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Based on interview and document review the facility failed to protect the rights of patients current and discharged, placing all 149 current patients at risk for loss of their rights.

1. The facility failed to have the appropriate contact information for the Quality Improvement Organization contact information for five of five (#5, 7, 10, 11, 13) the appeal of discharge from the facility. See tag A117.

2. The facility failed to maintain a safe environment free from harassment and abuse for patients to receive care. See tag A145.

Based on document review and interview the facility failed to ensure the Important Message from Medicare (IMM) was accurate with information in order for patients to call and appeal discharge from the hospital for five of five (#5, 7, 10, 11, 13) medical records reviewed for IMM, from a total sample of 19, resulting in the potential for denying all discharged and current Medicare patients their patient rights. Findings include:

On 12/12/2017 at 1032 during document review of Patient #11 medical record it was revealed the IMM being used listed the Quality Improvement Organization (QIO) as MPRO, instead of the correct QIO which is KEPRO. KEPRO was designated the QIO for facilities in this geographic region in 2014. On 12/12/2017 at 1045 staff F was queried as to if the document was the current information given to all Medicare patients about their right to appeal discharge from the facility. Staff K confirmed the sheet was the current sheet used for all Medicare patients. It should be noted that a telephone call was placed to the number provided for MPRO and was connected to a retail company.

Based on document review, and interview the facility failed to maintain a setting free from harassment and abuse for one of four (#1) patients reviewed for adverse events resulting in to potential to deny all 149 patients their patient rights. Findings include:

On 12/11/2017 at 1100 during document review of the adverse event log it was revealed patient #1 was documented as having an altercation on 11/18/2017 at 2220. A video segment was available to view of the event. On 12/11/2017 at 1405 the video from 11/18/2017 starting at 2217 was reviewed. On 11/18/2017 at 2217 the patient (#1) was viewed in the patient activity area watching TV. The patient was observed watching a football game and was viewed turning to converse with staff G the resident care associate (RCA #1). The patient was observed to be the only patient in the area and was also observed to have his arm in a sling from his previous altercation on 10/20/2017. The patient activity area had a total of five employees - four RCA's and one nurse. The patient was observed to walk to the table where four RCA's were present and pick up a TV remote and return to the TV. At 2219 the patient was observed to turn to the RCA (#1) and be engaged in conversation. The RCA (#1) was observed to be acting in a mocking motion toward the patient (#1). Two employees (RCA #2 and #3) were observed engaging in laughter at the occurrence between the RCA (#1) and the patient (#1). A fourth employee (RCA #4) was observed to be sitting behind RCA #1, #2, and #3. At 2220 the patient was observed to walk toward the table at which time RCA #1 was observed to lie down keys on the table as she stood. The RCA (#1) was observed to take her hands to the sides of her waist with her hands palm side up and in a semi-fist as a verbal exchange was occurring. The RCA (#1) was observed to lunge at the patient (#1) at 2221. The patient and the RCA (#1) struggled until the RCA (#1) fell backwards over a chair. Fourteen employees were observed to respond to the alarm of a patient altercation and the patient was sequestered and placed in a restraint chair at 2222.

On 12/12/2017 at 1300 the video segment was viewed again with staff P the facility trainer for the NAPPI program. Staff P was asked to explain the video from the perspective of a NAPPI expert. Staff P was asked if what he observed from the video at 2217 was the patient exhibiting any behaviors that he would consider as aggressive in nature. He responded "no. The patient is displaying "green" behaviors ...which is calm and nonaggressive." When asked if it was within guidelines to banter with or "mock" a patient as observed in the video staff P responded "no." Staff P was then asked if the interaction between the RCA (#1) and the patient (#1) seemed to escalate from "mocking" behavior. Staff P stated the patient (#1) seemed calm and cooperative until the point of verbal exchange with the RCA (#1) according to the video. Staff P was then asked if any other techniques could have been used according to NAPPI protocol. Staff P replied "yes ...the patient was not creating conflict or being aggressive at the time according to what is seen on the video ...the staff engaged in behaviors that aggravated the situation."

On 12/12/2017 at 1400 an interview was conducted with staff J RCA #4. Staff J was asked if she was present during the altercation between staff G and patient #1. Staff J stated "yes." Staff J was then asked to recap the incident that occurred on 11/18/2017 at 2220. Staff J stated that it was "difficult to remember." Staff J was then asked if she would care to watch the video in order help aid her recall of the event. Staff J responded "no ...I've seen the video since the time it happened and my memory of what happened is different than what actually shows on the video." Staff J was then asked what had triggered the event between the patient (#1) and staff G. Staff J stated " ...the situation had been going on all day long ...the patient (#1) had called the associate 'a nigger' and a 'jiggy boo' throughout the day ...they had not got along all day according to her." Staff J was then asked if staff assignments were able to be changed if there was a conflict between a patient and a staff member. Staff J responded "yes, we do that sometimes."

On 12/12/2017 at 1430 during document review an incident report from the 11/18/2017 event was reviewed. Staff M the Associate Director of Nursing was interviewed on 12/12/2017 at 1445. Staff M was queried if staff were encouraged to change assignments if there was a conflict between staff and a patient. Staff M replied "Absolutely we encourage staff to change assignments if there is a conflict ... (we) go as far as changing unit assignments if there is a conflict between a staff member and a patient." Staff M was then asked if during the event on 11/18/2017 between the patient (#1) and staff G should the patient assignment been changed if there was an ongoing conflict for the entire day. Staff M stated "yes. The staff (G) should have removed herself from the assignment and other staff members should have deescalated the situation ...it may not have escalated to point it did (an altercation) had the staff member reassigned the patient to another staff member."

Further review of the incident report showed the incident was opened for event reporting on 11/18/2017 at 2303. According to report seven employees reporting on the incident event failed follow policy for reporting incidents. According to the policy "unusual incidents and the reporting process involving patients" dated 4/29/2015, p. 5, section V, subsection c, states "Immediately report, verbally and in writing, any apparent or suspected rights violations to the Hospital Director and to the ORR (office of recipient rights)." According to the incident report four employees reported on 11/30/2017, one employee reported on 12/3/2017, and a final employee reported on 12/10/2017. The supervisor's review was conducted on 11/28/2017 prior to all reporting being completed. Staff M was interviewed on 12/12/2017 at 1530. Staff M was queried as to what the expectation was for employees to report when an incident occurs with a patient. Staff M stated "employees are to document an incident prior to leaving for their shift." Staff M was then asked to explain why the incident report was opened on 11/18/2017 at 2303 on the date of the incident and six employees did not report until after the supervisor's review had been completed on 11/28/2017. Staff M was then shown the supervisor's review stating "I was not present for the actual incident, I heard a commotion and went to the dayroom. The particular patient was not able to be redirected on that day several people had tried to establish a rapport with the particular patient and had been unable too." Staff M was asked if documentation could be provided showing the staff attempts to redirect or establish a rapport with the patient. Staff M stated "no." Staff M was then asked how the supervisor's review could be completed without any other documentation by staff involved in the incident. Staff M responded "that's a good question." Staff M was then asked if the patient (#1) had been involved in any incidents in which the patient showed being the initiator of physical aggression in physical altercation. Staff M replied "no ...the patient (#1) was verbally aggressive at many times but was never documented as being physically aggressive unless in the response to physical aggression by another person."