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Based on interview, record review, and review of facility policy it was determined the facility failed to ensure one (1) of ten (10) sampled patients was free from abuse (Patient #1). Interview with Patient #1 and the patient's roommate (unsampled Patient A) revealed on 01/11/17, Registered Nurse (RN) #1 yelled and threatened Patient #1. Interview with facility administrative staff revealed the RN was removed from caring for Patient #1 following the incident, but was reassigned to care for other patients.

The findings include:

Review of the facility policy, "Identifying Criteria for Abuse and Neglect," date unknown, revealed facility staff was to provide privacy, support, and safety to any patient that alleged that abuse, neglect, or exploitation had occurred.

Review of Patient #1's medical record revealed the facility admitted the patient on 01/07/17, with diagnoses including Atrial Fibrillation and Abdominal Pain. Further review of the patient's medical record revealed nursing assessments conducted on 01/11/17 revealed the patient was oriented to person, place, and time.

Interview with Patient #1 on 01/17/17 at 1:10 PM revealed on the morning of 01/11/17, the patient had activated the call light to request pain medication three (3) times. The patient stated RN #1 entered the patient's room and began "yelling" at the patient for requesting pain medication. The patient stated the RN used a "threatening" tone of voice and the patient was "scared."

Interview with Patient A on 01/17/17 at 2:21 PM revealed he/she had been the patient's roommate and was present when the incident occurred on 01/11/17. The patient stated he/she had overhead Patient #1 call out requesting pain medication "two or three" times on the morning of 01/11/17. Patient A stated RN #1 was observed to enter the room and state to Patient #1, "Don't you ever, ever call out and demand somebody to do something!" The patient stated the RN was "screaming" at Patient #1 and Patient A observed tears running down Patient #1's face after the incident occurred.

Interview with RN #1 on 01/17/17 at 2:36 PM revealed the RN denied yelling or threatening Patient #1 and stated he had given the patient pain medication when requested. RN #1 stated shortly after administering pain medication to the patient, he overheard Patient #1 call out again and request pain medication. RN #1 stated he heard Patient #1 state, "I want my meds; if you don't bring them I'm coming out to punch you in the face." The RN stated he spoke to the patient about not yelling or threatening the facility secretary. RN #1 stated Patient A's spouse came out into the hallway and stated she was going to report him/her for being verbally abusive to Patient #1. RN #1 stated at that time he was removed from Patient #1's care and reassigned to a different patient.

Interview with Patient #1's Family Member on 01/17/17 at 1:15 PM revealed the Family Member was not present at the facility when the incident occurred. However, Patient #1, Patient A, and Patient A's spouse made him aware of the incident approximately twenty (20) minutes after the incident occurred. The Family Member stated he requested that RN #1 no longer care for the patient. Further interview with the Family Member revealed Patient #1 had told him that RN #1 had been mean and rude, and yelled at him/her for asking for pain medication. Further interview with the Family Member revealed the concerns were reported to facility staff regarding the incident.

Interview with the Risk Manager on 01/17/17 at 5:10 PM revealed Family Member #1 had reported that he was "concerned for the patient's well-being" and was told by the patient's roommate and spouse that they had never heard staff speak to a patient or person the way RN #1 had spoken to Patient #1 prior to this incident. Further interview revealed Patient #1 reported that RN #1 had put his finger in the patient's face during the incident.

Interview with the Vice President on 01/17/17 at 5:30 PM revealed after the facility completed an investigation, they were unable to determine abuse had occurred. The Vice President stated the facility did not view the incident as abuse or neglect and stated they had done everything they were required to do. Further interview revealed the Vice President felt Patient #1 was protected because RN #1 had been removed from caring for the patient. However, the Vice President was unable to state how the facility protected other patients that were in the care of RN #1 from possible abuse.