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Based on observation, interview, and review of the facility's policy, it was determined the facility failed to protect patients after a credible allegation of verbal abuse against a patient by a staff member was reported to a supervisor for one (1) of ten (10) sampled patients, Patient #1.

The findings include:

Review of the facility's policy titled, "Protection of Adults: Reporting Abuse, Neglect or Exploitation," number A06-140, effective date 07/16/2018, revealed, regarding allegations of abuse by an employee, the immediate supervisor would immediately remove the employee or contractor from direct patient care. Further review revealed if the supervisor deemed it appropriate, the employee could be suspended pending investigation. Per policy, the immediate supervisor would immediately begin an investigation of the situation by interviewing witnesses and obtaining statements regarding the observed or alleged abuse.

Observation, on 10/02/2020 at 1:35 PM, of Patient #1 revealed the patient to be in his/her assigned room, sitting at a forty-five (45) degree angle in the bed. Patient #1 had a nasogastric (NG) tube secured to his/her nostril and was receiving nutritional support through the tube. Further observation revealed the patient's wrists were in soft restraints attached to the frame of the bed. Per observation, Patient #1 was awake, highly alert, and exhibiting signs of agitation.

Interview with Unit Manager #5, on 10/02/2020 at 10:37 AM, revealed Patient #1 was assigned to her unit. During the interview, Unit Manager #5 stated Patient #1 was a guardianship patient awaiting placement at a long-term care facility. The Unit Manager stated Patient #1 was continually monitored by a technician who observed the patient via a video camera and microphone. She stated, on 09/19/2020, Monitor Technician (MT) #6 reported, while she was monitoring Patient #1, she saw and heard Nursing Care Technician (NCT) #7 tell Patient #1 he would stick a straw up the patient's ass if that would shut him/her up. Unit Manager #5 stated, immediately after observing this staff-to-patient interaction, MT #6 informed the patient's assigned nurse what she had observed.

Interview with MT #6, on 10/02/2020 at 11:07 AM, revealed during the night shift on 09/19/2020, she was on duty monitoring Patient #1 through video and audio technology. During the shift, MT #6 informed NCT #7 that Patient #1 needed assistance with her water cup. MT #6 stated she saw and heard the interactions between Patient #1 and NCT #7. During the patient and staff interaction, Patient #1 made several requests for assistance from NCT #7. One of the requests was for the NCT to open the straw for him/her. MT #6 stated that NCT #7 responded to the patient by stating, "If I stick it up your ass would you be quiet?" MT #6 stated she immediately informed another NCT, who informed Patient #1's assigned nurse of what was observed. Per interview, Patient #1's assigned nurse instructed MT #6 to fill out an incident report of what she had observed, and the House Supervisor was also informed of the observed incident. MT #6 stated she regarded NCT #7's statement as verbal abuse against Patient #1.

Interview with NCT #7, on 10/02/2020 at 11:12 AM, revealed, on 09/19/2020, he was on duty and provided care to Patient #1. The NCT described that Patient #1 had a bed alarm that was alarming several times during the night, and during the shift, MT #6 informed him the Patient #1 needed assistance with his/her water cup. He stated, upon entering Patient #1's room, the patient began to make several demands for assistance, and he began to get frustrated with all the demands Patient #1 was making of him. Per interview, the NCT stated at one point, the patient asked for lip balm to be applied, to which he responded to the patient, "You could put it on your butt." The NCT stated he made this statement about three (3) feet from the patient and was wearing a mask; therefore, he did not believe the patient could hear his statement. During the interview, NCT #7 denied he made a statement regarding putting a straw in the patient's butt. NCT #7 speculated MT #6 was able to hear him because he was standing near the monitoring microphone. NCT #7 also stated that during his shift, on 09/19/2020, he was informed a complaint had been made against him by the monitoring technician regarding the statement he had made to Patient #1. The NCT stated he was allowed to work the remainder of his shift and continued to provide direct care to Patient #1.

Interview with with Charge Nurse (CN) #1, on 10/02/2020 at 11:30 AM, revealed she was on duty the night of 09/19/2020. During the interview, CN #1 stated she had been made aware that a report was going to be filed regarding an allegation of verbal abuse toward Patient #1. After being made aware of the allegation, CN #1 stated she spoke with NCT #7 to get his side of the story. During the interview, CN #1 stated she had been informed that NCT #7 had threatened to stick a straw up Patient #1's ass. CN #1 also stated she did not remove NCT #7 from his duties but allowed him to work the remainder of his shift. CN #1 stated she allowed NCT #7 to continue providing direct care to Patient #1 because she believed the incident would be investigated the following morning by his Unit Manager. CN #1 also stated she was not aware of the facility's abuse policy that a staff member should be immediately removed after an allegation of abuse was made.

Interview with Registered Nurse (RN) #4, on 10/02/2020 at 1:30 PM, revealed she was Patient #1's assigned nurse on 09/19/2020. RN #4 stated she was familiar with the care needs of Patient #1 from having been assigned to him/her for several previous shifts. RN #4 described Patient #1 as having Dementia with cognitive impairment. She stated the patient was oriented to name only; however, the patient was able to make his/her needs known and understood what was said to him/her. RN #4 stated Patient #1's condition had not changed over the past several weeks during the inpatient hospital stay.

Interview with Patient #1, on 10/02/2020 at 1:35 PM, revealed he/she insisted his/her assigned nurse remain in the room during the interview. Patient #1 was very concerned regarding the nature of the interview and only provided one (1) word responses when asked interview questions. The patient responded "no" when asked if anyone at the facility had ever abused her. Again, Patient #1 responded "no" when asked if anyone had ever said anything mean or disparaging to her. All answers regarding good staff treatment, care, and services were answered with an affirmative "yes" response from the patient. The interview was concluded abruptly due to the quickly ascending level of agitation exhibited by Patient #1.

Interview with the Director of Inpatients, on 10/02/2020 at 2:00 PM, revealed when CN #1 was made aware of an allegation of verbal abuse by NCT #7 to Patient #1, she should have immediately prevented the NCT from having any further contact with Patient #1 for the duration of his shift.