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Based on staff interview, facility policy review and review of the facility provided internal investigations; the facility failed to protect patients from potential abuse by allowing 1 of 2 employees to remain on duty following an allegation of abuse. Review of 2 incidents of alleged verbal abuse for 2 patients (Patients 4 and 10) revealed that an incident of verbal abuse occured for Patient 10 on 2/1/14 at 2315 (11:15 PM). The alleged perpetrator (a facility staff member) went off duty at 12:00 Midnight that night and did not return to work. The facility conducted an internal investigation and did terminate that staff member on 2/5/14 as a result of the incident. On 6/8/14, a witnessed incident of verbal abuse involving Patient 4 occured at approximately 0900 (9:00 AM). Although the incident was witnessed, by another staff member who entered the room, the perpetrator was left in the room with the patient alone for approximately 15 minutes after the verbal incident occured. After that period of time, the perpetrator was allowed to work and provide patient care the remaining 8 hours of their assigned shift. The facility did an internal investigation and the staff member/perpetrator was terminated on 6/13/2014 as a result of the incident. There was no evidence that the facility implemented interventions to protect the patient(s) from potential further abuse or that there was a system in place to protect the patient's right to be free of abuse. A review of facility policies revealed that the facility policy regarding abuse was "When a staff member witnesses, discovers, or reasonably suspects abuse or neglect, the first action shall be to report the incident to the charge nurse or supervisor in charge".

After conferring with the Centers for Medicare and Medicaid Services (CMS) at 1:42 PM on 7/16/14 it was determined that Immediate Jeopardy (IJ) conditions existed at the hospital since the 6/8/14 incident of verbal abuse. On 7/15/14, the hospital had 66 current inpatients who were at potential risk for abuse. The hospital administrative staff was notified on 7/16/14 at 2:10 PM that IJ conditions were found in the facility. These cumulative failures led to a determination that the Condition of Participation: Patient Rights was not met. See A144 and A 145 for additional information.

Based on a review of the patient rights (in the patient information guide) and staff interview, the hospital failed to inform patients of the right to be free from restraints or seclusion that are imposed as a means of coercion discipline, convince or retaliation by staff. Census on the first day of survey was 66. This deficient practice had the potential to affect all patients.

Findings are:

A. A review of the Patient Bill of Rights (no date) that was located in the Patient Information Guide which was placed in all patient rooms, lacked evidence of the following right: 'The patient has the right to be free from restraint or seclusion, of any form, imposed as a means of coercion discipline, convenience, or retaliation by staff'.

B. An interview with Risk Manager and Chief Nursing Officer on 7/16/14 at 10:35 AM confirmed the Patient Bill of Rights lacked the above information.

Based on staff interview, record review, facility policy review and review of the facility provided internal investigations; the facility failed to ensure that patients received care in a safe setting by allowing 1 of 2 employees to remain on duty and providing patient care, following an allegation of abuse for 1 patient (patient 4). This action had the potential to affect the other patients in the facility at the time of occurance. The facility census was 66, the total sample was 10.

Findings are:

A. A review of History and Physical (dated 6/7/2014) in the medical record for Patient (Pt) 4 revealed the patient "is moderately confused at present."

A review of the Nursing Assessment Flowsheet for 6/8/14 at 06:16 (6:16 AM) by Registered Nurse (RN) F revealed [under psychosocial assessment] the following:
-Alert, responds to voice.
-Orientation inconsistent to place, time and situation.
-Anxious mood
-Poor Eye contact
-Repetitive, restless behavior,
-Interventions include offer information, encourage expression, listen and reassure,
-Accompanied by a Nursing Assistant (NA) sitting with patient.

B. Interview with RN F on 7/16/14 at 2:45 PM revealed, "That was a Sunday (6/8/14) and I was taking care of Pt 4 in the Intensive Care Unit. The patient was confused and restless through the night so an aide was provided to sit with the patient. Nurse Aide (NA) C was sitting with the patient. I went in to reassess the patient and I heard NA C state under their breath something like "I am going to beat (the patient). Pt 4 turned to NA C and stated something like "If you do you will go to jail for a long time." I looked out in the nurses station and there wasn't any staff there. I stayed with the patient and finished the assessment. I kept looking for someone to come so I could replace NA C but no one was there. At one point another NA went by the room. I told that NA to get the Charge Nurse - RN G and come back, but that NA must of gotten busy and didn't come back. I finally left the room after opening the curtains up to the desk and left NA C with the patient. It was about 15 minutes later I found another staff to sit with the patient and pulled NA C from the room. When RN G got back from the meeting we talked with NA C and told (gender) we were going to have the other NA sit with the patient and NA C could help on the floor and answer lights."

C. Interview with RN G on 7/17/14 at 9:50 AM (regarding the incident of verbal abuse on Sunday 6/8/14) revealed, "I was at the bed meeting and when I returned RN F and NA C talked to me and both explained what happened in Pt 4's room. I felt that NA C was frustrated with the patient. I told NA C to stay away from that patient and room. I let NA C continue to work the floor and answer lights. I didn't let the house supervisor know, but I did email the Unit Manager about the incident and what I did."

D. Record review of the internal investigation conducted on 6/9/14 and 6/10/14 (related to the 6/8/14 alleged verbal abuse of Pt 4) revealed:
-The investigation stated the relationship of alleged [perpetrator] to the patient: "NA was providing 1:1 (one to one) care for the patient due to confusion, a sitter."
-Due to the patient's confusion and restlessness a NA was assigned to this patient (Pt 4) to provide 1:1 care.
-At approximately 9:00 AM on 6/8/14 RN F overheard NA C state "I am going to beat (Pt 4)."
-The facility documented that on 6/8/14 RN F found a replacement NA to care for the patient and told NA C to not enter Pt 4's room. When RN G returned from the meeting NA C was reassigned by RN G and instructed not to enter the Pt 4's room.
-After reviewing the incident and the written statements from the parties involved, the Director of Nursing Support, the Human Resources Department, and the Vice President of Patient Care Services decided to terminate NA C's employment at the facility.

E. A review of Policy 500.5.17 PATIENT ABUSE/NEGLECT [dated 12/99] revealed, "When a staff member witnesses, discovers, or reasonably suspects abuse or neglect, the first action shall be to report the incident to the charge nurse or supervisor in charge. The charge nurse or supervisor in charge will immediately intervene and is responsible to contact the Unit Director of the Unit in which the incident occurred. The charge nurse or supervisor in charge will also contact the House Supervisor, Vice President of Patient Care Services, or Administrator on call, and the Risk Manager and together with the staff member, fill out a "report of Abuse" Form. If the abuse is discovered to be caused within the chain of command, the abuse should then be reported to that person's immediate supervisor."

F. An interview with the Risk Manager on 7/16/14 at 8:50 AM revealed, "No, we haven't provided any additional staff education after this incident happened. The unit manager just talked to the individual staff involved. We have been talking (I and the Education Department) and are going to add some additional abuse education, such as how to handle difficult situations, to the next annual education day. We can go and start some additional education now though."

G. An interview with the Vice President of Patient Care Services on 7/16/14 at 10:02 AM revealed, "We have started educating and have probably talked with 35 staff. We have always stressed the 'Chain of Command', but can see if they are in a meeting or procedure, it needs to be taken care of now. We even had one nurse say (during the additional training), "You mean I can even remove the person if I hear the allegation?" We told the nurse YES, whoever it is a RN, NA, anyone. They need to be removed from the situation, then go to the Chain of Command."

Based on staff interview and faclity policy review, the facility failed to ensure that patients were protected from potential abuse by allowing 1 of 2 employees to remain on duty providing patient care following an allegation of abuse for 1 patient (Patient 4). The facility census was 66. The total sample was 10.

Findings are:

A. Interview with RN F on 7/16/14 at 2:45 PM revealed, "That was a Sunday (6/8/14) and I was taking care of Pt 4 in the Intensive Care Unit. The patient was confused and restless through the night so an aide was provided to sit with the patient. Nurse Aide (NA) C was sitting with the patient. I went in to reassess the patient and I heard NA C state under their breath something like "I am going to beat (the patient). Pt 4 turned to NA C and stated something like "If you do you will go to jail for a long time." I looked out in the nurses station and there wasn't any staff there. I stayed with the patient and finished the assessment. I kept looking for someone to come so I could replace NA C but no one was there. At one point another NA went by the room. I told that NA to get the Charge Nurse - RN G and come back, but that NA must of gotten busy and didn't come back. I finally left the room after opening the curtains up to the desk and left NA C with the patient. It was about 15 minutes later I found another staff to sit with the patient and pulled NA C from the room. When RN G got back from the meeting we talked with NA C and told (gender) we were going to have the other NA sit with the patient and NA C could help on the floor and answer lights."

B. Interview with RN G on 7/17/14 at 9:50 AM (regarding the incident of verbal abuse on Sunday 6/8/14) revealed, "I was at the bed meeting and when I returned RN F and NA C talked to me and both explained what happened in Pt 4's room. I felt that NA C was frustrated with the patient. I told NA C to stay away from that patient and room. I let NA C continue to work the floor and answer lights. I didn't let the house supervisor know, but I did email the Unit Manager about the incident and what I did."

C. Record review of the internal investigation conducted on 6/9/14 and 6/10/14 (related to the 6/8/14 alleged verbal abuse of Pt 4) revealed:
-The investigation stated the relationship of alleged [perpetrator] to the patient: "NA was providing 1:1 (one to one) care for the patient due to confusion, a sitter."
-Due to the patient's confusion and restlessness a NA was assigned to this patient (Pt 4) to provide 1:1 care.
-At approximately 9:00 AM on 6/8/14 RN F overheard NA C state "I am going to beat (Pt 4)."
-The facility documented that on 6/8/14 RN F found a replacement NA to care for the patient and told NA C to not enter Pt 4's room. When RN G returned from the meeting NA C was reassigned by RN G and instructed not to enter the Pt 4's room.
-After reviewing the incident and the written statements from the parties involved, the Director of Nursing Support, the Human Resources Department, and the Vice President of Patient Care Services decided to terminate NA C's employment at the facility.

D. A review of Policy 500.5.17 PATIENT ABUSE/NEGLECT [dated 12/99] revealed, "When a staff member witnesses, discovers, or reasonably suspects abuse or neglect, the first action shall be to report the incident to the charge nurse or supervisor in charge. The charge nurse or supervisor in charge will immediately intervene and is responsible to contact the Unit Director of the Unit in which the incident occurred. The charge nurse or supervisor in charge will also contact the House Supervisor, Vice President of Patient Care Services, or Administrator on call, and the Risk Manager and together with the staff member, fill out a "report of Abuse" Form. If the abuse is discovered to be caused within the chain of command, the abuse should then be reported to that person's immediate supervisor."

E. An interview with the Risk Manager on 7/16/14 at 8:50 AM revealed, "No, we haven't provided any additional staff education after this incident happened. The unit manager just talked to the individual staff involved. We have been talking (I and the Education Department) and are going to add some additional abuse education, such as how to handle difficult situations, to the next annual education day. We can go and start some additional education now though."

F. An interview with the Vice President of Patient Care Services on 7/16/14 at 10:02 AM revealed, "We have started educating and have probably talked with 35 staff. We have always stressed the 'Chain of Command', but can see if they are in a meeting or procedure, it needs to be taken care of now. We even had one nurse say (during the additional training), "You mean I can even remove the person if I hear the allegation?" We told the nurse YES, whoever it is a RN, NA, anyone. They need to be removed from the situation, then go to the Chain of Command."