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Based on record reviews and interviews, the hospital's Governing Body failed to ensure the protection of patients' rights to be free from abuse for 2 of 11 sampled patients (Patient #5 and #12), and failed to ensure the plans of correction, for the CMS Conditions of Participation (CoP) cited at the 12/27/18 complaint survey regarding abuse reporting and protection during investigation, were effective and sustainable for continued compliance with the CMS CoP for Governing Body (42 CFR (§482.12), the CoP for Patient Rights (42 CFR §482.13), and the CoP for Quality Assurance and Performance Improvement (QAPI)(42 CFR §482.21).

Findings:

1. A complaint investigation conducted in December of 2018 concluded that the hospital lacked a clear internal process for ensuring all staff were trained and compliant with the immediate reporting of any allegations of patient abuse. The investigation also determined that the hospital did not have a clear internal process and procedure for conducting adequate investigations of any witnessed or alleged incidents of abuse that occur within the hospital. This finding resulted in a determination of non-compliance with CMS CoP at the condition level.

The hospital's plan of correction for the December 2018 citations included the following: revising policies and procedures; a commitment to conducted training of all staff; and the development of a system to monitor staff for compliance with its policies and reporting requirements to ensure continued compliance through its QAPI process.

On 7/10/19, there was a witnessed incident of abuse that occurred which was not immediately reported consistent with hospital policy or regulatory requirements. Surveyors noted that the hospital's internal investigation lacked evidence to support a thorough investigation occurred consistent with regulatory guidelines as the alleged perpetrator of the abuse was permitted to continue working without any evidence of safeguards in place to ensure appropriate patient safety during the investigation. See citation A-145 for details.

2. Condition: §482.13 CoP: Patient Rights (A-0115) - Based on record review and interviews, the CoP for Patient Rights was not met as evidenced by the hospital's failure to ensure all patients were free from abuse in accordance with current standards and policies for 2 of 11 sampled patients (Patient #5 and #12). See A-0145 for details.

3. Condition: §482.21 CoP: QAPI (A-0263) - The Governing Body has an overall responsibility for the services furnished at the hospital which includes the review and approval of the hospital's performance and patient safety improvement plans (QAPI program). The Governing Body has failed to provide adequate oversight of QAPI programs within the hospital to ensure the plan of correction submitted to resolve the non-compliance with the CMS CoPs cited at the 12/27/18 complaint survey was fully effective and sustainable to ensure continued compliance with the CMS CoPs for Hospitals. See A-0263 for details.

The cumulative effect of the deficient practices resulted in noncompliance with this CoP.

Based on records reviews and interviews, the Condition Participation for Patient Rights was not met as evidenced by the Hospital's failure to ensure patients were free from abuse as evidenced by two separate incidents of physical abuse (assault) by two different staff members (Security Officer #1 and a Registered Nurse) involving 2 of 12 sampled patients (Patient #5 and #12). A determination of immediate jeopardy was made based on two patients being physically assaulted, several staff witnessing the incidents failed to intervene during the assaults, staff failed to immediately report the allegations in accordance to the Hospital policies for mandatory immediate reporting of abuse allegations, and, in the first case (Patient #5), the Hospital failed to ensure patients were protected from the perpetrator. The Hospital's security staff, whose responsibilities included protecting patients and staff, lacked sufficient training or experience in patient de-escalation techniques or methods to ensure safety and possibly avoid the use of physical restraints. This non-compliance constituted a determination of IJ beginning on 7/10/19.

Findings:

1. Standard: §482.13(c)(3) Patient Rights: Free from Abuse/Harassment also known as A-0145 - Based on interviews and record reviews, the Hospital failed to ensure patients were free from abuse as evidenced by two separate incidents of physical abuse (assault) by two different staff members (Security Officer #1 and a Registered Nurse) involving 2 of 12 sampled patients (Patient #5 and #12). This failure resulted in a determination of immediate jeopardy as two patients were physically assaulted, several staff witnessing an incident failed to intervene during the assault, staff failed to immediately report the allegations in accordance to the hospital policies and regulatory requirements for mandatory immediate reporting of abuse allegations, and the hospital failed to ensure patients were protected from the perpetrator. Please see A-0145 for details.


2. A previous complaint investigation conducted in December of 2018 concluded that the Hospital lacked a clear internal process for ensuring all staff were trained and compliant with the mandatory and immediate reporting of any allegations of patient abuse to the Department of Health and Human Services. The investigation also determined that the Hospital did not have a clear internal process and procedure for conducting adequate investigations of any witnessed or alleged incidents of abuse that occur within the Hospital. This finding resulted in a determination of non-compliance with CMS Conditions of Participation at the Condition Level.

As part of its Plan of Correction, the Hospital revised its policies and procedures and conducted training of all staff to resolve the non-compliance cited from the December 2018 complaint investigation. The Hospital developed a system to monitor staff for compliance with its policies and reporting requirements.

The "Reporting Suspected Elder/Adult Abuse, Neglect or Exploitation" policy indicated the following: "Maine law mandates that while acting in a professional capacity, when a health care provider knows or has reasonable cause to suspect that an incapacitated or dependent adult has been or is likely to be abused, neglected or exploited then that person shall immediately report or cause a report to be made to the Department of Health and Human Services, Office of Aging and Disability Services, Adult Protective Services". The Maine law, referenced in the hospital's policy (22 MRSA §3472), defines a dependent adult as, "an adult who has a physical or mental condition that substantially impairs the adult's ability to adequately provide for that adult's daily needs." and includes "a person, regardless of where that person resides, who is wholly or partially dependent upon one or more other persons for care or support because the person suffers from a significant limitation in mobility, vision, hearing or mental functioning or is unable to perform self-care because of advanced age or physical or mental disease, disorder or defect."

The "Internal" Investigation of Alleged Patient Abuse, Neglect, or Exploitation Reported within MMC Facilities" policy indicated the following:

"10. Mandated Reporter - a mandated report is a person acting in a professional capacity. Professionals who must report adult abuse of an incapacitated or dependent adult or of a child include RN, LPN, CNA, Medical Assistant ..."

"Appendix E Algorithm for Reporting to Offices of DHHS Adult Abuse (incapacitated or dependent) -> Mandatory Reporter -> Adult Protective Services"

In a revisit follow-up to the December 2018 complaint investigation, surveyors confirmed that Hospital staff had received the training that was part of the Hospital's Plan of Correction.

On 7/9/2019, Patient #5 was admitted to the Emergency Department (ED) with schizoaffective disorder, bipolar type diagnosis, and this patient, who was banging his/her head and exhibiting self- injurious behavior, was restrained on 7/10/19 at approximately 5:50 PM. The clinical record supported that at the time of this incident, Patient #5's mental condition was substantially impairing his/her ability to make rationale and appropriate decisions regarding his/her wellbeing, and safety; the medical provider had ordered the application of restraints to protect Resident #5 from injuring him/herself. During the restraint process, Security Officer #1, who had received Management of Aggressive Behavior (MOAB) training, was witnessed to have struck Patient #5 multiple times in the ED Acute Psychiatric Unit (APU), after Patient #5 allegedly struck Security Officer #1 in his face during the restraint application process. An ED APU registered nurse (RN), who witnessed the event, reported the incident to the ED Nurse Manager on 7/11/19, who in turn reported the incident to the Director of Security on 7/11/19. The ED Nurse Manager and the Director of Security viewed a tape recording of the incident and subsequently notified the Director of Security who then notified Human Resources of the incident. After being notified by the Director of Security, the Hospital's Human Resource department met with Security Officer #1, who was on duty, and after this meeting Security Officer #1 was placed on leave.

Record review and interview revealed that after being witnessed to strike Patient #5 multiple times, at approximately 5:50 PM on 7/10/19, the Hospital allowed Security Officer #1 to continue to work for another 6 hours until 12:15 AM on 7/11/19 during which time he was conducting security rounds throughout the Hospital including the ED. The Hospital allowed Security Officer #1 to return to work (including working in the ED) from 11:45 AM to 2:40 PM on 7/11/19, before he was placed on leave.

On 7/18/19, the Director of Security reported the event to the Hospital's Director of Accreditation and Regulatory Affairs, who reported the incident to Department of Health and Human Services on 7/19/19, nine days after the incident occurred.

On 7/25/19 at 3:50 PM, during the complaint investigation, the Associate Chief Medical Officer, who was also the Interim Director of Accreditation and Regulatory Affairs and the Project Manager, confirmed, to the surveyor, the Hospital did not report the abuse allegation immediately, as required by Hospital policy and regulation and despite staff training on abuse/neglect and mandatory reporting. Please see A-0145 for additional details.

The State Agency was made aware that Security Officer #1 has been criminally charged for assault.


3. Patient #12 was an 83-year-old individual who had been residing in a secure assisted living facility due to his/her diagnosis of Lewy Body Dementia and inability to care for him/herself. While in the assisted living facility, the patient sustained a fall resulting in bilateral rib fractures and a right-sided pneumothorax which required insertion of a chest tube. He/she was transferred from a community hospital to the Maine Medical Center R6 unit on 7/25/19 for inpatient care due to the trauma he/she sustained.

The patient was unable to get out of bed without the assistance of staff. She/he was noted to have exhibited behaviors of agitation and aggression on occasion towards staff and had attempted to remove his/her chest tube and IV lines due to his/her confusion. Patient #12 was wearing mitts on his/her hands to reduce the likelihood he/she would remove the chest tube and IV that were in place, thereby causing greater injury to his/herself. Patient #12 was noted to be a two-person assist with ambulation and was unable to get out of bed on his/her own.

On 7/26/19 at approximately 9:50 PM, RN #2 had entered Patient #12's room to administer medications with a certified nursing assistant (C.N.A. #2) assisting RN #2. Emails and interview notes provided by the Hospital, indicated C.N.A. #2 reported the following:

- The patient was in his/her bed, C.N.A. #2 was on the left side of the patient, and RN #2 was on the patient's right side;

- RN #2 was attempting to administer oral medications to the patient while the patient was in his/her bed;

- The patient spit the medication out and then the patient reached out with his/her left hand and struck/punched RN #2 on his chin;

- RN #2 instantly yelled, "You fucker" and punched the patient in the right rib area;

- RN #2 and C.N.A.#2 left the room and RN #2 stated to C.N.A, #2 "that was reactional" and indicated that they would attempt to provide the patient with medication later.

- RN #2 then re-entered the patient's room by himself, approximately three to five minutes later, and "angrily said to the patient 'thanks for hitting me'." and then RN #2 left Patient #12's room and was witnessed near the nurses station.

While there was evidence that RN #2 was removed from the floor and sent home pending an internal investigation, there was also evidence that C.N.A #2, who witnessed the incident, did not take any steps or measures to prohibit RN# 2 from reentering Patient #12's room unaccompanied, shortly after C.N.A. #2 witnessed RN#2 punch this patient. This could have placed the patient at greater risk of further assaults.

The State Agency was made aware that RN #2 was arrested and charged with endangering the welfare of a dependent person which is a Class C felony crime in the State of Maine.


4. On 7/22/19 at 9:00 AM in an interview with the Director of Accreditation & Regulatory Affairs and the Associate Chief Medical Officer they confirmed that the Hospital's policy on internal investigations and mandatory reporting of abuse allegations was not followed for the case involving Patient #5. The Director of Accreditation & Regulatory Affairs provided a copy of a one page "re-training" document that was developed on 7/19/19 regarding the mandatory reporting of abuse allegations which only directs Hospital staff to report allegations to the Hospital's Patient and Guest Relations Department.
On 7/25/19 at 12:47 PM in an interview with the Hospital's Human Resources Manager, the surveyor was informed that the Hospital's Human Resources Department (HR) was made aware of the case involving Patient #5 on 7/11/19 and did not notify the Hospital's Patient and Guest Relations Department as they believed that the Security Manager had already done so. The HR manager stated that several Hospital departments started their internal investigations on this matter concurrently.
A review of the Hospital's internal investigation for the 7/26/19 incident with Patient #12 denoted that CNA #2 reported that RN #2 "has a very short fuse" and CNA #2 stated that she "is intimidated by RN#2 and others are as well." There was nothing in the Hospital's investigation that demonstrated any further investigation or review of this allegation of intimidation or how it may have been identified earlier as a possible risk factor for RN#2 striking a patient.

Based on a review of the Hospital's internal investigation files, medical records, and interviews with staff for the case of abuse involving Patient #5, the Hospital failed to follow its internal investigations on abuse policy. This failure resulted in a delay in the reporting of an allegation of abuse which contributed to the failure to immediately implement appropriate patient protective measures (removal of the Security Guard#1) during an investigation of abuse. Additionally, the failure to conduct a thorough investigation into the 7/10/19 incident with Patient #5 resulted in the Hospital's failure to identify lack of sufficient training and competency in de-escalation techniques for staff assigned with protecting and caring for patients. Staff stated they lack sufficient training and competency to deescalate many of the situations in which they are placed. The lack of a thorough investigation into the 7/10/19 incident with Patient #5 resulted in the Hospital's inability to identify that staff do not clearly understand that they have a responsibility to speak up and prevent/stop abuse that they witness, and that physically striking a patient is abuse and not "unnecessary force." The failure to immediately conduct a thorough investigation of the 7/10/19 abuse incident resulted in the Hospital's failure to identify causative factors and failure to implement meaningful systems changes that might have reduced the probability of the 7/26/19 incident occurring.

The cumulative effect of the deficient practice resulted in noncompliance with this Condition of Participation.

Based on observation, interview, and record reviews, the hospital failed to ensure that a patient and/or legal representative received a "Hospital Consent to Treat" form, prior to treatment for 1 of 12 patients (Patient #1).

Finding:

The hospital's "Informed Consent" policy, dated 6/17, indicated, "By law, a minor-that is, a person under 18 years of age-is deemed to lack capacity to give informed consent to treatment or an informed refusal to consent to treatment. Consent to treat must be obtained from a parent or guardian, except in exceptional circumstances described later in this policy."

The medical record for Patient #1, who was a minor, was reviewed. On 7/24/19 at 11:00 AM, the Emergency Department Registered Nurse Manager confirmed Patient #1's record contained a "Surgical and Medical Treatment and Blood Transfusion" consent form, signed on 6/3/19. However, the patient's record did not contain a signed "Hospital Consent to Treat" form for the patient's hospital admission on 6/2/19.

On 7/24/19 at 1:50 PM, the electronic medical record for the patient identified the "Hospital Consent for Treatment" field was empty with no attachments for the patient's hospital admission on 6/2/19.

On 7/24/19 at 1:50 PM, the Director of Patient Access confirmed there was no signed "Hospital Consent to Treat" form for Patient #1 for the patient's hospital admission on 6/2/19.

On 7/25/19 at 3:00 PM, the parent of Patient #1 indicated Patient #1 was hospitalized from 6/2/19 through 6/4/19 with no "Hospital Consent to Treatment" form provided to the parent for signature prior to treatment and care of Patient #1.

Based on interviews and record reviews, the hospital failed to ensure patients were free from abuse as evidenced by two separate incidents of physical abuse (assault) by two different staff members (Security Officer #1 and a Registered Nurse) involving 2 of 12 sampled patients (Patient #5 and #12). This failure resulted in a determination of immediate jeopardy as two patients were physically assaulted, several staff witnessing an incident failed to intervene during the assault, staff failed to immediately report the allegations in accordance to the hospital policies and regulatory requirements for mandatory immediate reporting of abuse allegations, and the hospital failed to ensure patients were protected from the perpetrator. This non-compliance constituted a determination of IJ, beginning on 7/10/19. An on-site visit concluding on 8/14/19, validated that the IJ was abated.

Findings:

The hospital's "Reporting Suspected Elder/Adult Abuse, Neglect or Exploitation" policy indicated the following: "Maine law mandates that while acting in a professional capacity, when a health care provider knows or has reasonable cause to suspect that an incapacitated or dependent adult has been or is likely to be abused, neglected or exploited then that person shall immediately report or cause a report to be made to the Department of Health and Human Services, Office of Aging and Disability Services, Adult Protective Services". The Maine law, referenced in the hospital policy (22 MRSA §3472), defines a dependent adult as, "an adult who has a physical or mental condition that substantially impairs the adult's ability to adequately provide for that adult's daily needs." and includes, "a person, regardless of where that person resides, who is wholly or partially dependent upon one or more other persons for care or support because the person suffers from a significant limitation in mobility, vision, hearing or mental functioning or is unable to perform self-care because of advanced age or physical or mental disease, disorder or defect."

The hospital's policy titled "Internal Investigation of Alleged Patient Abuse, Neglect, or Exploitation Reported within MMC facilities" stated, under section 10. Mandated Reporter, "Mandated reporter is a person acting in a professional capacity. Professionals who must report adult abuse of an incapacitated or dependent adult or of a child include RN, LPN, CNA, Medical Assistant ...". The policy's "Appendix E" contained an "Algorithm for Reporting to Offices of DHHS" which indicated "Adult Abuse (incapacitated or dependent) -> Mandatory Reporter -> Adult Protective Services".

1. On 7/9/2019, Patient #5 was admitted to the Emergency Department (ED) with Schizoaffective Disorder, Bipolar Type diagnosis, and this Patient, who was banging his/her head and exhibiting self-injurious behavior, was restrained on 7/10/19 at approximately 5:50 PM. The clinical record supported that at the time of this incident, Patient #5's mental condition was substantially impairing his/her ability to make rationale and appropriate decisions regarding his/her wellbeing, and safety; the medical provider had ordered the application of restraints to protect Resident #5 from injuring him/herself. During the restraint process, Security Officer #1, who received Management of Aggressive Behavior (MOAB) training, was witnessed to have struck Patient #5 multiple times in the ED Acute Psychiatric Unit (APU), after Patient #5 allegedly struck Security Officer #1 in his face during the restraint application process. An ED APU Registered Nurse (RN), who witnessed the event, reported the incident to the ED Nurse Manager on 7/11/19, who in turn reported the incident to the Director of Security on 7/11/19. On 7/11/19, the Director of Security notified Human Resources and the Security Officer #1 was placed on leave.

Record review revealed that after being witnessed to strike Patient #5 multiple times, the hospital allowed Security Officer #1 to continue to work until 12:15 AM on 7/11/19 and allowed him to return to work from 11:45 AM to 2:40 PM on 7/11/19, before he was placed on leave.

On 7/18/19, the Director of Security reported the event to the Director of Accreditation and Regulatory Affairs, who reported the incident to Department of Health and Human Services on 7/19/19, nine days after the incident occurred.

On 7/23/19 at 1:05 PM, Security Officer #2, who was present during the 7/10/19 incident, was interviewed via telephone. Security Officer #2 stated the following:

- Security Officer #1 was the first staff person to enter into Patient #5's room;

- Security Officer #1 yelled, "Get the fuck on the ground" multiple times once he (Security Officer #1) was in Patient #5's room;

- He/She witnessed Security Officer #1 "strike the patient two or three times". When asked to define "strike", Security Officer #2 clarified Security Officer #1 "punched the patient";

- Security Officer #1 was "too aggressive" with Patient #5;

- He/She thinks "we need more de-escalation skills and training"; and

- He/She had completed MOAB and abuse/neglect training but added that he/she felt that MOAB was insufficient training for the situations they were being placed into within the hospital.

On 7/23/19 at 1:50 PM, Security Officer #3, who was also involved in the restraint of Patient #5 on 7/10/19, was interviewed. Security Officer #3 stated the following:

- "MOAB's a joke";

- He/She did not think staff were trained adequately for de-escalation of patients and restraints; and

- He/She confirmed Security Officer #1 told Patient #5 to "Get on the fucking ground", multiple times as Security Officer #1 went towards Patient #5 to restrain the patient.

On 7/25/19 at 3:50 PM, the Associate Chief Medical Officer, who was also the Interim Director of Accreditation and Regulatory Affairs and the Project Manager confirmed the hospital did not report this abuse allegation immediately, per policy and regulation and despite staff training on abuse/neglect and mandatory reporting.

On 8/8/19 at 11:18 AM, RN #1, who was involved in the care of Patient #5 on 7/10/19 at approximately 5:50 PM during the restraint process, was interviewed. RN #1 stated the following:

- There was a team of four Security Officers and two Nurses who briefly, prior to entering Patient #5's room, developed an action plan so each person was clear on their role once they entered the room;

- Once they opened the door and began to enter Patient #5's room, Security Officer #1 went first and he was way ahead of everyone else and immediately began yelling "Get the fuck down."

- RN#1 observed Security Officer #1's "elbow come up and down, with fist, punching patient about three times". When asked if she immediately reported this, consistent with hospital policy and regulatory requirements, RN#1 she stated "No";

- RN#1 felt this was excessive force but was not sure it was actual abuse;

- RN#1 thought the incident had been witnessed by the ED Nurse Manager who she saw observing the situation on the seclusion room camera system;

- After the incident, the ED Nurse Manager called a debrief and RN #1 did not recall anyone making any comments about Security Officer #1 punching the patient;

- RN#1 met with the Nurse Manager on 7/11/19 and once she realized that the Nurse Manager had not witnessed the incident, she reported that she had witnessed Security Officer #1 punch Patient #5 as they were getting the patient into restraints on 7/10/19;

- RN#1 did not recall seeing Security Officer #1 again after the incident on 7/10/19 as she was focused on care for this patient;

- The next day (7/11/19) at approximately 12:00 PM, RN#1 was caring for Patient #5 when Security Officer #1 arrived in the ED as part of his security rounds;

- RN#1 called the Security Office and demanded that Security Officer #1 be removed the ED;

- RN#1 felt it was not appropriate for Security Officer #1 to be in the ED in light of the previous days incident of Security Officer #1 punching Patient #5 who was still present in the ED as a patient; and

- Security Officer #1 was removed after approximately 15 minutes at 12:15 PM

When asked if anyone involved in the 7/10/19 restraint incident of Patient #5 had spoken up about Security Officer #1's departure of the restraint team plan, or if anyone attempted to stop or remove him once he began swearing commands at the patient, RN #1 stated she did not recall anyone attempting to stop or remove Security Officer #1; she indicated the incident occurred quickly; and that stated that, after Patient #5 was in full restrains and safe, she began her assessment and noted there was blood in Patient #5's mouth but she could not definitively determine if the cause of the blood was related the Security Officer #1's strike on this patient as Patient #5 was "violently banging his/her head into the door prior to having restraints applied."

Based on the above information, the above incident constitutes an immediate jeopardy situation. On 7/10/19 at approximately 5:50 PM, Patient #5 was physically assaulted by Security Officer #1, staff witnessing the incident failed to intervene during the assault and the hospital failed to ensure protections of patients as Security Officer #1 continued to work until 12:15 AM on 7/11/19 and worked from 11:45 AM to 2:40 PM on 7/11/19.

The State Agency was made aware that Security Officer #1 has been criminally charged for assault.

On 8/9/19 at 2:30 PM, the IJ template was sent electronically to the hospital and a copy was hand delivered to the hospital on 8/9/19 at 7:00 PM.

On 8/11/19, the hospital submitted a removal plan for the IJ determination which was reviewed and accepted by the State Agency on 8/12/19. This plan indicated the following:

For the Emergency Room and Patient Unit R6:

- For all shifts (24 hours a day/7 days a week) a nurse with training in de-escalation techniques (Safety Care Course) will be assigned the role of leading the units de-escalation (one charge nurse on R6, two nurses- one being a charge nurse-in the ED)
- At the beginning of every shift a handoff will occur between previous and incoming shift charge nurse (leading this role) to discuss any patients or visitors with potential disruptive behavior.
- Any potential disruptive behavior will be reported immediately to the charge nurse.
- A shift huddle will occur and all nurses and CNAs on the unit will be informed who the nurse is assuming this role for the shift. A schedule will be available for all staff on the unit.
- This nurse will take the lead in de-escalation of patients, round regularly on these patients/visitors, and will be notified immediately of any behavioral concerns and assist staff and security in provision of safe care.
- Note: 100% of ED nurses and 100% of R6 charge nurses have been trained in Safety Care Course de-escalation. They will serve as additional resources in the ED as necessary.

For Security:
- Security will be educated on the role of the charge nurse in leading de-escalation.
- At the beginning of each shift security will be informed of who the designated nurses are on R6 and the ED.

On 8/13/19 and 8/14/19, an unannounced onsite visit was conducted to verify that the hospital's plan to remove the IJ was implemented and was effective. Based on observations, interviews, and record reviews, the surveyor determined that the IJ had been abated as of 8/14/19. This determination was made by observations of the patient safety huddle sessions on patient unit R6 and in the ED, a review of staff training, a review of the designation of the Safety Care Responders (SCR) for the respective units and the use of the Charge Nurse Safety Care Checklist, interviews with with several staff on R6 and the ED who exhibited knowledge and competence on abuse reporting requirements, and the implementation of the Safety Care Responder (SCR, assumed by Charge Nurse/Coordinator trained in Safety Care). Staff within the ED were supplied with a quick reference laminated card which was affixed to their employee ID which identified how to report abuse, including phone numbers for Adult Protective and Child Protective Services and MMC Patient & Guest Relations. On 8/14/19, the surveyor was able to validate that R6 and ED staff interviewed regarding abuse reporting requirements and the role of the SCR were able to demonstrate knowledge and competence consistent with the removal plan.

2. Patient #12 was an 83-year-old individual who was residing in a secure assisted living facility due to his/her diagnosis of Lewy Body Dementia and inability to care for him/herself. The patient sustained a fall resulting in bilateral rib fractures and a right sided pneumothorax which required the use of a chest tube. He/She was transferred from a community hospital to Maine Medical Center R6 unit on 7/25/19 for inpatient care due to the trauma he/she sustained.

The patient was unable to get out of bed without the assistance of staff and was noted to have exhibited behaviors of agitation and aggression on occasion towards staff as well as attempting to remove his/her chest tube and IV lines due to his/her confusion. Patient #12 was wearing mitts on his/her hands to reduce the likelihood he/she would remove the chest tube and IV that were in place causing greater injury to his/herself. Patient #12 was noted to be a two person assist with ambulation and was unable to get out of bed on his/her own.

On 7/26/19 at approximately 9:50 PM, a RN #2 had entered Patient #12's room to administer medications with a Certified Nursing Assistant (C.N.A.) #2 assisting the RN. Emails and interview notes provided by the hospital, indicated C.N.A. #2 reported the following:

- The patient was in his/her bed, C.N.A. #2 was on the left side of the patient, and the RN was on the patient's right side;

- The RN was attempting to administer oral medications to the patient while the patient was in his/her bed;

- The patient spit the medication out and then the patient reached out with his/her left hand and struck/punched the nurse on his chin;

- The RN instantly yelled, "You fucker" and punched the patient in the right rib area;

- They left the room and the RN stated to her, "that was reactional" and that they would attempt again later.

- The RN then re-entered the patient's room by himself, approximately three to five minutes later, and "angrily said to the patient 'thanks for hitting me'." and then the RN left Patient #12's room and was witnessed near the nurses station.

- She called the Nurse Manager, approximately 10 to 15 minutes later, and reported what she witnessed and stated she would not work with this RN anymore.

Documentation by the Nurse Manager and the Nursing Supervisor indicated that they removed the RN #2 from his assignment and met with the RN. The Nursing Supervisor sent the nurse home advising him it would be best if he not work the rest of his shift and he would be contacted about next steps.

The hospital reported this incident to the Adult Protective Services hotline on Saturday, 7/27/19 at 11:11 AM. The State Agency was notified of this incident, via fax, on 7/29/19 at 8:12 AM.

While there is evidence that the RN #2 was removed from the floor and sent home pending an internal investigation, the lack of empowerment by the C.N.A., who witnessed the incident, to immediately prohibit the RN from engaging this patient allowed the RN the ability to re-enter the patient's room unaccompanied which could have placed the patient at greater risk.

The State Agency was made aware that the RN was arrested and charged with endangering the welfare of a dependent person which is a Class C felony crime in the State of Maine.

Based on record review and interviews, the hospital's Quality Assurance Performance Improvement (QAPI) program failed to ensure effective monitoring of the hospital's plan of correction for the Condition Level Non-compliance cited as a result of the 12/28/18 complaint survey. This failure to effectively monitor the hospital's plans of correction for effectiveness and sustainable compliance has resulted in repeat condition level findings for non-compliance with CMS Conditions of Participation for Patient Rights, Governing Body, and QAPI.

Findings:

The hospital QAPI Program failed to provide evidence of an ongoing program that showed measurable improvements based on the repeat deficient practices for failure to immediately report allegations of abuse and failure to conduct a thorough investigation into allegations and witnessed patient abuse cases while ensuring appropriate protections for patients during the investigation process. See A-0286 for details.

The cumulative effect of the deficient practices resulted in noncompliance with this Condition of Participation.

Based on record reviews and interviews, the hospital failed to provide effective ongoing program that showed measurable improvement of adverse patient events related to abuse reporting and prevention, implementation of preventive mechanisms for effective learning to ensure patient safety, and governing body responsibility for ensuring clear expectations for safety; as evidenced by the failure of staff to immediately report, and protect patients in incidents of witnessed or alleged abuse for 2 of 12 sampled patients (Patients #5 and #12).

Findings:

1. Standard: Program Scope: §482.21(a)(1) & (a)(2) - Based on review of the hospitals QAPI program policies, processes, data and interviews, the hospital failed to provide evidence of an ongoing monitoring program that demonstrated sufficient staff competence and clear knowledge of responsibility regarding the immediate reporting of all allegations of suspected abuse to the Department of Health & Human Services consistent with the hospital policy and State of Maine requirements. The hospital failed to ensure sufficient patient protections during the investigations of allegations of abuse as evidence by 1 of 12 sampled patients (Patients #5) involved in a case of witnessed abuse and staff failed to immediately report this allowing the accused individual to continue working with patients without any evidence of a system of monitoring, increased supervision, or suspension to ensure patient safety while conducting a thorough investigation.

2. Standard: Program Activities: §482.21(c)(2) - Based on record review and interviews, the hospital failed to adequately track performance indicator activities and adverse patient events, analyze causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital, as evidenced by hospital's failure to ensure all patients were free from abuse as provided in accordance with current standards of practice for patient safety and hospital procedures and policies for 2 of 12 sampled patients (Patient #5 and #12). See A-0145 for details.

3. Standard: Executive Responsibilities: §482.21(e)(3) - Based on review of policies, processes and interviews, the governing body failed to provide oversight to ensure staff had clear expectations for and comprehension of their roles in immediately reporting all allegations of witnessed and/or suspected abuse to DHHS and the hospital administration consistent with the hospital's policy titled "Internal Investigation of Alleged Patient Abuse, Neglect, or Exploitation Reported within MMC facilities." This failure of QAPI program to effectively monitor staff compliance and comprehension with previous training and policy changes regarding reporting of allegations of abuse resulted in hospital staff who failed to comply with hospital policies on abuse reporting and delayed the hospital's ability to conduct thorough investigations including the hospitals failure to implement appropriate protective measures for 1 of 12 sampled patients (Patients #5) during the investigation process.

Further, the Governing Body has overall responsibility for services furnished at hospital, which includes review and approval of the hospital's QAPI programs. The Governing Body has failed to provide effective oversight of QAPI programs within hospital to ensure continued sustainability of the plan of correction for abuse reporting and patient rights compliance cited at the 12/27/18 complaint investigation