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Based on observation, interview, and record review the facility failed to protect 1 (P-1) of 10 patients from abuse and failed to protect and promote the patients' right to a comprehensive grievance process, resulting in harm to P-1 and the potential for less than optimal outcomes for all patients served by the facility. Findings include:

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Failure to keep a grievance log and failure to respond to grievances received. (See A-0118)

Failure to provide care in a safe setting (See A-0144).

Based on interview and record review, the facility failed to maintain a current log of grievances, resulting in the failure to investigate, respond to, and resolve concerns within the facility and the failure to identify opportunities for improvement, resulting in less than optimal outcomes for all patients served by the facility. Findings include:

On 12/13/2023 a request was made for the complaints and grievance log for 8/1/2023 through 12/13/2023. On 12/14/2023 at 1100 during an interview with staff I, the Chief Operating Officer it was revealed the facility failed to keep a complaints and grievance log. Staff I stated, "We have been using the Office of Recipient Rights (ORR) log for complaints and grievances ...we have not had anyone in that position for a few months." Staff I was then asked how grievances received after a patient had been discharged from the hospital were handled. Staff I stated that they (facility) were in the process of hiring someone for that position. Staff I also stated that he was aware of the need for someone to help with complaints and grievances due to the volume of complaints that the ORR was receiving. Staff I was not able to provide any further documentation regarding the tracking, monitoring, resolution, and/or response to grievances.

Based on observation, interview, and record review the facility failed to provide care in a safe setting for 1 (P-1) of 10 patients on the developmentally delayed psychiatric unit resulting in the harm to P-1 and the potential for harm to all patients in the facility. Findings include:

On 12/13/2023 at 1054 while on tour of the 4-N unit designated for developmentally delayed patients P-1 was standing at the doorway of the activity room. P-1 was viewed having a resolving bruise of the left eye. P-1 was interviewed and asked what had occurred to cause his bruised eye. P-1 stated, "(Staff A) punched me." P-1 was then asked if staff A was another patient. P-1 replied, "No. He works here ...he punched me." P-1 was then asked if he was ok. P-1 replied, "Yes." P-1 was then asked when the incident occurred. P-1 responded, "it was a couple of days ago."

On 12/13/2023 at 1105 an interview occurred with staff D, the charge nurse for the unit. Staff D was queried if she was aware of the incident. Staff D replied, "I wasn't here during that time ...it happened on the night shift." Staff D continued, "I was the nurse in charge the next morning ...P-1 was found by (staff E) during the morning medication pass in the quiet room with a swollen eye. The incident was not reported to me during morning report." Staff D was then asked to explain the events of the morning of 12/7/2023 when P-1 was noted to have a swollen eye. Staff D stated a call was immediately placed to the nurse supervisor concerning P-1's injury. Staff D stated the nursing supervisor (staff J) then called the Director of Nursing, staff C. Staff D was then asked if staff A had returned to work since the occurrence. Staff D stated she only worked the day shift, but she had not seen staff A in the past week.

On 12/13/2023 1141 an interview was conducted with staff E, Licensed Practical Nurse (LPN). During the interview it was discovered that staff E has worked at the facility around three (3) years, and his role was mainly that of a medication nurse. Upon being queried regarding the incident in question Staff E stated, "I was working that day, but was not present. I do know that the patient received an injection and then was moved to the quiet room, this all occurred near shift end for me. When the patient (P-1) was assessed in the morning, he sat up, and his face was red, his eye was swollen, he couldn't even open his eye. I reported through text message, that I needed the charge nurse immediately. If I recall correctly, people were saying he (P-1) harmed himself, I knew he didn't do that to himself. After he was assessed by the charge nurse, I was asked to take P-1 for a portable X-Ray. Once the X-Ray was complete, there was an order for Motrin. The patient (P-1) was not sent to another facility for further evaluation." Review of P-1's records revealed there was no additional orders regarding treatment and/or monitoring of the patient regarding care post incident.

On 12/13/2023 at 1130 a request to review staff A's employee file was made. On 12/13/2023 at 1145 staff A's employee file was made available for review. Staff A's employee file contained a notice of suspension pending investigation dated 12/8/2023 in which the employee refused to sign. Staff A's employee file also had a notice of termination dated 12/13/2023. Review of the timesheet for 12/6/2023 showed staff A worked a night shift until 0700 on 12/7/2023 finishing his night shift assignment. Further review of the employee file indicated that staff A had been suspended on 6/14/2023 for allegations of physical abuse to a patient on 6/9/2023. Staff C the Director of Nursing was queried about the prior incident in June. Staff C stated that staff A was counseled and had repeated Crisis Prevention Intervention (CPI) training as a result of the ORR (Office of Recipient Rights) investigation after it was determined that staff A had used excessive force with a patient. Further documentation was requested for the incident on 6/9/2023. According to documentation a statement made by a former security guard employed there and who witnessed the incident on 6/9/2023 several staff told staff A to let go of the patient. The former security guard's statement to the Officer of Recipient Rights stated, "I told him (staff A) to let go ...you're going to break his arm." Review of staff A's timesheets after the 6/9/2023 incident showed that staff A worked assigned shifts on 6/10/2023 and 6/11/2023.

An interview with staff I, Chief Operating Officer occurred on 12/13/2023 at 1140. Staff I was asked if video footage of the incident was available for review. Staff I stated, "Yes. We have the video footage ...I will have security provide the video for review." On 12/13/2023 at 1410 review of the video footage occurred. Upon reviewing the video documentation of 12/6/2023 at 2052 staff B mental health technician was observed walking in the P-1's room and turned on the light. Staff A was observed standing in the far corner of the room in front of a patient bed. A shoe was then seen being thrown at staff A. Staff A was then observed rushing toward the patient bed and drawing back his right arm as to punch something. Staff B was noted to witness the incident and turned to walk out of the room. P-1 was not visualized at this time in the video. As staff B was walking out of the room three staff members were noted to be walking into the room, staff F mental health technician, staff M nurse manager, and staff P charge nurse. Staff B walked back into the room as well.

An interview with the Officer of Recipient Rights, staff H, was conducted on 12/13/2023 at 1445. Staff H was queried when she was made aware of the possible abuse incident with P-1. Staff H stated she was not aware of the incident until 12/7/2023 at around 1030. Staff H was queried when she was supposed to be contacted with possible incidents of abuse with harm. Staff H stated that she is supposed to be called immediately when the facility is aware of suspected harm. Staff H stated that staff were to call her immediately after notification to the administrator and the Director of Nursing. Staff H was asked to bring a log of complaints filed with the ORR. Staff H stated she did not have a log that was current. Staff H stated, "I have been busy investigating all the submissions by patients and the log is not current ...My log is current through the end of October." Staff H was then queried when she was made aware of the incident that occurred on June 9, 2023. Staff H stated, "It was the same ...I wasn't notified until days later." Staff H stated, "I just can't keep up with all the submissions especially when I have investigations to conduct like abuse ...it takes a lot of time and I am very thorough interviewing all parties involved."

An interview was conducted on 12/13/2023 at 1540 with staff M the nurse manager on duty on 12/6/2023. According to staff M P-1 was given an injection ordered by the physician for aggressive behavior. Staff M was queried if P-1 had made any statements about being punched and she stated, "No ...I did notice his face was red, but I didn't think anything of it because (P-1) has a history of self-destructive behavior." Staff M was queried what steps were necessary with allegations of abuse. Staff M was unable to verbalize the need to immediately report abuse to the Chief Nursing Officer and to ORR. Staff M was also unaware that any allegation of physical abuse required the accused employee to be immediately removed from patient care.

Review of facility policies did not specify ALL types of abuse (alleged or witnessed) are to be reported immediately. The policies do not address immediate removal of an alleged perpetrator from direct patient care for all types of abuse. As written, the policies fail to protect the patient from further abuse or other patients from abuse.

According to P-1 medical record on 12/6/2023 at 2200 a nursing progress note from staff P, "patient noted to be pacing the unit, agitated and aggressive. Pt (patient) became very agitated and aggressive towards staff and other pt. Pt destroyed his room by punching holes in his wall and also the hallway. Pt attacked staff physically. Pt was escorted to qt (quiet) room to redirect. Physician notified and orders initiated. Doctor ordered PRN medications for aggression and agitation. Doctor ordered Benadryl 100 mg IM, Ativan 2mg IM and Haldol 10 mg for agitation and aggression. Patient was given medications as ordered, and escorted to the quiet room. Within 30 minutes after medications was administered, patient observed resting in the quiet room. Patient will be monitored every 15 minutes for safety. Safety and well being maintained."

On 12/14/2023 at 1225 a telephone interview was conducted with Staff B, a Mental Health Technician. When queried regarding witnessing staff A's interactions with P-1, staff B denied seeing Staff A punch the patient. Upon further query Staff B stated, "I did see (P-1) throw a shoe at (Staff A). After he threw the shoe, they both charged at each other. That is when he (Staff A) picked him (P-1) up and threw him on the bed. He (Staff A) actually threw the patient against the nightstand, that's when I turned to get out. I was afraid, he (P-1) hit his head on the nightstand." At this point Staff B was asked if she was concerned for the patient's safety, and if she was concerned for her own safety. Staff B stated, "I knew that was not Crisis Prevention Intervention (CPI). That was nothing I was trained in CPI."
When staff B was asked if she alerted anyone else for help, or if she reported what she had witnessed, Staff B said she had not called for help, and she did not tell anyone what she saw. Staff B stated, "I didn't tell anyone what I saw because I was afraid. (Staff A) is 6'3" and weighs 390 pounds. I have worked with him about 6-7 months, and yes, I heard about another incident where he (staff A) was involved in the harm of another patient. Security was called and I heard that the security guard told (staff A) to let go of his arm, you're going to break it. Yeah, I guess I was scared, that's why I didn't report, we live in a small town, and you could run into people at the gas station or anywhere. I could be approached in the parking lot and there's no one out there to protect me."

On 12/14/2023 a request was made for staff A's current background check. The background check in staff A's employee file was made on 8/2013 for his previous employment at the facility. Staff A returned to the facility in September 2022 as an employee. No current background check could be provided for staff A's employment since September 2022. Staff I stated, "We have been without a consistent manager for the Human Resources Department for quite some time ...we have had 4 or 5 people in that position." Staff I was asked how an employee could work at the facility without a current background check prior to working with patients. Staff I agreed that employees are required to have a current background check prior to working with patients.

Based on the above findings, the facility failed to create a culture of safety where staff know how and when to report safety concerns, and failed to properly screen and monitor staff with behavioral concerns.