would be reported immediately to the appropriate agencies including but not limited to Community Based Resources and the Division of Licensing and Regulation, and other officials in accordance with State and Federal law.

Review of the facility's policy titled "Patient Rights," not dated, revealed the patient had the right to considerate and respectful care, with recognition of their personal dignity and consideration of psychological variables that influence their perception of illness. Furthermore, the patient had the right to receive care in a safe setting, free from mental, physical, sexual, or verbal abuse and neglect, exploitation or harassment; and to access protective and advocacy services including notification of government agencies of neglect or abuse.

Review of the facility's policy titled "Incident Reporting," with a revision date of 10/12/2010, revealed the purpose of the policy was to provide a uniformed process to capture information on unexpected events. The policy defined an incident as any unusual event that was inconsistent with routine patient care. The policy stated a "near miss" was an event or situation that did not result in a patient injury, but could have. Reporting of near misses provided the hospital with valuable examples of how following a process could help avoid an actual incident. Abuse and neglect was listed as an example of a type of event that should be reported as soon as possible after the event occurred. Further review of the policy revealed that after an event was reported, there would be an investigation to gather additional information.

Review of Patient #1's medical record revealed the facility admitted the patient on 08/02/2019 to a swing bed with diagnoses including Subdural Hematoma, Dementia, Agitation, Hemiplegia affecting the left non-dominant side, and Bipolar Disorder.

Observations of Patient #1 on 04/14/2021 at 12:55 PM and 2:40 PM revealed the patient was in bed leaning toward the right side of the bed. Patient #1 had a purple bruise to the top of his/her right hand. No bruising was observed to Patient #1's fingers. An interview was attempted with Patient #1 however, it was unsuccessful as the resident was asking about his/her grandmother.

Review of the facility investigation dated 03/29/2021, revealed the CNO observed a note on the communication board behind the nurse's station at approximately 3:30 PM stating "Elder abuse is {a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person.}" The CNO questioned who placed the note on the board and RN #3 stated she had placed the note on the board earlier on the morning of 03/29/2021. The CNO questioned as to why the note was placed on the communication board and RN #3 stated she observed SRNA #4 flicking a wash cloth at Patient #1 on 03/28/2021 on video monitors and that she went to Patient #1's room and told SRNA #4 to stop flicking the wash cloth at Patient #1 and to leave his/her room. The investigation stated RN #3 reported that Patient #1 was already agitated and that SRNA #4 was making it worse by taunting the patient and "she could not stand for it." RN #3 stated that SRNA #1 was present in Patient #1's room and had observed the incident as well. The CNO informed RN #3 that she should have brought the incident to her attention immediately, rather than placing a note on the communication board, and that she would investigate and take care of the matter. Further review of the investigation revealed that the CNO performed a skin assessment on Patient #1 on 03/30/2021 that revealed several bruises to his/her bilateral arms and hands, and an old skin tear to his/her left lower leg. The CNO documented that none of the bruises stood out to be anything out of the normal for the patient. Continued review of the investigation revealed the facility did not report the abuse allegation to APS or the state survey agency as required.

The investigation revealed that SRNA #1 had sent the CNO a text message at approximately 4:00 PM on 03/29/2021, inquiring if RN #3 had spoken to her, and if she had not that SRNA #1 needed to do so. SRNA #1 was unable to discuss the events of 03/28/2021 due to being with family and not having a private place to talk and would talk to the CNO later. On 03/30/2021 the CNO reported to the CEO what was reported to her on 03/29/2021 at which time employee interviews began.

Per the investigation, .SRNA #4 was not on duty; however, came into work on 03/30/2021 to discuss the incident which occurred with Patient #1 on 03/28/2021 with the CNO and CEO. SRNA #4 stated that they (SRNA #1, #2, and #3) had transferred Patient #1 from his/her bed to his/her Geri-chair and the patient was "fighting and cussing." SRNA #4 stated she flicked a wash cloth at Patient #1's tray table on the Geri-chair and that she did not hit the patient with the wash cloth, she was just kidding with him/her attempting to calm him/her down. SRNA #4 stated that RN #3 entered Patient #1's room and jumped on her and told her never to do that again. The investigation stated that the CNO and CEO advised SRNA #4 that when she worked her upcoming shifts on 03/31/2021, 04/01/2021, and 04/02/2021 she was not to enter Patient #1's room, that they would be conducting staff interviews and needed to speak with RN #3 again.

The investigation revealed that Ward Clerk #1 that was working 03/28/2021, was interviewed and stated she did not observe anything on camera. However, interview with Ward Clerk #1 on 04/01/2021 at approximately 2:45 PM revealed she entered the CNO's office and reported she did not observe SRNA #4 flick a wash cloth at Patient #1 on video monitoring but that she did observe her "jerk" the lift bar from the patient's hands.

Continued review of the investigation revealed on 03/31/2021, Licensed Practical Nurse (LPN) #1 was interviewed regarding the incident that occurred on 03/28/2021. LPN #1 was assigned to Patient #1 and she stated she observed SRNA #4 flicking a wash cloth at Patient #1 on the video monitor and that she and RN #3 entered Patient #1's room and RN #3 instructed SRNA #4 to "stop and no do that again" and told SRNA #4 to leave. LPN #1 further stated that SRNA #4 did not leave but continued to work.

Review of the investigation revealed on 04/02/2021 at approximately 12:00 PM the CNO and CEO held a telephone conference with RN #3, at which time the CEO inquired if she alleged abuse occurred on 03/28/2021 and RN #3 replied yes. The CNO informed RN #3 that the abuse allegation would be reported to Office of Inspector General (OIG) and an investigation would occur.

Further review of the investigation revealed that on 04/02/2021 the CEO reached out to Patient #1's Power of Attorney (POA) and reported that RN #3 alleged abuse and that SRNA #4 would be suspended until the investigation was completed. The CNO and CEO attempted to contact OIG to report the abuse allegation, however it was a holiday and the office was closed therefore, it was determined they would contact the OIG on 04/05/2021.

Interview with SRNA #4 was attempted on 04/13/2021 at 1:33 PM, 04/14/2021 at 11:00 AM and 2:00 PM, and 04/15/2021 at 10:09 AM without success. SRNA #4 was suspended on 04/02/2021 and resigned on 04/06/2021.

No interview was performed with RN #3 due to her husband's sudden passing and his funeral services were conducted on 04/13/2021 and 04/14/2021.

Review of RN #3's statement revealed she did not immediately report the allegation of abuse on 03/28/2021 but instead completed the second part of her shift in the emergency department cross training. RN #3 placed on note on the communication board at the nurse's station with the definition of elder abuse at the beginning of her shift on 03/29/2021. At approximately 3:30 PM the CNO saw the note and questioned who had placed the note on the board, at which time RN #3 stated she did. RN #3 entered the CNO's office and reported that on 03/28/2021 prior to 1:00 PM, she observed SRNA #4 on camera monitors flicking a wash cloth at Resident #1 when providing patient care. RN #3 went to Patient #1's room and told SRNA #4 to stop flicking the wash cloth at Patient #1, and to leave the patient's room. RN #3 stated that Patient #1 was already agitated and SRNA #4 was making it worse by taunting him/her, and "she could not stand for it." RN #3 stated SRNA #1 and Ward Clerk #1 witnessed what had occurred, that she did not want to be a troublemaker, however "she couldn't let it continue." RN #3 was unavailable for interview by the CNO or CEO again until 04/02/2021 due to her husband's recent illness. On 04/02/2021 a telephone conference was conducted at approximately 12:00 PM with RN #3 at which time she stated she felt the incident was abuse.

Interview with Physician #1 on 04/14/2021 at 11:48 PM revealed he was not notified of the allegation of abuse until after he returned from an out of town trip. He stated he was under the impression that the incident occurred when he was out of town between 04/03/2021 and 04/11/2021. He stated he should have been notified of the allegation because he had performed daily rounds at the facility from 03/29/2021 through 04/02/2021.

Interview with SRNA #1 on 04/13/2021 at 2:14 PM revealed she was working with SRNA #2 and SRNA #4 on 03/28/2021 around lunchtime with Patient #1. She stated that they had given him/her a bed bath and had transferred him/her from his/her bed to his/her Geri-chair with the mechanical lift. SRNA #1 stated Patient #1 was agitated and would not let go of the lift bar, she coaxed the patient's left hand from the bar and SRNA #4 "yanked" the bar out of his/her right hand. She stated she told SRNA #4 that Patient #1 was agitated and she should go on and she would finish up, but SRNA #4 continued care. She stated she had bent down to pick soiled linens up out of the floor when RN #3 entered Patient #1's room and when she looked up SRNA #4 was flicking a wash cloth at the patient's face back and forth. She stated SRNA #4 did not hit the patient with the wash cloth but that he/she was already mad and she was making things worse. She stated when RN #3 entered Patient #1's room she told SRNA #4, "you don't do that."

Interview with the CNO on 04/14/2021 at 2:17 PM revealed she was not notified of the allegation of abuse on 03/28/2021. She stated that on 03/29/2021 at approximately 3:30 PM, she observed a note on the communication board behind the nurse's station with the definition of elder abuse. She stated she was the only person that typically posted anything on the board and questioned who had placed the note on the board, at which time. RN #3 stated she had posted the note and proceeded to report to her that on 03/28/2021 she observed SRNA #4 flick a wash cloth at Patient #1 on the video monitor. She stated RN #3 stated she went to Patient #1's room and told SRNA #4 to stop and get out of the patient's room. She stated RN #3 told her that "I couldn't let it go." The CNO stated she told RN #3 that she should reported the incident to her and not post a note on the communication board. The CNO stated that Patient #1 was not in danger because SRNA #4 was not scheduled to work again until 03/31/2021 and RN #3 did not say that she wanted the incident reported as abuse. She stated on her way home from work at approximately 4:00 PM, SRNA #1 messaged her inquiring if she had spoken with RN #3, and if not, she needed to. The CNO stated she called SRNA #1 and SRNA #1 could not talk because she was with family and needed to speak to her in private and they would talk on 03/30/2021. She stated she completed a skin assessment on Patient #1 on 03/30/2021, and did not find any areas of concern that suggested abuse. She stated the following morning 03/30/2021, she reported to the CEO what RN #3 reported to her on 03/29/2021 and was instructed to talk to the staff involved. Continued interview with the CNO revealed she was unable to speak with RN #3 again until 04/02/2021 due to RN #3's husbands' recent cancer diagnosis and hospitalization. The CNO stated she contacted SRNA #4 and requested her to come to the facility for her statement and SRNA #4 stated she had provided care to Patient #1 on 03/28/2021 with SRNA #1 and SRNA #2. She stated SRNA #4 reported to her that Patient #1 was agitated and cussing and after they transferred the patient. Per the CNO, the SRNA stated was playing with the patient in an attempt to calm him/her down and flung the wash cloth at the tray table attached to his/her Geri-chair. RN #3 entered the patient's room and told her to stop. The CNO stated the SRNA then reported the events to the CEO. The CEO and CNO both told SRNA #4 that when she returned for her shift on 03/31/2021 through 04/02/2021 she was not to enter Patient #1's room and that SRNA #4 verbalized understanding. Further interview with the CNO revealed she continued staff interviews which included SRNA #1 on 03/30/2021 at approximately 12:15 PM in which SRNA #1 reported that on 03/28/2021 she transferred Patient #1 with a mechanical lift along with SRNA #2 and SRNA #4. She stated Patient #1 was agitated and was holding to the lift bar with his/her hands, when SRNA #4 "jerked" the lift bar from the patient's hands causing bruising to a finger on his/her right hand. The CNO stated SRNA #1 also reported that she observed SRNA #4 flick a wash cloth back and forth at Patient #1 making the patient's agitation even worse. Continued interview with the CNO revealed she did not consider the note defining elder abuse, RN #3's report of the incident, or SRNA #1's report of the incident was an allegation of abuse. She stated she did not consider it an abuse allegation until 04/02/2021 when RN #3 stated that she felt abuse had occur

Interview with the CEO on 04/14/2021 at 3:29 PM revealed he was notified on 03/30/2021 by the CNO of the "situation" and at that time he had not heard that abuse was involved. He stated that the CNO reported to him that she had found a note on the communication board with the definition of elder abuse on 03/29/2021 and that she did not know what the note meant. He stated the CNO told him that RN #3 had placed the note on the board and then notified the CNO of the occurrence on 03/28/2021. The CEO stated that he did not interpret SRNA #4 flicking a wash cloth at Patient #1 or RN #3's placement of the definition of elder abuse on the communication board as abuse. He stated SRNA #4's actions were inappropriate; however, did not consider her actions as abuse. He stated he wanted to hear RN #3's account of the incident but due to her husband's emergent medical condition, he did not feel it was an appropriate time to discuss the events of 03/28/2021 with her. He stated he did not know RN #3's intent was therefore, when SRNA #4 was interviewed in person on 03/30/2021, she was instructed to not enter Patient #1's room on her scheduled shifts on 03/31/2021 through 04/02/2021. He stated he was not made aware of the incident with the mechanical lift until he read the investigation summary that was completed by the CNO on 04/02/2021. He stated he should have been made aware of the lift incident immediately after SRNA #1 reported it to the CNO on 03/30/2021. The CEO stated he felt the lift incident constituted abuse because it was "different circumstances." He stated after they (himself and the CNO) were in contact with RN #3 on 04/02/2021 via telephone conference, he asked RN #3 if she was alleging abuse occurred on 03/28/2021, and RN #3 stated yes. He said that was all he needed to know, and SRNA #4 was suspended at that time. He stated if staff had immediately reported to him on 03/28/2021 the actions that had occurred, he would have immediately suspended SRNA #4, and began an investigation. Further interview with the CEO revealed flicking a wash cloth at an already agitated patient was inappropriate. He stated he would not like it if someone was flicking a wash cloth at him. Continued interview with the CEO revealed the facility substantiated the abuse allegation.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to develop a comprehensive care plan to address the amount of assistance Patient #1 required with activities of daily living (ADL) care and aggressive behaviors for one (1) of three (3) sampled patients (Patient #1). On 03/28/2021, Stated Registered Nurse Aides (SRNA) #1, #2, and #4 where providing ADL care to Patient #1 when the patient became agitated with staff. Staff continued to provide patient care and SRNA #4 was observed by her co-workers to flick a wash cloth in Patient #1's face and "yanked" a lift bar out of the patient's hand. Patient #1 had a history of becoming agitated during ADL care; however, the facility failed to develop a comprehensive care plan to address the patient's agitation with care and how staff should respond when Patient #1 was agitated. Furthermore, the facility failed to develop a comprehensive care plan that addressed the amount of assistance that Patient #1 required during ADL care.

The findings include:

Review of the facility's policy titled "Care Plans," with a revision date of 08/23/17, revealed each patient would have an individualized care plan based on his/her needs and problems initiated upon admission or within the first 12 hours of arrival. The policy stated that the patient care plan would be reviewed on a daily basis and updated as needed.

Review of Patient #1's medical record revealed the facility admitted the patient on 08/02/19 to a swing bed with diagnoses including Subdural Hematoma, Dementia, Agitation, Hemiplegia affecting the left non-dominant side, and Bipolar Disorder.

Review of Patient #1's care plan revealed the facility did not address the amount of assistance the patient required with ADL care or how staff were expected to respond when Patient #1 exhibited agitation during patient care.

Review of the facility investigation dated 03/29/2021, revealed the Chief Nursing Officer (CNO) questioned as to why a note related to elder abuse was placed on the communication board and RN #3 stated she observed SRNA #4 flicking a wash cloth at Patient #1 on 03/28/2021 on video monitors. The investigation stated RN #3 reported that Patient #1 was already agitated and that SRNA #4 was making it worse by taunting the patient.

Interview with SRNA #1 on 04/13/2021 at 2:14 PM revealed she was working with SRNA #2 and SRNA #4 on 03/28/2021 around lunchtime with Patient #1. She stated that they had given him/her a bed bath and had transferred him/her from his/her bed to his/her Geri-chair with the mechanical lift. SRNA #1 stated Patient #1 was agitated and would not let go of the lift bar, she coaxed the patient's left hand from the bar and SRNA #4 "yanked" the bar out of his/her right hand.

Interviews with State Registered Nurse Aide (SRNA) #1 on 04/13/2021 at 2:14 PM, SRNA #2 on 04/16/2021 at 3:46 PM, SRNA #3 on 04/14/2021 at 10:27 AM revealed when Patient #1 was agitated, it sometimes took three (3) or four (4) staff to provide ADL care. They stated the patient had been at the facility for a long time, and most staff know when to get extra help when providing care to Patient #1.

Interview with the Chief Nursing Officer (CNO) on 04/14/2021 revealed nursing staff were responsible for initiating and revising patient care plans. She stated she did not routinely review patient care plans to ensure they were accurate and up to date. She stated the SRNAs print a report at the beginning of their shift on all patients and that it addresses whether the patient is independent/dependent with ADL care. She stated Patient #1's care plan did not address the amount of assistance he/she required with ADL care because staff were familiar with the patient and depending on the care they were giving three (3) or more staff might be required.