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Based on interview, record review, and review of the facility's video, policies, and documents, it was determined the facility failed to provide care free from abuse for one (1) patient, Patient #1, who received abusive treatment from Mental Health Technician (MHT) #1 (see A0057).

Patient #1 was admitted to the facility from a long-term care facility on 09/19/18 with diagnoses of End-stage Alzheimer's Disease, Multiple Falls, Status-Post Fractured Hip, Status-Post Subdural Hematoma, Angina, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and Compression Fractures of Thoracic Vertebrae Related to Falls. He/she had become increasingly combative and aggressive at the previous facility. Patient #1 was admitted to a locked geriatric unit which specialized in caring for the elderly with underlying medical conditions. Patient #1 was ordered to be on one-to-one,1:1, observation because of a history of repeated falls with injuries.

On 09/21/18 at 4:59 AM, MHT #1 entered Patient #1's room and began treating him/her abusively. Patient #1 was on one-to-one, 1:1, observation and had another staff member, MHT #2, providing this intensive observation. MHT #1 was working the entire floor, providing patient care and documenting on patients that were not on 1:1 observation, every fifteen (15) minutes, along with the unit charge nurse, Registered Nurse (RN) #2. According to the facility's video and statement made by MHT #2, when MHT #1 entered Patient #1's room, she pushed him/her back on the bed because the patient was trying to get out-of-bed. When the patient was sitting on the side of the bed, he/she began swatting/hitting MHT #1's abdomen, and consequently, her fetus, due to MHT #1's pregnancy. MHT #1 hit Patient #1 twice on the face and/or arm. Also, when taking Patient #1 to the bathroom to sit on the commode, she dragged him/her, allowing the patient to strike the rear of the bed with his/her back. Once in the bathroom, MHT #1 struck Patient #1 in the mouth and pushed him/her onto the commode. Patient #1 slid off the commode seat between the wall and the commode, and MHT #1 picked him/her up and placed Patient #1 back on the commode in a rough manner. Then, MHT #1 began spraying Patient #1 directly in the face with water from the shower hose and also sprayed the rest of the patient's body without using any soap or shampoo. Next, review of the video revealed Patient #1 was dragged out of the bathroom and placed face-down on the bed to be dried off with a towel(s). The patient's clothes were then placed on him/her in this position and also after he/she laid supine on the bed. After the patient was dressed, RN #2 came into the room, Patient #1 was put into a wheelchair, and he/she was wheeled out of the room into the Day Room. MHT #2 did not report the abuse immediately, but waited for five (5) days, during which MHT #1 worked four (4) additional shifts on the unit.

The failure of the facility to provide a nonabusive environment, effective supervision, and effective training on abuse recognition and reporting placed Patient #1 at risk for serious injury, harm, impairment, or death.

The facility was notified on 10/05/18 that Immediate Jeopardy was determined to exist related to Governing Body. The facility initiated corrective actions, and the Immediate Jeopardy was determined to be removed on 10/11/18, prior to exit on that date. (Refer to A0057)

Based on interview, medical record review, and review of the facility's video, policies and procedures, and other facility documents, it was determined the facility failed to effectively educate and train employees on recognizing abuse and suspected abuse and the immediate reporting requirements. This ineffective training resulted in one (1) patient out of ten (10) sampled patients, Patient #1, receiving abusive care from nursing staff.

The findings include:

Review of the video, on 10/02/18, of Room 102, geriatric unit, Patient #1's room from 09/19/18 to 09/24/18, revealed on 09/21/18 at 4:58 AM, Mental Health Technician (MHT) #2 was sitting at the bedside of Patient #1. At 4:59 AM. MHT #1 came into the room. At 5:01 AM while Patient #1 was sitting on the side of the bed, the patient hit MHT #1 in the abdomen, and MHT #1 hit the patient twice on the left side of the face or arm. At 5:02 AM, MHT #1 dragged Patient #1 to the bathroom (BR) where the patient's back hit the back of the bed, and she hit the patient in the mouth and pushed the patient down on the commode. At 5:03 PM, MHT #1 roughly pushed Patient #1 back on the commode again and sprayed water in the patient's face. At 5:04 AM, MHT #1 dragged Patient #1 from the commode back to the bed and put him/her on the bed face down and started drying him/her off with towels. From 5:04 AM until 5:09 AM drying off continued, and Patient #1's clothes were put on, with the patient being placed in the bed in a supine position. At 5:09 AM, RN #2 entered the room, put the patient in a wheelchair, and wheeled him/her out of the room.

Review of the facility's policy titled, "Patient Rights and Responsibilities," policy number RI. 046, revised 04/11/13, revealed without limitation patients were entitled to considerate, respectful, humane care and treatment; to be treated with human dignity and in an environment that contributed to a positive self-image; to receive care in a safe and sanitary setting; and to be free from all forms of abuse, including verbal, mental, physical, and sexual.

Review of the facility's policy titled, "Suspected Patient Neglect and Abuse by Staff," policy number RI.064, revised 12/2016, revealed abuse was defined as any physical or verbal action directed towards a patient, infliction of injury, sexual abuse, unreasonable confinement, intimidation, or punishment that resulted in physical pain or injury, including mental injury. Further review revealed suspected or witnessed incidents of abuse by staff should be reported immediately to the staff member's immediate supervisor or in his/her absence, to the Chief Nursing Officer and Director of Clinical Operations. The policy stated all allegations of suspected or witnessed abuse by staff were immediately investigated by Administrative Staff with the Chief Executive Officer (CEO) being apprised of the allegation and investigation results and approving the final decision in all cases. The policy revealed the alleged perpetrator would be immediately suspended pending the internal investigation with indicated disciplinary action taken. In addition, the policy revealed any employee who was aware of patient abuse and did not report it should also be considered for disciplinary action up to and including employment termination.

Review of the facility's policy titled, "Abuse Reporting: Adult," policy number RI.056, revised 12/2016, revealed any staff member who observed or received a report of an adult being abused, or had reason to suspect that an adult had been abused must report this information immediately to the Unit Charge Nurse and Department Manager or Nursing House Supervisor. In addition, Adult Protective Services (APS) must be notified, and the Director of Risk Management or designee would notify the Cabinet for Health and Family Services, Licensure and Regulation if the internal investigation indicated it was warranted.

Review of the facility's policy titled, "Corrective Action Process," policy number HR: 012, reviewed 05/2017, revealed corrective action could be initiated for many reasons, including but not limited to violations of the facility's policies. The policy stated the severity of the action generally depended on the nature of the offense and the employee's work record, and the action could range from a preventative counseling session to immediate employment termination. Further review revealed for preventative counseling, a verbal counseling by the supervisor may be documented and placed in the employee's personnel file, at the supervisor's sole discretion.

Review of the facility's job description titled, "Mental Health Technician I (Inpatient)," revised 11/15/13, revealed he/she was in the Nursing Department and reported to the Nurse Manager. It also revealed a license was not required for the position, and in general, the Mental Health Technician (MHT) provided routine non-acute physical care for the patient. Specifically, the policy revealed the MHT must maintain self-control in volatile or hostile situations such as when verbally or physically confronted; seek direction or clarification from the supervisor when necessary; treat patients with respect according to patient rights and responsibilities, and document and report incidents immediately and according to policy.

Review of Patient #1's medical record revealed he/she was admitted on 09/19/18 from a long-term care facility with diagnoses of End-stage Alzheimer's Disease, Multiple Falls, Status-Post Fractured Hip, Status-Post Subdural Hematoma, Angina, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and Compression Fractures of Thoracic Vertebrae Related to Falls. Patient #1's most recent fall was approximately one (1) week prior to admission where he/she struck his/her head. A CT scan done at the time did not show any acute findings. The record revealed since the fall, Patient #1 had decompensated and had exhibited combative behaviors with increased anxiety. The patient could get up in a wheelchair and required assistance with activities of daily living (ADL's). Further review revealed the comprehensive nursing assessment, completed on 09/19/18 at 11:30 PM, showed a skin assessment with bruising on both hands; skin tears on the right forearm; scar on the anterior, mid-line chest; scar at the umbilicus; two (2) bruises on the right lower quadrant of the abdomen; two (2) bruises on the left anterolateral thigh; skin tear around the right knee; scab on the right lower extremity; scab on the left foot; bruising and cut on the left palm; and bruising and discoloration on the left forearm. The assessment revealed Patient #1 was unable to respond to questions, was total care with bathing, was partial assistance with walking, dressing, toileting, and feeding. Also, Patient #1's gait was extremely unsteady, and he/she almost fell twice. The chart revealed the patient's height was sixty (60) inches and weight was one-hundred thirteen (113) pounds; he/she was oriented to person only and unable to cooperate. Further review revealed, on 09/20/18 at 12:10 AM, the physician ordered one-to-one (1:1) observation because of extreme fall risk. Also, another CT scan of the head was ordered to follow-up on the previous CT scan because of a fall where the patient hit his/her head prior to admission. This was scheduled for 09/24/18 at 3:00 PM. On 09/24/18 at 11:15 AM, the Physician Assistant-Certified (PA-C) wrote an order, which was co-signed by the Physician, to call 911 and send Patient #1 to an acute care hospital's emergency department for acute hypotension, altered mental status, tachycardia, and hypoxia. Patient #1's blood pressure was 80/64; pulse 147; oxygen saturation level 79 percent without oxygen (was given oxygen after this reading at two (2) liters per nasal cannula); and glucose of 163.

Review of the "24 Hour Nursing Progress Note" revealed, on 09/20/18, Patient #1 became ambulatory with 1:1 assist and by using a gait belt. On 09/21/18 at 6:00 AM, Registered Nurse (RN) #2 charted on the patient, and no incidents were reported. Further review revealed, on 09/21/18 at 10:00 PM, Patient #1 lowered self to ground twice while 1:1 and with an MHT holding the patient by a gait belt. The patient scraped an elbow on an unknown item during the first event which opened up old scabs from incidents prior to admission; the scrapes were cleaned with a dressing applied. Further review of the nursing notes revealed, on 09/24/18 at 11:00 AM, Patient #1's color became gray, with shallow respirations of twenty-four (24), blood pressure of 80/64, pulse 147, and oxygen saturation of 79%. The PA-C was called to the floor where orders were received and followed to send the patient to a nearby emergency department by calling 911 and sending the patient by ambulance.

Review of the "Progress Record," on 09/21/18 at 12:15 AM, revealed
MHT #2 was working 1:1 observation with Patient #1. MHT #2 charted hourly from 12:15 AM until 6:15 AM. She revealed Patient #1 was asleep or if roused went back to sleep until 5:20 AM. Further review revealed at 5:20 AM, Patient #1 was awake, confused, and uncooperative, trying to get out-of-bed, with re-direction done each time. The chart stated Patient #1 started to hit/slap staff when MHT #1 was trying to get the patient into bed. Then, Patient #1 was taken to the shower, and he/she was still confused and uncooperative, trying to hit staff. Further review revealed when Patient #1 was finished with the shower, he/she got dressed, got in the wheelchair but would not stay in it. MHT #2 charted again the patient was confused and uncooperative with staff. She revealed the patient sat in the middle of the floor when being walked in the hallway and was taken to the Day Room in a wheelchair. MHT #2 charted the patient continued to pace and walk the hallway with assistance and then go back to the Day Room and sit. This continued until she left. The oncoming MHT charted at 7:00 AM that Patient #1 was sitting in a chair in the Day Room getting blood drawn and was calm but confused with no agitation. Additional review of the nursing notes, on 09/21/18 at 11:00 PM, revealed MHT #1 was on 1:1 observation with Patient #1. MHT #1 charted every hour from 11:00 PM until 6:00 AM on 09/22/18 that Patient #1 slept through the night without getting out-of-bed.

Review of "Patient Observation Rounds," on 09/20/18 at 11:15 PM until 09/21/18 at 7:00 AM, revealed MHT #2 charted on Patient #1 every fifteen (15) minutes. The charting revealed Patient #1 was in his/her room until 5:00 AM sleeping except for three (3) times when he/she was awake. Further review revealed, at 5:00 AM, Patient #1 was in the bathroom and was awake and uncooperative. At 5:15 AM, Patient #1 was in the Day Room and was awake, confused, uncooperative, and pacing. This behavior basically continued until MHT #2 stopped charting at 7:00 AM. Review of "Patient Observation Rounds," on 09/21/18 at 11:00 PM until 09/22/18 at 6:15 AM, revealed MHT #1 charted on Patient #1 every fifteen (15) minutes. The charting revealed Patient #1 was in his/her room until 6:15 AM sleeping. Another staff member took over charting at 6:30 AM.

Review of Patient #1's hospital record after his/her transfer on 09/24/18 revealed, in the emergency department, blood pressure was 134/65, heart rate was 80, and oxygenation was 96 to 100 percent, on room air. A CT scan of the head without contrast showed no gross acute intracranial abnormality but atrophy of the brain. A Chest X-ray showed no acute disease. Further review revealed during Patient #1's hospitalization, he/she developed Atrial Fibrillation and was treated for that. Patient #1 was discharged, on 09/28/18, to home care with daughter with a hospice consult.

Review of the facility's staffing schedules revealed Mental Health Technician (MHT) #1 worked all 11:00 PM to 7:30 AM (night) shifts. It also revealed she worked the nights of 09/20/18, 09/21/18, 09/22/18, 09/23/18, and 09/25/18. Continued review revealed MHT #2 worked the nights of 09/20/18, 09/24/18, and 09/25/18.

Review of Mental Health Technician (MHT) #1's personnel file revealed she had a date-of-hire (DOH) of 06/19/18, was suspended on 09/26/18, and was terminated on 09/27/18. MHT #1 was not a licensed person, was not on the Nurse Aide Abuse Registry, and had a criminal background check completed on 05/22/18 which contained no adverse information. Her previous work experience included five (5) years doing home care with an out-of-state facility, and "Verbal De-Escalation" was completed 06/26/18 with a competency test score of one-hundred (100) percent. The file revealed MHT #1 was pregnant and had been off work for several weeks after hire, so her orientation was resumed on 07/17/18. In addition, her file revealed the "Handle with Care Behavioral Management System" was completed on 07/31/18; her orientation competency checklist was signed off by her preceptor on 08/07/18 with her first day of working independently 08/09/18, and her "Employee 60-Day Check-In" was completed by her supervisor on 09/09/18 with no problems noted. There were two (2) documents in MHT #1's personnel file. The first, was by Unit Manager (UM) #2, on 09/27/18 at 4:00 PM, who wrote he had spoken with Patient #1's daughter to inform her of the incident and the notification of Adult Protective Services (APS). He reported the daughter told him she had not noticed any new marks on the patient's face or arms when she visited over the weekend. In addition, the note stated the daughter told UM #2 the patient was going home with hospice because he/she had only around one (1) week to live. The second, was the "Employee Correction Action Report," dated 09/27/18, which described the incident as: a report by another MHT, revealed on 09/21/18, MHT #1 was rough with a patient, slapped the patient twice, and gave inappropriate care and handling that was not within the facility's expectations. MHT #1 was suspended on 09/26/18, pending investigation. A camera review was completed by the Director of Risk Management and the Chief Nursing Officer (CNO) that confirmed the complaint statement by reporting staff. Due to the seriousness and nature of the allegations being confirmed, MHT #1 was terminated. Further review revealed MHT #1's comments were she did not abuse Patient #1 and would never abuse a patient. She stated she was only trying to stop Patient #1 from hitting her abdomen, and consequently her fetus because she wouldn't let anyone hurt her baby. MHT #1 further wrote she thought she was defending herself, and she did not treat Patient #1 roughly, like MHT #2's statement described. This document was signed by MHT #1, UM #2, the CNO, and the Director of Human Resources.

Review of MHT #1's web-based training (WBT) revealed she had completed the learning module titled, "Identifying and Assessing Victims of Abuse and Neglect," on 06/21/18, with a score of one-hundred (100), passing. She also completed the module titled, "Ridge-High Risk Policy Acknowledgement," on 06/21/18, with a score of one-hundred (100), passing. The content of the High Risk Policies included RI.064, "Suspected Patient Neglect/Abuse by Staff," RI.056, "Reporting Adult Abuse," and RI.046, "Patient Rights and Responsibilities." Further review revealed MHT #1 completed the learning module, "Patient Observation Rounds," on 06/20/18, with a score of one-hundred (100), passing.

Review of Mental Health Technician (MHT) #2's personnel file revealed she had a date of hire (DOH) of 09/04/18. Her criminal background check revealed no adverse information, but the Central Registry Check was pending receipt (usually took eight (8) weeks for results). The file also revealed MHT #2 had completed "Handle with Care Behavioral Management System" on 09/11/18 and "Verbal De-Escalation Competency" with a score of one hundred (100) percent on 09/10/18. In addition, there were two (2) notes in the file. The first was an e-mail from Unit Manager #1 on the education she provided to MHT #2 the morning of 09/26/18 regarding the importance of reporting abuse or suspected abuse immediately to her supervisor. The second note was from Registered Nurse (RN) #2 which stated she instructed MHT #2 on the morning of 09/26/18 to immediately report abuse or suspected abuse to her supervisor and to protect the patient at all costs by removing him/her from harm.

Review of MHT #2's web-based training (WBT) revealed she had completed the learning module titled, "Identifying and Assessing Victims of Abuse and Neglect," on 09/05/18 with a score of ninety (90), passing. She also completed the module titled, "Ridge-High Risk Policy Acknowledgement," on 09/05/18, with a score of one-hundred (100), passing. The content of the High Risk Policies included RI.064, "Suspected Patient Neglect/Abuse by Staff," RI.056, "Reporting Adult Abuse," and RI.046, "Patient Rights and Responsibilities." Further review revealed MHT #2 completed the learning module, "Patient Observation Rounds," on 09/05/18, with a score of one-hundred (100), passing.

Review of the training module, given at New Employee Orientation during the first week by the Director of Risk Management, revealed it included adult abuse reporting and stated any staff member who observed abuse of an adult or had reason to suspect that abuse had occurred, must report this immediately to the adult abuse hotline. The training also stated this included a verbal report or allegations made by the patient to any staff member, and applied specifically to protecting hospital patients, family members, and adult clients who contacted a hospital staff member by phone or in face-to-face interview. It also referenced policy RI.056, "Adult Abuse Reporting."

Review of the web-based training (WBT) post-test for the learning module, "Identifying and Assessing Victims of Abuse and Neglect," revealed it was a ten (10) question, multiple-choice test which required a passing score of eighty (80) out of one-hundred (100). Further review revealed it had no specific questions concerning staff-to-patient abuse but was focused on identifying and responding to abuse which occurred outside the facility.

Review of the web-based training titled, "Patient Observation Rounds," included when a staff member was assigned to a patient who was on increased level of observation, i.e. one-to-one,1:1, staff would remain close enough to the patient to assure the patient's safety was maintained at all times and in compliance with facility policy. This would prohibit engaging in other activities that diverted attention away from patient observation, such as reading or conversing with other patients or staff members.

Review of the statements obtained by the Chief Nursing Officer, on 09/26/18, revealed Registered Nurse (RN) #2 had observed Mental Health Technician (MHT) #1 telling some patients to "shut-up" once recently. RN #2 stated she redirected her that "shut-up" was inappropriate, and patients were not talked to that way. Further review revealed MHT #1 was instructed to use more professional language. In addition, RN #3 reported to the CNO once when she was 1:1 with a patient on the geriatric unit, she asked MHT #1 for assistance. RN #3 reported MHT #1 was more forceful than she would have expected when MHT #1 kept pushing the patient back down in bed when he/she was trying to get up. RN #3 revealed MHT #1 was not violent but was rougher than she needed to be.

Review of the report titled, "Delinquent/Past Due Report," generated on 10/03/18, revealed no staff members were delinquent in taking their annual web-based trainings (WBT) on abuse.

Interview with Registered Nurse (RN) #1, on 10/02/18 at 1:30 PM, revealed she was the geriatric unit charge nurse where Patient #1 was an inpatient from 09/19/18 to 09/24/18. She revealed the geriatric unit had an eighteen (18) bed capacity, and the average census was eight (8) to twelve (12) patients. She stated Room 102, Patient #1's room, had a video camera with images that could be seen at the nurse's station. The video camera also had film which could be preserved. RN #1 revealed if the census were greater than nine (9) patients, the unit would be staffed with two (2) RN's and two (2) Mental Health Technicians (MHT). If less than nine (9) the unit might be staffed with one (1) RN and (1) or two (2) MHT's depending on the acuity level of the patients on the unit. RN #1 stated every patient was observed every fifteen (15) minutes, with this documented, unless the physician ordered one-to-one, 1:1 observation. Further interview revealed Patient #1 was on 1:1 observation with every fifteen (15) minute documentation. She stated 1:1 observation meant there was always someone with Patient #1, within an arm's length. Patient #1 was placed on this strict observation level because of his/her fall risk and because, on admission, he/she was reported to be aggressive; however, RN #1 had not seen any aggressive behaviors, only swats at the staff at times. She revealed she did not work from 09/22/18 through 09/26/18, returning on 09/27/18. At that time, MHT #1 had already been terminated. Further interview revealed RN #1 did not know MHT #2, the witness, because she had not worked on the geriatric unit before the 11:00 PM to 7:30 AM shift starting on 09/20/18. RN #1 also stated, on the 7:00 AM to 3:30 PM shift on 09/21/18, Patient #1 had not exhibited any physical changes. She stated the patient was admitted with multiple bruises and skin tears from multiple previous falls. RN #1 revealed MHT #1 was a new employee of less then two (2) to three (3) months. She stated she was never told of any untoward or abusive behavior by MHT #1 to other staff or patients, and she would see MHT #1 in the mornings between shift change and never witnessed any inappropriate behavior.

Interview with the Physician Assistant-Certified (PA-C), on 10/03/18 at 11:22 AM, revealed the medical team saw all patients when first admitted for a physical, and then, if not needed, would only see a patient again if there were a medical consult from the attending physician. She revealed there was constant communication between the psychiatric team and the medical team. Further interview revealed, on 09/24/18, she was called to the geriatric unit to see Patient #1 because of increased lethargy and hypotension. She stated she assessed Patient #1 and decided to send him/her to the hospital. The PA-C revealed Patient #1 had only been seen initially for a history and physical with no additional consults until she was called to the unit on 09/24/18. Further interview revealed the PA-C did not believe the actions by MHT #1, on 09/21/18, contributed to his/her apparent declining medical condition.

Interview with Mental Health Technician (MHT) #1, on 10/03/18 at 2:17 PM, revealed she worked on the geriatric unit, her primary unit, the shift starting at 11:00 PM on 09/20/18 and ending at 07:30 AM on 09/21/18. She stated MHT #2, a new employee, asked her to help with Patient #1 who was trying to get out-of-bed. She stated she tried to calm the patient who appeared to have been incontinent of urine, and she thought the patient needed to go to the toilet. Further interview revealed Patient #1 hit MHT #1, and she told the patient not to hit her. MHT #1 stated she was not trying to abuse the patient but was trying to push his/her arm back and prevent the patient from hitting her fetus. She revealed when she helped Patient #1 to the bathroom, she had a strong hold on the patient to prevent him/her from falling. MHT #1 stated she put Patient #1 on the commode because she thought he/she needed to toilet; and, she did not want to leave the patient to get a shower chair, so she left Patient #1 on the commode to wash him/her. Further interview revealed she did not use soap because she wanted to quickly wash him/her off with water, and Patient #1 could have a better shower that night when she worked again. MHT #1 stated she put a stream of water from the shower hose on Patient #1's face to wash his/her face and hair, and she put the patient face down on the bed to dry him/her off because she was afraid the patient would fall. MHT #1 revealed she started at the facility in June 2018; had completed orientation during which she received abuse training; and to her knowledge, she did not abuse Patient #1. She stated she had required some time off because of her pregnancy, but had been working independently for several weeks. Further interview revealed if a person wanted to abuse a patient, he/she would not do it in front of another person or in a patient room that had a camera and was videotaping patient care. MHT #1 stated she had always received compliments on her care, and she had never been pulled aside and informed her behavior was inappropriate. She revealed she had witnessed the video, signed a statement, and was suspended on 09/26/18 with termination on 09/27/18.

Interview with Registered Nurse (RN) #2, on 10/03/18 at 3:22 PM, revealed she was the RN on duty when the abuse incident occurred. She stated she had been with the facility for one and one-half (1.5) years and had worked on the geriatric unit the whole time. RN #2 revealed, on the shift which began at 11:00 PM on 09/20/18 and ended at 7:30 PM on 09/21/18, she worked with Mental Health Technician (MHT) #1 and also two (2) additional employees that each had a one-to-one (1:1) observation patient which included MHT #2 being on 1:1 with Patient #1. She stated it was an uneventful shift until around 4:30 AM when she went to help the other MHT give a shower to the other 1:1 observation patient. RN #2 stated when she finished, she checked on Patient #1 and MHT #1 told her he/she had already had his/her shower. She stated at no time did anyone mention any inappropriate behavior by MHT #1 to Patient #1. RN #2 revealed she saw Patient #1 after the incident, when taking him/her to the Day Room, and he/she appeared to be baseline with multiple bruises and skin tears which were present on admission. Further interview revealed she had only seen MHT #1 behave inappropriately one (1) time when MHT #1 told a patient/patients to "shut-up." She stated MHT #1 did not appear to be angry and used a normal tone of voice; in fact, she might have been joking. RN #2 stated she took MHT #1 aside and told her that saying "shut-up" to patients was not acceptable, and she never heard MHT #1 say it again nor did she see MHT #1 being rough with patients. Further interview revealed MHT #1 had always been very cooperative and finished assignments. RN #2 revealed she was very surprised by the incident.

Interview with Unit Manager (UM) #1, on 10/03/18 at 3:45 PM, revealed MHT #2 worked primarily on the Child Unit where she was the manager. The orientation for MHT #2 was two (2) weeks computer/classroom then five (5) days on the floor with a preceptor. The UM stated MHT #2 had just completed her orientation period before the incident. She revealed she arrived at work at 7:15 AM the morning of 09/26/18, and she had already been informed by House Supervisor (HS) #1 of the abuse incident with MHT #2 who had already completed a written statement describing the incident. Also, HS #1 had sent an e-mail to the Chief Nursing Officer (CNO) about the incident. UM #1 stated she had witnessed MHT #1 leaving the facility when she arrived and knew she was no longer at the facility. Further interview revealed she, along with the CNO, the Director of Risk Management, and UM #2 (manager of the geriatric unit) watched a video of the abuse incident and contacted other employees who had worked with MHT #1. UM #1 stated, from the employees she interviewed, none reported any abusive behavior they had witnessed from MHT #1. UM #1 reported after MHT #1 watched the video and made a statement, she was terminated by the CNO. UM #1 stated MHT #2 revealed she did not know what to do at the immediate moment and had experienced much anxiety since the incident; therefore, she gave MHT #2 immediate education on recognizing and reporting abuse immediately. She also revealed, on 09/26/18, there was no planned intervention with the remaining employees, but she made rounds on 09/26/18, 09/27/18, and 09/29/18 and talked with employees, doing education on recognizing and immediately reporting abuse.

Interview with the Director of Performance Improvement, on 10/04/18 at 9:50 AM, revealed Mental Health Technician (MHT) #1's first day of working independently was 08/09/18. Further interview, on 10/04/18 at 10:10 AM, revealed MHT #2's first day of working independently was 09/20/18.

Interview with HS #1, on 10/04/18 at 9:55 AM, revealed the abuse incident happened when she was on duty, but she was not made aware of the incident by MHT #2. She stated MHT #2 had been assigned to do one-to-one,1:1, observation with Patient #1, to sit next to him/her and ensure he/she did not get out of bed and fall, or to provide assistance. HS #1 revealed she checked on MHT #2 three (3) times the night of the incident and both the patient and MHT #2 were fine with the patient being asleep. After the incident which occurred in the AM of 09/21/18, MHT #2 did not work for several days. She returned for the 11:00 PM to 7:30 AM shift which began on 09/25/18. Further interview revealed, the morning of 09/26/18, MHT #2 came to her and was upset stating she had not been able to sleep and did not know what to do. MHT #2 related the incident to her and she instructed MHT #2 that she had done the right thing to report, but she should have done it immediately. HS #1 stated MHT #2 was a new employee, but the only requirement for 1:1 observation was to sit by the patient and observe because there was a Registered Nurse (RN) and another MHT on the floor at the same time.

Interview with RN #3, on 10/04/18 at 10:50 AM, revealed she had been on the geriatric unit as a one-to-one, 1:1, observer on the 11:00 PM to 7:30 AM shift, date unknown, when MHT #1 was also working. RN #3 stated she had needed help with the patient and called MHT #1. She revealed MHT #1 pushed the patient on the bed at little more forcefully than necessary. Further interview revealed she did not consider it abuse at the time and did not think about it until the abuse incident on 09/21/18. RN #3 stated she had worked at the facility for about five (5) months and had received abuse training during orientation, although she could not specifically recall being trained on staff-to-patient abuse. She also revealed she was not aware of any abuse trainings since the incident.

Interview with Unit Manager (UM) #2, on 10/04/18 at 11:05 AM, revealed he had been at the facility since 05/2018. He stated he arrived at work at 10:30 AM the morning of 09/26/18, and UM #1 (they are the unit managers for the entire inpatient units and inpatient population) showed him Mental Health Technician (MHT) #2's statement about the abuse incident. Further interview revealed he saw the video and then started talking with staff with the goals being to get any additional information about the incident and to educate on how to respond to witnessed abuse. He stated this education lasted approximately three (3) hours, and the feedback from staff on what to do if abuse were witnessed was a mixed bag, with some correct answers. He also revealed, for Patient #1 and other patients which required it, one-to-one, 1:1, observation could be done by a Registered Nurse (RN) or MHT and involved sitting by the bedside or else being within an arm's length of the patient. In Patient #1's case, 1:1 was required for his/her safety to prevent the patient from getting up without assistance and falling. UM #2 stated MHT #2 was a new employee, had no training in geriatric care, and must not have realized the magnitude of what she witnessed. He stated he had never received any negative information about MHT #1. Further interview revealed he believed the "shut-up" remark was verbal abuse and should have been reported to him. He stated if RN #2 had reported it to him, he would have given MHT #1 at a minim a final written warning. UM #2 revealed it was a missed opportunity in possibly preventing the abuse episode on 09/21/18. Further interview revealed during his orientation, UM #2 had abuse training which included reporting requirements; however, he did not specifically recall having staff-to-patient abuse training. He stated he had been an RN for many years and had received numerous trainings on abuse. UM #2 stated, for a new employee, all the informati

Based on interview, record review, and review of the facility's video, policies, and documents, it was determined the facility failed to provide care free from abuse for one (1) patient, Patient #1, who received abusive treatment from Mental Health Technician (MHT) #1 (see A0145).

Patient #1 was admitted to the facility from a long-term care facility on 09/19/18 with diagnoses of End-stage Alzheimer's Disease, Multiple Falls, Status-Post Fractured Hip, Status-Post Subdural Hematoma, Angina, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and Compression Fractures of Thoracic Vertebrae Related to Falls. He/she had become increasingly combative and aggressive at the previous facility. Patient #1 was admitted to a locked geriatric unit which specialized in caring for the elderly with underlying medical conditions. Patient #1 was ordered to be on one-to-one,1:1, observation because of a history of repeated falls with injuries.

On 09/21/18 at 4:59 AM, MHT #1 entered Patient #1's room and began treating him/her abusively. Patient #1 was on one-to-one, 1:1, observation and had another staff member, MHT #2, providing this intensive observation. MHT #1 was working the entire floor, providing patient care and documenting on patients that were not on 1:1 observation, every fifteen (15) minutes, along with the unit charge nurse, Registered Nurse (RN) #2. According to the facility's video and statement made by MHT #2, when MHT #1 entered Patient #1's room, she pushed him/her back on the bed because the patient was trying to get out-of-bed. When the patient was sitting on the side of the bed, he/she began swatting/hitting MHT #1's abdomen, and consequently, her fetus, due to MHT #1's pregnancy. MHT #1 hit Patient #1 twice on the face and/or arm. Also, when taking Patient #1 to the bathroom to sit on the commode, she dragged him/her, allowing the patient to strike the rear of the bed with his/her back. Once in the bathroom, MHT #1 struck Patient #1 in the mouth and pushed him/her onto the commode. Patient #1 slid off the commode seat between the wall and the commode, and MHT #1 picked him/her up and placed Patient #1 back on the commode in a rough manner. Then, MHT #1 began spraying Patient #1 directly in the face with water from the shower hose and also sprayed the rest of the patient's body without using any soap or shampoo. Next, review of the video revealed Patient #1 was dragged out of the bathroom and placed face-down on the bed to be dried off with a towel(s). The patient's clothes were then placed on him/her in this position and also after he/she laid supine on the bed. After the patient was dressed, RN #2 came into the room, Patient #1 was put into a wheelchair, and he/she was wheeled out of the room into the Day Room. MHT #2 did not report the abuse immediately, but waited for five (5) days, during which MHT #1 worked four (4) additional shifts on the unit.

The failure of the facility to provide a nonabusive environment, effective supervision, and effective training on abuse recognition and reporting placed Patient #1 at risk for serious injury, harm, impairment, or death.

The facility was notified on 10/05/18 that Immediate Jeopardy was determined to exist related to Patient Rights. The facility initiated corrective actions, and the Immediate Jeopardy was determined to be removed on 10/11/18, prior to exit on that date. (Refer to A0145)

Based on interview, medical record review, and review of the facility's video, policies and procedures, and other facility documents, it was determined the facility failed to provide care in a non-abusive environment for one (1) of ten (10) sampled patients, Patient #1.

The findings include:

Review of the facility's video, on 10/02/18, of Room 102, geriatric unit, Patient #1's room from 09/19/18 to 09/24/18, revealed on 09/21/18 at 4:58 AM, Mental Health Technician (MHT) #2 was sitting at the bedside of Patient #1. At 4:59 AM. MHT #1 came into the room. At 5:01 AM while Patient #1 was sitting on the side of the bed, the patient hit MHT #1 in the abdomen, and MHT #1 hit the patient twice on the left side of the face or arm. At 5:02 AM, MHT #1 dragged Patient #1 to the bathroom (BR) where the patient's back hit the back of the bed, and she hit the patient in the mouth and pushed the patient down on the commode. At 5:03 PM, MHT #1 roughly pushed Patient #1 back on the commode again and sprayed water in the patient's face. At 5:04 AM, MHT #1 dragged Patient #1 from the commode back to the bed and put him/her on the bed face down and started drying him/her off with towels. From 5:04 AM until 5:09 AM drying off continued, and Patient #1's clothes were put on, with the patient being placed in the bed in a supine position. At 5:09 AM, RN #2 entered the room, put the patient in a wheelchair, and wheeled him/her out of the room.

Review of the facility's policy titled, "Patient Rights and Responsibilities," policy number RI. 046, revised 04/11/13, revealed without limitation patients were entitled to considerate, respectful, humane care and treatment; to be treated with human dignity and in an environment that contributed to a positive self-image; to receive care in a safe and sanitary setting; and to be free from all forms of abuse, including verbal, mental, physical, and sexual.

Review of the facility's policy titled, "Suspected Patient Neglect and Abuse by Staff," policy number RI.064, revised 12/2016, revealed abuse was defined as any physical or verbal action directed towards a patient, infliction of injury, sexual abuse, unreasonable confinement, intimidation, or punishment that resulted in physical pain or injury, including mental injury. Further review revealed suspected or witnessed incidents of abuse by staff should be reported immediately to the staff member's immediate supervisor or in his/her absence, to the Chief Nursing Officer and Director of Clinical Operations. The policy stated all allegations of suspected or witnessed abuse by staff were immediately investigated by Administrative Staff with the Chief Executive Officer (CEO) being apprised of the allegation and investigation results and approving the final decision in all cases. The policy revealed the alleged perpetrator would be immediately suspended pending the internal investigation with indicated disciplinary action taken. In addition, the policy revealed any employee who was aware of patient abuse and did not report it should also be considered for disciplinary action up to and including employment termination.

Review of the facility's policy titled, "Abuse Reporting: Adult," policy number RI.056, revised 12/2016, revealed any staff member who observed or received a report of an adult being abused, or had reason to suspect that an adult had been abused must report this information immediately to the Unit Charge Nurse and Department Manager or Nursing House Supervisor. In addition, Adult Protective Services (APS) must be notified, and the Director of Risk Management or designee would notify the Cabinet for Health and Family Services, Licensure and Regulation if the internal investigation indicated it was warranted.

Review of the facility's policy titled, "Corrective Action Process," policy number HR: 012, reviewed 05/2017, revealed corrective action could be initiated for many reasons, including but not limited to violations of the facility's policies. The policy stated the severity of the action generally depended on the nature of the offense and the employee's work record, and the action could range from a preventative counseling session to immediate employment termination. Further review revealed for preventative counseling, a verbal counseling by the supervisor may be documented and placed in the employee's personnel file, at the supervisor's sole discretion.

Review of the facility's job description titled, "Mental Health Technician I (Inpatient)," revised 11/15/13, revealed he/she was in the Nursing Department and reported to the Nurse Manager. It also revealed a license was not required for the position, and in general, the Mental Health Technician (MHT) provided routine non-acute physical care for the patient. Specifically, the policy revealed the MHT must maintain self-control in volatile or hostile situations such as when verbally or physically confronted; seek direction or clarification from the supervisor when necessary; treat patients with respect according to patient rights and responsibilities, and document and report incidents immediately and according to policy.

Review of Patient #1's medical record revealed he/she was admitted on 09/19/18 from a long-term care facility with diagnoses of End-stage Alzheimer's Disease, Multiple Falls, Status-Post Fractured Hip, Status-Post Subdural Hematoma, Angina, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and Compression Fractures of Thoracic Vertebrae Related to Falls. Patient #1's most recent fall was approximately one (1) week prior to admission where he/she struck his/her head. A CT scan done at the time did not show any acute findings. The record revealed since the fall, Patient #1 had decompensated and had exhibited combative behaviors with increased anxiety. The patient could get up in a wheelchair and required assistance with activities of daily living (ADL's). Further review revealed the comprehensive nursing assessment, completed on 09/19/18 at 11:30 PM, showed a skin assessment with bruising on both hands; skin tears on the right forearm; scar on the anterior, mid-line chest; scar at the umbilicus; two (2) bruises on the right lower quadrant of the abdomen; two (2) bruises on the left anterolateral thigh; skin tear around the right knee; scab on the right lower extremity; scab on the left foot; bruising and cut on the left palm; and bruising and discoloration on the left forearm. The assessment revealed Patient #1 was unable to respond to questions, was total care with bathing, was partial assistance with walking, dressing, toileting, and feeding. Also, Patient #1's gait was extremely unsteady, and he/she almost fell twice. The chart revealed the patient's height was sixty (60) inches and weight was one-hundred thirteen (113) pounds; he/she was oriented to person only and unable to cooperate. Further review revealed, on 09/20/18 at 12:10 AM, the physician ordered one-to-one (1:1) observation because of extreme fall risk. Also, another CT scan of the head was ordered to follow-up on the previous CT scan because of a fall where the patient hit his/her head prior to admission. This was scheduled for 09/24/18 at 3:00 PM. On 09/24/18 at 11:15 AM, the Physician Assistant-Certified (PA-C) wrote an order, which was co-signed by the Physician, to call 911 and send Patient #1 to an acute care hospital's emergency department for acute hypotension, altered mental status, tachycardia, and hypoxia. Patient #1's blood pressure was 80/64; pulse 147; oxygen saturation level 79 percent without oxygen (was given oxygen after this reading at two (2) liters per nasal cannula); and glucose of 163.

Review of the "24 Hour Nursing Progress Note" revealed, on 09/20/18, Patient #1 became ambulatory with 1:1 assist and by using a gait belt. On 09/21/18 at 6:00 AM, Registered Nurse (RN) #2 charted on the patient, and no incidents were reported. Further review revealed, on 09/21/18 at 10:00 PM, Patient #1 lowered self to ground twice while 1:1 and with an MHT holding the patient by a gait belt. The patient scraped an elbow on an unknown item during the first event which opened up old scabs from incidents prior to admission; the scrapes were cleaned with a dressing applied. Further review of the nursing notes revealed, on 09/24/18 at 11:00 AM, Patient #1's color became gray, with shallow respirations of twenty-four (24), blood pressure of 80/64, pulse 147, and oxygen saturation of 79%. The PA-C was called to the floor where orders were received and followed to send the patient to a nearby emergency department by calling 911 and sending the patient by ambulance.

Review of the "Progress Record," on 09/21/18 at 12:15 AM, revealed
MHT #2 was working 1:1 observation with Patient #1. MHT #2 charted hourly from 12:15 AM until 6:15 AM. She revealed Patient #1 was asleep or if roused went back to sleep until 5:20 AM. Further review revealed at 5:20 AM, Patient #1 was awake, confused, and uncooperative, trying to get out-of-bed, with re-direction done each time. The chart stated Patient #1 started to hit/slap staff when MHT #1 was trying to get the patient into bed. Then, Patient #1 was taken to the shower, and he/she was still confused and uncooperative, trying to hit staff. Further review revealed when Patient #1 was finished with the shower, he/she got dressed, got in the wheelchair but would not stay in it. MHT #2 charted again the patient was confused and uncooperative with staff. She revealed the patient sat in the middle of the floor when being walked in the hallway and was taken to the Day Room in a wheelchair. MHT #2 charted the patient continued to pace and walk the hallway with assistance and then go back to the Day Room and sit. This continued until she left. The oncoming MHT charted at 7:00 AM that Patient #1 was sitting in a chair in the Day Room getting blood drawn and was calm but confused with no agitation. Additional review of the nursing notes, on 09/21/18 at 11:00 PM, revealed MHT #1 was on 1:1 observation with Patient #1. MHT #1 charted every hour from 11:00 PM until 6:00 AM on 09/22/18 that Patient #1 slept through the night without getting out-of-bed.

Review of "Patient Observation Rounds," on 09/20/18 at 11:15 PM until 09/21/18 at 7:00 AM, revealed MHT #2 charted on Patient #1 every fifteen (15) minutes. The charting revealed Patient #1 was in his/her room until 5:00 AM sleeping except for three (3) times when he/she was awake. Further review revealed, at 5:00 AM, Patient #1 was in the bathroom and was awake and uncooperative. At 5:15 AM, Patient #1 was in the Day Room and was awake, confused, uncooperative, and pacing. This behavior basically continued until MHT #2 stopped charting at 7:00 AM. Review of "Patient Observation Rounds," on 09/21/18 at 11:00 PM until 09/22/18 at 6:15 AM, revealed MHT #1 charted on Patient #1 every fifteen (15) minutes. The charting revealed Patient #1 was in his/her room until 6:15 AM sleeping. Another staff member took over charting at 6:30 AM.

Review of Patient #1's hospital record after his/her transfer on 09/24/18 revealed, in the emergency department, blood pressure was 134/65, heart rate was 80, and oxygenation was 96 to 100 percent, on room air. A CT scan of the head without contrast showed no gross acute intracranial abnormality but atrophy of the brain. A Chest X-ray showed no acute disease. Further review revealed during Patient #1's hospitalization, he/she developed Atrial Fibrillation and was treated for that. Patient #1 was discharged, on 09/28/18, to home care with daughter with a hospice consult.

Review of the facility's staffing schedules revealed Mental Health Technician (MHT) #1 worked all 11:00 PM to 7:30 AM (night) shifts. It also revealed she worked the nights of 09/20/18, 09/21/18, 09/22/18, 09/23/18, and 09/25/18. Continued review revealed MHT #2 worked the nights of 09/20/18, 09/24/18, and 09/25/18.

Review of Mental Health Technician (MHT) #1's personnel file revealed she had a date-of-hire (DOH) of 06/19/18, was suspended on 09/26/18, and was terminated on 09/27/18. MHT #1 was not a licensed person, was not on the Nurse Aide Abuse Registry, and had a criminal background check completed on 05/22/18 which contained no adverse information. Her previous work experience included five (5) years doing home care with an out-of-state facility, and "Verbal De-Escalation" was completed 06/26/18 with a competency test score of one-hundred (100) percent. The file revealed MHT #1 was pregnant and had been off work for several weeks after hire, so her orientation was resumed on 07/17/18. In addition, her file revealed the "Handle with Care Behavioral Management System" was completed on 07/31/18; her orientation competency checklist was signed off by her preceptor on 08/07/18 with her first day of working independently 08/09/18, and her "Employee 60-Day Check-In" was completed by her supervisor on 09/09/18 with no problems noted. There were two (2) documents in MHT #1's personnel file. The first, was by Unit Manager (UM) #2, on 09/27/18 at 4:00 PM, who wrote he had spoken with Patient #1's daughter to inform her of the incident and the notification of Adult Protective Services (APS). He reported the daughter told him she had not noticed any new marks on the patient's face or arms when she visited over the weekend. In addition, the note stated the daughter told UM #2 the patient was going home with hospice because he/she had only around one (1) week to live. The second, was the "Employee Correction Action Report," dated 09/27/18, which described the incident as: a report by another MHT, revealed on 09/21/18, MHT #1 was rough with a patient, slapped the patient twice, and gave inappropriate care and handling that was not within the facility's expectations. MHT #1 was suspended on 09/26/18, pending investigation. A camera review was completed by the Director of Risk Management and the Chief Nursing Officer (CNO) that confirmed the complaint statement by reporting staff. Due to the seriousness and nature of the allegations being confirmed, MHT #1 was terminated. Further review revealed MHT #1's comments were she did not abuse Patient #1 and would never abuse a patient. She stated she was only trying to stop Patient #1 from hitting her abdomen, and consequently her fetus because she wouldn't let anyone hurt her baby. MHT #1 further wrote she thought she was defending herself, and she did not treat Patient #1 roughly, like MHT #2's statement described. This document was signed by MHT #1, UM #2, the CNO, and the Director of Human Resources.

Review of MHT #1's web-based training (WBT) revealed she had completed the learning module titled, "Identifying and Assessing Victims of Abuse and Neglect," on 06/21/18, with a score of one-hundred (100), passing. She also completed the module titled, "Ridge-High Risk Policy Acknowledgement," on 06/21/18, with a score of one-hundred (100), passing. The content of the High Risk Policies included RI.064, "Suspected Patient Neglect/Abuse by Staff," RI.056, "Reporting Adult Abuse," and RI.046, "Patient Rights and Responsibilities." Further review revealed MHT #1 completed the learning module, "Patient Observation Rounds," on 06/20/18, with a score of one-hundred (100), passing.

Review of Mental Health Technician (MHT) #2's personnel file revealed she had a date of hire (DOH) of 09/04/18. Her criminal background check revealed no adverse information, but the Central Registry Check was pending receipt (usually took eight (8) weeks for results). The file also revealed MHT #2 had completed "Handle with Care Behavioral Management System" on 09/11/18 and "Verbal De-Escalation Competency" with a score of one hundred (100) percent on 09/10/18. In addition, there were two (2) notes in the file. The first was an e-mail from Unit Manager #1 on the education she provided to MHT #2 the morning of 09/26/18 regarding the importance of reporting abuse or suspected abuse immediately to her supervisor. The second note was from Registered Nurse (RN) #2 which stated she instructed MHT #2 on the morning of 09/26/18 to immediately report abuse or suspected abuse to her supervisor and to protect the patient at all costs by removing him/her from harm.

Review of MHT #2's web-based training (WBT) revealed she had completed the learning module titled, "Identifying and Assessing Victims of Abuse and Neglect," on 09/05/18 with a score of ninety (90), passing. She also completed the module titled, "Ridge-High Risk Policy Acknowledgement," on 09/05/18, with a score of one-hundred (100), passing. The content of the High Risk Policies included RI.064, "Suspected Patient Neglect/Abuse by Staff," RI.056, "Reporting Adult Abuse," and RI.046, "Patient Rights and Responsibilities." Further review revealed MHT #2 completed the learning module, "Patient Observation Rounds," on 09/05/18, with a score of one-hundred (100), passing.

Interview with Registered Nurse (RN) #1, on 10/02/18 at 1:30 PM, revealed she was the geriatric unit charge nurse where Patient #1 was an inpatient from 09/19/18 to 09/24/18. She revealed the geriatric unit had an eighteen (18) bed capacity, and the average census was eight (8) to twelve (12) patients. She stated Room 102, Patient #1's room, had a video camera with images that could be seen at the nurse's station. The video camera also had film which could be preserved. RN #1 revealed if the census were greater than nine (9) patients, the unit would be staffed with two (2) RN's and two (2) Mental Health Technicians (MHT). If less than nine (9) the unit might be staffed with one (1) RN and (1) or two (2) MHT's depending on the acuity level of the patients on the unit. RN #1 stated every patient was observed every fifteen (15) minutes, with this documented, unless the physician ordered one-to-one, 1:1 observation. Further interview revealed Patient #1 was on 1:1 observation with every fifteen (15) minute documentation. She stated 1:1 observation meant there was always someone with Patient #1, within an arm's length. Patient #1 was placed on this strict observation level because of his/her fall risk and because, on admission, he/she was reported to be aggressive; however, RN #1 had not seen any aggressive behaviors, only swats at the staff at times. She revealed she did not work from 09/22/18 through 09/26/18, returning on 09/27/18. At that time, MHT #1 had already been terminated. Further interview revealed RN #1 did not know MHT #2, the witness, because she had not worked on the geriatric unit before the 11:00 PM to 7:30 AM shift starting on 09/20/18. RN #1 also stated, on the 7:00 AM to 3:30 PM shift on 09/21/18, Patient #1 had not exhibited any physical changes. She stated the patient was admitted with multiple bruises and skin tears from multiple previous falls. RN #1 revealed MHT #1 was a new employee of less then two (2) to three (3) months. She stated she was never told of any untoward or abusive behavior by MHT #1 to other staff or patients, and she would see MHT #1 in the mornings between shift change and never witnessed any inappropriate behavior.

Interview with the Physician Assistant-Certified (PA-C), on 10/03/18 at 11:22 AM, revealed the medical team saw all patients when first admitted for a physical, and then, if not needed, would only see a patient again if there were a medical consult from the attending physician. She revealed there was constant communication between the psychiatric team and the medical team. Further interview revealed, on 09/24/18, she was called to the geriatric unit to see Patient #1 because of increased lethargy and hypotension. She stated she assessed Patient #1 and decided to send him/her to the hospital. The PA-C revealed Patient #1 had only been seen initially for a history and physical with no additional consults until she was called to the unit on 09/24/18. Further interview revealed the PA-C did not believe the actions by MHT #1, on 09/21/18, contributed to his/her apparent declining medical condition.

Interview with Mental Health Technician (MHT) #1, on 10/03/18 at 2:17 PM, revealed she worked on the geriatric unit, her primary unit, the shift starting at 11:00 PM on 09/20/18 and ending at 07:30 AM on 09/21/18. She stated MHT #2, a new employee, asked her to help with Patient #1 who was trying to get out-of-bed. She stated she tried to calm the patient who appeared to have been incontinent of urine, and she thought the patient needed to toilet. Further interview revealed Patient #1 hit MHT #1, and she told the patient not to hit her. MHT #1 stated she was not trying to abuse the patient but was trying to push him/her arm back and prevent him/her from hitting her fetus. She revealed when she helped Patient #1 to the bathroom (BR), she had a strong hold on the patient to prevent him/her from falling. MHT #1 stated she put Patient #1 on the commode because she thought he/she needed to toilet, and she did not want to leave the patient to get a shower chair, so she left the patient on the commode to wash him/her. Further interview revealed she did not use soap because she wanted to quickly wash him/her off with water, and Patient #1 could have a better shower that night when MHT #1 worked again. MHT #1 stated she put a stream of water from the shower hose on Patient #1's face to wash his/her face and hair, and she put the patient face down on the bed to dry him/her off because she was afraid the patient would fall. MHT #1 revealed she started at the facility in June 2018; had completed orientation during which she received abuse training; and to her knowledge, she did not abuse Patient #1. She stated she had required some time off because of her pregnancy, but had been working independently for several weeks. Further interview revealed if a person wanted to abuse a patient, he/she would not do it in front of another person or in a patient room that had a camera and was videotaping patient care. MHT #1 stated she had always received compliments on her care, and she had never been pulled aside and instructed her behavior was inappropriate. She revealed she had witnessed the video, signed a statement, and was suspended on 09/26/18 with termination on 09/27/18.

Interview with Registered Nurse (RN) #2, on 10/03/18 at 3:22 PM, revealed she was the RN on duty when the abuse incident occurred. She stated she had been with the facility for one and one-half (1.5) years and had worked on the geriatric unit the whole time. RN #2 revealed, on the shift which began at 11:00 PM on 09/20/18 and ended at 7:30 PM on 09/21/18, she worked with Mental Health Technician (MHT) #1 and also two (2) additional employees that each had a one-to-one (1:1) observation patient which included MHT #2 being on 1:1 with Patient #1. She stated it was an uneventful shift until around 4:30 AM when she went to help the other MHT give a shower to the other 1:1 observation patient. RN #2 stated when she finished, she checked on Patient #1 and MHT #1 told her he/she had already had his/her shower. She stated at no time did anyone mention any inappropriate behavior by MHT #1 to Patient #1. RN #2 revealed she saw Patient #1 after the incident, when taking him/her to the Day Room, and he/she appeared to be baseline with multiple bruises and skin tears which were present on admission. Further interview revealed she had only seen MHT #1 behave inappropriately one (1) time when MHT #1 told a patient/patients to "shut-up." She stated MHT #1 did not appear to be angry and used a normal tone of voice; in fact, she might have been joking. RN #2 stated she took MHT #1 aside and told her that saying "shut-up" to patients was not acceptable, and she never heard MHT #1 say it again nor did she see MHT #1 being rough with patients. Further interview revealed MHT #1 had always been very cooperative and finished assignments. RN #2 revealed she was very surprised by the incident.

Interview with Unit Manager (UM) #1, on 10/03/18 at 3:45 PM, revealed MHT #2 worked primarily on the Child Unit where she was the manager. The orientation for MHT #2 was two (2) weeks computer/classroom then five (5) days on the floor with a preceptor. The UM stated MHT #2 had just completed her orientation period before the incident. She revealed she arrived at work at 7:15 AM the morning of 09/26/18, and she had already been informed by House Supervisor (HS) #1 of the abuse incident with MHT #2 who had already completed a written statement describing the incident. Also, HS #1 had sent an e-mail to the Chief Nursing Officer (CNO) about the incident. UM #1 stated she had witnessed MHT #1 leaving the facility when she arrived and knew she was no longer at the facility. Further interview revealed she, along with the CNO, the Director of Risk Management, and UM #2 (manager of the geriatric unit) watched a video of the abuse incident and contacted other employees who had worked with MHT #1. UM #1 stated, from the employees she interviewed, none reported any abusive behavior they had witnessed from MHT #1. UM #1 reported after MHT #1 watched the video and made a statement, she was terminated by the CNO. UM #1 stated MHT #2 revealed she did not know what to do at the immediate moment and had experienced much anxiety since the incident; therefore, she gave MHT #2 immediate education on recognizing and reporting abuse immediately. She also revealed, on 09/26/18, there was no planned intervention with the remaining employees, but she made rounds on 09/26/18, 09/27/18, and 09/29/18 and talked with employees, doing education on recognizing and immediately reporting abuse.

Interview with the Director of Performance Improvement, on 10/04/18 at 9:50 AM, revealed Mental Health Technician (MHT) #1's first day of working independently was 08/09/18. Further interview, on 10/04/18 at 10:10 AM, revealed MHT #2's first day of working independently was 09/20/18.

Interview with HS #1, on 10/04/18 at 9:55 AM, revealed the abuse incident happened when she was on duty, but she was not made aware of the incident by MHT #2. She stated MHT #2 had been assigned to do one-to-one,1:1, observation with Patient #1, to sit next to him/her and ensure he/she did not get out of bed and fall, or to provide assistance. HS #1 revealed she checked on MHT #2 three (3) times the night of the incident and both the patient and MHT #2 were fine with the patient being asleep. After the incident which occurred in the AM of 09/21/18, MHT #2 did not work for several days. She returned for the 11:00 PM to 7:30 AM shift which began on 09/25/18. Further interview revealed, the morning of 09/26/18, MHT #2 came to her and was upset stating she had not been able to sleep and did not know what to do. MHT #2 related the incident to her and she instructed MHT #2 that she had done the right thing to report, but she should have done it immediately. HS #1 stated MHT #2 was a new employee, but the only requirement for 1:1 observation was to sit by the patient and observe because there was a Registered Nurse (RN) and another MHT on the floor at the same time.

Interview with RN #3, on 10/04/18 at 10:50 AM, revealed she had been on the geriatric unit as a one-to-one, 1:1, observer on the 11:00 PM to 7:30 AM shift, date unknown, when MHT #1 was also working. RN #3 stated she had needed help with the patient and called MHT #1. She revealed MHT #1 pushed the patient on the bed at little more forcefully than necessary. Further interview revealed she did not consider it abuse at the time and did not think about it until the abuse incident on 09/21/18. RN #3 stated she had worked at the facility for about five (5) months and had received abuse training during orientation, although she could not specifically recall being trained on staff-to-patient abuse. She also revealed she was not aware of any abuse trainings since the incident.

Interview with Unit Manager (UM) #2, on 10/04/18 at 11:05 AM, revealed he had been at the facility since 05/2018. He stated he arrived at work at 10:30 AM the morning of 09/26/18, and UM #1 (they are the unit managers for the entire inpatient units and inpatient population) showed him Mental Health Technician (MHT) #2's statement about the abuse incident. Further interview revealed he saw the video and then started talking with staff with the goals being to get any additional information about the incident and to educate on how to respond to witnessed abuse. He stated this education lasted approximately three (3) hours, and the feedback from staff on what to do if abuse were witnessed was a mixed bag, with some correct answers. He also revealed, for Patient #1 and other patients which required it, one-to-one, 1:1, observation could be done by a Registered Nurse (RN) or MHT and involved sitting by the bedside or else being within an arm's length of the patient. In Patient #1's case, 1:1 was required for the patient's safety to prevent him/her from getting up without assistance and falling. UM #2 stated MHT #2 was a new employee, had no training in geriatric care, and must not have realized the magnitude of what she witnessed. He stated he had never received any negative information about MHT #1. Further interview revealed he believed the "shut-up" remark was verbal abuse and should have been reported to him. He stated if RN #2 had reported it to him, he would have given MHT #1 at a minimum a final written warning. UM #2 revealed it was a missed opportunity in possibly preventing the abuse episode on 09/21/18. Further interview revealed during his orientation, UM #2 had abuse training which included reporting requirements; however, he did not specifically recall having staff-to-patient abuse training. He stated he had been an RN for many years and had received numerous trainings on abuse. UM #2 stated, for a new employee, all the information provided at orientation might not sink in.

Interview with David Nicholson, Staff Educator (SE), on 10/04/18 at 12:20 PM, revealed he had been an employee of the facility for two (2) years, and he spent more than one-half (1/2) of his working time in training. He stated he also was a preceptor and completed skills competencies on individual units. The SE revealed for abuse training, new employees received it during "New Employee Orientation" (NEO), on the first day, from the Director of Risk Management. He stated all the abuse policies were available to employees on the internet. Further interview revealed their was a web-based training (WBT) component that new employees completed during orientation and all employees annually. The SE stated during orientation, a new employee had one (1) week of computer module training and one (1) week of classroom training. To work independently, he then revealed a Mental Health Technician (MHT) worked a minimum of three (3) shifts with a preceptor, depending on his/her previous experience. For a Registered Nurse (RN) it was a minimum of five (5) shifts with a preceptor, depending on his/her previous experience.

Interview with the Chief Nursing Officer (CNO), on 10/04/18 at 2:05 PM, revealed she was first made aware of the abuse incident with Patient #1 on 09/26/18 between 7:00 AM and 7:30 AM. She revealed she was called by Unit Manager (UM) #1 and informed there was a situation that needed to be dealt with immediately. House Supervisor #1 had just reported to UM #1 that Mental Health Technician (MHT) #2 had completed a written statement concerning witnessed patient abuse that had occurred five (5) days earlier, on 09/21/18. UM #1 told the CNO that she spoke with MHT #2 and did in-the-moment training with her about reporting abuse immediately to her supervisor. Continued interview revealed the CNO told UM #1 to send her an e-mail about this, and she would put it in MHT #2's personnel file. The CNO revealed at this point, she, along with UM #1 and UM #2 (unit manager of the geriatric unit) devised a plan to investigate the abuse incident, and MHT #1 was suspended until the completion of the investigation. The investigation team each had three (3) to four (4) staff that had worked with MHT #1 to interview to determine if any of these employees had witnessed any inappropriate behavior from MHT #1. The investigation team reviewed the video of the incident. It matched the written statement of MHT #2. At this point, the decision was made to terminate MHT #1. Further interview revealed the CNO contacted MHT #1 for a meeting the next day. MHT #1 reviewed the video and was given an opportunity to respond in writing. MHT #1 stated and wrote d

Based on interview, record review, and review of the facility's video, policies, and documents, it was determined the facility failed to provide care free from abuse for one (1) patient, Patient #1, who received abusive treatment from Mental Health Technician (MHT) #1 (see A0395).

Patient #1 was admitted to the facility from a long-term care facility on 09/19/18 with diagnoses of End-stage Alzheimer's Disease, Multiple Falls, Status-Post Fractured Hip, Status-Post Subdural Hematoma, Angina, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and Compression Fractures of Thoracic Vertebrae Related to Falls. He/she had become increasingly combative and aggressive at the previous facility. Patient #1 was admitted to a locked geriatric unit which specialized in caring for the elderly with underlying medical conditions. Patient #1 was ordered to be on one-to-one,1:1, observation because of a history of repeated falls with injuries.

On 09/21/18 at 4:59 AM, MHT #1 entered Patient #1's room and began treating him/her abusively. Patient #1 was on one-to-one, 1:1, observation and had another staff member, MHT #2, providing this intensive observation. MHT #1 was working the entire floor, providing patient care and documenting on patients that were not on 1:1 observation, every fifteen (15) minutes, along with the unit charge nurse, Registered Nurse (RN) #2. According to the facility's video and statement made by MHT #2, when MHT #1 entered Patient #1's room, she pushed him/her back on the bed because the patient was trying to get out-of-bed. When the patient was sitting on the side of the bed, he/she began swatting/hitting MHT #1's abdomen, and consequently, her fetus, due to MHT #1's pregnancy. MHT #1 hit Patient #1 twice on the face and/or arm. Also, when taking Patient #1 to the bathroom to sit on the commode, she dragged him/her, allowing the patient to strike the rear of the bed with his/her back. Once in the bathroom, MHT #1 struck Patient #1 in the mouth and pushed him/her onto the commode. Patient #1 slid off the commode seat between the wall and the commode, and MHT #1 picked him/her up and placed Patient #1 back on the commode in a rough manner. Then, MHT #1 began spraying Patient #1 directly in the face with water from the shower hose and also sprayed the rest of the patient's body without using any soap or shampoo. Next, review of the video revealed Patient #1 was dragged out of the bathroom and placed face-down on the bed to be dried off with a towel(s). The patient's clothes were then placed on him/her in this position and also after he/she laid supine on the bed. After the patient was dressed, RN #2 came into the room, Patient #1 was put into a wheelchair, and he/she was wheeled out of the room into the Day Room. MHT #2 did not report the abuse immediately, but waited for five (5) days, during which MHT #1 worked four (4) additional shifts on the unit.

The failure of the facility to provide a nonabusive environment, effective supervision, and effective training on abuse recognition and reporting placed Patient #1 at risk for serious injury, harm, impairment, or death.

The facility was notified on 10/05/18 that Immediate Jeopardy was determined to exist related to Nursing Services. The facility initiated corrective actions, and the Immediate Jeopardy was determined to be removed on 10/11/18, prior to exit on that date. (Refer to A0395)

Based on interview, medical record review, and review of the facility's video, policies and procedures, and other facility documents, it was determined the facility failed to adequately supervise nursing personnel so patient care would be provided in a non-abusive environment for one (1) of ten (10) sampled patients, Patient #1.

The findings include:

Review of the video, on 10/02/18, of Room 102, geriatric unit, Patient #1's room from 09/19/18 to 09/24/18, revealed on 09/21/18 at 4:58 AM, Mental Health Technician (MHT) #2 was sitting at the bedside of Patient #1. At 4:59 AM. MHT #1 came into the room. At 5:01 AM while Patient #1 was sitting on the side of the bed, the patient hit MHT #1 in the abdomen, and MHT #1 hit the patient twice on the left side of the face or arm. At 5:02 AM, MHT #1 dragged Patient #1 to the bathroom (BR) where the patient's back hit the back of the bed, and she hit the patient in the mouth and pushed the patient down on the commode. At 5:03 PM, MHT #1 roughly pushed Patient #1 back on the commode again and sprayed water in the patient's face. At 5:04 AM, MHT #1 dragged Patient #1 from the commode back to the bed and put him/her on the bed face down and started drying him/her off with towels. From 5:04 AM until 5:09 AM drying off continued, and Patient #1's clothes were put on, with the patient being placed in the bed in a supine position. At 5:09 AM, RN #2 entered the room, put the patient in a wheelchair, and wheeled him/her out of the room.

Review of the facility's policy titled, "Patient Observations," policy number PC.084, revised 06/2016, revealed there were two (2) types of observation levels. The first was routine which required every fifteen (15) minute observation; and, the second was one-to-one, 1:1, which required observation of the patient within arm's length at all times. Further review revealed documentation on 1:1 observation required an hourly behavioral note from staff summarizing the patient's behavior and, on the "Patient Observation Sheet," the patient's location and behavior charted every fifteen (15) minutes. In addition, no other responsibilities could be given to the designated staff member assigned to perform the 1:1 observation.

Review of the facility's policy titled, "Patient Rights and Responsibilities," policy number RI. 046, revised 04/11/13, revealed without limitation patients were entitled to considerate, respectful, humane care and treatment; to be treated with human dignity and in an environment that contributed to a positive self-image; to receive care in a safe and sanitary setting; and to be free from all forms of abuse, including verbal, mental, physical, and sexual.

Review of the facility's policy titled, "Suspected Patient Neglect and Abuse by Staff," policy number RI.064, revised 12/2016, revealed abuse was defined as any physical or verbal action directed towards a patient, infliction of injury, sexual abuse, unreasonable confinement, intimidation, or punishment that resulted in physical pain or injury, including mental injury. Further review revealed suspected or witnessed incidents of abuse by staff should be reported immediately to the staff member's immediate supervisor or in his/her absence, to the Chief Nursing Officer and Director of Clinical Operations. The policy stated all allegations of suspected or witnessed abuse by staff were immediately investigated by Administrative Staff with the Chief Executive Officer (CEO) being apprised of the allegation and investigation results and approving the final decision in all cases. The policy revealed the alleged perpetrator would be immediately suspended pending the internal investigation with indicated disciplinary action taken. In addition, the policy revealed any employee who was aware of patient abuse and did not report it should also be considered for disciplinary action up to and including employment termination.

Review of the facility's policy titled, "Abuse Reporting: Adult," policy number RI.056, revised 12/2016, revealed any staff member who observed or received a report of an adult being abused, or had reason to suspect that an adult had been abused must report this information immediately to the Unit Charge Nurse and Department Manager or Nursing House Supervisor. In addition, Adult Protective Services (APS) must be notified, and the Director of Risk Management or designee would notify the Cabinet for Health and Family Services, Licensure and Regulation if the internal investigation indicated it was warranted.

Review of the facility's policy titled, "Corrective Action Process," policy number HR: 012, reviewed 05/2017, revealed corrective action could be initiated for many reasons, including but not limited to violations of the facility's policies. The policy stated the severity of the action generally depended on the nature of the offense and the employee's work record, and the action could range from a preventative counseling session to immediate employment termination. Further review revealed for preventative counseling, a verbal counseling by the supervisor may be documented and placed in the employee's personnel file, at the supervisor's sole discretion.

Review of the facility's job description titled, "Mental Health Technician I (Inpatient)," revised 11/15/13, revealed he/she was in the Nursing Department and reported to the Nurse Manager. It also revealed a license was not required for the position, and in general, the Mental Health Technician (MHT) provided routine non-acute physical care for the patient. Specifically, the policy revealed the MHT must maintain self-control in volatile or hostile situations such as when verbally or physically confronted; seek direction or clarification from the supervisor when necessary; treat patients with respect according to patient rights and responsibilities, and document and report incidents immediately and according to policy.

Review of Patient #1's medical record revealed he/she was admitted on 09/19/18 from a long-term care facility with diagnoses of End-stage Alzheimer's Disease, Multiple Falls, Status-Post Fractured Hip, Status-Post Subdural Hematoma, Angina, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and Compression Fractures of Thoracic Vertebrae Related to Falls. Patient #1's most recent fall was approximately one (1) week prior to admission where he/she struck his/her head. A CT scan done at the time did not show any acute findings. The record revealed since the fall, Patient #1 had decompensated and had exhibited combative behaviors with increased anxiety. The patient could get up in a wheelchair and required assistance with activities of daily living (ADL's). Further review revealed the comprehensive nursing assessment, completed on 09/19/18 at 11:30 PM, showed a skin assessment with bruising on both hands; skin tears on the right forearm; scar on the anterior, mid-line chest; scar at the umbilicus; two (2) bruises on the right lower quadrant of the abdomen; two (2) bruises on the left anterolateral thigh; skin tear around the right knee; scab on the right lower extremity; scab on the left foot; bruising and cut on the left palm; and bruising and discoloration on the left forearm. The assessment revealed Patient #1 was unable to respond to questions, was total care with bathing, was partial assistance with walking, dressing, toileting, and feeding. Also, Patient #1's gait was extremely unsteady, and he/she almost fell twice. The chart revealed the patient's height was sixty (60) inches and weight was one-hundred thirteen (113) pounds; he/she was oriented to person only and unable to cooperate. Further review revealed, on 09/20/18 at 12:10 AM, the physician ordered one-to-one (1:1) observation because of extreme fall risk. Also, another CT scan of the head was ordered to follow-up on the previous CT scan because of a fall where the patient hit his/her head prior to admission. This was scheduled for 09/24/18 at 3:00 PM. On 09/24/18 at 11:15 AM, the Physician Assistant-Certified (PA-C) wrote an order, which was co-signed by the Physician, to call 911 and send Patient #1 to an acute care hospital's emergency department for acute hypotension, altered mental status, tachycardia, and hypoxia. Patient #1's blood pressure was 80/64; pulse 147; oxygen saturation level 79 percent without oxygen (was given oxygen after this reading at two (2) liters per nasal cannula); and glucose of 163.

Review of the "24 Hour Nursing Progress Note" revealed, on 09/20/18, Patient #1 became ambulatory with 1:1 assist and by using a gait belt. On 09/21/18 at 6:00 AM, Registered Nurse (RN) #2 charted on the patient, and no incidents were reported. Further review revealed, on 09/21/18 at 10:00 PM, Patient #1 lowered self to ground twice while 1:1 and with an MHT holding the patient by a gait belt. The patient scraped an elbow on an unknown item during the first event which opened up old scabs from incidents prior to admission; the scrapes were cleaned with a dressing applied. Further review of the nursing notes revealed, on 09/24/18 at 11:00 AM, Patient #1's color became gray, with shallow respirations of twenty-four (24), blood pressure of 80/64, pulse 147, and oxygen saturation of 79%. The PA-C was called to the floor where orders were received and followed to send the patient to a nearby emergency department by calling 911 and sending the patient by ambulance.

Review of the "Progress Record," on 09/21/18 at 12:15 AM, revealed
MHT #2 was working 1:1 observation with Patient #1. MHT #2 charted hourly from 12:15 AM until 6:15 AM. She revealed Patient #1 was asleep or if roused went back to sleep until 5:20 AM. Further review revealed at 5:20 AM, Patient #1 was awake, confused, and uncooperative, trying to get out-of-bed, with re-direction done each time. The chart stated Patient #1 started to hit/slap staff when MHT #1 was trying to get the patient into bed. Then, Patient #1 was taken to the shower, and he/she was still confused and uncooperative, trying to hit staff. Further review revealed when Patient #1 was finished with the shower, he/she got dressed, got in the wheelchair but would not stay in it. MHT #2 charted again the patient was confused and uncooperative with staff. She revealed the patient sat in the middle of the floor when being walked in the hallway and was taken to the Day Room in a wheelchair. MHT #2 charted the patient continued to pace and walk the hallway with assistance and then go back to the Day Room and sit. This continued until she left. The oncoming MHT charted at 7:00 AM that Patient #1 was sitting in a chair in the Day Room getting blood drawn and was calm but confused with no agitation. Additional review of the nursing notes, on 09/21/18 at 11:00 PM, revealed MHT #1 was on 1:1 observation with Patient #1. MHT #1 charted every hour from 11:00 PM until 6:00 AM on 09/22/18 that Patient #1 slept through the night without getting out-of-bed.

Review of "Patient Observation Rounds," on 09/20/18 at 11:15 PM until 09/21/18 at 7:00 AM, revealed MHT #2 charted on Patient #1 every fifteen (15) minutes. The charting revealed Patient #1 was in his/her room until 5:00 AM sleeping except for three (3) times when he/she was awake. Further review revealed, at 5:00 AM, Patient #1 was in the bathroom and was awake and uncooperative. At 5:15 AM, Patient #1 was in the Day Room and was awake, confused, uncooperative, and pacing. This behavior basically continued until MHT #2 stopped charting at 7:00 AM. Review of "Patient Observation Rounds," on 09/21/18 at 11:00 PM until 09/22/18 at 6:15 AM, revealed MHT #1 charted on Patient #1 every fifteen (15) minutes. The charting revealed Patient #1 was in his/her room until 6:15 AM sleeping. Another staff member took over charting at 6:30 AM.

Review of Patient #1's hospital record after his/her transfer on 09/24/18 revealed, in the emergency department, blood pressure was 134/65, heart rate was 80, and oxygenation was 96 to 100 percent, on room air. A CT scan of the head without contrast showed no gross acute intracranial abnormality but atrophy of the brain. A Chest X-ray showed no acute disease. Further review revealed during Patient #1's hospitalization, he/she developed Atrial Fibrillation and was treated for that. Patient #1 was discharged, on 09/28/18, to home care with daughter with a hospice consult.

Review of the facility's staffing schedules revealed Mental Health Technician (MHT) #1 worked all 11:00 PM to 7:30 AM (night) shifts. It also revealed she worked the nights of 09/20/18, 09/21/18, 09/22/18, 09/23/18, and 09/25/18. Continued review revealed MHT #2 worked the nights of 09/20/18, 09/24/18, and 09/25/18.

Review of Mental Health Technician (MHT) #1's personnel file revealed she had a date-of-hire (DOH) of 06/19/18, was suspended on 09/26/18, and was terminated on 09/27/18. MHT #1 was not a licensed person, was not on the Nurse Aide Abuse Registry, and had a criminal background check completed on 05/22/18 which contained no adverse information. Her previous work experience included five (5) years doing home care with an out-of-state facility, and "Verbal De-Escalation" was completed 06/26/18 with a competency test score of one-hundred (100) percent. The file revealed MHT #1 was pregnant and had been off work for several weeks after hire, so her orientation was resumed on 07/17/18. In addition, her file revealed the "Handle with Care Behavioral Management System" was completed on 07/31/18; her orientation competency checklist was signed off by her preceptor on 08/07/18 with her first day of working independently 08/09/18, and her "Employee 60-Day Check-In" was completed by her supervisor on 09/09/18 with no problems noted. There were two (2) documents in MHT #1's personnel file. The first, was by Unit Manager (UM) #2, on 09/27/18 at 4:00 PM, who wrote he had spoken with Patient #1's daughter to inform her of the incident and the notification of Adult Protective Services (APS). He reported the daughter told him she had not noticed any new marks on the patient's face or arms when she visited over the weekend. In addition, the note stated the daughter told UM #2 the patient was going home with hospice because he/she had only around one (1) week to live. The second, was the "Employee Correction Action Report," dated 09/27/18, which described the incident as: a report by another MHT, revealed on 09/21/18, MHT #1 was rough with a patient, slapped the patient twice, and gave inappropriate care and handling that was not within the facility's expectations. MHT #1 was suspended on 09/26/18, pending investigation. A camera review was completed by the Director of Risk Management and the Chief Nursing Officer (CNO) that confirmed the complaint statement by reporting staff. Due to the seriousness and nature of the allegations being confirmed, MHT #1 was terminated. Further review revealed MHT #1's comments were she did not abuse Patient #1 and would never abuse a patient. She stated she was only trying to stop Patient #1 from hitting her abdomen, and consequently her fetus because she wouldn't let anyone hurt her baby. MHT #1 further wrote she thought she was defending herself, and she did not treat Patient #1 roughly, like MHT #2's statement described. This document was signed by MHT #1, UM #2, the CNO, and the Director of Human Resources.

Review of MHT #1's web-based training (WBT) revealed she had completed the learning module titled, "Identifying and Assessing Victims of Abuse and Neglect," on 06/21/18, with a score of one-hundred (100), passing. She also completed the module titled, "Ridge-High Risk Policy Acknowledgement," on 06/21/18, with a score of one-hundred (100), passing. The content of the High Risk Policies included RI.064, "Suspected Patient Neglect/Abuse by Staff," RI.056, "Reporting Adult Abuse," and RI.046, "Patient Rights and Responsibilities." Further review revealed MHT #1 completed the learning module, "Patient Observation Rounds," on 06/20/18, with a score of one-hundred (100), passing.

Review of Mental Health Technician (MHT) #2's personnel file revealed she had a date of hire (DOH) of 09/04/18. Her criminal background check revealed no adverse information, but the Central Registry Check was pending receipt (usually took eight (8) weeks for results). The file also revealed MHT #2 had completed "Handle with Care Behavioral Management System" on 09/11/18 and "Verbal De-Escalation Competency" with a score of one hundred (100) percent on 09/10/18. In addition, there were two (2) notes in the file. The first was an e-mail from Unit Manager #1 on the education she provided to MHT #2 the morning of 09/26/18 regarding the importance of reporting abuse or suspected abuse immediately to her supervisor. The second note was from Registered Nurse (RN) #2 which stated she instructed MHT #2 on the morning of 09/26/18 to immediately report abuse or suspected abuse to her supervisor and to protect the patient at all costs by removing him/her from harm.

Review of MHT #2's web-based training (WBT) revealed she had completed the learning module titled, "Identifying and Assessing Victims of Abuse and Neglect," on 09/05/18 with a score of ninety (90), passing. She also completed the module titled, "Ridge-High Risk Policy Acknowledgement," on 09/05/18, with a score of one-hundred (100), passing. The content of the High Risk Policies included RI.064, "Suspected Patient Neglect/Abuse by Staff," RI.056, "Reporting Adult Abuse," and RI.046, "Patient Rights and Responsibilities." Further review revealed MHT #2 completed the learning module, "Patient Observation Rounds," on 09/05/18, with a score of one-hundred (100), passing.

Interview with Registered Nurse (RN) #1, on 10/02/18 at 1:30 PM, revealed she was the geriatric unit charge nurse where Patient #1 was an inpatient from 09/19/18 to 09/24/18. She revealed the geriatric unit had an eighteen (18) bed capacity, and the average census was eight (8) to twelve (12) patients. She stated Room 102, Patient #1's room, had a video camera with images that could be seen at the nurse's station. The video camera also had film which could be preserved. RN #1 revealed if the census were greater than nine (9) patients, the unit would be staffed with two (2) RN's and two (2) Mental Health Technicians (MHT). If less than nine (9) the unit might be staffed with one (1) RN and (1) or two (2) MHT's depending on the acuity level of the patients on the unit. RN #1 stated every patient was observed every fifteen (15) minutes, with this documented, unless the physician ordered one-to-one, 1:1 observation. Further interview revealed Patient #1 was on 1:1 observation with every fifteen (15) minute documentation. She stated 1:1 observation meant there was always someone with Patient #1, within an arm's length. Patient #1 was placed on this strict observation level because of his/her fall risk and because, on admission, he/she was reported to be aggressive; however, RN #1 had not seen any aggressive behaviors, only swats at the staff at times. She revealed she did not work from 09/22/18 through 09/26/18, returning on 09/27/18. At that time, MHT #1 had already been terminated. Further interview revealed RN #1 did not know MHT #2, the witness, because she had not worked on the geriatric unit before the 11:00 PM to 7:30 AM shift starting on 09/20/18. RN #1 also stated, on the 7:00 AM to 3:30 PM shift on 09/21/18, Patient #1 had not exhibited any physical changes. She stated the patient was admitted with multiple bruises and skin tears from multiple previous falls. RN #1 revealed MHT #1 was a new employee of less then two (2) to three (3) months. She stated she was never told of any untoward or abusive behavior by MHT #1 to other staff or patients, and she would see MHT #1 in the mornings between shift change and never witnessed any inappropriate behavior.

Interview with the Physician Assistant-Certified (PA-C), on 10/03/18 at 11:22 AM, revealed the medical team saw all patients when first admitted for a physical, and then, if not needed, would only see a patient again if there were a medical consult from the attending physician. She revealed there was constant communication between the psychiatric team and the medical team. Further interview revealed, on 09/24/18, she was called to the geriatric unit to see Patient #1 because of increased lethargy and hypotension. She stated she assessed Patient #1 and decided to send him/her to the hospital. The PA-C revealed Patient #1 had only been seen initially for a history and physical with no additional consults until she was called to the unit on 09/24/18. Further interview revealed the PA-C did not believe the actions by MHT #1, on 09/21/18, contributed to his/her apparent declining medical condition.

Interview with Mental Health Technician (MHT) #1, on 10/03/18 at 2:17 PM, revealed she worked on the geriatric unit, her primary unit, the shift starting at 11:00 PM on 09/20/18 and ending at 07:30 AM on 09/21/18. She stated MHT #2, a new employee, asked her to help with Patient #1 who was trying to get out-of-bed. She stated she tried to calm the patient who appeared to have been incontinent of urine, and she thought the patient needed to toilet. Further interview revealed Patient #1 hit MHT #1, and she told the patient not to hit her. MHT #1 stated she was not trying to abuse the patient but was trying to push his/her arm back and prevent the patient from hitting her fetus. She revealed when she helped Patient #1 to the bathroom, she had a strong hold on the patient to prevent him/her from falling. MHT #1 stated she put Patient #1 on the commode because she thought the patient needed to toilet, and she did not want to leave him/her to get a shower chair, so she left the patient on the commode to wash him/her. Further interview revealed she did not use soap because she wanted to quickly wash him/her off with water, and Patient #1 could have a better shower that night when MHT #1 worked again. MHT #1 stated she put a stream of water from the shower hose on Patient #1's face to wash his/her face and hair, and she put the patient face down on the bed to dry him/her off because she was afraid the patient would fall. MHT #1 revealed she started at the facility in June 2018; had completed orientation during which she received abuse training; and to her knowledge, she did not abuse Patient #1. She stated she had required some time off because of her pregnancy, but had been working independently for several weeks. Further interview revealed if a person wanted to abuse a patient, he/she would not do it in front of another person or in a patient room that had a camera and was videotaping patient care. MHT #1 stated she had always received compliments on her care, and she had never been pulled aside and instructed her behavior was inappropriate. She revealed she had witnessed the video, signed a statement, and was suspended on 09/26/18 with termination on 09/27/18.

Interview with Registered Nurse (RN) #2, on 10/03/18 at 3:22 PM, revealed she was the RN on duty when the abuse incident occurred. She stated she had been with the facility for one and one-half (1.5) years and had worked on the geriatric unit the whole time. RN #2 revealed, on the shift which began at 11:00 PM on 09/20/18 and ended at 7:30 PM on 09/21/18, she worked with Mental Health Technician (MHT) #1 and also two (2) additional employees that each had a one-to-one (1:1) observation patient which included MHT #2 being on 1:1 with Patient #1. She stated it was an uneventful shift until around 4:30 AM when she went to help the other MHT give a shower to the other 1:1 observation patient. RN #2 stated when she finished, she checked on Patient #1 and MHT #1 told her he/she had already had his/her shower. She stated at no time did anyone mention any inappropriate behavior by MHT #1 to Patient #1. RN #2 revealed she saw Patient #1 after the incident, when taking him/her to the Day Room, and he/she appeared to be baseline with multiple bruises and skin tears which were present on admission. Further interview revealed she had only seen MHT #1 behave inappropriately one (1) time when MHT #1 told a patient/patients to "shut-up." She stated MHT #1 did not appear to be angry and used a normal tone of voice; in fact, she might have been joking. RN #2 stated she took MHT #1 aside and told her that saying "shut-up" to patients was not acceptable, and she never heard MHT #1 say it again nor did she see MHT #1 being rough with patients. Further interview revealed MHT #1 had always been very cooperative and finished assignments. RN #2 revealed she was very surprised by the incident.

Interview with Unit Manager (UM) #1, on 10/03/18 at 3:45 PM, revealed MHT #2 worked primarily on the Child Unit where she was the manager. The orientation for MHT #2 was two (2) weeks computer/classroom then five (5) days on the floor with a preceptor. The UM stated MHT #2 had just completed her orientation period before the incident. She revealed she arrived at work at 7:15 AM the morning of 09/26/18, and she had already been informed by House Supervisor (HS) #1 of the abuse incident with MHT #2 who had already completed a written statement describing the incident. Also, HS #1 had sent an e-mail to the Chief Nursing Officer (CNO) about the incident. UM #1 stated she had witnessed MHT #1 leaving the facility when she arrived and knew she was no longer at the facility. Further interview revealed she, along with the CNO, the Director of Risk Management, and UM #2 (manager of the geriatric unit) watched a video of the abuse incident and contacted other employees who had worked with MHT #1. UM #1 stated, from the employees she interviewed, none reported any abusive behavior they had witnessed from MHT #1. UM #1 reported after MHT #1 watched the video and made a statement, she was terminated by the CNO. UM #1 stated MHT #2 revealed she did not know what to do at the immediate moment and had experienced much anxiety since the incident; therefore, she gave MHT #2 immediate education on recognizing and reporting abuse immediately. She also revealed, on 09/26/18, there was no planned intervention with the remaining employees, but she made rounds on 09/26/18, 09/27/18, and 09/29/18 and talked with employees, doing education on recognizing and immediately reporting abuse.

Interview with the Director of Performance Improvement, on 10/04/18 at 9:50 AM, revealed Mental Health Technician (MHT) #1's first day of working independently was 08/09/18. Further interview, on 10/04/18 at 10:10 AM, revealed MHT #2's first day of working independently was 09/20/18.

Interview with HS #1, on 10/04/18 at 9:55 AM, revealed the abuse incident happened when she was on duty, but she was not made aware of the incident by MHT #2. She stated MHT #2 had been assigned to do one-to-one,1:1, observation with Patient #1, to sit next to him/her and ensure he/she did not get out of bed and fall, or to provide assistance. HS #1 revealed she checked on MHT #2 three (3) times the night of the incident and both the patient and MHT #2 were fine with the patient being asleep. After the incident which occurred in the AM of 09/21/18, MHT #2 did not work for several days. She returned for the 11:00 PM to 7:30 AM shift which began on 09/25/18. Further interview revealed, the morning of 09/26/18, MHT #2 came to her and was upset stating she had not been able to sleep and did not know what to do. MHT #2 related the incident to her and she instructed MHT #2 that she had done the right thing to report, but she should have done it immediately. HS #1 stated MHT #2 was a new employee, but the only requirement for 1:1 observation was to sit by the patient and observe because there was a Registered Nurse (RN) and another MHT on the floor at the same time.

Interview with RN #3, on 10/04/18 at 10:50 AM, revealed she had been on the geriatric unit as a one-to-one, 1:1, observer on the 11:00 PM to 7:30 AM shift, date unknown, when MHT #1 was also working. RN #3 stated she had needed help with the patient and called MHT #1. She revealed MHT #1 pushed the patient on the bed at little more forcefully than necessary. Further interview revealed she did not consider it abuse at the time and did not think about it until the abuse incident on 09/21/18. RN #3 stated she had worked at the facility for about five (5) months and had received abuse training during orientation, although she could not specifically recall being trained on staff-to-patient abuse. She also revealed she was not aware of any abuse trainings since the incident.

Interview with Unit Manager (UM) #2, on 10/04/18 at 11:05 AM, revealed he had been at the facility since 05/2018. He stated he arrived at work at 10:30 AM the morning of 09/26/18, and UM #1 (they are the unit managers for the entire inpatient units and inpatient population) showed him Mental Health Technician (MHT) #2's statement about the abuse incident. Further interview revealed he saw the video and then started talking with staff with the goals being to get any additional information about the incident and to educate on how to respond to witnessed abuse. He stated this education lasted approximately three (3) hours, and the feedback from staff on what to do if abuse were witnessed was a mixed bag, with some correct answers. He also revealed, for Patient #1 and other patients which required it, one-to-one, 1:1, observation could be done by a Registered Nurse (RN) or MHT and involved sitting by the bedside or else being within an arm's length of the patient. In Patient #1's case, 1:1 was required for the patient's safety to prevent him/her from getting up without assistance and falling. UM #2 stated MHT #2 was a new employee, had no training in geriatric care, and must not have realized the magnitude of what she witnessed. He stated he had never received any negative information about MHT #1. Further interview revealed he believed the "shut-up" remark was verbal abuse and should have been reported to him. He stated if RN #2 had reported it to him, he would have given MHT #1 at a minimum a final written warning. UM #2 revealed it was a missed opportunity in possibly preventing the abuse episode on 09/21/18. Further interview revealed during his orientation, UM #2 had abuse training which included reporting requirements; however, he did not specifically recall having staff-to-patient abuse training. He stated he had been an RN for many years and had received numerous trainings on abuse. UM #2 stated, for a new employee, all the information provided at orientation might not sink in.

Interview with David Nicholson, Staff Educator (SE), on 10/04/18 at 12:20 PM, revealed he had been an employee of the facility for two (2) years, and he spent more than one-half (1/2) of his working time in training. He stated he also was a preceptor and completed skills competencies on individual units. The SE revealed for abuse training, new employees received it during "New Employee Orientation" (NEO), on the first day, from the Director of Risk Management. He stated all the abuse policies were available to employees on the internet. Further interview revealed their was a web-based training (WBT) component that new employees completed during orientation and all employees annually. The SE stated during orientation, a new employee had one (1) week of computer module training and one (1) week of classroom training. To work independently, he then revealed a Mental Health Technician (MHT) worked a minimum of three (3) shifts with a preceptor, depending on his/her previous experience. For a Registered Nurse (RN) it was a minimum of five (5) shifts with a preceptor, depending on his/her previous experience.

Interview with the Chief Nursing Officer (CNO), on 10/04/18 at 2:05 PM, revealed she was first made aware of the abuse incident with Patient #1 on 09/26/18 between 7:00 AM and 7:30 AM. She revealed she was called by Unit Manager (UM) #1 and informed there was a situation that needed to be dealt with immediately. House Supervisor #1 had just reported to UM #1 that Mental Health Technician (MHT) #2 had completed a written statement concerning witnessed patient abuse that had occurred five (5) days earlier, on 09/21/18. UM #1 told the CNO that she spoke with MHT #2 and did in-the-moment training with her about reporting abuse immediately to her supervisor. Continued interview revealed the CNO told UM #1 to send her an e-mail about this, and she would put it in MHT #2's pe