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Based on document review and interview, it was determined that the Hospital failed to protect and promote each patient's rights by preventing Pt. #1 (who was catatonic) from being bathed by Pt #2 (who was on sexually acting out precautions). This failure could potentially affect all patients at the Hospital who require bathing assistance. As a result, the
Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure care in a safe setting for a catatonic and selectively mute patient (Pt #1) during unsupervised bathing given by another patient (Pt #2) See deficiency at A-144.

The immediate jeopardy (IJ) began on 7/8/2020, due to the Hospital's failure to provide care in a safe setting by having Pt #2 (who was on sexually acting out precautions) bathe Pt #1 (who was catatonic). This placed all patients requiring bathing assistance at potential risk for harm.

The IJ was identified on 10/6/2020 and was announced on 10/6/2020 at 3:45 PM during a meeting with the Chief Compliance Officer and Chief Executive Officer. The IJ was removed by the survey exit date of 10/7/2020.

The IJ was removed on 10/7/2020, based on interview and document review as follows:

1. On 10/7/2020 at 9:00 AM, an interview was conducted with the Chief Compliance Officer (E #5). E #5 stated that the Registered Nurse (E #11) was terminated. E #1 stated that the Hospital staff has been trained in abuse/neglect, boundaries, patient safety, code of conduct and refusal of assignments. E #5 stated that staff members are not allowed to return to work until they have completed the training.

2. Review of the Hospital training packet included sign in sheets for employees and a handout that was provided to each employee. The training packet included information about abuse/neglect, patient safety, code of conduct and refusal of assignments.

3. E #11's personnel file was reviewed on 10/6/2020 for evidence of termination. E#11's personnel file dated 10/6/2020 included documentation that E #11 was terminated.

Based on document review and interview, it was determined that for 1 of 1 patient (Pt #2) who was instructed by Hospital staff to perform nursing duties, including the bathing of another patient, the Hospital failed to ensure patient rights were exercised, in that no patient was asked to perform work without being paid.

Findings include:

1. On 10/6/2020, the Hospital's "Rights of Individuals Receiving Mental Health and Developmental Disabilities Services" (undated) was reviewed and indicated, "...You must be paid for work you are asked to perform which benefits the facility. NOTE: You may be required to do personal housekeeping chores without being paid."

2. On 10/6/2020, Pt #1's clinical record was reviewed. Pt #1 was admitted on 6/27/2020 with a diagnosis of undifferentiated schizophrenia and was documented as catatonic and selectively mute. Pt #1 was on elopement and self-injury precautions and required assistance with ADLs (activities of daily living.)

3. On 10/6/2020, Pt #2's clinical record was reviewed. Pt #2 was admitted on 7/2/2020 with a diagnosis of bipolar schizoaffective.

4. On 10/6/2020 at 9:20 AM, an interview was conducted with a Registered Nurse (E #11). E #11 stated that on the evening of 7/8/2020, E #11 instructed Pt. #2 to bathe Pt. #1. E #11 stated that Pt. #2 gave Pt. #1 an unsupervised shower in the hall bathroom.

5. On 10/6/2020 at 9:30 AM, an interview was conducted with the CEO (E #12 ). E #12 stated that it is not acceptable for one patient to bathe another patient. E #12 stated that it was the staff's job to assist with bathing. E #12 did not state in the interview that Pt #2 was paid to bathe Pt #1.

Based on document review and interview, it was determined that for 2 of 2 (Pt. #1 and Pt. #2) clinical records reviewed for patient care, the Hospital failed to ensure care in a safe setting for a catatonic and selectively mute patient (Pt. #1) during unsupervised bathing which was given by another patient (Pt. #2) who was on sexually acting out precautions. This potentially placed Pt #1 at risk for serious physical, emotional, and psychological harm and could potentially affect all patients at the Hospital who require bathing assistance.

Findings include:

1.On 10/6/2020, the Hospital's policy titled, "Grooming and Personal Hygiene" (revised by the Hospital 9/2019) was reviewed and included, "Nursing staff bathes and provides assistance with bath depending on level of ability."

2. On 10/6/2020, the Hospital's policy titled, "Patient Precautions" (approved by the Hospital 5/2019) was reviewed and required, "Sexual acting out precautions may be instituted for patients with a known history of and/or demonstrated sexually but not limited to the following: Sexually inappropriate behaviors ...monitor person-to-person interactions."

3.On 10/5/2020, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 6/27/2020 with a diagnosis of undifferentiated schizophrenia. Pt. #1 was discharged on 7/20/2020.
-The physician's order, dated 6/27/2020, included orders for routine 15 minute checks, elopement precautions.
-The Nursing Reassessment Note, dated 7/8/2020, included, "Pt. [Pt. #1] is unable to take care of ADL's. Pt. [Pt. #1] is given assistance with her ADL's and monitored closely by staff.
-The Patient Observation/Precaution form, dated July 8, 2020, included documentation that Pt. #1 showered from 2200 - 2215 (10:00 PM - 10:15PM).
-The discharge summary dated 8/19/2020, included, "During the initial psychiatric evaluation, the patient was bizarre in appearance with poor hygiene ...The patient was mute ..."

4. On 10/5/2020, Pt. #2's clinical record was reviewed. Pt. #2 was admitted on 7/2/2020 with the diagnosis of bipolar schizoaffective. Pt. #2 was discharged on 7/15/2020.
-The physician's order, dated 7/2/2020, included, routine 15 minute checks and sexually acting out precautions.
-The Nursing Shift Reassessment, dated 7/8/2020, included, "3-11 Reassessment - ADL's/Hygiene Status - Independent."
-The Patient Observation/Precaution form, dated 7/8/2020, included documentation that Pt. #2 showered on 7/8/2020 between 2145 - 2200 (9:45 PM - 10:00 PM).
-The discharge summary included, "Hospital course: Patient [Pt. #2] was admitted to the unit and placed under sexually acting out precautions...Pt. #2 was observed being delusional and sexually acting out. Pt. #2 gets naked in her room and spoke very inappropriately and sexually."
Pt. #2's person-to-person interactions were not closely monitored in accordance with Hospital policy for patients on sexually acting out precautions. Pt. #2 was placed in a position, by staff, to engage in an inappropriate interaction with a peer (Pt. #1).

5. On 10/6/2020 at 9:20 AM, with E #5 and E #12 present, a telephone interview was conducted with E #11. E #11 stated that on 7/8/2020 he was the nurse assigned to care for Pt. #1 and Pt. #2. E #11 stated that the Mental Health Associates working on 7/8/2020 refused to bathe Pt. #1. E #11 stated that Pt. #2 gave Pt. #1 an unsupervised shower in the hall bathroom. E #11 stated that he allowed Pt. #2 to bathe Pt. #1 but did not go into the bathroom with the patients in order to respect their privacy. E #11 stated that he checked on Pt. #1 and Pt. #2 periodically by knocking on the door to inquire if they were okay. E #11 stated that he was aware that Pt. #2 had sexually acting out precautions in place but felt that it was safe for Pt. #2 to bathe Pt. #1 because Pt. #2 had not displayed any behaviors, and Pt #2 used to be a nurse so should be able to bathe Pt #1. E #11 stated that he immediately informed the Nursing supervisor (E #1) and the Assistant Director of Nursing (E #2) on 7/8/2020, that he allowed Pt. #2 to bathe Pt. #1 because Pt. #1 had a bad odor and the Mental Health Associates refused to bathe Pt. #1. E #11 stated that he felt it was a positive outcome because Pt. #1 was bathed.

6. On 10/6/2020 at 10:51 AM, with E #5 present, a telephone interview was conducted with a Mental Health Associate (E #13). E #13 stated that on 7/8/2020, during the evening shift, E #11 asked her to bathe Pt. #1. E #13 stated that E #11 later informed her that a nurse would be bathing Pt. #1. E #13 stated that E #11 later informed her that Pt. #2 was a former nurse and had bathed Pt. #1. E #13 stated that Pt. #2 was hypersexual and made sexual comments to her peers.

7. On 10/6/2020 at 12:23 PM, a telephone interview was conducted with a former Mental Health Associate (E #14). E #14 stated that on 7/8/2020 E#11 asked her to bathe Pt. #1. E #14 stated that she offered to assist E #11 with bathing Pt. #1 but E #11 later returned to the nursing station to inform E #14 that he did not need her help because Pt. #2 was currently bathing Pt. #1. E #14 stated that she told E #1 and E #2 that E #11 allowed Pt. #2 to bathe Pt. #1 and that they should be more concerned about that issue. E #14 stated that E #1 and E #2 did not address the issue of Pt. #2 bathing Pt. #1 but continued to focus on the issue that she did not bathe Pt. #1. E #14 stated that Pt. #2 was hypersexual and Pt. #1 was unable to verbalize enough to tell anyone to stop. E #14 stated that she informed E#11 that patients should not bathe each other because it was inappropriate and unsafe.

8. On 10/5/2020 at 12:08 PM, an interview was conducted with the Assistant Director of Nursing (E #2). E #2 stated that he does not recall anyone reporting that a patient gave another patient a bath. E #2 stated that patients are not allowed to bathe each other and there is only one patient allowed in the bathroom at a time for patient safety.

9. On 10/5/2020 at 12:34 PM, an interview was conducted with a Nurse Supervisor (E #1). E #1 stated that she is not aware of an incident involving a patient bathing another patient. E#1 stated that it would be inappropriate for patients to bathe each other, and staff is only present for bathing if the patient is on 1:1 (one staff to one patient) observations.

Based on document review and interview, it was determined that for 1 of 3 (incident involving Pt #1) incidents reviewed for reporting and investigating, the Hospital failed to ensure the patient's right to be free from all forms of abuse/neglect by failing to timely identify and investigate an incident of abuse/neglect where the Nurse (E #11) instructed and allowed Pt #2 (who was on sexually acting out precautions) to bathe Pt. #1 (who was catatonic) unsupervised.

Findings include:

1. The Hospital's policy titled, "Suspected Abuse/Neglect of Adult" (approved the Hospital 9/2019) was reviewed and required, "Patient Protection from Abuse Act: Action Steps: Any staff member who has reasonable cause to believe that any patient with whom he/she has direct contact with has been subjected to abuse in the hospital shall promptly report it to Hospital Administration."

2. On 10/5/2020, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 6/27/2020 with a diagnosis of undifferentiated schizophrenia. Pt. #1 was discharged on 7/20/2020.
-The physician's order, dated 6/27/2020, included orders for routine 15 minute checks, elopement precautions.
-The Nursing Reassessment Note, dated 7/8/2020, included, "Pt. [Pt. #1] is unable to take care of ADL's. Pt. [Pt. #1] is given assistance with her ADL's and monitored closely by staff.
-The Patient Observation/Precaution form, dated July 8, 2020, included documentation that Pt. #1 showered from 2200 - 2215 (10:00 PM - 10:15PM).
-The discharge summary dated 8/19/2020, included, "During the initial psychiatric evaluation, the patient was bizarre in appearance with poor hygiene ...The patient was mute ..."

3. On 10/5/2020, Pt. #2's clinical record was reviewed. Pt. #2 was admitted on 7/2/2020 with the diagnosis of bipolar schizoaffective. Pt. #2 was discharged on 7/15/2020.
-The Physician order, dated 7/2/2020, included, routine 15 minute checks and sexually acting out precautions.
-The Nursing Shift Reassessment, dated 7/8/2020, included, "3-11 Reassessment - ADL's/Hygiene Status - Independent."
-The Patient Observation/Precaution form, dated 7/8/2020, included documentation that Pt. #2 showered on 7/8/2020 between 2145 - 2200 (9:45 PM - 10:00 PM).
-The discharge summary included, "Hospital course: Patient [Pt. #2] was admitted to the unit and placed under sexually acting out precautions...Pt. #2 was observed being delusional and sexually acting out. Pt. #2 gets naked in her room and spoke very inappropriately and sexually."

4. On 10/6/2020 at 9:20 AM, with E #5 and E #12 present, a telephone interview was conducted with E #11. E #11 stated that on 7/8/2020, he was the nurse assigned to care for Pt. #1 and Pt. #2. E #11 stated that Pt. #2 gave Pt. #1 an unsupervised shower in the hall bathroom. E #11 stated that he instructed and allowed Pt. #2 to bathe Pt. #1 but did not go into the bathroom with the patients in order to respect their privacy. E #11 stated that he checked on Pt. #1 and Pt. #2 periodically by knocking on the door to inquire if they were okay. E #11 stated that he was aware that Pt. #2 had sexually acting out precautions in place but felt that it was safe for Pt. #2 to bathe Pt. #1 because Pt. #2 had not displayed any behaviors, and Pt #2 used to be a nurse so should be able to bathe Pt #1. E #11 stated that he immediately informed the Nursing supervisor (E #1) and the Assistant Director of Nursing (E #2) on 7/8/2020, that he allowed Pt. #2 to bathe Pt. #1." E #11 did not complete an incident report regarding this event.

5. On 10/6/2020 at 12:23 PM, a telephone interview was conducted with a former Mental Health Associate (E #14). E #14 stated that she told E #1 and E #2 that E #11 allowed Pt. #2 to bathe Pt. #1. E #14 stated that E #1 and E #2 did not address the issue of Pt. #2 bathing Pt. #1. E #14 did not complete an incident report regarding this event.

6. On 10/6/2020, the Hospital's incident reports from (Jan. 2020 to Oct. 2020) were reviewed. The incident report did not include an incident report for Pt #1's bathing incident.

7. On 10/5/2020 at 12:08 PM, an interview was conducted with the Assistant Director of Nursing (E #2). E #2 stated that he does not recall anyone reporting that a patient gave another patient a bath.

8. On 10/5/2020 at 12:34 PM, an interview was conducted with a Nurse Supervisor (E #1). E #1 stated that she is not aware of an incident involving a patient bathing another patient.

9. On 10/6/2020 at 9:00 AM, with the Chief Executive Officer (E #12) present, an interview was conducted with the Chief Compliance Officer (E #5). E #5 stated that the Hospital staff did not report the incident to Hospital Administration, and Hospital Administration only learned of the incident during the Department of Public Health's survey (10/6/2020). The Hospital staff should have reported the incident to Hospital administration, and an investigation should have been conducted.