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Based on interview, record review and policy review, the facility failed to investigate allegations that Staff Q, Registered Nurse, harassed and intimidated one behavioral health patient (#19) of one patient reviewed, which resulted in the patient's mental anguish (Refer to A-0145). This failure had the potential to affect all patients on the Behavioral Health Unit as well as throughout the hospital by causing mental abuse of the patients through harassment and intimidation. The facility also failed to investigate unauthorized access of one patient's (#19) medical record by Staff Q, of one medical record reviewed for unauthorized access (Refer to A-0146). This failure had the potential to affect all patients, by failing to ensure the confidentiality of personal and medical information contained in patients' medical records.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation: Patient's Rights.

Based on interview, record review and policy review, the facility failed to recognize inappropriate, unprofessional behavior of one Registered Nurse (RN) who gave personal and unsafe gifts along with his phone number, to one discharged patient (#19) of one adult psychiatric patient while on the Behavioral Health Unit (BHU). The facility also failed to recognize abuse of the nurse/patient relationship and did not conduct an abuse/harassment investigation. This failure had the potential to place all patients at risk for their safety from abuse/harassment by staff members. The facility census was 64. The BHU census was 12.

Findings included:

1. Record review of the facility's policy titled, "Abuse and Neglect," dated 08/05/13 showed:
-The facility "upholds the right of every Patient to be free from Abuse, Neglect, or harassment".
-"Ensures a timely and thorough investigation of any incident where reasonable cause to suspect Abuse, Neglect, or harassment is present."
-Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish.

Record review of the facility's policy titled, "Adverse Event Response," dated 09/11/15 showed:
-The facility "will respond to and manage Adverse Events promptly, effectively, and efficiently to ensure patient safety and risk reduction, as well as engagement of workforce expertise in the implementation of best solutions to prevent similar events."
-The responsibility of the Patient Safety/Risk Manager was to interview involved Workforce Members, patients, family, witnesses and vendors as appropriate.
-The responsibility of the Patient Safety/Risk Manager was to recognize event-related content outside the scope of Patient Safety and hand-off to appropriate divisions, including Office of General Counsel, Human Resources, Compliance, Information Technology (IT), Security, and/or Medical Staff.

2. Record review of Patient #19's medical record showed that she was a 52 year old female with a history of depression and previous suicide attempts, who was admitted on 01/25/16 to the Behavioral Health Unit for worsening depression and suicidal ideations (thoughts related to self-harm).

During an interview on 02/18/16 at 11:10 AM, Staff N, Nurse Case Manager stated that:
-She had met with Patient #19 on 02/03/16 at the patient's home to complete her hospital follow-up appointment.
-Patient #19 disclosed that while she was hospitalized for her depression and suicidal ideation, she was given a deck of cards with writing on one side with a staff RN name (Staff Q), and a phone number. On the other side of the card it was written "Coupon 1 Free Massage". Also Patient #19 was given a letter in Spanish and a silver bracelet. All items were given to her by Staff Q.
-Patient #19 proceeded to ask if Staff N could listen to the voicemail that she had received from Staff Q's cell phone on the day that she was discharged from the hospital checking in on her, and view a number of non-professional, inappropriate text messages from Staff Q insinuating going on dates, and allowing him to take care of her.
-She reported all of her findings to her Supervisor immediately upon disclosure of the information. -
-With consent of the patient, Staff N also photographed the items given to patient by Staff Q.
-Patient #19 indicated to Staff N, that while she was in the hospital she was "uncomfortable, but did not feel unsafe" with Staff Q's attention.

3. Record review of photographs taken by Staff N on 02/03/16 showed the following:
-A Jack of Hearts playing card with Staff Q's name written on the face of the card as well as a phone number.
-On the backside of the card the following was written: Coupon 1 Free Masaje (massage in English.)
-A note typed in Spanish
-A small cuff bracelet

4. Record review of Patient Safety/Patient Interview Documentation Form, completed by Staff T, Patient Safety/Behavioral Health, dated 02/15/16, showed the following information given by Patient #19:
-Reported that her first contact with Staff Q was at her admission when he assisted with the intake process and was listening to her heart, and right after followed her to her room and offered to give her a massage.
-Stated that Staff Q came to her room several times during her admission to talk to her, but he was never her primary nurse.
-Staff Q brought her a deck of cards and a coke. She stated that on one of the cards, he wrote "1 Free Massage" and his phone number. Later that evening another nurse came to her room and said she could not have the items and took them.

During an interview on 02/17/16 at 4:45 PM, Staff D, RN Behavioral Health, stated the following:
-She recalled being the primary nurse for Patient #19 during her inpatient stay.
-She recalled that she removed an unopened can of soda and a deck of playing cards from the patient.
-She received no recent education regarding abuse/neglect.

During an interview on 02/17/16 at 3:25 PM, Staff H, Corporate Accreditation Officer, stated that under the guidance of Human Resources (HR), no interviews with staff or patients were completed for the event reported on 02/03/16.

During an interview on 02/17/16 at 4:10 PM, Staff G, Director of Nursing Services for Behavioral Health, stated the following:
-She defined abuse as any relationship or behavior with a patient other than a professional one either inside or outside of the hospital.
-Her first concern was for the patient and whether the patient was ok.
-Staff Q was immediately put on administrative leave as of 02/03/16, and that her intent was to find out what had happened.
-No interviews had been conducted with patients that had been present during Patient #19's admission dates due to the mental condition of the patients.
-No interviews with staff had been completed as it was felt to be an HR matter, and that staff were currently not aware of the situation.
-No education had been completed for the staff regarding Abuse/Neglect, since the report of the behavior of Staff Q.

5. Record review of facility investigation titled Behavioral Health Event Summary, of event reported on 02/03/16 regarding Staff Q, RN, showed the following:
-Type of Event was an HR event- contact post discharge.
-Event reported on 02/03/16 to the facility by Staff N, Nurse Case Manager.
-Staff Q placed on administrative leave 02/03/16.
-Attempts were made to contact him on 02/03/16 to communicate (administrative leave), but Staff Q did not respond to message.
-Several attempts were made to bring him in to interview and get clarification, but he never showed or responded.
-Text message received by Assistant Director of Nursing from Staff Q on 02/09/16 indicated a resignation. No further contact was made.
-Interview conducted with Patient #19 on 02/15/16, and no additional information was obtained per the report.
-Conclusion: Employee issue handled through HR. Nurse reported to Missouri State Board of Nursing on 02/16/16.

The facility failed to recognize that the violation of the nurse/patient relationship by Staff Q was abuse/harassment; therefore, no investigation for abuse and neglect was initiated. This failure led to no interviews with staff or patients, as well as no education to staff regarding abuse/harassment.

6. Record review of the Timeline Regarding Staff Q showed that a resignation was accepted and processed by Human Resources on 02/11/16.

During an interview on 02/18/16 at 11:50 AM, Staff O, Employee Relations Partner with Human Resources, stated the following:
-He was first made aware of the situation with Staff Q on 02/03/16.
-Staff Q was immediately suspended for allegations of misconduct pending an investigation.
-Staff Q never returned calls from the facility, and they were never able to talk to Staff Q to determine if it was abuse/neglect.
-Any allegations of abuse/neglect were investigated by Patient Safety with a collaborative/consultation role by HR.
-HR did not advise leadership to refrain from interviewing staff or patients regarding the event.

During an interview on 02/23/16 at 10:45 AM, Staff S, RN Behavioral Health, stated the following:
-Staff should not give gifts to patients.
-No soda cans were allowed on the unit as they are a danger to patients.
-"We are strict on what they can and can't have. "

Based on interview, record review and policy review, the facility failed to investigate unauthorized access to a medical record, when Staff Q, Registered Nurse (RN), accessed one patient's medical record (#19) of one patient's medical record reviewed for unauthorized staff access. This had the potential to affect the privacy of all patients' Protected Health Information (PHI, includes personal information about current health, hospitalizations diagnoses) as well as their personal demographic information (full name, social security number, address, phone number, etc.). The facility census was 64. The Behavioral Health Unit census was 12.

Findings included:

1. Record review of the facility policy titled, "Confidentiality of Patient Information," dated 10/2014, showed:
- Authorized users were responsible for maintaining the security of the information and may only access information required for the performance of their specific job assignments.
- Workforce members are prohibited from accessing, reviewing, disclosing or discussing confidential information that is not required to perform their specific job assignment and from attempting to obtain information for which they have not received access authorization.
- Workforce members will not misuse their professional position in the facility to obtain confidential information for any purpose.

During an interview on 02/18/16 at approximately 1:30 PM, Staff U, Medical Director and Staff H, Corporate Accreditation Officer, stated that Staff Q was not assigned to care for Patient #19 during her admission from 01/25/16 through 01/28/16, and therefore should not have accessed the patient's medical record.

2. Record review of a medical record access inquiry, showed that Staff Q, RN, accessed Patient #19's medical record:
- Three times on 01/26/16;
- Four times on 01/27/16;
- 25 times on 01/28/16, from 4:36 PM to 4:58 PM.

During an interview on 02/22/16 at 3:34 PM and again on 02/24/16 at 8:03 AM, Staff R, Director of Medical Records, stated that if the facility believed a patient's medical record was unnecessarily accessed, they would take the following steps to investigate the allegation:
- Corporate Compliance/Chief Corporate Compliance Officer would be notified;
- The staff members involved in unnecessary access would be interviewed; and
- The staff member would be disciplined accordingly.
Staff R added that he was unaware Staff Q unnecessarily accessed Patient #19's medical record until the survey team requested the information during the survey, was unaware if the access had been investigated, and stated Corporate Compliance would be responsible for that information.

During an interview on 02/24/16 at 11:02 AM, Staff H, Corporate Accreditation Officer, stated that the facility was aware Staff Q accessed Patient #19's medical record unnecessarily after the patient's outpatient counseling center reported the patient had received text messages on her personal cell phone from Staff Q. Staff H added that there was no further investigation completed, and no re-education provided to staff related to medical record confidentiality, after the allegations were confirmed.