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Based on record review, interview, and policy review the provider failed to ensure their policy for suspected or potential abuse for one of one patient (2) by one of one registered nurse (RN) C was followed during an investigation regarding the forceful administration of oral medications. Findings include:

Review of a complaint filed with the South Dakota Department of Health (SD DOH) revealed:
*RN C was attempting to administer oral medication to patient 2.
*Patient 2 was confused, combative, and spitting out his medications.
*RN D was holding applesauce to give with the medications for patient 2.
*RN C had instructed patient care tech (PCT) E to hold patient 2's hands down while she attempted to administer the oral medications.
*PCT E held patient 2's hands down while RN C held patient 2's jaw open with her hands administered the oral medications, and then forced the patient's mouth shut with her hands.
*Medical lab technician (MLT) H had been in the patient's room at the time and witnessed the above event.

Interview and record review on 9/7/23 at 4:50 p.m. with RN B regarding the SD DOH report filed on 7/25/23 revealed:
*On 6/24/23 she received a phone call from certified nurse practitioner (CNP) J regarding RN C forcing patient 2 during medication administration.
*She removed RN C from caring for patient 2 but was still caring for other patients in the hospital.
*RN C had not been placed on temporary leave pending an investigation related to the 6/23/23 suspected abuse.
*Administrator A was contacted immediately after her phone conversation with CNP J to inform him of the situation and the plan of action.
*She had initiated the investigation on 6/24/23 with an interview with RN C and resumed the investigation again on 7/24/23 when RN B had returned from vacation.
*On 7/24/23 she had interviewed RN D, PCT E, and MLT H.
*RN B's initial and final report was sent to the South Dakota Department of Health on 7/25/23 one month after the potential abuse to patient 2 had occurred.


Review of the provider's April 2023 Corrective Action policy revealed:
*"Employees are expected to conduct themselves in a manner consistent with the provider's mission, care standards for service excellence, and all applicable rules, regulations, laws, and polices."
*A formal process where the provider may, depending on the nature and severity of the issue, suspend an employee with or without pay when there is immediate need to remove the employee from the work place."
-"Examples of when an employee should be suspended pending an human resource investigation include, but no limited to:"
--"A situation that involves allegation of abuse by an employee."

Refer to: C1046.

Based on record review, interview, and policy review the provider failed to ensure one of one sampled patient (2) was not physically forced to take his medication by one of one registered nurse (RN) C during oral medication administration. Findings include:

Review of patient 2's electronic medical record (EMR) revealed:
*He was a 76 year old and had been admitted from his own home on 6/22/23.
*Admitting diagnoses included:
-Dehydration, loose stools, and pneumonia.
*He had a past medical history of the following: Parkinson's disease with psychosis, and dementia.
*He was treated with intravenous (IV) fluids, and IV antibiotics.
*The date of discharge to a long-term care facility was on 6/28/23.

Review of the South Dakota Department of Health report that was received revealed the following:
*On 6/23/23 RN C was attempting to administer oral medications to patient 2.
*Patient 2 had been confused, combative, and had refused to take his oral medications for RN C.
*RN D had entered patient 2's room to attempt to administer the medications to the patient.
*Patient Care Tech (PCT) E had entered patient 2's room and was instructed by RN C to hold patient 2's hands down since he was striking out at staff during the attempt to administer those medications.
*RN C then grabbed patient 2's jaw with her hands, forcefully opened his mouth, gave him the medications, and then closed his mouth holding it shut with her hand.
*MLT H had been in the patient's room while the medications had been administered.

Interview on 9/7/23 at 12:05 p.m. with medical lab technician (MLT) H regarding the above event revealed:
*She had witnessed the event and spoke with RN D and PCT E following the event.
*PCT E had stated that she thought the whole situation was "barbaric".
*MLT H informed RN D and PCT E that was patient abuse by RN C.
*On 6/24/23 MLT H filed an internal Risk Management report regarding her observation of the event on 6/23/23.
*She had spoken with certified nurse practitioner (CNP) J on 6/24/23 and informed her of her observation on 6/23/23.
*MLT H had left for vacation on 6/25/23 and returned to work on 7/12/23 she verified with RN I that her internal Risk Management report had been received.
*RN B had contacted MLT H on 7/25/23 and met with RN B in person to get the information regarding the above event.

Interview on 9/7/23 at 1:00 p.m. with RN F regarding oral medication administration to a confused and agitated patient revealed:
*She would have explained to the patient that she was giving them their medication.
*Evaluation of the explanation and the patient's response would have determined if medication should have been administered at that time or to wait a period of time and reapproach the patient.
*Combative patients who were hitting and kicking staff would indicate that the patient was not receptive to the oral medication administrations.
*RN F would have then contacted the provider to change the route of administration or inform the provider the patient refused that medication.
*She would not have forcefully opened a patient's mouth and forced it shut to administer a medication to a patient.

Interview on 9/7/23 at 1:10 p.m. with PCT E regarding the incident of physically forceful medication administration to patient 2 on 6/23/23 revealed:
*She had heard loud voices coming from patient 2's room.
*RN C was having trouble administering patient 2 oral medications.
*RN D had entered the patient's room to assist with the oral medication administration.
*RN C instructed her to hold patient 2's hands down due to him hitting staff during the attempted medication administration.
*RN C had one hand over patient 2's nose and one under his jaw, she moved her hand over the patient's nose and used the other hand to administer the medication. RN C then held his clamped her hand over the patient's mouth.
*PCT E stated that she thought it was "barbaric" to administer medication in that manner.

Interview on 9/7/23 at 1:14 p.m. with RN G regarding oral medication administration to a confused and combative patient revealed:
*She would have tried to redirect the patient and explain what the medication was for and then assess for the patient's comprehension.
*Patients that were combative, she would not attempt to administer the medication and would have tried to calm them down.
*She would have contacted the provider and suggest a possible alternative route for medication administration.

Interview on 9/7/23 at 1:30 p.m. with RN I regarding receiving a internal Risk Management report filed on 6/24/23 regarding patient 2 revealed:
*She had received the report on 6/26/23 when she had returned to work.
*She would fill in as the director of patient care services if RN B was on leave.

Interview on 9/7/23 at 2:03 p.m. with RN C regarding her medication administration on 6/23/23 with patient 2 revealed:
*She was in the patient's room by herself trying to get him to take his oral medication Sinemet 25/100 milligrams (mg) and Mirtazapine 15 mg.
*Patient 2 had accepted the medications she had administered on 6/22/23.
*Patient 2 was confused, and she had spoken with him for approximately 15 minutes to convince him to take his medication.
*She had attempted to crush the medication and administer them in applesauce.
*Patient 2 continued to spit out the medication.
*RN D had been asked to administer the medication to patient 2.
*Patient 2 was hitting and kicking at staff.
*She instructed PCT E to hold patient 2's hands down and then she opened his lips "like a fish "squeezing on both sides of his cheeks.
*Patient 2's mouth was open and then she administered the medication in applesauce, and he then spit them back out.
*She then contacted the provider to get an alternative medication that could have been administered IV for his behaviors.
*RN C then administered lorazepam 0.25 mg IV to patient 2 per the provider's order.
*Dementia training was not provided to the staff.
*She had to have assistance with holding patient 2's hands down on other occasions to have gotten them to take his medications.
*She had thought she had tried everything to get him to take his medications.

Interview on 9/7/23 at 2:35 p.m. with RN D regarding the medication administration on 6/23/23 with patient 2 revealed:
*She had entered patient 2's room due to RN C being away from the nurse's station for 20-30 minutes.
*Loud words and screaming from patient 2's room was heard in the hallway.
*She had worked with patient 2 for a couple of nights and was familiar with him.
*Patient 2 had been combative on 6/22/23 and she had reported that to the oncoming shift on 6/23/23.
*She had noticed that PCT E was talking with patient 2 to try and get him to take his medication from RN C.
*RN C had tried applesauce and pudding to help aid with the medication administration without success.
*RN C pinched patient 2's cheeks like a "kissy face" and forced the medication into his mouth.
*Patient 2 then spit out those medications
*RN C then stated, "We're done."
*She would not have tried as long to get patient 2 to take his medication.
*She would not have placed her hands on the patient, nor would she have had someone hold the patient's hands down while attempting to give medication.

Interview on 9/7/23 at 4:50 p.m. with administrator A and RN B regarding patient 2's medication administration on 6/23/23 and the suspected abuse allegation revealed:
*On 6/24/23 RN B received a phone call from CNP J regarding the concern that had been brought to her attention involving RN C.
*She contacted administrator A to inform him of the situation.
*She had contacted RN C to get her perspective on what happened on 6/23/23
*RN B informed RN C not to provide any care to patient 2 on 6/24/23.
*She had spoken to MLT B on 7/25/23 to get her account of the incident on 6/23/23.
*Once RN B had gathered her information and shared all that information to human resources.
*Administrator A was not involved in the interviewing of staff.
*They both had not felt that RN C using her hand to make a "kissy face" to get him to take his medication was abuse.
*They had both felt that holding a patient's hands down depended on the situation.
*Administrator A had informed us that human resources had felt that there was no abuse, so they did not treat it as such.
*Neither administrator A nor RN B had followed their Corrective Action policy.
*They both had confirmed that RN C had been working and continued to care for other patients during the investigation process.
*RN C was hired in 2003 had worked for the facility for 20 years, and there were no concerns with her performance.
*They wanted to give RN C the benefit of the doubt.
*Neither administrator A nor RN B had thought about the psycho-social affect that could have had on patient 2.

Review of the provider's June and July 2023 nursing schedule for the dates of 6/23/23 through 7/25/23 revealed:
*RN C had worked 20 out of 32 shifts during that period.
*She had not been placed on temporary leave pending an investigation related to the 6/23/23 suspected abuse.

Review of the provider's January 2023 Abuse Elder, Suspected or Alleged policy revealed:
*"Abuse: means physical harm, injury or attempt to cause physical harm or injury or the infliction of fear of imminent physical harm or body injury."

Review of the provider's April 2023 Corrective Action policy revealed:
*"Employees are expected to conduct themselves in a manner consistent with the provider's mission, care standards for service excellence, and all applicable rules, regulations, laws, and polices."
*A formal process where the provider may, depending on the nature and severity of the issue, suspend an employee with or without pay when there is immediate need to remove the employee from the workplace."
-"Examples of when an employee should be suspended pending a human resource investigation include, but not limited to:"
--"A situation that involves allegation of abuse by an employee."