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Based on document review and interview, it was determined that the Hospital failed to conduct a thorough abuse investigation following a staff to patient abuse allegation. This potentially places all 44 patients on census and future patients at risk for serious harm. As a result, the Condition of Participation, 42 CFR 482.13 Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to conduct a thorough abuse investigation following a staff to patient abuse allegation. (A145-A).

An Immediate Jeopardy (IJ) began on 4/13/19, for the Hospital's failure to conduct a thorough abuse investigation, thus potentially placing all 44 patients on census, at risk for serious harm or injury.

The IJ was identified and announced on 4/18/19 at 2:22 PM, during a meeting with the Chief Clinical Officer, Clinical Nurse Manager, Director of Radiology, Respiratory, and Laboratory, Pharmacy Director, Director of Case Management, Wound Care Coordinator, Dietician, Clinical Educator, Rehabilitation Manager, Infection Control Manager, Vice President of Quality Systems and Accreditation, Senior Director of Clinical Operations, Vice President of Operations and Care Coordination, and Interim Chief Executive Officer. The IJ was not removed by the survey exit date of 4/18/19.

Also, the condition of Patient Rights is not met as evidenced by:

2. The Hospital failed to maintain employee suspension while conducting an abuse investigation. (A145-B)

3. The Hospital failed to immediately report an abuse allegation to the state agency. (A145-C)

A. Based on document review and interview it was determined that for 2 (Pt. #1, Pt. #3) of 5 patients reviewed for pressure ulcer treatment, the Hospital failed to ensure that the patients were turned and repositioned every 2 hours per physician order. This has the potential to affect 2 patients (Pt. #1 and Pt. #3) who are recieving pressure ulcer treatment.

Findings include:
1. On 04/17/19 at approximately 12:30 PM, the Hospital policy titled, "Prevention and Treatment of Pressure Ulcers and Non-Pressure Related Wounds" (effective 06/2016) was reviewed. The policy included, "6. Preventative and healthy skin care interventions are utilized and may include but not limited to: a. Reduce pressure, friction and shear. i. Repositioning at intervals determined per patient's risk level and condition. ii. High risk patients are turned at a minimum of every 2 hours."

2. The clinical record of Pt #1 was reviewed on 04/17/19. Pt #1 was a 63 year old male who was admitted to the Hospital on 04/06/19 at 2:10 PM, with diagnoses of acute stroke, end stage renal disease (ESRD) and for maintaining the anticoagulation levels.

- The physician order dated 04/06/19 at 4:00 PM included, "Apply turning wedge; apply pillow between knees and legs; document if patient clean/cleaned, turning and repositioning q2h (every two hours)."

- The nursing notes dated 04/06/19 at 4:00 PM included, "Repositioning: Apply turning wedge, place pillow between knees and legs, document if clean/cleaned. Pt. (Pt. #1) turned to the right side." At 8:00 PM, "Repositioning: ...Pt. (Pt. #1) turned to the left side." Duration of time lapsed for repositioning: 4.0 (four) hours.

- The nursing notes dated 04/07/19 at 6:00 AM included, "Repositioning: Apply turning wedge, place pillow between knees and legs, document if clean/cleaned. Pt. (Pt. #1) turned to the right side." At 9:00 AM, "Repositioning: ...Pt. (Pt. #1) turned to the left side." Duration of time lapsed for repositioning: 3.0 (three) hours.

- The nursing notes dated 04/07/19 at 12:00 PM included, "Repositioning: Apply turning wedge, place pillow between knees and legs, document if clean/cleaned. Pt. (Pt. #1) turned to the left side." At 8:00 PM, "Repositioning: ...Pt. (Pt. #1) turned to the right side." Duration of time lapsed for repositioning: 8.0 (eight) hours.

- The nursing notes dated 04/08/19 at 6:12 AM included, "Repositioning: Apply turning wedge, place pillow between knees and legs, document if clean/cleaned. Pt. (Pt. #1) turned to the right side." At 2:12 PM included, "Repositioning: ...Pt. (Pt. #1) turned to the right side." Duration of time lapsed for repositioning: 8.0 (eight) hours.

- The nursing notes dated 04/09/19 at 10:48 AM included, "Repositioning: Apply turning wedge, place pillow between knees and legs, document if clean/cleaned. Pt. (Pt. #1) turned to the left side." At 2:13 PM included, "Repositioning: ...Pt. (Pt. #1) turned to supine position." Duration of time lapsed for repositioning: 3.0 (three) hours 12 (twelve) minutes.

- The nursing notes dated 04/09/19 at 4:00 PM included, "Repositioning: Apply turning wedge, place pillow between knees and legs, document if clean/cleaned. Pt. (Pt. #1) turned to the left side." On 04/10/19 at 8:00 AM included, "Repositioning: ...Pt. (Pt. #1) turned to right side." Duration of time lapsed for repositioning: 16 (sixteen) hours.

- The nursing notes dated 04/10/19 at 6:04 PM included, "Repositioning: Apply turning wedge, place pillow between knees and legs, document if clean/cleaned. Pt. (Pt. #1) turned to supine position." On 04/11/19 at 11:42 AM included, "Repositioning: ...Pt. (Pt. #1) turned to right side." Duration of time lapsed for repositioning: 11 (eleven) hours 38 (thirty eight) minutes.

- The physical therapy note dated 4/11/19 at 4:29 PM included, " ...Bed mobility, rolls side to side, with mod [moderate] A [assistance] X 1 [one person], with verbal cues, with guard rails, with visual cues, with tactile cues ..."

3. The clinical record of Pt #3 was reviewed on 04/17/19. Pt #3 was a 26 year old male who was admitted to the Hospital on 04/04/19 at 5:38 PM, with diagnoses of sacro-osteomyelitis (inflammation of the spinal bone) and gunshot wound.

- The physician order dated 04/04/19 at 8:21 PM included, "Apply turning wedge; apply pillow between knees and legs; document if patient clean/cleaned, turning and repositioning q2h (every two hours)."

- The nursing notes dated 04/08/19 at 4:00 PM included, "Repositioning: Apply turning wedge, place pillow between knees and legs, document if clean/cleaned. Pt. (Pt. #3) turned to the right side." At 8:00 PM included, "Repositioning: ...Pt. (Pt. #3) turned to the right side." Duration of time lapsed for repositioning: 4.0 (four) hours.

- The nursing notes dated 04/09/19 at 4:00 AM included, "Repositioning: Apply turning wedge, place pillow between knees and legs, document if clean/cleaned. Pt. (Pt. #3) turned to the right side." At 9:00 AM included, "Repositioning: ...Pt. (Pt. #3) turned to left side." Duration of time lapsed for repositioning: 5.0 (five) hours.

- The nursing notes dated 04/10/19 at 4:00 AM included, "Repositioning: Apply turning wedge, place pillow between knees and legs, document if clean/cleaned. Pt. (Pt. #3) turned to the right side." At 8:00 AM included, "Repositioning: ...Pt. (Pt. #3) turned to the right side." Duration of time lapsed for repositioning: 4.0 (four) hours.

4. On 04/17/19 at approximately 2:00 PM, an interview was conducted with the Wound Care Coordinator (E #4). E #4 stated, "Patients on pressure ulcer treatment must be turned every two (2) hours. If they are not turned, there is a risk of developing new pressure wounds and worsening of the existing pressure wounds."

5. On 04/17/19 at approximately 2:30 PM, an interview was conducted with the CNA (E #5). E #5 stated, "I forgot to document the turning and repositioning in patient's chart. The pressure sore will get worsened if the patient is not repositioned every two hours."

6. On 04/18/19 at approximately 12:10 PM, an interview was conducted with the Chief Clinical Officer (E #1). E #1 stated, "I was surprised looking into the gaps in turning and repositioning of patients with pressure injury."



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B. Based on document review, observation and interview it was determined that for 1 of 6 patients (Pt. #2) reviewed for call lights, the Hospital failed to ensure that the call light was accessible to the patient and operational.

Findings include:

1. On 4/18/19, the Hospital's policy titled, "Patient Call Devices" (dated 06/2018) was reviewed. The policy included, " ...a. Assure that there is a functional call light easily accessible by the patient ...1. When rounding/interacting with patient staff shall: a. Verify that the patient's call device is easily accessible for use ..."

2. On 4/17/19 from 9:35 AM - 10:20 AM, an observational tour of the 2nd floor was conducted. At approximately 9:45 AM, during the observational tour, with the Director of Radiology, Laboratory and Respiratory (E #6), Pt. #2's call light was noticed unplugged from the wall. Pt. #2 was in need of staff assistance but the call light was not functional to allow Pt. #2 to call for assistance.

3. On 4/17/19 at approximately 9:45 AM, an interview was conducted with E #6. E #6 stated that the call light was not plugged into the wall.

4. On 4/17/19 at approximately 9:45 AM, E #6 plugged the call light into the wall and told Pt. #2 that she (Pt. #2) could now use the call light to call for assistance.

A. Based on document review and interview, it was determined that for 1 of 6 (Pt. #1) records reviewed for abuse allegations, the Hospital failed to ensure that a thorough investigation was conducted following a staff to patient abuse allegation. This has the potential to affect all current and future patients in the Hospital.

Findings include:

1. On 4/17/19, the Hospital's policy titled, "Abuse of Patient, Elder, Child by Staff Identification - Response and Reporting" (dated 10/2018) was reviewed. The policy included, "Investigation Guidelines ...3.f. Investigate all other possible sources of information relating to the incident and/or the persons involved ..."

2. On 4/17/19, Pt. #1's medical record was reviewed. Pt. #1 was a 63 year old male who was admitted to the Hospital with a diagnosis of cerebral infarction. Pt. #1's Physician progress note dated 4/14/19 at 11:01 PM, included, "Patient and his family have filed an abuse complaint. Per them [patient and family], he [Pt. #1] was abused by a staff member yesterday [4/13/19] ...patient [Pt. #1] accuses a staff member (CNA/Certified Nursing Assistant) [E #2] of ...roughly grabbing his [Pt. #1] leg, and twisting it."

3. On 4/17/19, the Hospital's patient and family complaint/grievance report form was reviewed.
- The complaint/grievance intake dated 4/13/19 at 11:45 AM, included, "...I [E #3] asked the patient [Pt. #1] why he [Pt. #1] was upset and he stated 'he's [E #2] mean'...The spouse [Z #1] then stated 'I do not want him [E #2] to return'.."
- The administrative follow-up dated 4/15/19, included, "CCO [Chief Clinical Officer] came to meet the family on 4/14/19 at 1030 [10:30 PM] following a call from NS [Nursing Supervisor/E #9] stating wife alleges abuse. Wife [Z #1] states she thinks [E #1] was abused by [E #2] on 4/13/19. She [Z #1] states when she came in at 1200 [12:00 PM] on Saturday she found [Pt. #1] crying and shaking his [Pt. #1] head stating that 'he hurt me', indicating [E #2]. She states he [E #2] was verbally threatening and that he [E#2] twisted his [Pt. #1's] leg causing increased pain and that she [Z #1] is concerned about his [Pt. #1] safety..."
- A telephone interview with E #2 dated 4/15/19, included, "..E #3 [Nursing Supervisor] came and told me that [Pt. #1] said 'I was mean' and [Pt. #1] said 'I was in control now and you can't use the call light anymore'. I supposedly 'roughed him up'..."
- The follow-up by E #1 included, "Met with [Pt. #1] on 4/15...I [E #1] advised [Pt. #1] that [E #2] would be in the building tomorrow...He [Pt. #1] indicated he thought that may be problematic..."
- The follow-up by E #1 included, "Met with wife [Z #1] on 4/16 at 0820 [8:20 AM] and told her that [E #2] would be back in the building...she [Z #1] stated she was anxious..."
- The follow-up by E #1 included, "Met with [E #2] on 4/16/19 at 0830 [8:30 AM] and told him that he was being accused of abusing the patient [Pt. #1] I obtained his explanation of the event..."
- The Hospital's Patient and Family Complaint/Grievance report form dated 4/13/19 - 4/16/19, lacked interviews with any staff members involved in Pt. #1's care on 4/13/19, with the exception of the Certified Nursing Assistant (CNA/E #2), who was accused of abusing Pt. #1.

4. On 4/17/19 at approximately 1:00 PM, an interview with the Chief Clinical Officer (E #1) was conducted. E #1 stated that on 4/14/19 E#2 was notified of his suspension and instructed not to report to work on 4/15/19. E #1 stated the abuse investigation was completed on 4/15/19 at 5:30 PM and E #2 was allowed to return to work because it was determined that there was no intentional abuse. E #1 stated that the investigation was complete but other staff may need to be interviewed.

B. Based on document review, observation and interview it was determined that the Hospital failed to maintain employee suspension while conducting an abuse investigation.

Findings include:

1. On 4/17/19, the Hospital's policy titled, "Abuse of Patient, Elder, Child by Staff Identification - Response and Reporting" (dated 10/2018) was reviewed. The policy included, "...Immediate action measures may include, but are not limited to: suspension of an employee involved in the abuse allegation...The employee may be suspended during the investigation..."

2. On 4/17/19, Pt. #1's medical record was reviewed. Pt. #1 was a 63 year old male who was admitted to the Hospital with a diagnosis of cerebral infarction.
- Pt. #1's Physician progress note dated 4/14/19 at 11:01 PM, included, "Patient and his family have filed an abuse complaint. Per them [patient and family], he [Pt. #1] was abused by a staff member yesterday [4/13/19] ...patient [Pt. #1] accuses a staff member (CNA/Certified Nursing Assistant) [E #2] of ...roughly grabbing his [Pt. #1] leg, and twisting it.

3. On 4/17/19, the Hospital's patient and family complaint/grievance report form was reviewed.
- The complaint/grievance intake dated 4/13/19 at 11:45 AM, included, "...I [E #3] asked the patient [Pt. #1] why he [Pt. #1] was upset and he stated 'he's [E #2] mean'...The spouse [Z #1] then stated 'I do not want him [E #2] to return'.."
- The administrative follow-up dated 4/15/19, included, "CCO [Chief Clinical Officer] came to meet the family on 4/14/19 at 1030 [10:30 PM] following a call from NS [Nursing Supervisor/E #9] stating wife alleges abuse. Wife [Z #1] states she thinks [E #1] was abused by [E #2] on 4/13/19. She [Z #1] states when she came in at 1200 [12:00 PM] on Saturday she found [Pt. #1] crying and shaking his [Pt. #1] head stating that 'he hurt me', indicating [E #2]. She states he [E #2] was verbally threatening and that he [E#2] twisted his [Pt. #1's] leg causing increased pain and that she [Z #1] is concerned about his [Pt. #1] safety..."
- A telephone interview with E #2 dated 4/15/19, included, "..E #3 [Nursing Supervisor] came and told me that [Pt. #1] said 'I was mean' and [Pt. #1] said 'I was in control now and you can't use the call light anymore'. I supposedly 'roughed him up'..."
- The follow-up by E #1 included, "Met with [Pt. #1] on 4/15...I [E #1] advised [Pt. #1] that [E #2] would be in the building tomorrow...He [Pt. #1] indicated he thought that may be problematic..."
- The follow-up by E #1 included, "Met with wife [Z #1] on 4/16 at 0820 [8:20 AM] and told her that [E #2] would be back in the building...she [Z #1] stated she was anxious..."
- The follow-up by E #1 included, "Met with [E #2] on 4/16/19 at 0830 [8:30 AM] and told him that he was being accused of abusing the patient [Pt. #1] I obtained his explanation of the event..."
- The Hospital's Patient and Family Complaint/Grievance report form dated 4/13/19 - 4/16/19, lacked interviews with any staff members involved in Pt. #1's care on 4/13/19, with the exception of the Certified Nursing Assistant (CNA/E #2), who was accused of abusing Pt. #1.

4. On 4/17/19 at 9:30 AM, during an observational tour on the 2nd floor Medical/Surgical Unit, the Certified Nursing Assistant (E #2) was observed walking through the corridor.

5. On 4/17/19 at approximately 1:00 PM, an interview with the Chief Clinical Officer (E #1) was conducted. E #1 stated that on 4/14/19, E#2 was notified of his suspension and instructed not to report to work on 4/15/19. E #1 stated the abuse investigation was completed on 4/15/19 at 5:30 PM and E #2 was allowed to return to work because it was determined that there was no intentional abuse. E #1 stated that the investigation was complete but other staff may need to be interviewed.

6. On 4/18/19 at 8:58 AM, an interview with the Chief Executive Officer (E #8) was conducted. E #8 stated that the investigation is ongoing and the Hospital is still in the process of gathering information. E #8 stated that E #2 should not have been allowed to return to work until the abuse investigation was complete.


C. Based on document review and interview it was determined that for 1 of 6 abuse allegations reviewed, the Hospital failed to ensure that the state agency was notified of the allegation.

Findings include:

1. On 4/17/19, the Hospital's policy titled, "Abuse of Patient, Elder, Child by Staff Identification - Response and Reporting" (dated 10/2018), was reviewed. The policy included, " ...Policy 3. The Hospital maintains a strict policy to prevent or respond to allegations of abuse, neglect or mistreatment, including prompt reporting of any alleged abuse incident to hospital leaders and applicable state agencies ..."

2. On 4/17/19, the Hospital's patient and family complaint/grievance report form was reviewed. The report form indicated that, on 4/14/19 at 10:30 PM, the Chief Clinical Officer (E #1) received a call from the Nursing supervisor regarding a staff to patient abuse allegation from Pt. #1 and family.

3. On 4/17/19 at approximately 1:00 PM, an interview with the Chief Clinical Officer (E #1) was conducted. E #1 stated that the abuse allegation was not reported to the state agency. E #1 stated that it did not '"click" that this was abuse until the complaint started to escalate.

4. On 4/18/19 at approximately 8:58 AM, an interview with the Chief Executive Officer (E #8) was conducted. E #8 stated that any abuse allegations should be reported to the state agency within 24 hours.