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Based on interview, record and review of the facility's Policy, it was determined the facility failed to ensure staff immediately report an allegation of abuse immediately to administration and failed to report to the Cabinet in a timely manner for one (1) of ten (10) sampled patients, Patient #1.

State Registered Nursing Assistant (SRNA) #3 waited approximately one (1) hour to report an allegation of potential abuse. Registered Nurse #6 failed to immediately report the allegation to Administration after it was reported to her by two (2) staff. The facility failed to immediately report the allegation of potential abuse to the Cabinet.

The findings include:

Review of the facility's Policy, A02-A Abuse and Neglect, reviewed 07/01/2017, revealed abuse was defined as the willful infliction of injury with resulting physical harm, pain or mental anguish. Continued review revealed, all allegations of abuse would be reported to Management immediately and Management would notify appropriate Local and State Agencies.

Review of Kentucky Revised Statutes (KRS) Chapter 209.030, revealed an oral or written report was to be made immediately to state agencies upon knowledge of suspected abuse, neglect, or exploitation of an adult.

Interview with State Registered Nurse Aide (SRNA) #3, on 02/24/2021 at 1:05 PM, revealed that on 12/24/2020, he was standing at the door of Patient #1's room applying personal protective equipment (PPE) prior to assisting the Respiratory Therapy Manager (RTM) provide care to Patient #1. He stated he heard the RTM ask, in a mean sounding voice, what Patient #1 was doing, that the tracheostomy (trach) was there to help him/her breathe. Continued interview revealed he heard a slapping sound. Per interview, Patient #1 was in restraints due to being anxious about the tracheostomy tube (trach) and was constantly attempting to remove it. Patient #1 was able to bend his/her arms and move his/her trunk forward in attempts to dislodge the trach. He stated he reported this to the Charge Nurse approximately one (1) hour later. He stated it took a while for him to report the incident because he had to think about it. He stated he heard a slapping sound; however, he was not at the bedside and did not see what happened. Further interview revealed he could not remember if abuse education was presented on hire or thereafter and was not aware he should have reported this to his supervisors immediately.

Interview with State Registered Nurse Aide (SRNA) #2, on 02/23/2021 at 4:15 PM, revealed she had not witnessed abuse but stated she and a couple other staff were standing in the hallway on 12/24/2020 when it was mentioned there had been an incident earlier involving Patient #1, the Respiratory Therapy Manager (RTM) and SRNA #3. She stated she reported the incident to Registered Nurse (RN #6).

Interview with RN #6, on 02/24/2021 at 3:44 PM, revealed on 12/24/2020, SRNA #3 reported the incident to her. She stated SRNA #2 also reported the incident to her charge nurse sometime in mid-to the end of January 2021. Per interview, RN #6 was not able to remember if she reported the allegation to the Chief Nursing Officer (CNO), per the facility's policy. Continued interview revealed she should have reported the incident to ensure each patient's safety.

Interview with the Respiratory Therapy Manager (RTM), on 02/24/2021 at 2:00 PM, revealed she was aware of the components/reporting process of abuse. Continued interview revealed Patient #1 was constantly trying to dislodge the trach and needed restraints and constant reminders to leave the trach alone, that it was what was helping him/her breathe. She stated on 12/24/2020, she was preparing to suction Patient #1's trach. Per interview Patient #1 was attempting to dislodge the trach and she covered the trach with her hand to protect the patient's airway. Per interview, Patient #1 swatted at her hand, striking at her hand. She continued by stating she would never be abusive to any patient, she was simply trying to protect Patient #1's airway. Further interview revealed that SRNA #3 was not at bedside when the chain of events happened; he was at the doorway, donning his personal protective equipment (PPE).

Interview with the Human Resource Manager (HRM), on 02/23/2021 at 9:25 AM and again on 02/25/2021 at 2:40 PM, revealed she became aware of the allegation on 12/29/2020 when SRNA #3 came to her office, almost at the end of his shift and spoke of initial concerns for about half hour about how he was being spoken to by the RTM and others. At the end of the conversation, he stated it was spilling over into patient care and there may have been a situation involving the RTM. Continued interview revealed SRNA #3 would not commit to saying it was abuse in a factual manner, there was lots of conjecture; it was like the abuse allegation had been an afterthought. Per interview, when she asked SRNA #3 if he wanted to report abuse, telling him, what if that was your loved one/family member, what would you want done? The HRM stated he was not direct and never did say it was abuse. She stated, his interview was so vague, she felt she needed more information so an investigation was initiated. Per the HRM, she did conduct an investigation. Per interview the RTM was scheduled off and did not work while she conducted the investigation. Per interview, she found Patient #1 and other patients were not interviewable. During the investigation, she questioned staff on duty on 12/24/2020, no one reported any observations of abuse by the RTM. Per the HRM interviews, staff reported the RTM to be a direct no-nonsense person. Continued interview revealed during the investigation the RTM was interviewed and Patient #1 was in restraints due to attempts to pull out his/her trach tube. The HRM stated her investigation determined the RTM had her hand over the trach tube to protect the airway and Patient #1 swatted at the RTM hand. Per interview, the facility unsubstantiated any abuse occurred.

Interview with the Director of Quality Management (DQM), on 02/25/2021 at 3:35 PM, revealed she was on leave at time of alleged incident but fully supported the reporting, handling of events and investigation by peers/leaders of the facility. Further interview revealed she believed that if this had been presented as an allegation of abuse, then the appropriate reporting would have occurred as per state and federal guidelines and facility policy and procedures. Continued interview revealed she felt that staff provide safe care. She stated if peers and leaders that investigated had felt that the concerns had met willful infliction of abuse, then the reporting standards would have been met.

Interview with the Chief Nursing Officer (CNO), on 02/24/2021 at 4:04 PM, revealed RN #6 did not notify her of any allegation of potential abuse on 12/24/2020. Continued interview revealed RN #6 did not notify her that any occurrence had been reported. She stated her first knowledge was 02/01/2021 or 02/02/2021. She stated it was her expectation that any reports of abuse or neglect would be handled according to policy and taken up the chain of command. Per interview, as the CNO, all progress and outcomes were reported to the Chief Executive Officer (CEO).

Interview with the CEO, on 02/25/2021 at 3:25 PM, revealed she was having difficulty understanding how the allegation would be called abuse. She stated, the facility's investigation revealed the RTM's actions did not reflect willful intent. She stated the RTM's explanation was both credible and replicable about protecting the airway of a high risk dislodgement patient. She continued the interview by stating that if the facility's investigation had determined it had been abuse, she certainly would not have hesitated to report the allegation of abuse and comply with all regulations, Conditions of Participation as well as policy and procedure.