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Based on video surveillance review, interviews, and facility document review, it was determined that the facility staff did not substantially comply with this condition of participation by:

1.Failing to immediately provide protection for the patient 's health and safety while failing to adhere to standards of care, policy and procedure, law and regulation. (TAG A144)

2. Failing to ensure the patient was free of all forms of abuse, neglect, or harassment while failing to adhere to standards of care, policy and procedure, law and regulation. (TAG 145)

3. Failing to conduct restraint procedures in adherence with safe and approved restraint and seclusion training techniques that adheres to policies and procedures, law and regulation. (TAG 167)

The findings include:

1. On February 13, 2020 at 11:00 a.m., Staff Member # 1 reported to a surveyor that the facility had an incident of abuse on February 12, 2020.

Upon review of the video surveillance the surveyor observed a staff member touch, hit and drag a patient on the floor. Other staff members who were present or working at the time verified the actions observed on the video. Staff present failed to follow the facility's policy and procedure to immediately ensure patient safety, including direction related to staff members. Please see A-0144 & A-0145 for additional information.

2. Staff interview and review of facility policy and procedure revealed staff used a towel to protect themselves when a patient spit. Interviews revealed this action was taught in staff training, but was inconsistent with the facility policy and procedure. Please see A-0167 for additional information.









28361

The facility's failed to immediately provide protection for the patient ' s emotional health and safety as well as his/her physical safety by not immediately placing an employee on leave in adherence to policy and appropriate patient safety standards of pratice, for (1) of one (1) patients (Patient # 2).

On February 20, 2020 at 12:00 p.m. an interview with Staff Member #1 revealed "The Nursing Supervisor was notified of the incident at 6:25 p.m. [Staff Member #11] continued to work on Unit 8 until the end of the scheduled shift. [Staff Members #1 and #2] (Administrative Staff) were notified of the incident on February 13, 2020 at 5:00 a.m. [Staff Member #11] was terminated on February 13, 2020 at 3:00 p.m."

A review of the facility policy provided by Staff Member #2 on February 19, 2020 at 3:30 p.m. titled "Hospital Policy on Reporting Patient/Resident abuse or neglect" read in part, "Immediate reporting of an actual, alleged or suspected incident of abuse or neglect to a patient while in the direct care of [Name of facility] to the Nursing Supervisor/Unit Coordinator on duty at the time of the occurrence and respective supervisor. The Department Supervisor/Nursing Supervisor shall immediately take steps/actions to protect the patient/resident until investigation is complete by placing the employee on administrative leave."

The facility failed to follow their policy by not taking immediate action and allowing Staff Member #11 to continue to work until the end of the shift.



28361

Based on video surveillance review, interviews, and facility document review, it was determined that the facility staff failed to ensure the patient was free of all forms of abuse, neglect, or harassment, for (1) of one (1) patients (Patient # 2).

The findings include:

On February 13, 2020 at 11:00 a.m., Staff Member # 1 reported that the facility had an incident of abuse on February 12, 2020, that the facility would be self-reporting that day to the applicable state agencies and law enforcement.

On February 18, 2020, Staff Member #1 and the surveyor reviewed the video recording of the events of February 12, 2020. The following was observed:

At approximately 6:14 p.m., Patient #2 was seated on the couch with another patient when Staff Member #11 approached the couch and took a seat between the two patients.

At approximately 6:15 p.m., Patient #2 placed their left hand in front of Staff Member #11's face and appeared to be conversing (there was no sound to the video) with Staff Member #11.

Patient #2 did this several times over the next minute.

At 6:16 p.m., Patient #2 placed their left arm on Staff Member #11's right shoulder. Staff Member #11 appeared to be engaged in conversation with the second patient sitting on the couch, and was not observed to respond to Patient #2.

At 6:17 p.m., Patient #2 again put their left hand in front of Staff Member #11's face with the left pointer finger extended, and Staff Member #11 shrugged off the patients arm and hand while appearing to be redirecting the patient's actions. Patient # 2 turned towards Staff Member #11 and appeared to spit at Staff Member #11's face.

At that time, Staff Member #11 stood and put a hand on Patient #2 at the neckline, and attempted to pull the patient up to a standing position as the patient was resisting with the left arm extended out to Staff Member #11's right shoulder. Patient #2, in an attempt to free self from Staff Member #11, kicked with the left leg into Staff Member #11's abdominal area. Staff Member #11 released the hold on Patient #2, grabbed the patient's ankles and pulled the patient to the floor, Patient #2's head and back was observed to strike the floor.

While Patient #2 was on the floor, Staff Member #11 was seen striking Patient #2 in the chest and abdomen with a closed fist approximately 4 times. Another Staff Member then separated Staff Member #11 and Patient #2. Staff Member #11 grabbed Patient #2's ankles again and drug Patient #2 approximately 15 feet across the floor.

Documentation by Staff Member # 9, Registered Nurse (RN), in the Nursing Notes on February 12, 2020 at 8:00 p.m. read in part "Pt (Patient) complained of stomach pain. Pt stated that [pt] targeted and spit in face of staff and then the staff punched [pt] in the stomach. Pt changed story to nothing-happened back to original story. No bruises noted to abdominal or stomach. No bruises noted to frontal trunk area. [Pt] requested to call [parent]. Pt stated that [pt] was punched in dayroom area. Pt's [parent] notified at 7:25 p.m. and verbalized understanding. Nursing Supervisor notified at 7:24 p.m. [Patient # 2's name] talked on phone with [parent] without incident. Oncoming nurse give report."

Documentation by Staff Member # 16, RN Nursing Supervisor, in the Nursing Supervisor Notes on February 12, 2020 read in part "[Patient # 2's name] sitting on couch, spit at staff, reported to [parent] that staff hit [them] in abdomen. Please review camera at 6:00 p.m. to 6:30 p.m. Staff reported that she witnessed punches. [Parent] to call to find out if [Patient # 2's name] was punched." According to Staff Member # 2, it was not unusual for the parent to call as they usually calls multiple times.

On February 17, 2020 at 1:40 p.m., an interview with Staff member # 9 revealed, "I was at the nurse's station. I know [Patient #2] was being aggressive prior to this and staff had to intervene to keep [Patient #2] away from a female patient. I did not see what took place but [Patient #2] told me [Staff Member #11] punched [Patient #2] in the stomach and then told me it didn't happen and then changed story and said it did happen. I did not see [Staff Member #11] put hands on [Patient #2]. I wasn't out there. I did report what [Patient #2] told me the supervisor."

On February 17, 2020 at 4:00 p.m., an interview with Staff Member # 8 revealed, "I usually don't work on Unit 8. I am assigned to 7 B or A, but I can work on any unit. I started hearing it first. I could hear [Staff Member #11] say "get on the floor. Get on the floor" or something like that. Myself and the other BT (behavioral tech) ran to the commotion and [Staff Member #11] had [Patient #2] on the floor and [Patient #2] pants were half down and I was trying to get in there to help [Patient #2] and I saw [Staff Member #11] punch [Patient #2] in the stomach. I tried to separate them but [Staff Member #2] told me to get back and I was so shocked I stepped back. I saw [Staff Member #11] punch [Patient #2] 5 or 6 times. [Staff Member #11] was connecting with those punches. [Staff Member #11] grabbed [Patient #2] by the ankles and drug [Patient #2] out in the floor by the cabinets. I was in total shock. I look at the other BT and [other BT] went to [Staff Member #11] and I went to [Patient #2]. [Other BT] moved [Staff Member #11] out of the way. Other BTs swooped in to [Patient #2]. I didn't know what to do. I've never witnessed anything like that before. I saw the Nursing Supervisor on 8 and told [Nursing Supervisor] I needed to talk to [Nursing Supervisor]. I was sent back to 7 and when the Supervisor came over there I talked to [Nursing Supervisor] about it in the kitchen and reported what I'd seen. I don't know what made [Staff Member #11] do that. I can't understand why [Staff Member #11] would do that. This obviously isn't the job for [Staff Member #11]. I have never had a bad experience with any staff here that I have worked with. [Staff member #11] sounded agitated and one thing that I did notice was, after it was over and [Staff Member #11] was pushed away by the other BT, [Staff Member #11] walked away and had a smile on face. I am upset with myself. I look back and I know I should have handled this differently. In the future I certainly will handle this differently if it ever happened again I just hope it never happens again."

On February 17, 2020 at 4:30 p.m., an interview with Staff Member #10 revealed, "I was not familiar with [Name of Staff Member #11], this was the first time I worked with [staff member]. Staff Member got here late that day at about 5:10 p.m. [Staff Member] went to the kitchen, and got drink, and came to us (other techs) to see what we were doing on the unit (activities, groups). We explained that things were fine. We were in the midst of eating, sitting at a table in the big room. I heard what sounded like "Oh my (expletive) god" or "Oh the (expletive) not". When I jumped up to see what was going on [Staff Member #11's name] and [Patient #2's name] were in the floor and [Staff Member #11] was punching [Patient #2]. I was trying to get to [Patient #2], but [Patient #2] was kicking [Staff Member #11] and [Staff Member #11] grabbed [Patient #2] out into the floor. I put my arm out and told [Staff Member #11] to get back that [Staff Member #11] need to go "tap out" with [Name of another Staff Member]. I heard [Staff Member #11] say when [Staff Member #11] came in that "everything that could go wrong today has". I think [Staff Member #11] was late waiting for [Staff Member #11] car to get fixed. After that happened with [Patient #2] I told [Staff Member #11], I pulled [Staff Member #11] to the side and said "Nothing you can say can explain, what you've done". I do believe I reported to the nurse but all my days run together and it's hard to remember. I know if this ever happened again I'd call the supervisor immediately myself."

On February 20, 2020 at 12:00 p.m. an interview with Staff Member #1 revealed "The Nursing Supervisor was notified of the incident at 6:25 p.m. [Staff Member #11] continued to work on Unit 8 until the end of the scheduled shift. [Staff Members #1 and #2] (Administrative Staff) were notified of the incident on February 13, 2020 at 5:00 a.m. [Staff Member #11] was terminated on February 13, 2020 at 3:00 p.m."

A review of the facility policy provided by Staff Member #2 on February 19, 2020 at 3:30 p.m. titled "Hospital Policy on Reporting Patient/Resident abuse or neglect" read in part, "Immediate reporting of an actual, alleged or suspected incident of abuse or neglect to a patient while in the direct care of [Name of facility] to the Nursing Supervisor/Unit Coordinator on duty at the time of the occurrence and respective supervisor. The Department Supervisor/Nursing Supervisor shall immediately take steps/actions to protect the patient/resident until investigation is complete by placing the employee on administrative leave."

The facility failed to follow their policy by not taking immediate action and allowing Staff Member #11 to continue to work until the end of the shift.

Based on interviews and document review, it was determined the facility failed to ensure their practice of placing a towel four (4) to six (6) inches in front of a patient's face during restraint was a part of a safe and appropriate restraint and seclusion techniques in their policies and procedures and an approved CPI (Crisis Prevention Institute) techinique in accordance with CPI training.

The findings include:

The Policy titled Restrictive Procedures #303.25 was provided by Staff Member #7 and reviewed on 8/17/2020. The policy did not include the procedures for the use of a towel being held four (4) to six (6) inches above a patient's face who is spitting.

Staff Member #7 was interviewed several times on 8/17 and 19/2020 and stated, "Before a staff member can assist with a patient who is combative or trying to harm themselves or someone else they must have attended and passed the CPI course."

Staff Member #12 was interviewed on 8/17/2020 at 3:00 P.M. and stated, "We are taught in CPI to use a towel above a patient's head if they are spitting. The towel should be held about six (6) inches above the patient's face."

Staff Member #8 was interviewed on 8/17/2020 at 4:02 P.M. and stated, "If a patient is spitting we hold a towel above the patient's face to protect the staff."

Staff Member #2 was interviewed on 8/19/2020 at approximately 2:20 P.M. and stated, "I am a CPI instructor. We teach the staff to use a towel to protect the staff when a patient is spitting. The towel is held four (4) to six (6) inches above the patient's head. Spitting is considered a strike and the towel is used to block the strike."

The CPI handbook was reviewed on 8/17/2020 and does not address the use of a towel above a patient's face when they are spitting. The handbook does not address spitting.

Staff Member #3 was interviewed at various times on both 8/17 and 19/2020 and stated, "Our trainer is going away in October to be re-certified in CPI. We will have them addresses this issue with their staff in the meantime we will update our policy to include a spit barrier."

Based on medical record review, staff interview, facility document review and facility regulatory complaint history, it was determined the facility did not substantially comply with this condition by:

Failing to ensure the Quality Assessment and Performance Improvement (QAPI) program considered the incidences, prevalence, and severity of complaints and to develop a plan of action to mitigate and prevent reoccurrences of issues,

Failing to report events involving potential patient harm to the QAPI program (see tag A-0286), and;

Failing to ensure all staff members have the ability to report incidents in order to enable accurate and immediate reporting and investigation of incidents and concerns. (See tag A-0286)

The findings include:

The facility's regulatory compliance history was reviewed and evidenced a concerning number of complaints and reoccurring events. Specifically, the surveyor identified 27 complaints since January, 2018 that involved allegations of patient abuse or harm.

Furthermore, the survey team investigated six (6) additional complaints during the August 2020 survey. The current complaints provided evidence that incidents were continuing/reoccurring and the QAPI program failed to prevent reoccurrences and find long-term solutions.

The surveyor discussed these concerns with staff during the survey. The facility staff stated the issues are taken to QAPI, however, there is evidence by the facility history that actions implemented are not sustained or are ineffective in decreasing complaints. The facility staff discussed the development of new interventions consisting of personnel changes, addition of a full time Patient Advocate, and the formation of committees to work on concerns, however the facility stated the interventions were still "in the development stages".

(See tag A-0286)

Based on clinical record review, staff interview and a review of facility documents, it was determined the facility staff failed to ensure the timely reporting of two (2) incidents involving potential harm to patients to the Quality Assessment and Performance Improvement (QAPI) program (Patient #2 and Patient #4).

The findings included:

Patient #2 experienced a seizure with a fall that was not reported as per the facility policy for reporting and tracking of adverse events.

The clinical record for Patient #2 was reviewed and evidenced that on 8/5/2020 at approximately 9:14 a.m., it was documented in the "Patient Care Flow Sheet" : . ..."Had seizure, fell hit head-checked by nurse ...checked by doctor ..."

On 8/17/2020 at 3:00 p.m., the surveyor interviewed Staff Member #16 (Behavioral Tech [BT]). Staff member #16 stated, "I was with another BT and the patient (Patient #2) was standing in between us ... (Patient #2) suddenly fell and hit (their) head on the door and began to jerk, having a seizure in the floor...I got on the floor by the patient and asked the nurse to get a pillow. The pillow was put under (Patient #2) head ...when the seizure ended (the patient) was snoring ...(the patient) was not able to walk, so I scooped (them) up and carried (Patient #2) to their room..."

On 8/19/2020 at approximately 9:30 a.m. the surveyor reviewed the video footage of the incident above which occurred on 8/5/2020 at 9:14 a.m. From the video footage the surveyor was able to see the patient fall, hit (their) head on the door facing and land on the floor experiencing jerking body movements. The surveyor observed the RN to place a pillow under the patient's head, obtain a blood pressure cuff and obtain vital signs once the jerking stopped. The surveyor could also observe two other staff members standing by the patient. One staff member bent down and began rubbing the patient's back. The RN was observed to go to the desk and use the telephone, while the two other staff members remained with the patient. The patient was then observed to be picked up by a staff member and carried to (the patient's) room.

The surveyor reviewed the facility policy and procedure for "Incident Reporting" . The document revealed the following, in part: "...Definitions ...7. Serious Injuries/Events constitute any of the following outcomes as a result of healthcare intervention but may not be limited to this list: r. Accidents such as falls ...Procedure: 18. Any facility employee or staff member who discovers, is directly involved in or is responding to an event/incident is to complete or direct the completion of a Healthcare Peer Review (HPR) incident report into MIDAS (electronic reporting system) by RDE. a. This report is to be entered through RDE into the MIDAS system prior to the end of the staff members scheduled shift ...b. Healthcare Peer Review (HPR) Incident reports are to be signed by the individual preparing the report. c. The Nurse Charge of Shift (identified by Staff Member #6 as the House Supervisor) on duty at time of event is notified of any HPR incident, reviews HPR for completeness, making suggestions or additions as necessary from nursing perspective ...h. The completed form is forwarded to the Risk Manager within 72 hours ..."

On 8/19/2020 at 2:00 p.m., the surveyor reviewed the adverse event/incident reporting log. The concern related to Patient #2's incident (seizure with fall) was not listed on the log. The surveyor requested further information on the reporting of the incident. At 2:40 p.m., Staff Member # 3 (Safety/Risk) stated there was no incident form completed for this event but "The expectation is, there should have been a report filled out ... "

On 8/20/2020 at 8:40 a.m., the surveyor discussed the incident with Staff Member #6 (Quality). Staff Member #6 stated, "(Risk) was on vacation during that time and I am the back-up. I cannot enter falls into the system myself. I don't have access and have not had the training to be able to put them in ...there was a step missed in the documentation process and no incident report was filed ...it was on my morning meeting notes for that day and I told (Staff Member 7) that there was no incident report and it should have been put in. Every nurse has access to put in the reports ... " The surveyor also discussed the concern regarding reporting. Staff Member #6 stated, "There is no policy that staff cannot report to any agency they feel they need to. We just ask that they report to us first, because if the allegation or concern has to do with abuse or neglect we need to know immediately so that we can keep the patient safe..."

The surveyor discussed the concerns throughout the investigation process and during a review of the Quality Program on 8/20/20. The surveyor also discussed the concerns with Staff Members #1 (CEO), #6 (Quality) and #7 (COO) on 8/20/20 at 11:15 a.m.

Patient #4 purposely ingested medication not intended for them and the incident was not reported as per the facility policy for reporting and tracking of adverse events.

A medical record review for Patient #4 on August 17, 2020 at 12:32 p.m. revealed a note entered by Staff Member #19 (Behavioral Tech) on April 17, 2020 that advised Patient #4 admitted to taking medication not intended for them. The note further added the patient took the medication from the nurse's station while the patient experienced a panic attack. Staff Member #19 advised they reported the incident to the charge nurse, Staff Member #18.

During an interview with Staff Member #7 on August 17, 2020 at 1:23 p.m., Staff Member #7 advised that Patient #4 did take and ingest medication not intended for them from the nurse's station. This occurred when Staff Member #18 left the medication sitting on the counter while the staff member left the area to use the phone. Staff Member #19 did report the incident to Staff Member #18 when Patient #4 advised them of the event. Staff Member #19 did not report the event as required. The incident was not reported to the QAPI program until August 29, 2020, or namely twelve (12) days later, when the patient advised another staff member of the incident.

During an interview with Staff Member #6 on August 17, 2020 at 3:00 p.m., Staff Member #6 advised that only charge nurses have the ability to enter incidents into the reporting system. Behavioral techs do not have that ability and instead are supposed to report events to a charge nurse. Behavioral techs do have the option to report incidents anonymously through the employee compliance hotline.