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Based on interview and record review the facility failed to ensure that 1 of 3 patients (#1) with abuse or neglect complaints were free of all forms of abuse and that the facility followed their policies for responding to abuse allegations resulting in increased risk of patient abuse. Findings include:

Facility Policy:
10.3.2, "Definitions and Reporting of Abuse & Neglect," dated 11/15/10.
III. A. Procedures:
20.) "Assures that DHS and the appropriate law enforcement agency is contacted in cases involving suspected Criminal Abuse, Abuse Class I and II, Neglect Class I and II..."
21. "Safety Department Director/Designee files a written report within 72 hours of the criminal Abuse, Abuse Class I and II or Neglect Class I and II.

Record Review & Interviews:

1. On 6/13/12 from 0900-1030 hours, review of 2012 Safety Department Incident Reports involving allegations of staff abuse of patients were reviewed. On the morning of 11/17/11 patient #1's Treatment Team became aware of patient #1's physical injuries and allegations that the injuries occurred as the result of physical abuse by staff, witnessed by multiple staff members, on the evening of 11/16/11.
2. The facility did not take steps to initiate a police investigation until 11/18/11. The "Report Filed to Police Agency" form regarding the incident was unsigned and the Narrative Section stated "State Police were contacted" but contained no specifics on whom was contacted and the time of contact.
3. On 6/13/12 at approximately 1000 hours the Director of Security verified that no written report was filed with the State Police following the Incident as required by facility policy. The Director of Security was not aware whether video taped evidence of the incident was made available to the State Police.
3. On 6/13/12 at approximately 1030 hours the State Police agency, named as the investigating agency, was contacted by phone. State Police Sergent #1 stated that he was the officer in charge on 6/13/12 but had no access to information on this investigation. Sergent #1 stated that the only person who has access to information on this investigation is the investigating officer (Officer #2). He stated that there is no timeline for completing investigations and no expectation of reporting back to the facility, even if charges against facility employees are filed.
4. Phone messages left for State Police Officer #2, requesting a call back, were not returned.
5. On 6/13/12 the Director of Security, Recipient Rights Officer and Director of Nursing stated that they were unaware of a process for informing law enforcement agencies when the facility investigation substantiates allegations of patient abuse.

Facility Policy:

10.3.2, "Definitions and Reporting of Abuse & Neglect," dated 11/15/10.
II.B. Any employee that observes, suspects, or is informed of an allegation of abuse/neglect, shall immediately take the following actions:
1. Verbally notify their immediate supervisor. During non-business hours or in the absence of the immediate supervisor, this notification shall be made to the Central Nursing Office Supervisor.
2. Verbally notify the Office of Recipient Rights...
3. Complete an Incident Report form (DCH-0044)...

Record Review & Interviews:

1. From 6/12/12-6/13/12 review of patient #1's clinical record and documentation related to allegations of abuse (of patient #1) on 11/16/11, revealed that the facility substantiated 4 allegations of staff abuse or neglect of patient #1. The substantiated allegations stemmed from an incident that occurred on 11/16/11. Record review included video taped evidence of patient #1 being pushed up against a wall by staff, taken into a patient room by staff and multiple staff present in the areas when the incident occurred. Patient #1's injuries were first noted in a Treatment Team meeting on 11/17/11. Not one staff member present in the hallway where the abuse occurred on 11/16/11 had filed an Incident Report or was documented as following facility procedure for reporting abuse prior to the Team's discovery of the abuse allegations on 11/17/11. As a result of facility investigations, two staff received substantiated allegations of abuse and two staff received substantiated allegations of neglect for witnessing abuse and not reporting it.

2. In an interview on 12/7/11 Nurse #1 stated that she did see Nurse #2 come out of the medication room (on 11/16/12) and saw Nurse #2 holding patient #1's arm and that, "..... it wasn't a NAPPI (Non-aggressive Psychological & Physical Intervention) technique" used according to facility protocol, ".... with the patient (#1) against the wall." The video shows Nurse #1 flattening patient #1 into the hallway wall with her body. Patient #1 is not resisting. Nurse #1 stated that she did not report the incident to the RN Supervisor (Nurse #3). Also, Nurse #1 did not file an Incident Report or notify the Office of Recipient Office on 11/16/11.

3. On 6/12/12 at approximately 1400 hours the Recipient Rights Officer (RRO) viewed the video evidence of the above incident with this surveyor, noting Nurse #1's presence in the hallway during the episode when Nurse #2 flattened patient #1 into the hallway wall. The RRO verified that Nurse #1 was not disciplined or charged with neglect for failure to report observing abuse of patient #1 on 11/16/11, as required by policy.




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Based on document review, policy review, and interview the facility failed to ensure that the patient was free from all forms of abuse. The facility also failed to follow their policy for notifying the appropriate law enforcement agency when Abuse Class II has occurred, failed to ensure a copy of the written report was placed in the patient's clinical record, and also failed to ensure an employee with a substantiated significant recipients rights violation was placed on intensive supervision and performance progress monitoring. Findings include:

Facility Policy #203 Patient Abuse & Neglect (effective date 6/4/10) stated standards:

"H. When there is reasonable cause to suspect that Abuse...Class II...has occurred, the Hospital Director/Designee shall ensure that DHS, the appropriate law enforcement agency...are notified."

"I. The Safety Department shall follow-up the notification required in Standard H by filing a written report of the allegation with the same law enforcement agency within 72 hours, with a copy forwarded to the Hospital Director/Designee and ORR...A copy of the report shall be placed in the patient's clinical record..."

"T. ...For significant violations, intensive supervision and performance progress reports shall be required on the form 'Employee Performance and Monitoring Plan for Abuse and Neglect (WRPH-121).'"


On 6-13-12 the personnel file for resident care aide (RCA) #1 was reviewed. It was discovered that the personnel file for RCA#1 contained a Notice of Charges dated 4-10-12 that stated, RCA#1 "You are found to have exhibited unacceptable employee conduct or performance specifically, the following: Violation of MDCH Section II Work Rule 8: Recipient Abuse II. Disciplinary Action: 5- day suspension without pay. The suspension will be retroactive to April 5, 2012." The Notice of Charges was signed by RCA#1 on 4-10-12.

On 5-1-12 the Bureau of Health Professions received the Report of Change in Staff Privileges from the facility. The report to the Bureau stated, "On March 09, 2012, (RCA#1) committed abuse class II as noted by using inappropriate techniques to remove a patient from restricted area. Grabbed pt (patient) around neck to remove...(RCA#1) Placed on Abuse and Neglect Monitoring for 1 year, due to Class II Abuse substantiated." The report was signed by the facility DON on 4-25-12.

On 6-13-12 at 1440 the facility DON was queried as to the Abuse and Neglect Monitoring Plan for RCA#1, the DON stated, "I think (RCA#1) returned to work on April 11 th (2012) and I have not received anything notifying the nursing department about the disciplinary actions regarding (RCA#1)."

Also, on 6-13-12, the clinical record of Patient #1 was reviewed for the presence of a written report of the allegation of abuse filed within 72 hours by the facility's Safety Department with the law enforcement agency. The clinical record of Patient #1 failed to contain a written report of the allegation of abuse filed by the Safety Department with law enforcement.