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Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure patients were free from abuse for one (1) of nine (9) sampled patients (Patient #1).

Although abuse was witnessed towards Patient #1 on 03/14/16 by two (2) staff members, the abuse was not reported to administrative staff and the perpetrator was not removed from patient care until 03/16/16, two (2) days later.

The findings include:

Review of the facility's "Incident Management: Protection of Patients for Abuse, Neglect, Exploitation, Harassment and Injury" Policy (Policy # MLI0010), undated, revealed "it is the responsibility of any staff member to make an immediate verbal report about an incident" to an immediate supervisor.

Review of the facility "General Hospital Orientation Assessment", signed by Mental Health Assistant (MHA) #2 on 04/09/14, and MHA #3 on 11/02/15, revealed a section that stated, "if I observe a situation that involves patient abuse or neglect I must ensure the patient is safe, notify my supervisor, and complete an Incident Report Form".

Review of Patient #1's medical record revealed the facility admitted him/her on 07/11/14 with a diagnosis of Advanced Huntington's Disease. Review of Physician's orders dated 03/12/16, revealed orders for the patient to be a two (2) staff person to one (1) patient level of supervision due to behaviors and being at risk for harm to others. Review of a Physician's Progress Note, dated 03/18/16 revealed the patient was non-verbal, only able to answer "yes or no" or "thumbs up or down". The Progress Note further described the Patient as "attempts to strike out towards staff."

Review of the Incident Report Form, completed by MHA #1, on 03/16/16 at 11:07 AM, revealed on 03/14/16 at times listed as: 8:30 AM-9:30 AM, 10:30 AM-11:30 AM, and 12:30 PM-1:30 PM an incident occurred in Patient #1's room. Per the Form, Patient #1 got up to attack MHA #2 and MHA #2 grabbed the patients wrist, made him/her stand up, then pushed him/her onto his/her bed. Further review, revealed MHA #2 would make fun of the patient for crying and told the patient if he/she acted up, he/she wasn't going for meals. Per the Form, MHA #2 also told the patient to learn how to speak better so they could understand him/her. Continued review, revealed MHA #1 and MHA #3 observed the incident. Further review, revealed MHA #1 was new and afraid to speak up, and MHA #3 pretty much ignored the situation.

Review of the facility "Report of Unusual Incident", completed by Risk Manager #1, revealed on the morning of 03/16/16 a staff member reported, on 03/14/16 at approximately 9:00 AM, the following incident was witnessed: patient #1 was in his/her bedroom and attacked MHA #2, MHA#2 then grabbed Patient #1's wrists, making Patient #1 stand up and then pushed the patient back onto his/her bed. Staff also reported MHA #2 made fun of Patient #1 for crying and stated if Patient #1 acted up, he/she wasn't going for meals. Also, MHA #2 made the statement to Patient #1 he/she needed to learn how to speak better. MHA #2 was immediately removed from patient care and Patient #1 was assessed. MHA #3 did not recall the incident.

Review of the Witness Statement Form, completed by MHA #3 on 03/18/16 at 9:38 AM, revealed on 03/14/16 at 8:30 AM, MHA #3, MHA #2, and MHA #1 were in Patient #1's room and MHA #2 was sitting close to the edge of the patient's bed. Further review revealed the patient got up on his/her elbows and asked for something and MHA #2 asked what he/she wanted. Per the Statement, Patient #1 again asked for something and MHA #2 asked again what the patient wanted. Patient #1 quickly moved forward and grabbed MHA #2's shirt and in the process MHA #2 grabbed the patient by the arms. The patient finally let go of MHA #2's shirt and now the patient was on the floor.

Further review of MHA #3's Witness Statement, revealed MHA #2 grabbed Patient #1 by the arms and the patient got on his/her knees and was trying to fight MHA #2. The patient was trying to stand up and was still fighting MHA #2 by trying to kick her. MHA #2 while holding the patients arms, pushed the patient to go back to bed and the patient laid down on his/her bed. MHA #2 still holding the patients arms, asked the patient what he/she wanted and the patient did not reply. MHA #2 let go of the patient and put a blanket on top of him/her. Before lunch about 12:30 PM, Patient #1 was making usual noises, and mumbling and MHA #2 made a comment, if he/she didn't behave he/she would not go for lunch.

Observation on 03/22/16 at 4:15 PM of Patient #1, revealed he/she was dressed in personal clothing, lying in a corner of his/her room on a padded floor mat. A second floor mat was lying adjacent to the first. Two (2) additional padded mats were positioned against walls, joining at the corner of the room where the patient was lying. Further observation, revealed two (2) MHA's were sitting in chairs across the room from the patient.

After surveyor request, the two (2) MHA's assisted Patient #1 into his/her wheelchair for an interview. When asked if anyone had recently pushed him/her down on his/her mat, the patient responded with his/her head lowered and uttered a barely audible "yes". When an attempt was made to ask a second interview question, the patient positioned his/her wheelchair facing the door to the hallway and began to maneuver herself towards the door. Patient #1 did not respond to any further interview questions.

Telephone Interview on 03/22/16 at 2:03 PM with MHA #1, revealed 03/14/16 was her first day assigned to patient care following classroom orientation, and MHA #2 was her preceptor. MHA #1 further revealed on 03/14/16 at 8:30 AM, she (MHA #1), MHA #2 and MHA #3 were assigned to supervise Patient #1 in the patient's room. Further interview revealed MHA #1 and MHA #3 were sitting in chairs across the room from where the patient was lying on his/her mat and MHA #2 was sitting in a chair at the foot of the patient's mat. MHA #1 stated, Patient #1 positioned himself/herself on his/her hands and knees at the foot of his/her mat and lunged at MHA #2. MHA #2 caught the patient by the wrists, and lifted the patient to a standing position and pushed him/her backwards down on the mat. MHA #1 further revealed Patient #1 began to cry and curled up in a ball. MHA #1 stated, MHA #2 then took a blanket and threw it on top of the patient.

Continued interview with MHA #1, revealed on 03/14/16 at 10:30 AM the three (3) MHA's were again supervising Patient #1, and Patient #1 began trying to attack MHA #2. MHA #1 stated Patient #1 kept losing his/her balance and falling on his/her mat. MHA #1 stated MHA #2 would laugh and say "that's what happens when you try to attack me". Per interview with MHA #1, MHA #2 also told Patient #1 he/she would not be getting lunch if he/she didn't start behaving.

Further interview with MHA #1, revealed after witnessing MHA #2's actions towards Patient #1, she was afraid to say anything since it was her first day following classroom orientation. However, MHA #1 stated, the following day, on 03/15/16 MHA #1 she decided what she had witnessed during her shift on 03/14/16 was something that needed to be reported. MHA #1 stated she was scheduled to be off duty on 03/15/16 and she decided to send an email to Unit Manager #1 informing the supervisor he/she needed to talk, but did not provide any details of the the actions of MHA #2 in the email. MHA #1 revealed her supervisor set up a meeting for the next morning, and on the morning of 03/16/16, MHA #1 informed Unit Manager #1 what she witnessed between MHA #2 and Patient #1 on the morning of 03/14/16.

Telephone interview was attempted on 03/22/16 at 2:30 PM and again at 3:30 PM with MHA #3. Neither the first nor the second telephone call was answered.

Telephone interview on 03/22/16 at 3:34 PM with MHA #2 revealed on the morning of 03/14/16 Patient #1 was being combative with her and MHA #2 was scratched on the chest during the incident. Further interview revealed during the attack Patient #1 shuffled himself/herself over to the bed which was a mat on the floor and flopped himself/herself down. MHA #2 stated she was holding Patient #1's hands while the patient was shuffling his/her feet to the mat to prevent the patient from attacking her. MHA #2 stated when Patient #1 reached the bed/mat, he/she flopped himself/herself down. Continued interview revealed MHA #1 and MHA #3 did not physically interact during this incident.

Telephone interview on 03/22/16 at 2:37 PM with the Unit Manager where Patient #1 resided, revealed MHA #1 had sent her an e-mail on 03/15/16 saying she needed to talk to her about something that was bothering her but no details were provided in the e-mail. The Unit Manager stated she met with MHA #1 on 3/16/16, and MHA #1 informed her of what she had observed on 03/14/16. The Unit Manager stated after she learned of this incident, MHA #2 was immediately removed from the unit. Further interview revealed she went to the shift coordinator about the incident, and both she and the shift coordinator reported the incident to the Risk Manager for investigation. She revealed the allegation of abuse towards Patient #1 should have been reported immediately on 03/14/16.

Interview on 03/21/16 at 4:53 PM with Risk Manager #2, revealed upon becoming aware of the possible abuse situation on 03/16/16, MHA #2 was immediately removed from the unit and placed on suspension pending results of the facility's internal investigation.

Interview on 03/22/16 at 2:52 PM, with Risk Manager #1, revealed she conducted an interview with MHA #3 on 03/18/16. The Risk Manager reported MHA #3 described he/she did not believe the interactions witnessed on 03/14/16 between MHA # 2 and patient # 1 was a possible abuse situation. Risk Manager # 1 reported after reading MHA #3's written Witness Statement, he/she felt the the facility needed to provide abuse reporting re-education to MHA #3. Risk Manager #1 revealed this abuse allegation should have been reported immediately.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure patients were free from abuse for one (1) of nine (9) sampled patients (Patient #1).

Although abuse was witnessed towards Patient #1 on 03/14/16 by two (2) staff members, the abuse was not reported to administrative staff and the perpetrator was not removed from patient care until 03/16/16, two (2) days later.

The findings include:

Review of the facility's "Incident Management: Protection of Patients for Abuse, Neglect, Exploitation, Harassment and Injury" Policy (Policy # MLI0010), undated, revealed "it is the responsibility of any staff member to make an immediate verbal report about an incident" to an immediate supervisor.

Review of the facility "General Hospital Orientation Assessment", signed by Mental Health Assistant (MHA) #2 on 04/09/14, and MHA #3 on 11/02/15, revealed a section that stated, "if I observe a situation that involves patient abuse or neglect I must ensure the patient is safe, notify my supervisor, and complete an Incident Report Form".

Review of Patient #1's medical record revealed the facility admitted him/her on 07/11/14 with a diagnosis of Advanced Huntington's Disease. Review of Physician's orders dated 03/12/16, revealed orders for the patient to be a two (2) staff person to one (1) patient level of supervision due to behaviors and being at risk for harm to others. Review of a Physician's Progress Note, dated 03/18/16 revealed the patient was non-verbal, only able to answer "yes or no" or "thumbs up or down". The Progress Note further described the Patient as "attempts to strike out towards staff."

Review of the Incident Report Form, completed by MHA #1, on 03/16/16 at 11:07 AM, revealed on 03/14/16 at times listed as: 8:30 AM-9:30 AM, 10:30 AM-11:30 AM, and 12:30 PM-1:30 PM an incident occurred in Patient #1's room. Per the Form, Patient #1 got up to attack MHA #2 and MHA #2 grabbed the patients wrist, made him/her stand up, then pushed him/her onto his/her bed. Further review, revealed MHA #2 would make fun of the patient for crying and told the patient if he/she acted up, he/she wasn't going for meals. Per the Form, MHA #2 also told the patient to learn how to speak better so they could understand him/her. Continued review, revealed MHA #1 and MHA #3 observed the incident. Further review, revealed MHA #1 was new and afraid to speak up, and MHA #3 pretty much ignored the situation.

Review of the facility "Report of Unusual Incident", completed by Risk Manager #1, revealed on the morning of 03/16/16 a staff member reported, on 03/14/16 at approximately 9:00 AM, the following incident was witnessed: patient #1 was in his/her bedroom and attacked MHA #2, MHA#2 then grabbed Patient #1's wrists, making Patient #1 stand up and then pushed the patient back onto his/her bed. Staff also reported MHA #2 made fun of Patient #1 for crying and stated if Patient #1 acted up, he/she wasn't going for meals. Also, MHA #2 made the statement to Patient #1 he/she needed to learn how to speak better. MHA #2 was immediately removed from patient care and Patient #1 was assessed. MHA #3 did not recall the incident.

Review of the Witness Statement Form, completed by MHA #3 on 03/18/16 at 9:38 AM, revealed on 03/14/16 at 8:30 AM, MHA #3, MHA #2, and MHA #1 were in Patient #1's room and MHA #2 was sitting close to the edge of the patient's bed. Further review revealed the patient got up on his/her elbows and asked for something and MHA #2 asked what he/she wanted. Per the Statement, Patient #1 again asked for something and MHA #2 asked again what the patient wanted. Patient #1 quickly moved forward and grabbed MHA #2's shirt and in the process MHA #2 grabbed the patient by the arms. The patient finally let go of MHA #2's shirt and now the patient was on the floor.

Further review of MHA #3's Witness Statement, revealed MHA #2 grabbed Patient #1 by the arms and the patient got on his/her knees and was trying to fight MHA #2. The patient was trying to stand up and was still fighting MHA #2 by trying to kick her. MHA #2 while holding the patients arms, pushed the patient to go back to bed and the patient laid down on his/her bed. MHA #2 still holding the patients arms, asked the patient what he/she wanted and the patient did not reply. MHA #2 let go of the patient and put a blanket on top of him/her. Before lunch about 12:30 PM, Patient #1 was making usual noises, and mumbling and MHA #2 made a comment, if he/she didn't behave he/she would not go for lunch.

Observation on 03/22/16 at 4:15 PM of Patient #1, revealed he/she was dressed in personal clothing, lying in a corner of his/her room on a padded floor mat. A second floor mat was lying adjacent to the first. Two (2) additional padded mats were positioned against walls, joining at the corner of the room where the patient was lying. Further observation, revealed two (2) MHA's were sitting in chairs across the room from the patient.

After surveyor request, the two (2) MHA's assisted Patient #1 into his/her wheelchair for an interview. When asked if anyone had recently pushed him/her down on his/her mat, the patient responded with his/her head lowered and uttered a barely audible "yes". When an attempt was made to ask a second interview question, the patient positioned his/her wheelchair facing the door to the hallway and began to maneuver herself towards the door. Patient #1 did not respond to any further interview questions.

Telephone Interview on 03/22/16 at 2:03 PM with MHA #1, revealed 03/14/16 was her first day assigned to patient care following classroom orientation, and MHA #2 was her preceptor. MHA #1 further revealed on 03/14/16 at 8:30 AM, she (MHA #1), MHA #2 and MHA #3 were assigned to supervise Patient #1 in the patient's room. Further interview revealed MHA #1 and MHA #3 were sitting in chairs across the room from where the patient was lying on his/her mat and MHA #2 was sitting in a chair at the foot of the patient's mat. MHA #1 stated, Patient #1 positioned himself/herself on his/her hands and knees at the foot of his/her mat and lunged at MHA #2. MHA #2 caught the patient by the wrists, and lifted the patient to a standing position and pushed him/her backwards down on the mat. MHA #1 further revealed Patient #1 began to cry and curled up in a ball. MHA #1 stated, MHA #2 then took a blanket and threw it on top of the patient.

Continued interview with MHA #1, revealed on 03/14/16 at 10:30 AM the three (3) MHA's were again supervising Patient #1, and Patient #1 began trying to attack MHA #2. MHA #1 stated Patient #1 kept losing his/her balance and falling on his/her mat. MHA #1 stated MHA #2 would laugh and say "that's what happens when you try to attack me". Per interview with MHA #1, MHA #2 also told Patient #1 he/she would not be getting lunch if he/she didn't start behaving.

Further interview with MHA #1, revealed after witnessing MHA #2's actions towards Patient #1, she was afraid to say anything since it was her first day following classroom orientation. However, MHA #1 stated, the following day, on 03/15/16 MHA #1 she decided what she had witnessed during her shift on 03/14/16 was something that needed to be reported. MHA #1 stated she was scheduled to be off duty on 03/15/16 and she decided to send an email to Unit Manager #1 informing the supervisor he/she needed to talk, but did not provide any details of the the actions of MHA #2 in the email. MHA #1 revealed her supervisor set up a meeting for the next morning, and on the morning of 03/16/16, MHA #1 informed Unit Manager #1 what she witnessed between MHA #2 and Patient #1 on the morning of 03/14/16.

Telephone interview was attempted on 03/22/16 at 2:30 PM and again at 3:30 PM with MHA #3. Neither the first nor the second telephone call was answered.

Telephone interview on 03/22/16 at 3:34 PM with MHA #2 revealed on the morning of 03/14/16 Patient #1 was being combative with her and MHA #2 was scratched on the chest during the incident. Further interview revealed during the attack Patient #1 shuffled himself/herself over t