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I. Based on document review and staff interview, the acute care hospital's administrative staff failed to:

1. Ensure the staff protected all patients from abuse, neglect, or harassment, when the staff failed to separate a staff member accused of abuse from all other potential victims. Please refer to A-0115 for additional information.

2. Ensure the hospital's policy on abuse addressed instances of abuse where an alleged abuser assaulted a patient, but did not cause any physical injury. Please refer to A-0115 for additional information.

The cumulative effect of these failures resulted in the hospital's inability to ensure staff protected all patients on Ward S from all forms of abuse when the hospital's administration placed a staff member accused of abusing a patient on Ward R onto Ward S, and allowed him to work with patients on Ward S. The hospital identified a census of 15 female patients on Ward S on the day of entrance.


II. During the course of the investigation of incident 80803-I, the on-site survey team identified an Immediate Jeopardy (IJ) situation (a crisis that placed the health and safety of patients at risk) related to Condition of Participation for Patient's Rights (42 CFR 482.13). The hospital staff failed to protect all patients from abuse.

1. The administrative staff failed to initially separate an alleged abuser from all patients when they allowed the alleged abuser to work with 15 female patients on Ward S and failed to provide policy guidance about when a physical assault took place but did not result in physical injury.

2. While on-site, the survey team identified an Immediate Jeopardy situation and notified the administrative staff on 1/23/19. The administrative staff promptly took action to remove the immediacy of the situation. The hospital staff removed the immediacy prior to the survey team exiting the complaint investigation when the administrative staff took the following actions:

a.. The Nursing Operations Manual Policy, "Patient Abuse Reporting", Procedure #4, has been revised to state "If the alleged abuser is an employee, the alleged abuser will be separated from any patient contact at the facility pending completion of the investigation by the DIA.".

b. The administrative staff placed the staff member who allegedly abused a patient on administrative leave, starting on 1/23/2019, and did not allow the staff member to return to the hospital grounds until the completion of the investigation.

c. The administration notified the Nursing Supervisors the staff member was placed on administrative leave and could not return to work until after the conclusion of the investigation.

d. The administrative staff created a new "Patient Abuse Policy" to address: the screening of prospective employees; process for an internal investigation at the hospital; the process to address staff members accused of abusing patients; and updated the definitions of abuse to include instances of potential abuse which did not result in physical injury to a patient.

The following Condition level deficiency remained for the Condition of Patient's Rights (42 CFR 482.13).

Based on document review and staff interviews the psychiatric acute care hospital administrative staff failed to protect all patients from all forms of abuse, neglect, or harassment for 15 of 55 patients when they allowed RTW A to continue to work. Failure to protect patients from all forms of abuse may result in significant mental anguish, physical pain, injury, long term disability or death. The hospital identified a census of 15 patients on Ward S upon entrance.

Findings included:

1. During an interview on 1/22/19 at 9:16 AM, RTW C revealed that on 12/23/18 at approximately 11:45 AM, they had just returned to the front day room (where patients on Ward R eat lunch). RTW C heard loud yelling from the opposite corner of the room, where staff serve the lunch trays. RTW C saw RTW A grab Patient #1 at the top center of the shirt with both fists and forcefully sat Patient #1 in a nearby chair. RTW C reported Patient #1's behavior was nothing out of the ordinary prior to the incident. Patient #1 did not respond to directives and did only what Patient #1 wanted to do. RTW C observed that Patient #1 was "wide eyed" and put up a struggle when forced to sit down onto a chair. RTW C noted Patient #1 was awfully quiet after the incident, which was not typical behavior for Patient #1. Patient #1 appeared surprised, or shocked, by RTW A grabbing Patient #1's shirt, but Patient #1 did not appear to suffer pain from the incident. RTW C reported they had never witnessed RTW A or any staff place hands on a patient and yell prior to this incident and never wanted to see this happen again. RTW C verbalized RTW A apologized to both RTW C and RTW D, who had also been present. RTW C revealed RTW D informed RTW C that RTW A reported the incident to RN F. RTW C was surprised that RN F failed to question the residential treatment workers who witnessed the incident after RTW A grabbed Patient #1's shirt.

RTW C had difficulty sleeping the night of the incident, and decided they should have reported the incident to RN F, instead of just relying on RTW A to self-report the issue. RTW C reported the incident to the hospital's administration on the morning of 12/24/19.

2. During an interview on 1/22/19 at 10:06 AM, RTW D revealed that on 12/23/19 at approximately 11:45 AM, RTW D made rounds in the day/dining room to ensure the 19 patients had left their rooms and got ready for lunch. RTW D heard a noise and noticed RTW A was trying to get the patients to line up in a single file line, so they could pick up their lunch trays. RTW D heard someone yell "[expletive]!" RTW D saw RTW A had grabbed Patient #1 by the shirt, near the collar. RTW A tried to force Patient #1 to sit onto a chair. RTW D yelled at RTW A, "Hey, hey, knock it off!" RTW A released Patient #1 into the chair. Patient #1 looked started and everyone in the room (including the other patients) became quiet. All of the patients looked very surprised by the incident. RTW D saw a tear in Patient #1's eye and "it broke my heart."

3. During an interview on 1/17/19 at 1:40 PM, RN F revealed that RTW A came into the nursing station after lunch. RTW A verbalized hoping the other staff did not think RTW A "over did it" with Patient #1. RTW A related they assisted Patient #1 into a chair, and Patient #1 sat on their own foot in the process. RTW A did not provide any indication that something serious happened, and nothing RTW A told RN F indicated that RN F should check on Patient #1. RTW A failed to inform RN F that RTW A became upset with Patient #1, had yelled at Patient #1, or used explicit language towards Patient #1.
RN F completed a physical assessment of Patient #1 on 12/24/18. RN F requested 2 RTWs, both who frequently bathed Patient #1, to assist with the assessment. The staff did not identify any new injuries or marks. Patient #1

4. During an interview on 1/22/19 at 1:47 PM, RTW A revealed that around lunch time on 12/23/18, the dietary staff delivered the lunch trays on a cart. RTW A was preparing to hand out the lunch trays to patients in line. Patient #1 sits in a chair right next to the location where RTW A was passing out lunch trays. Patient #1 began yelling, screaming, and displaying extremely disruptive behavior. RTW A lost his composure, yelled at Patient #1 to sit down, grabbed Patient #1's shirt, and forcefully sat Patient #1 down in the chair by pulling downward on Patient #1's shirt. Patient #1 lost their balance in the process of sitting down, and sat on their own left leg. Patient #1 wrinkled their face in apparent discomfort.

RTW A informed RN F about the incident within approximately 5 to 10 minutes of the incident occurring. RTW A worked the remainder of their shift. RTW A was placed on administrative leave and served a 5 day suspension for the incident. Following the suspension, the administrative staff allowed RTW A to return to work on Ward S (an inpatient mental health unit for mentally ill female patients) but not Ward R (an inpatient mental health unit for mentally ill male patients, where Patient #1 lived).

8. Review of a letter sent to RTW A, dated January 7, 2019, revealed in part, "Effective January 7, 2019, you are being suspended for five working days without pay .... You will resume your normal schedule on January 8, 2019. Upon your return to work, you will be assigned to work ... Ward S ... pending closure of the report to the Department of Inspections and Appeals (DIA, a separate governmental agency responsible for enforcing federal hospital regulations and determining if hospital staff abused patients in hospitals)."

9. Review of staffing schedules between 1/9/19 to 1/22/19, revealed RTW A worked 12 shifts (6:45 AM to 3:15 PM) on Ward S (an inpatient mental health unit for mentally ill female patients, who are considered dependent adults vulnerable to abuse).

10. Review of policy "PATIENT ABUSE REPORTING", reviewed 2018, revealed in part, "Employees who believe that patient abuse or neglect may have occurred within the hospital must notify the Supervisor immediately." "If the alleged abuser is an employee, the alleged abuser must be separated from the victim until the facility receives the written report from [Department of Inspections and Appeals] regarding the outcome of the investigation."

The abuse policy failed to address instances where an individual physically assaulted a patient, and the patient did not suffer any physical injury and/or bruising. The abuse policy failed to require the hospital staff to separate the alleged perpetrator of dependent adult abuse from other patients. The policy also failed to require the hospital staff to perform their own investigation into allegations of abuse, evaluate staff conduct, and not rely on an outside agency to determine if abuse occurred.


11. During an interview on 1/22/19 at 1:32 PM, the Administrator of Nursing revealed that she considered the incident between RTW A and Patient #1 to violate the MHI-Independence work rules. The Administrator of Nursing did not know if the incident met the criteria for dependent adult abuse (since the hospital's policy failed to reflect instances of abuse that do not involve physical injury to the patient) since RTW A did not injure Patient #1. The Administrator of Nursing expected the DIA staff to determine if RTW A abused Patient #1.

The Administrator of Nursing acknowledged they allowed RTW A to work on Ward S, since they believed RTW A, who was accused of abusing Patient #1, could work with other dependent adults, just not Patient #1.

12. During an interview on 1/22/19 at 2:37 PM, the Superintendent of the MHI revealed they determined the incident between RTW A and Patient #1 violated the MHI-Independence work rules. The Superintendent of the MHI stated they expected the DIA staff to investigate the incident between RTW A and Patient #1. The Superintendent of the MHI was relying on the DIA staff to determine if RTW A abused Patient #1. If the DIA staff determined RTW A abused Patient #1, the Superintendent of the MHI would terminate RTW A's employment, otherwise the Superintendent of the MHI would allow RTW A to continue employment at the hospital.