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Based on interview and document review, the hospital failed to ensure all patient rights were protected when the facility failed to thoroughly investigate following a report/allegation of staff to patient (P1) abuse.

A condition level deficiency was issued. See A0145.

An IJ was identified 7/11/22, related to patients receiving care in a safe setting. The IJ was removed on 7/12/22, but the hospital remained out of compliance at the Condition of Patient Rights. See A0144

Based on interview and document review, the hospital failed to ensure all patient rights were protected when the facility failed to thoroughly investigate following a report/allegation of staff to patient (P1) involving physically and verbally abuse. This deficient practice resulted in an immediate jeopardy (IJ) for P1.

The IJ began on 6/21/22, at approximately 9:00 a.m. when patient (P)1 required manual hold for medication administration related to behaviors. psychiatric associate (PA)-A placed P1 in a basket hold, pushed P1 towards the bed and down onto the mattress with his full weight and proceeded to yell in P1 face "Don't you ever hit me again!". The Facility System Director for Regulatory & Accreditation, Vice President (VP) & Chief Nursing Officer (CNO), System Program Manager, Regulatory and the Accreditation and Service Line Executive for Mental Health & Addiction Services were notified of the IJ finding on 7/11/22, at 3:30 p.m. were notified of the IJ finding on 7/11/22, at 3:30 p.m.

Findings include:

On 6/27/22, at 10:33 a.m. a facility report to the State Agency (SA) indicated on 6/21/22, at approximately 9:00 a.m. P1 had become aggressive and hit PA-A the left eye with an open hand. PA-A immediately took P1 into a basket manual hold and pushed P1 towards the bed and down onto the mattress with his full weight. PA-A proceeded to yell at P1 in her face "Don't you EVER hit me again!". At this time, nursing staff tapped PA-A on the right arm and said, "you can't do that, back off". PA-A remained on top of P1 long enough to state, "I've said my peace, I'm done." At which time PA-A release the manual hold and moved off of P1's body allowing her to be able to sit on the side of the bed.

P1 was admitted to the hospital on 5/15/22, at with a diagnosis of schizophrenia and psychosis. P1was noted to speak and understand very limited English and required an interrupter due to speaking Somalia.

P1 had a history of violence which resulted in numerous assaults of staff during her hospital stay. On 6/21/22, at approximately 8:00 a.m. P1 assaulted PA-A resulting in PA-A placing P1 in a manual hold. PA-A was observed to have pushed P1 towards the bed and down onto the mattress with his full weight and proceeded to yell in P1 face "Don't you ever hit me again!".
RN-B instructed PA-A to cease the manual hold and that his language was inappropriate. PA-A then stated, "I said my peace I am done here" and exited P1's room.

On 7/7/22, at 12:15 p.m. P1 was interviewed with an interrupter and stated she felt safe.

On 7/8/22, at 8:50 a.m. PA-A was interviewed and stated he had placed P1 in a manual hold due to physical aggression towards staff. PA-A stated he placed P1 onto the bed with her face into the mattress to prevent P1 from kicking him. PA-A stated he had raised his voice and had stated to P1 "you do not get to hit people". PA-A stated RN-B had instructed him to release the hold and that he was not allowed to talk to patients in that manner. PA-A stated he went to the ED for evaluation and had returned at approximately 11:30 to the unit and worked with patients including P1 for the remainder of his shift. PA-A stated he had no knowledge of an investigation or that he was not allowed to return to work following a scheduled vacation and that he had to work on 6/26/22 and worked his entire shift. PA-A stated on 6/27/22, he was told he needed to leave the hospital and was placed on administrative leave pending an investigation.

On 7/8/22, at 9:45 a.m. PA-B was interviewed and stated she had been present at the time of the incident and observed PA-A place P1 in a manual hold and tripped and fell onto the bed. PA-B stated she had heard PA-A yell at P1 "Don't you ever hit me again!". PA-B stated she had worked with PA-A for the remainder of his shift on 6/21/22 and also on 6/26/22.

On 7/8/22, at 10:25 a.m. registered nurse (RN)-B was interviewed and stated she had witnessed PA-A put P1 into a manual hold and onto the bed with her face into the mattress. RN-A she witnessed PA-A yelled loudly into P1 face "Don't you ever hit me again do you understand" and at that point RN-B tapped PA-A on the shoulder and stated to PA-A he could not do that, and that PA-A needed to back off. RN-A stated PA-A then released the manual hold and stated, "I said my peace I am done here" PA-A then exited the room. RN-A stated at approximately 10:00 a.m. she reported the incident to RN-A who then instructed her to fill out an internal initial report (Compass) which initiates the facility investigation. RN-A stated although RN-A had instructed her to fill put the Compass report RN-B had not filled out and submitted a report until 6/23/22.

On 7/8/22, at 10:25 a.m. registered nurse (RN)-C was interviewed and stated he had witnessed PA-A put P1 into a manual hold and onto the bed with her face into the mattress. RN-C stated he heard PA-A yelled loudly into P1 face something like you cannot do that, you will not hit me in a loud unprofessional tone. RN-C stated RN-B instructed Pa-A that he could not talk like that to patients and PA-A responded by saying "I will say what I want too, she will not hit me in the face and sometimes they need discipline" RN-C stated at that point I advised PA-A that he needed to cease the hold and leave the area.

On 7/8/22, at 11:26 a.m. registered nurse (RN)-A was interviewed and stated her role was the unit manager for the intensive care unit which P1 was placed on. RN-A stated on 6/21/22, RN-B had informed her of the incident involving PA-A and P1. RN-A stated she had instructed RN-B to file a Compass report however RN-B had not filled a Compass report until 6/23/22. RN-B stated she had received approval from the leadership team on 6/24/22 to file a report with the SA, however she had not filed with the SA until 6/27/22. RN-A stated an investigation had not been initiated until 6/23/22 due to a Compass report not being completed. RN-A stated she had no knowledge that PA-A worked the remainder of his shift on 6/21/22 until 7/8/22. RN-A stated PA-A should not have been allowed to work after there had been an allegation of abuse involving P1 pending a full investigation. RN-A further stated PA-A also worked an entire dayshift on 6/26/22, even though he was placed on administrative leave pending an investigation.
RN-A verified the hospital failed to report in a timely manner an allegation of staff to patient abuse to the State Agency (SA). RN-A stated she had filed the report on 6/27/22 with the SA even though the incident occurred on the morning of 6/21/22, at approximately 9:00 a.m.

On 7/11/22, at 8:25 a.m. chief nursing officer (CNO) was interviewed and stated RN-A had been informed of the incident between P1 and PA-A regarding PA-A demonstrating unprofessional behavior on the morning of 6/21/22. CNO verified PA-A had been allowed to work his dayshift after the incident on the same unit P1 was located. CNO stated a compass report had not been completed and submitted until 6/23/22, which indicated PA-A
Yelled at P1 "don't you ever hit me again" when a staff member had suggested to PA-A that he should stop, it was reported by staff that PA-A stayed on top of P1 and stated to P1 "I've said my piece, I'm done" and then removed himself from being on top of PA. CNO stated on 6/24/22, PA-A was informed he had been placed on administrative leave by RN-A via phone message. CNO stated PA-A had called in sick for his 6/24/22, and 6/25/22, scheduled shifts. On 6/26/22, PA-A came in and worked a full shift from 7:00 a.m.-3: 30p.m and had provided direct care for P1 even though he was on administrative leave. CNO stated on 6/27/22, PA-A had again come into work however, at that time he was instructed to leave the hospital due to being on administrative leave and pending an investigation. CNO verified PA-A was allowed to return to work on 7/4/22, even though PA_A had not been interviewed nor had corrective action taken place related to the incident which occurred on 6/21/22. CNO stated on 7/6/22, PA-A had meet with RN-A and HR and at that time corrective action was provided to PA-A.

The facility policy Vulnerable Adults, Identifying and Reporting Suspected or Actual Maltreatment effective date 8/13/21, titled Vulnerable Adults, Identifying and Reporting Suspected or Actual Maltreatment directed hospital staff in accordance with applicable state laws, staff will be alert to signs of vulnerable adult abuse, maltreatment and/or neglect in our patient population. Suspected or actual maltreatment of a vulnerable adult patient while receiving services will be timely and properly evaluated, reported and documented. The policy further directs staff that conduct which is not an accident or therapeutic conduct, which produces or could reasonably be expected to produce physical pain or Injury or emotional distress including, but not limited to, use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening.

The IJ was removed on 7/12/22, at 3:30 p.m. when it could be verified the hospital had submitted and implemented an acceptable removal plan which included appropriate education and training of all employees, including psychiatric associate (PA). This was verified through interview and policy review.