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Based on interview and record review, the hospital failed to:

1. Prevent an incident of abuse. (See A 145)

2. Investigate allegations of abuse. (See A 145)

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe environment.

Based on interview and record review, the hospital failed to:

1. Investigate an allegation of sexual abuse by one of four sampled patients (A).

2. Protect one of four sampled patients (B) from physical abuse.

These failures had the potential to result in mental and physical anguish for two patients.

Findings:

1. During an interview with the Quality Assurance Manager (QAM), on 7/24/13, at 3:07 PM, he stated Nurse 1 submitted an incident report on 5/9/13 which indicated Patient A stated his roommate had touched his private area.

During a review of the clinical record for Patient A, the Nurses Notes, dated 5/10/13, at 8:20 PM indicated "notified sister reg (regarding) pt stated 'my roommate touched my private area'."

During a review of the clinical record for Patient C, the Nurses Notes, dated 5/10/13, at 7 PM, indicated "c/o (complains of) conflict with peer acusing [sic] him of things."

During an interview with the QAM on 7/24/13, at 3:07 PM, he stated no investigation was done regarding the allegation of sexual assault because there was not an assault. When asked how he knew there was not an assault without a completed investigation, he was unable to answer.

During an interview with the QAM on 7/24/13, at 3:07 PM, he verified the nurses did not document the incident in the clinical record for either Patient A or Patient C on 5/9/13.

During an interview with the Chief Nursing Officer on 7/25/13, at 2:22 PM, he stated an investigation should have been done.

During an interview with Nurse 1, on 7/30/13, at 4:11 PM, she stated she submitted an incident report, but she was never spoken to about it.

2. During an interview with Family Member (FM) 1 of Patient B, on 7/11/13, at 9:17 AM, she stated he told her that when he was a patient at the facility, Mental Health Worker (MHW) 1 decided to take Patient B to the locked quiet room, however Patient B did not want to go. She further stated MHW 1 pulled Patient B's arm back and slammed him into the wall. FM 1 stated when Patient B was discharged from the facility, he had scratches, swelling and bruising to his face, which he did not have when he had been admitted.

During a review of the clinical record for Patient B, the Nurses Notes, dated, 7/9/13, at 11:30 AM, indicated "Patient escorted by staff to time-out... Patient's face hit wall next to seclusion/time-out room... Patient observed to have redness and slight swelling to left eye area...patient reporting pain to left eye area."

During a review of the clinical record for Patient B, the Nurses Notes, dated 7/9/13, at 3:30 PM, indicated "Patient observed with mild swelling and redness to left eye area...slight redness to right eye area."

During a review of the clinical record for Patient B, the Discharge Summary, dated 7/10/13, at 4:19 PM, indicated on 7/10/13, at 8:45 AM, the patient was observed to have redness and purple bruising to the left eye area, redness to the right eye area, and a scab underneath his chin.

During an interview with Nurse Manager on 7/30/13, at 1:24 PM, she stated the hospital looked into the incident but did not believe there was any abuse.

During an interview with MHW 2 on 8/5/13, he stated he and MHW 1 were escorting Patient B to the seclusion room; MHW 1 on one side, holding one arm, and MHW 2 on the other side, holding the other arm. He stated Patient B started to pull away; MHW 1 was "dragging him" (Patient B) towards the door and then moved Patient B all the way to the wall. MHW 1 had one hand on Patient B's upper arm and on hand on his shoulder. MHW 2 stated "I think he got the scratches and bruises from the wall. It was done incorrectly. MHW 1 was too forceful. That's not how we are supposed to do it."

During an interview with MHW 3, on 8/6/13, at 10:12 AM, when describing what to do with a combative (physically aggressive) patient, he stated "Hands should be placed on upper arm and wrist of the patient; hands should not be placed on the patient's back or shoulder. You should take the patient down to the ground because it is safer for the patient. We are not supposed to use the wall. It goes against our yearly training."

The facility policy and procedure titled "Abuse: Identifying and Reporting" dated 3/2012, indicated "Physical Abuse: Physical injury which results in substantial harm to the person...including an injury that is at variance with the history or explanation given...scratches, cuts, bruises or burns..."

The facility policy and procedure titled "Patient Rights" dated 3/2012, indicated "...12. Receive care in a safe setting, free from verbal or physical abuse or harassment..."

The facility policy and procedure titled "Adverse Event Report to the Department of Public Health Services" last reviewed 3/12, read "It is the policy of (hospital name) to be proactive and immediate in its response to any unanticipated occurrence that results in....psychological injury, or the risk thereof, to a patient or client. It shall be the policy of (hospital name) to investigate the source of any such occurrence, initiate any safety measures deemed necessary...."

Based on interview and document review, the hospital failed to develop an effective quality assessment and performance improvement (QAPI) program to identify opportunities the hospital could have taken to ensure patient safety as evidenced by failure to:

1. Provide evidence the hospital's QAPI program tracked, analyzed, and implemented improvement measures concerning abuse allegations and investigations. (Refer to A 286)

2. Reported abuse allegations and investigations to the Medical Executive Committee. (Refer to A 286)

The cumulative effect of this systemic problem resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on interview and record review, the hospital failed to provide evidence the hospital's Quality Assessment and Performance Improvement (QAPI) program:

1. Tracked, analyzed, and implemented improvement measures concerning abuse allegations and investigations.

2. Reported abuse allegations and investigations to the Medical Executive Committee.

These failures had the potential for the abuse of the hospital's patient population to continue without implementation of improvement measures and without oversight by the Medical Executive Committee.

Findings:

During a concurrent interview with the Chief Nursing Officer (CNO) and review of the hospital's QAPI program binder on 7/30/13 at 12:55 PM, the QAPI program documentation did not include reference to actual or alleged abuse and the lack of investigation by the hospital staff for the abuse allegations on 5/9/13. The CNO stated those issues were discussed in "closed sessions" during a combined meeting with the Governing Board (the person or persons designated by the owner as the governing authority who shall have supreme authority in the hospital) and the Medical Executive Committee (this committee acts as the organizational body which oversees the functions and duties of the medical staff. It is empowered to act for the staff and to coordinate all activities and policies of the staff, its departments and committees). The CNO stated any documentation concerning abuse and abuse investigations was not available for review by the Department. He stated he was unable to provide evidence the QAPI program was tracking, and analyzing alleged abuse incidents with resulting investigations and that the Medical Executive Committee was informed of the concerns listed above.

The hospital's Medical Staff Bylaws revised 2007, read "The Quality Review Committee shall perform the following duties: Recommend, for approval of the Medical Executive Committee, plans for maintaining quality patient care within the Hospital including but not limited to, the following mechanisms: establish systems to identify potential problems in patient care; set priorities for action on problem correction; refer priority problems for assessment and corrective action to appropriate Departments or Committees; monitor the results of patient care evaluation activities throughout the Hospital; coordinate patient care evaluation activities... initiate and evaluate quality review reports, oversight of care path, clinical practice guideline development, implementation, and ongoing evaluation... review appropriateness of care in all areas of the Hospital... submit regular reports to the Medical Executive committee on the quality of medical care provided and on quality review activities conducted.

The Medical Staff Bylaws continued to read "The duties of the Medical Executive Committee shall include, but not be limited to: ....receiving and acting upon reports and recommendations from Medical Staff Departments, committees, and assigned activity groups....participating in the development of all Medical Staff and Hospital policy, practice, and planning...."

Based on interview and record review, the hospital failed to develop a Care Plan for one patient (B). This failure had the potential to result in unmet care needs.

Findings:

During a review of the clinical record for Patient B, the Nurses Notes, dated 7/9/13, at 3:30 PM, indicated "Patient observed with mild swelling and redness to left eye area...slight redness to right eye area."

During a review of the clinical record for Patient B, the Discharge Summary, dated 7/10/13, at 4:19 PM, indicated on 7/10/13, at 8:45 AM, the patient was observed to have redness and purple bruising to the left eye area, redness to the right eye area, and a scab underneath his chin.

During an interview with the Nurse Manager, on 7/30/13, at 1:24 PM, she reviewed the clinical record for Patient B and was unable to find documentation of a skin integrity care plan. She stated "The nurse should have revised the care plan for skin integrity, but she did not."

The facility policy and procedure titled "Treatment Planning-Protocol of the Use of the Interdisciplinary Format" dated 3/2013, read "The RN (registered nurse) and/or responsible staff will revise and/or update the problem specific plans of care. This will include all changes in goals, objectives and interventions..."