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Based on record review, adverse event review, interview and policy review, the facility failed to protect patients from staff abuse by not immediately reporting or investigating alleged incidents of staff to patient abuse (A145). This affected four (Patients #3, #4, #7 and #9) of ten sampled patients.

The failure to report and investigate alleged incidents of abuse resulted in a determination of Immediate Jeopardy. The census was 26.

Based on record review and interview, the facility failed to protect patients from staff abuse by not immediately reporting or investigating alleged incidents of staff to patient abuse. This affected four (Patients #3, #4, #7 and #9) of ten sampled patients.

Findings include:

Review of the facility policy titled "Recognizing and Reporting Suspected Abuse/Neglect/Exploitation, Policy #CC.21", dated May 2016, stated all allegations, observations or suspected cases of abuse that occur in the hospital will be investigated by the hospital. Cases of suspected abuse will be given priority and will be investigated thoroughly. If it is proven that the patient is experiencing abuse caused by a staff member, that staff member will be suspended pending investigation by both the hospital and the Department of Health Services. If allegations exist that the patient is experiencing abuse caused by a staff member, that staff member will be placed on suspension, pending completion of an investigation.

The facility policy titled "Elder, Spousal/Partner, or Abuse, Policy No. CC.22", dated May 2016, stated all staff has a responsibility to immediately report any incidents of suspected abuse involving patients by contacting the appropriate chain of command.

1. Patient #9 was admitted to the facility on 08/01/19 at 5:09 P.M. The patient was combative on admission. Patient #9 was admitted with behavioral changes including irritability and mood swings. Staff observed the patient every 15 minutes as ordered by the psychiatric physician. A nursing note dated 08/07/19 at 8:35 A.M. stated "Patient tearful, making accusation of physical/verbal abuse by staff in early AM around 5:00 A.M."

An incident report was completed by Staff B at 8:45 AM. It stated the patient gave a "different version" of the story when interviewed. The note further stated the patient had an "extensive history of false reporting." The note stated the patient reported two female State Tested Nursing Assistants (STNA) getting him/her up "too fast" and talked with "loud" voices.

During interview on 09/05/19 at 3:50 P.M., Staff B stated Patient #9 has "constant paranoia." Staff B reported giving one on one general education with all staff to give patient care in a slow manner, but was unable to provide documentation of any staff education. Staff B stated a thorough investigation would have been done had she "felt this was a serious allegation." Staff B was unaware of which STNA;s had cared for Patient #9 the morning of the allegation.

The facility policy titled "Elder, Spousal/Partner, or Abuse, Policy No. CC.22", dated May 2016, stated "any report must be taken with all due seriousness. When patients with dementia attest to abuse, it is important to verify by means of interviews with other available sources, such as family members other than the suspected abuser, home care personnel or friends."

2. Review of the facility's adverse events from 06/01/19 through 09/03/19 revealed an incident dated 08/29/19 that allegedly occurred at 9:30 A.M. Staff K, a Licensed Practical Nurse (LPN) reported overhearing Staff F, an STNA, cursing at Patient #4. According to the incident report, Staff E, the Nurse Practitioner (NP), was informed of the allegation of staff to patient abuse on 08/29/19 at 2:00 P.M. Staff E reported the incident to Staff L, the Assistant Director of Nursing (ADON).

Staff E's (NP) written statement revealed she was rounding on patients the afternoon of 08/29/19 when two patients, Patient #3 and Patient #4, reported verbal abuse by Staff F (STNA). Both patients reported that Staff F (STNA) yelled at them and "belittled" them.

Follow-up action stated the following: "Investigation concluded that this incident may have occurred. Staff F resigned before termination would be given." The report noted all documentation was complete and no new precautions were put in place.

Four staff members, Staff H, Staff I, Staff G, and Staff J, (all STNAs) were identified as having worked from 7:00 AM to 7:00 PM on 8/29/19. All four staff members were interviewed separately and asked if they had been interviewed about any incident that may have occurred on 08/29/19. All four denied having been interviewed by anyone in administration.

During interview on 09/05/19 at 12:30 P.M., Staff A, Corporate Quality, confirmed the investigation to the allegation of staff to patient abuse was not thoroughly investigated.

During interview on 09/05/19 at 3:45 P.M., Staff C, administrative staff, stated there were complaints from nursing staff that Staff F was rude to patients and other staff. Staff C denied that any staff member reported that Staff F abused any patients. Staff C stated no other staff members were interviewed as part of the facility investigation. Staff C stated that after Staff F's resignation, she didn't think it was necessary to continue the investigation and further acknowledged the investigation was not thorough.

3. Patient #7 was transferred from an extended care facility to the psychiatric hospital on 08/22/19 for behaviors including wandering, exit seeking, entering others' rooms and becoming agitated and uncooperative with attempted re-direction by staff. The patient was admitted with diagnoses that included dementia and Alzheimer's disease.

During interview on 09/06/19 at 10:20 A.M., Staff J, a STNA, described Patient #7 as having "super human strength." She reported there have been numerous occasions where Patient #7 became extremely agitated and combative with staff. Staff J described an incident that occurred on 09/02/19, when the patient became combative and a staff member "gently" guided the patient by the shoulders toward the milieu. A psychiatric physician accused the staff member of abuse. Staff J reported being asked to write a statement but indicated she had not had the chance to write a statement.

During interview on 09/05/19 at 12:30 P.M., Staff A, Corporate Quality, confirmed there was no investigation to the allegation of staff to patient abuse.