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I. Based on document review and staff interview, the acute care hospital's administrative staff failed to ensure that hospital staff separated 1 of 1 identified Psychiatric Nursing Assistant (PNA A) from all dependent adults once the hospital received notification that PNA A was under investigation for dependent adult abuse. Please refer to A-145 for additional information.

The cumulative effect of these failures and deficient practices resulted in the hospital staff failing to ensure all patients had the right to be free from abuse. The hospital's administrative staff identified a census of 14 inpatients in the Geriatric Behavioral Health unit at the start of the investigation.





II. During the complaint surveys that ended on 5/5/22, the survey team identified an Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patients at risk) related to the Condition of Participation for Patient Rights (42 CFR 482.13). The hospital staff failed to ensure that a PNA was separated from all patients after the hospital staff received notification that the PNA was under investigation for alleged dependent adult abuse.

The survey team identified an Immediate Jeopardy (IJ) situation and notified the administrative staff on 5/4/22. The administrative staff promptly took action to remove the immediacy of the situation. The hospital staff removed the immediacy prior to the survey team exiting the abuse investigation when the administrative staff took the following actions:

a. Immediately removed the PNA from the patient care and placed on administrative leave until further notice.

b. Education was provided to the Accreditation Services team on 5/4/22 regarding the Dependent Adult Abuse Notification to Facility or Program of the requirement to immediately work with the hospital's administrative staff to place the identified staff member on administrative leave until the resolution of the investigation. The Accreditation Services team will receive education annually on the requirements.

c. The Clinical Leadership of any staff member under investigation for dependent adult abuse will review the staffing schedules on a biweekly basis to ensure the staff member under investigation is not scheduled for work during the administrative leave. The auditing will continue until the hospital staff receive the results of the investigation.

Based on document review and staff interview, the hospital's administrative staff failed to ensure the Behavioral Health staff separated 1 of 1 Psych Nursing Assistants (PNA A) from all dependent adults, including the patients on an inpatient behavioral health unit, after the hospital's administrative staff received notification that that PNA A was under investigation for alleged dependent adult abuse related to the care of Patient #1. Failure to separate PNA A from all dependent adults, including the patients on an inpatient behavioral health unit, resulted in the administrative staff allowing PNA A to continue working with dependent adults after identification that PNA A potentially committed dependent adult abuse, potentially allowing PNA A to engage in another act of dependent adult abuse. The hospital's administrative staff identified a census of 14 patients upon entrance in the unit PNA A worked on (JPE2).

Findings include:

1. Review of the policy "Policies and Procedures for Suspected Child and Dependent Adult Abuse," revealed that the policy failed to include language requiring the hospital's administrative staff to separate a staff member accused of dependent adult abuse from all patients when the hospital's administrative staff received an allegation of dependent adult abuse against the staff member.


2. During an interview on 4/26/22 at 11:30 AM, PNA C revealed that on 11/17/21 PNA C witnessed Patient #1 strike PNA A while PNA A was attempting to give Patient #1 a shower. After Patient #1 struck PNA A, PNA A struck Patient #1 (an act of dependent adult abuse).

PNA C notified Behavioral Health Nurse Manager D at the time PNA C witnessed PNA A assault Patient #1. Behavioral Health Nurse Manager did not separate PNA A from other dependent adults at the time of the allegation and PNA A continued to work with other dependent adults in the inpatient Geriatric Behavioral Health unit.


3. On 5/3/22 at approximately 3:12 PM, the Associate Director of Accreditation Services received a document titled "Dependent Adult Abuse Notification to Facility or Program" which revealed in part, "Please be advised there has been an allegation of abuse of dependent adult(s), [Patient #1's name] against employee(s)/staff member(s) [PNA A's name] on or about 11/17/21 at your facility/program. DIA [Department of Inspections and Appeals] will be investigating this allegation of dependent adult abuse." On 5/3/22 at approximately 3:30 PM, the Director of Support Services signed the document acknowledging receipt of the information that the DIA was investigating PNA A for possible dependent adult abuse.

4. Review of PNA A's timecard revealed PNA A clocked in to work on 5/4/22 at 7:00 AM (14 hours after the hospital staff received notification that the DIA was investigation PNA A for dependent adult abuse). PNA A clocked out of work on 5/4/22 at 12:00 PM (19 hours after the hospital staff received notification that the DIA was investigation PNA A for dependent adult abuse. PNA A worked approximately 3.5 hours, after the hospital staff received notice that PNA A was under investigation for possible dependent adult abuse)

5. Observations on 5/4/22 at approximately 11:00 AM (18 hours after the hospital staff received notification that the DIA was investigating PNA A for dependent adult abuse), revealed that PNA A was working on the Geriatric Behavioral Health Unit (JPE2 2). Review of the "Assignment Worksheet," dated 5/4/22, revealed the nursing staff assigned PNA A to work with 7 patients on the Geriatric Behavioral Health unit.

6. During an interview on 5/4/22 at 11:12 AM, Registered Nurse (RN) B acknowledged that PNA A worked on the inpatient Geriatric Behavioral Health unit on 5/4/22 (the day after the hospital staff received notification that the DIA was investigating PNA A for dependent adult abuse). RN B verified that PNA A had provided care for patients on the unit, including dependent adults.

7. During an interview on 5/4/22 at 10:44 AM, the Associate Director of Accreditation Services verified that PNA A had worked on 5/4/22 with dependent adults on the Geriatric Behavioral Health Unit (after the hospital staff received notification that the DIA was investigating PNA A for dependent adult abuse).

8. During an interview on 5/4/22 at approximately 11:00 AM, the Director of Behavioral Health verified that PNA A had worked on 5/4/22 with dependent adults on the Geriatric Behavioral Health Unit (after the hospital received notification that the DIA was investigating PNA A for dependent adult abuse). The hospital staff allowed PNA A to work with dependent adults on 5/4/22 from 7:00 AM through 10:30 AM, when the hospital staff removed PNA A from patient care (and access to dependent adults). The Director of Behavioral Health acknowledged that the patients on the inpatient geriatric behavioral health unit qualified as dependent adults, and that the hospital staff allowed PNA A to work (and was planning to continue allowing PNA A to work) with dependent adults, even after the Associate Director of Accreditation Services received a written notice that PNA A was being investigated for dependent adult abuse of a patient in the inpatient geriatric behavioral health unit.