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Based on document review, policy review, medical record review, observation and interview, the hospital failed to promote a hospital wide system that ensures abuse prevention and protection for all patients.

The findings included:

The hospital failed to ensure all patients were protected from all forms of abuse.
Refer to A 145

Based on document review, policy review, medical record review, observation and interview, the facility failed to report allegations of abuse, and ensure measures were implemented to promote all patients' right to be free from abuse and harassment for 6 of 7 (Patients #1, 2, 3, 4, 5 and 6) sampled patients.

The findings included:

1. Review of the facility's "Allegation of Patient Abuse/Suspicion of Domestic Abuse or Neglect" policy revealed, "...It is the policy of [initials of hospital] to immediately and effectively investigate and resolve any allegations of patient abuse. This policy applies to any [name of hospital] personnel who discovers witnesses or receives information related to the suspicion of abuse/neglect of a patient. This policy also applies to any employee suspected of abuse/neglect of a patient...IV. Definitions, Characteristics, Indicators...Types of Abuse...Physical - Any inflicted injury by the patient or caregiver of a child/adult/geriatric patient...Verbal - Use of oral, written or gestured language that willfully includes disparaging and derogatory terms to patients or within their hearing distance, regardless of age, ability to comprehend or disability...Neglect - Involves acts of omission or failure to meet the basic needs of a child/adult/geriatric patient...Emotional - Failing to provide a nurturing environment in which an individual can fully develop emotionally and intellectually...Sexual - Any sexual activity or contact between a child and adult, whether by force or consent, any forced or unconsented sexual activity between adults...VI. Procedure...1. An investigation of the alleged perpetrator (employee, family member, and visitor) will be conducted by the manager/director in consultation with the Risk manager or Designee....For protection of the patient and employee, the employee should be suspended immediately pending investigation...H. The Risk Manager/Patient Safety Officer or designee makes notification to the Tennessee Department of Health in accordance with State guidelines for reporting..."

2. Medical record review revealed Patient #1 was a newborn who was admitted to the hospital on 8/12/17 and was discharged home on 8/21/17. Review of the 8/21/17 Discharge Summary revealed Patient #1 was admitted to the Neonatal Intensive Care Unit (NICU) with Respiratory Distress Syndrome after having been born prematurely at 36 weeks gestation.

Review of the hospital's abuse investigations revealed an incident had occurred on 8/18/17 on the 7:00 PM to 7:00 AM shift. The hospital's investigation documented at approximately 1:00 AM Witness #1 was looking through the window blinds of the NICU. Witness #1 observed RN #1 holding Patient #1 who was crying. Witness #1 reported RN #1 said to Patient #1, "Don't you start" and Patient #1 continued to cry. RN #1 then held Patient #1 up "face to face" and "said very harshly [to Patient #1] 'Shut up'". RN #1 then laid Patient #1 back into the crib.

In an interview on 10/11/17 at 7:45 AM in Conference Room #2, RN #2 stated she was working in the NICU during the incident with RN #1. RN #2 stated, "...She [RN #1] held the baby up to her face and said 'Shut up'. I think she was frustrated..." RN #2 stated she did not report the incident.

In a telephone interview on 10/12/17 at 9:25 AM Witness #1 stated he was looking through the window blinds of the NICU and RN #1 was "handling the baby [Patient #1] rough" and "held the baby up to her face and told the baby to 'Shut up' and 'Don't you start'." Witness #1 stated, "I tried to buzz back [call the NICU using the buzz system at the entry door] on the unit and tell them...Can I please tell you something. They wouldn't come to the door." Witness #1 stated, "I went to the ER [Emergency Room]...Spoke to 3 employees at the desk in the ER". Witness #1 stated he was told to call the Director of Women's Services (DOWS) on Monday. Witness #1 stated he left the DOWS a voice message on 8/20/17 and she returned the call on Monday 8/21/17.

In an interview on 10/10/17 at 2:00 PM in Conference Room #1 the Associate Chief Nursing Officer (ACNO) verified RN #1 also worked a shift the following night on 8/20/17 at 7:00 PM - 8/21/17 at 7:00 AM, after the incident with Patient #1 had occurred.

Review of the corrective actions taken by the hospital provided to this surveyor by the Risk Manager (RM) on 10/11/17 revealed there was no documentation of education or follow up with the 3 ER employees who Witness #1 had first reported the Incident to in order for the facility to start their investigation in order to protect the other patients in the NICU.

3. Medical record review for Patient #2 revealed the patient was admitted to the hospital's adolescent psychiatric unit on 12/15/16 and was discharged on 12/28/16. Review of the 12/28/16 Discharge Summary revealed Patient #2 was a 17 year old male, had the diagnoses of Substance-induced Psychosis and Disruptive Mood Dysregulation Disorder.

Review of the medical record for Patient #3 revealed the patient was admitted to the hospital's adolescent unit on 12/20/16 and was discharged on 12/28/16. Review of the 12/28/16 Discharge Summary revealed Patient #3 was a 17 year old female, had the diagnoses of Major Depressive Disorder, Conduct Disorder of Adolescent Onset, Post-Overdose of Xanax and Alcohol, Suicidal Ideations, Alcohol and Cannabis use.

Review of the medical record for Patient #4 revealed the patient was admitted to the hospital's adolescent unit on 12/19/16 and discharged on 12/29/16. Review of the 12/29/16 Discharge Summary revealed Patient #4 was a 15 year old female, had the diagnoses of Recurrent Major Depressive Disorder, Abuse Victim and Suicidal Ideations secondary to increased Depression.

Review of the hospital's abuse investigations revealed on 1/3/17 the hospital was informed of allegations that 2 male employees (Staff #1 and #2) had inappropriate sexual contact with an adolescent patient; promoted sexually inappropriate behaviors; and provided alcohol to adolescent patients. The allegations involved Patients #2, #3 and #4 on the hospital's adolescent psychiatric unit. The hospital terminated Staff #1 and #2 and notified the local Law Enforcement Agency (LEO) of the incident. The 2 staff members were arrested in July 2017 and charged with multiple counts of rape on a suicidal teen patient while they were employed at the hospital's adolescent psychiatric unit.

In an interview on 10/10/17 at 3:00 PM in Conference Room #1, the ACNO stated there was not a hospital policy preventing male staff members from entering a female patient's room without being accompanied by a female staff member, however, it was the hospital's standard of practice that a male staff member should not be alone with a female patient.

In an interview on 10/11/17 at 8:30 AM in the Behavioral Health Director's office, the ACNO stated employees on the adolescent psychiatric unit should not have their back pack, drinks or other personal items in the day room or patient areas.

Review of the hospital's video (no audio) recordings revealed the following at the approximated camera times:

On 12/23/16 at 10:16 PM Staff #1 goes into female adolescent Patient #4's room alone and comes out 3 1/2 minutes later. At 10:21 PM Staff #1 goes into adolescent male Patient # 2's room, escorts patient #2 into Patient 3's room and leaves Patient #2 and #3 in the room alone. At almost 10:26 PM Staff #1 goes back into Patient #3's room, escorts Patient #2 out of the room and takes him back to his room.

On 12/24/16 from 4:41 PM - 7:00 PM revealed Staff #2 has a Styrofoam drink cup and his back pack in the dayroom. During this time frame when the supper trays are being served Patient #2 is observed to be entering the dayroom and Patient #3 is observed to be exiting the day room. Patient #2 and #3 are observed to brush hands with each other as they pass in the dayroom door.

On 12/25/16 at 2:55 PM in the dayroom, Patient #2 and #3 were observed kissing each other.
At 3:02 PM Staff #2 and Patient #4 were observed in the back of the dayroom and then out of camera range.
At 3:03 PM both Staff #2 and Patient #4 came back into view of the camera in the back of the dayroom.
Observations of the dayroom on 10/12/17 at 8:40 AM revealed when they were out of camera range, the only area they could have been was in the dayroom closet, which is the only area out of camera view. This was verified by the Behavioral Health Director.

On 12/26/16 at 9:49 PM Staff #1 was observed taking a linen cart to Patient #2's room. Patient #2 walked beside the linen cart down the hallway, around the corner and entered Patient #3's room. At 10:08 PM Staff #1 entered Patient #3's room and immediately exits the room. At 10:09 PM Staff #2 re-entered Patient #3's room and escorted Patient #2 back to his room.

In a telephone interview on 10/13/17 at 12:00 PM, Lieutenant #1 with the LEO stated both of the accused (Staff #1 and #2) had admitted guilt of multiple counts of rape on a suicidal teen patient while they were employed at the adolescent unit of the hospital, and the case would be going to criminal court.

The hospital failed to ensure Patients #2, #3 and #4 were protected, measures implemented to ensure patients were free from abuse and all substantiated abuse was reported to the Department.

4. Medical record review of Patient #5 revealed the patient was admitted to the hospital's adult psychiatric unit on 7/24/17 and discharged on 8/24/17. Review of the 8/24/17 Discharge Summary revealed Patient #5 was a 58 year old female, had the diagnoses of Depression, Hypertension, Alcohol Abuse and Limited Social Involvement. The Discharge Summary revealed the patient had been admitted for increased agitation and confusion.

Review of the hospital's video (no audio) recording revealed on 7/28/17 at approximately 10:00 AM, Patient #5 was sitting in a chair in the common area of the unit. Patient #5 was seen reaching for an article on an empty chair beside her that appeared to be a red folder. Patient #5 picked up the red folder and was holding onto it. Staff #3 reached to get the red folder from Patient #5. Staff #3 and Patient #5 appeared to tug the red folder back and forth between them until Staff #3 took it from the patient. Patient #5 then reached over and tapped Staff #3 on the left arm. Staff #3 got up out of her chair reached toward her pocket, and then raised her left arm toward Patient #5.

Review of the facility's abuse investigations revealed on 7/28/17 LPN #3 witnessed Staff #3 take her ink pen out of her pocket, "...showed it to the patient [Patient #5]. [Name of Staff #3] told her, 'I will stick you in your damn eye with this pen...and 'our [your] eyeball will go rolling across the floor'..."

In an interview on 10/11/17 at 1:10 PM in the Conference Room #2, LPN #1 stated Staff #3 told Patient #5, "I'll stick you in the damn eye with this pen...your eye will go rolling across the floor." LPN #1 stated that she told a supervisor that she needed to talk with them, but was not able to at that time. LPN #1 stated she finally told a nurse at the end of the 3:00 PM shift.

The hospital failed to immediately respond to an allegation of abuse to ensure all the patients protected; and failed to report the substantiated abuse to the Department.

5. Medical record review revealed Patient #6 was admitted to the hospital's adolescent psychiatric unit on 6/01/17 and was discharged on 6/19/17. Review of the 6/19/17 Discharge Summary revealed Patient #6 was a 17 year old female, had the diagnoses of Disruptive Mood Dysregulation Disorder, Victim of Abuse and Posttraumatic Stress Disorder.

Review of the hospital's abuse investigations revealed on 6/10/17 about 9:00 PM the following statements regarding Staff #4, a hospital employed sitter:
A statement from Staff #6, "...[Names of Staff #4 and Patient #6] were standing right in front of each other [in the dayroom] screaming at one another. I [Staff #6]...attempted to separate them. When my attempts were unsuccessful, I physically inserted myself between the staff and patient...In the midst of the scuffle, [Name of Staff #4] forcefully poked the patient's right cheek...[Name of Staff #4] continued to provoke the patient...[Name of Staff #4] left her assigned patient to follow us [Staff #6 and Patient #6] out into the hallway to further incite the patient...[Name of RN #3]...had to say forcefully, 'You need to get back into the dayroom!' before [Name of Staff #4] complied..."
A statement from Patient #6, "...[Name of Staff #4] was trying to start something...[Staff #4] siad [said] I will beat your ass and that's [that's] when my staff had try to take me out [of the room] and the lady [Staff #4] kept trying to hit me...She [Name of Staff #4] grabbed my jaw and swessed [squeezed] it."

Review of the hospital's video (no audio) recording revealed on 6/10/17 at approximately 8:33 PM Patient #6 was standing in the dayroom when Staff #4 got out of a chair and approached the patient. The video showed Staff #6 then got of their chair and stood between Patient #6 and Staff #4, appearing to try and separate them. Staff #4 was seen raising her arm and striking toward Patient #6's face. During the video, Staff #6 is seen intervening and taking Patient #6 toward the exit door and into the hallway. Staff #4 is then seen walking towards the same exit door approaching Patient #6 again. Staff #5 was seen extending her arm in attempted to stop Staff #4 from following the patient. Staff #4 pushed Staff #5's arm out of the way and followed Patient #6 into the hallway. There were 3 times during the video recording where Staff #4 aggressively was seen lunging and swinging her arm towards and Patient #6.

In an interview on 10/12/17 at 7:40 AM in the Conference Room #2, RN #3 stated she received a telephone call to come to the dayroom hallway. When she arrived, Staff #6 was with Patient #6 in the hallway with his arms around the patient to calm her down. RN #3 stated, "...Then [Name of Staff #4] burst out of the dayroom, yelling and screaming and looked angry. I called a code [for assistance] to assist with a show of force [deescalate the situation]. [Name of Staff #4] was supposed to be with another patient...I called the supervisor to get [Name of Staff #4] replaced. [Patient #6] said she [Staff #4] grabbed her [the patient's] face. [Name of Staff #4] went back with her level [assigned patient] until replacement came".

After the incident, Staff #4 (a hospital employed sitter) was sent back to her assigned patient until a relief sitter was sent to replace Staff #4. The hospital failed to immediately protect the patients.

In an interview on 10/12/17 at 9:30 AM in Conference Room #2, the Risk Manager stated Staff #4 was terminated and no other actions were taken related to this incident as the actions were appropriate.
The hospital's investigation failed to identify the cause of Staff #4's verbal and physical abusive behaviors and implement actions to prevent further abuse.

Based on facility policy review, document review video observation, and interview, the hospital failed to ensure it maintained an effective and on-going Quality Assessment and Performance Improvement (QAPI) program that ensured patient safety and an environment free from abuse.

The findings included:

1. The facility failed to ensure the QAPI committee implemented appropriate preventative actions to prevent abuse.
Refer to A 0286

Based on document review, policy review, medical record review, video observation and interview, the hospital's Quality Assessment Performance Improvement (QAPI) Committee failed to ensure an ongoing hospital-wide program that identified, fully analyzed and addressed all allegations of abuse in order to promote and provide a safe patient environment for 6 of 7 (Patients #1, 2, 3, 4, 5 and 6) sampled patients reviewed with allegations of abuse.

The findings included:

1. Review of the hospital's "Allegation of Patient Abuse/Suspicion of Domestic Abuse or Neglect" policy revealed, "...It is the policy...to immediately and effectively investigate and resolve any allegations of patient abuse. This policy applies to any [name of hospital] personnel who discovers witnesses or receives information related to the suspicion of abuse/neglect of a patient. This policy also applies to any employee suspected of abuse/neglect of a patient...Types of Abuse...Physical - Any inflicted injury by the patient or caregiver of a child/adult/geriatric patient...Verbal - Use of oral, written or gestured language that willfully includes disparaging and derogatory terms to patients or within their hearing distance, regardless of age, ability to comprehend or disability...Neglect - Involves acts of omission or failure to meet the basic needs of a child/adult/geriatric patient...Emotional - Failing to provide a nurturing environment in which an individual can fully develop emotionally and intellectually...Sexual - Any sexual activity or contact between a child and adult, whether by force or consent, any forced or unconsented sexual activity between adults...VI. Procedure...1. An investigation of the alleged perpetrator (employee, family member, and visitor) will be conducted by the manager/director in consultation with the Risk manager or Designee....For protection of the patient and employee, the employee should be suspended immediately pending investigation...H. The Risk Manager/Patient Safety Officer or designee makes notification to the Tennessee Department of Health in accordance with State guidelines for reporting..."

2. Review of the hospital's abuse allegations investigations revealed on 8/20/17 a witness observed RN #1 holding a newborn baby, roughly and yelling at the baby to "Shut up." The witness unsuccessfully attempted to notify the nursery staff of what he had observed. The witness then notified employees of the hospital emergency department (ED) who failed to take the report, instead they asked the witness to contact the hospital on the following Monday to report his concerns. The hospital's investigation revealed there was no action taking for the employees failing to immediate respond and report allegations of abuse. There was no documentation the QAPI committee had identified any lack of inappropriate response to the substantiated abuse of the newborn baby.
Refer to A145.

3. Review of the hospital's abuse allegation investigations revealed on 1/3/17 the facility was informed of allegations that Staff #1 and #2 had sexual contact with a female adolescent female; promoted sexually inappropriate behaviors; and provided alcohol. The patients listed as the victims were Patients #2, #3 and #4 who were patients on the inpatient adolescent psychiatric unit.

Review of the hospital's video camera recordings revealed suspicious and inappropriate behaviors were conducted by Staff # and #2.

There was no documentation the QAPI committee had identified the inappropriateness of Staff #1 and #2 with all the victims, implemented a facility wide educational program, a facility wide monitoring program, and increased staff and patient awareness of signs of abuse and abuse prevention actions.
Refer to A145.


4. Review of the hospital's abuse allegation investigations revealed on 7/28/17 at approximately 10:30 AM, LPN #3 witnessed Staff #3 raising an ink pen towards Patient #5. Witnesses stated Staff #3 yelled at Patient #5 and said she would poke the patient's "damn eye with this pen...your eye will go rolling across the floor." The hospital's video recording revealed an incident had occurred between the staff and the patient. After the incident had occurred, the accused staff member was allowed to continue to work her shift. There was no documentation the QAPI committee intervened with a revised/updated action plan to ensure all staff were knowledgeable of the immediate staff requirements of alleged abuse to ensure patient safety.
Refer to A145.

5. Review of the hospital's abuse allegation investigations revealed on 6/10/17 Staff #4 had a verbal altercation with Patient #6 which eventually became physical when Staff #4 hit Patient #6. Medical record review revealed Patient #6 was an adolescent patient being treated on the psychiatric unit. Witnesses validated the incident had occurred. Management was aware of the incident. After the incident Staff #4 was sent back to her assigned patient, until a replacement for her could be found. There was no documentation the QAPI committee intervened with a revised/updated action plan to ensure all staff were knowledgeable of the immediate staff requirements of alleged abuse to ensure patient safety.
Refer to A145.

6. The QAPI committee had failed to re-evaluate its abuse prevention plan/procedures and ensure there was an active facility-wide culture of safety with all staff for the promotion of patient safety and prevention of abuse. The QAPI failed to ensure a plan was in place for increased monitoring of all patients and staff was implemented in order to evaluate the effectiveness of the hospital's abuse prevention/plan.