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Based upon interview and record review the facility failed to assess Pt. #1 after an allegation of abuse, failed to protect other patients while an investigation was being conducted, failed to fully investigate and document allegations of abuse and failed to provide annual education to facility staff on abuse in 1 of 1 abuse investigations reviewed (patient #1) in a sample of 10 records reviewed.

Findings Include:

The facility failed to protect other patients in the facility while the investigation was being conducted. See Tag 0145.

The facility failed to provide annual education on abuse and neglect to facility staff. See Tag 0145.

The facility failed to assess Pt.#1 for injury and failed to notify the physician following the allegation of abuse per facility policy. See Tag 0145.

The facility failed to thoroughly investigate and provide documentation of the investigation per facility policy.
See Tag 0145.

The facility failed to inform patients of their rights upon admission and failed to obtain consent for treatment per facility policy. See Tag 0117.

Failure to fully investigate the allegation, assess the patient, notify the provider following the abuse allegation, educate facility staff yearly, and remove the accused caregiver from direct patient care had the potential to impact all patients receiving care at this facility.

Based on record review and interview, the facility staff failed to issue Medicare recipients with the "Important Message From Medicare" within 2 days of admission and/or 2 days prior to discharge per their policy and procedure in 3 of 8 medicare eligible patients (Patient # 1, #5, and #7 ) and failed to obtain consents to treat in 2 of 10 patients (Patient #6 and #10) in a total of 10 medical records reviewed.

Findings include:

Record review of policy "Medicare Beneficiary Notification of Discharge Appeal Rights" last reviewed 6/22/2021 revealed the hospital must "issue the IM (Important Message From Medicare) within two calendar days of admission, must obtain the signature of the beneficiary or his or her representative, the date and time of the signature, and must provide a copy to the patient. Hospitals must also deliver a second notice as far in advance of discharge as possible, but not more than two calendar days before discharge."

On 1/18/2023 at 10:54 AM, patient #7's medical record was reviewed. Patient #7 was admitted to the hospital on 9/08/2022 and was discharged on 9/19/2022. Patient #7 was issued the first copy of the Important Message from Medicare on 9/10/2022. Patient #7 was declared incompetent on 9/14/2022 and his power of attorney (POA) was activated. There was no documentation of the second copy being issued to Patient #7 or the POA.

On 1/18/2023 at 11:00 AM patient #5's medical record was reviewed. patient #5 was admitted to the hospital on 9/03/2022 and was discharged on 9/16/2022. Patient #5 was issued the first copy of the Important Message from Medicare on 9/05/2022 at 9:42 AM. There was no documentation of the second copy being issued.

On 1/18/2023 at 12:18 PM, patient #1's medical record was reviewed. patient #1 was admitted to the hospital on 9/12/2022 and was discharged on 9/22/2022. Patient #1 was issued the first copy of the Important Message from Medicare on 9/15/2022 at 5:25 PM (greater than 2 days after admission.) Patient #1 was declared incompetent on 9/13/2022 and (his/her) power of attorney (POA) was activated. There was no documentation of the second copy being issued to Patient #1 or the POA.

On 1/18/2023 from 9:58 AM through 1:48 PM during interview while reviewing medical records, Director of Nursing Service M and Emergency Department (ED) Manager F stated there was no documentation that a second Important Message From Medicare was given to Patient #1, #5 or #7.

Record review of policy "Consent for Treatment," last reviewed 6/22/2021, revealed "A patient's authorization for treatment must be secured at the time of admission to the hospital or Emergency Department... No procedure or treatment may be performed without consent except in emergency situations... At the time of hospital admission, it is the responsibility of Patient Registration personnel to obtain a signed "Consent to Treatment and Assignment of Benefits" form as soon as possible. ..When the correct signature has not been obtained... the nurse is to obtain the consent as quickly as possible."

On 1/18/2023 at 10:38 AM patient #6's medical record was reviewed. Patient #6 was admitted to the hospital through the Emergency Department on 9/06/2022 and discharged on 9/23/2022. There was no signed "Consent to Treatment and Assignment of Benefits" form in Patient #6's medical record.

On 1/18/2023 at 1:48 PM Patient #10's medical record was reviewed. Patient #10 was admitted to the hospital through the Emergency Department on 5/24/2022 and discharged on 5/26/2022. There was no signed "Consent to Treatment and Assignment of Benefits" form in Patient #10's medical record.

On 1/18/2023 at 2:12 PM during interview with Director of Nursing Service M, Director M confirmed there was no additional Important Message from Medicare documentation in Patient #1, #5 or #7's medical records and no "Consent to Treatment and Assignment of Benefits" forms in Patient #6 and #10's medical records.

Based upon record review and interview facility staff failed to investigate allegations of patient abuse, failed to assess the patient and to notify the physician following the allegation of abuse per policy, and failed to take immediate action by removing the accused caregiver from patient care in order to protect patients from abuse in 1 of 1 patient abuse allegations (Pt. #1) in a sample of 10 patient records reviewed. The facility also failed to educate staff in abuse and neglect policies and procedures every year in 1 of 1 education program reviewed.

Findings Include:

Review of facility Patient Rights brochure, titled, "(Facility) Patients' rights and responsibilities, revealed, "You will be treated with respect and courtesy and will be free from all forms of abuse and harassment."

Review of facility policy, GA.300 titled, "Reporting of Caregiver Misconduct and Discipline of Caregivers: Client Abuse, Neglect, Mistreatment, and Misappropriation of Property," last reviewed 11/21/2022 revealed, "(Facility) patients....(referred to in this policy as Client(s)....have the right to be free from abuse...neglect, mistreatment...Clients must not be subject to abuse, neglect, mistreatment...including but not limited to, facility staff....Abuse: i. the willful infliction of: injury, unreasonable confinement, intimidation...with resulting physical harm, pain or mental anguish...e. mistreatment is inappropriate treatment...of a Client....II Procedure for investigation of actual or alleged caregiver misconduct - all locations...a. If a partner believes that an incident of potential Misconduct has occurred, the staff member must protect the Client from further potential Misconduct, which may include removing the Client to a safe location, and then report the incident to the partner's immediate supervisor immediately.....If there is an allegation that the Client was or may have been injured, an appropriate physician, psychologist, or clinical or administrator director/manager must ensure that the Client is properly examined....c. The director or designee will conduct a thorough internal investigation of the alleged incident and will take such steps as are appropriate to prevent potential Misconduct while the investigation is in progress. The internal investigation may include: ii. Interviewing alleged victims and witnesses; iii. collecting other corroborating and disproving evidence:.....d. The investigation must be fully and completely documented...e. Regardless of location or facility, when the results of an investigation indicate...that a Caregiver is the perpetrator of abuse, that Caregiver will be immediately barred from any further contact with Clients, pending the outcome of any further investigation, prosecution, or disciplinary action against the Caregiver."

Review of facility professional conduct event 48914 dated 09/15/2022 revealed, "(RN A) was observed aggresivley (sic) yelling at a patient, after the patient struck her. The video monitor also went off and stated that the nurse (RN A) pushed the patient. (sic)....I was watching the patient on Video Monitoring for falls. Patient was sitting on the edge of the bed and started to get up. Approximately 1 second later I sounded the alarm. The Nurse (RN A) who was in the room came over and started to firmly restrain patient (sic) to get them back in bed. I heard the RN state the patient punched me and at this time the patients back was facing the bed and the RN pushed the patient onto the bed." Under description: "An investigation of this incident was done immediately on the day of the incident by (Nursing Director J) and (RN Manager K). On 9/19 I sent the information to the agency's recruiter. (RN A's) contract was terminated with (Facility). All information was relayed to the agency for follow up."

Review of Patient #1's medical record on 01/18/2023 at 9:55 AM with Registered Nurse Educator O and Registered Nurse Director N revealed the incident involving RN A occurred at 11:20 AM, Pt. #1 was not assessed until 2:10 PM by nursing staff, 2.5 hours after the incident had occurred. There is no evidence of provider notification of the alleged abuse. When RN O was asked if these findings were correct that no assessment was completed until 2:10 PM, RN O stated, "That is correct, there was no assessment completed and the doctor was not notified."

On 01/17/2023 at 12:28 PM during an interview with RN P, RN P stated (She/He) has worked at this facility for 21 years, the last 18 years mostly on the medical floor. RN P stated, that they receive abuse and neglect training in their annual education modules but (she/he) could not recall the last time (she/he) did it, "It's been a while." RN P stated if (he/she) witnessed staff pushing a patient, (she/he) would separate the staff and the patient or call security for help and let the supervisor know. RN P stated, (he/she) would expect the staff to be reassigned to other patients "Until it got resolved" and stated, "We've had to do that."

In an interview on 01/17/2023 at 1:10 PM with Director J, who initially interviewed RN A on 9/15/2022, when asked what happened on 09/15/2022, stated, "I was asked by (CNO B) to go to the medical unit for an altercation that happened between an RN and a Patient. (RN A) said a patient was belligerent and hit (him/her). (RN A) needed to be removed, and another nurse had taken over for (her/him). (RN A) had said that the patient was trying to get up and (RN A) put the patient back in bed." When asked if abuse of Pt. #1 had occurred, Director J stated, "No one visually saw anything except the video monitor, who said it looked aggressive." When asked what the video monitor actually told Director J, J stated, "I never spoke to the video monitor." When asked what happened for the remainder of (RN A's) shift, Director J stated, (RN A) stayed for (his/her) shift on 9/15 and took care of other patients. I offered to send (her/him) home after being hit by (Pt. #1) but (he/she) declined and wanted to stay. When these incidents happen and there is a personality conflict with the RN or the patient then we reassign the nurse to other patients." When asked how do you determine if it is abuse, Director J stated, "Typically it goes through HR (Human Resources) if there is a complaint and we utilize HR to figure out if what occurred was abuse." When asked how do you know that (RN A) didn't abuse the other patients (he/she) was reassigned to, Director J stated, "I can't say that, I don't know."

In an interview on 01/17/2023 at 1:30 PM with CNO (Chief Nursing Officer) B, when asked what investigation happened following the incident on 9/15/2022, CNO B stated, "I was at a conference and I received a call from (Director J and Manager K) They had spoken with (RN A) who said the patient hit them. They changed (RN A's) assignment and gave (him/her) different patients, we were still investigating." When asked how do you know (RN A) didn't push or hurt someone else, stated, "I guess I don't, (RN A) continued to work until the end of their shift at 7:00 PM. This has never happened before and it's the first time we reported it to the state." When asked what follow up was done with education or training with staff to prevent this from happening again, B stated, "Nothing was done with staff. I was told we would be canceling (RN A's) contract. Looking back I should have sent (him/her) home since it was an allegation." When asked what other interviews were completed as part of the investigation, Staff B stated, "I didn't talk to any patients, I spoke with the (video monitor, the CNA, the RN manager and the RN director) and decided to cancel the contract and report the incident. I didn't feel anything else was needed, we notified the chain of command, I honestly don't remember if we did anything with staff."

In an interview on 01/17/2023 at 3:30 PM with Director J, when asked what steps they took to investigate the incident with (RN A) and Pt. #1, J stated, "I spoke with (RN A and CNA C) at the nurses desk. (RN A) said they weren't injured and offered to have them go home. I talked to (CNA C) what they saw and heard, it was around noon. The way (RN A) described the incident it wasn't abuse, so I was the one to allow her to continue to work." When asked if J had talked to (Pt. #1) to get their side of the story or to other patients or staff, J stated, "I didn't talk to any patients or who saw the video, only (CNA C) and I emailed everything to (CNO B)." When Director J was asked is an investigation not complete if you're unable to interview everyone involved, J stated, "Correct."

In an interview on 01/17/2023 at 3:35 PM with Manager K when asked to describe what happened with Pt. #1 on 09/15/2022, Staff K stated, "I was alerted by staff right after it happened and (Pt. #1) was reassigned to a different nurse. I spoke with the CNA and the video monitor and I was on the floor to supervise (RN A)." When asked if K observed (RN A) while providing cares to other patients, K stated, "No."

In an interview on 01/18/2023 at 9:30 AM with CNA C when asked what happened on 9/15/2022 with (RN A) and (Pt. #1), CNA C stated, "(RN A) was in the room with the patient's door shut, I heard screaming from (RN A and Pt. #1), I walked in the room and they were by the window and the patient said, "You just pushed me and you're not supposed to push patient's" I stepped between them and (RN A) went over to the computer and was screaming at the patient saying you punched me. Then the patient was sitting in a chair in the room and after about 15 minutes (RN A) tried to give medications to the patient and was yelling at the patient about the medications and pointing a finger at the patient. The charge nurse came into the room and had (RN A) leave. The patient then calmed down and I called the video monitor to see what had happened and was told that (RN A) had aggressively pushed the patient. When I got off the phone I texted (Manager K) and met with her and explained what happened."

In an interview on 01/17/2023 at 1:30 PM, CNO B was asked for the detailed investigation notes of interviews, discussion and findings as a result of the investigation and was told that everything was in the documents that were sent to the state. On 01/18/2023 at 1:30 PM received a document from CNO, and Vice President H titled, "Investigation regarding (RN A) 9/15/22, revealed interviews with Manager K, Nursing Director J, CNA C and Video Monitor D." No documentation was evident about follow up with staff, interviews with Pt. #1 or other patients or staff and no evidence of process changes made following the investigation. When asked when this document was was created, Staff H stated, "This was in a file in CNO B's office and was started on 9/16."

Review of memo received on 01/18/2023 at 9:30 AM from Chief Nursing Officer B, signed by Vice President of Operations I, revealed, "1. Education for Abuse was last assigned in 3rd Quarter of 2021 (7/1/21). In August of 2021 we converted to a different online education platform. 2. We assigned new education to all partners last evening through our new electronic education system. 3. We are unable to pull transcripts from the previous program. We only have documentation of completion of education on hire."Review of memo received on 01/18/2023 at 9:30 AM from Chief Nursing Officer B, signed by Vice President of Operations I, revealed, "1. Education for Abuse was last assigned in 3rd Quarter of 2021 (7/1/21). In August of 2021 we converted to a different online education platform. 2. We assigned new education to all partners last evening through our new electronic education system. 3. We are unable to pull transcripts from the previous program. We only have documentation of completion of education on hire."

In an interview on 01/17/2023 at 5:00 PM with CNO B, and Vice President of Operations I, Staff I stated, "Abuse and Neglect training was completed in 2021. There is an 18 month gap where this education didn't carry over, so only new hires would have gotten this training. Everyone should get this training on hire and caregivers get it annually." When asked when were you aware that this training was missed in 2022, I stated, "Just today when you asked for it."