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Based on interview and record review, the facility failed to develop and implement a policy that protected patients from an alleged abuser resulting in the potential for negative outcomes for all patients served by the facility. Findings include:

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A-145 Failure to develop and implement policy protecting patients from an alleged abuser

Based on interview and record review, the facility failed to develop and implement a policy that protected patients from an alleged abuser while an investigation was in progress resulting in the potential for unsatisfactory outcomes for all patients served by the facility. Findings include:

According to Facility incident #373607, originally dated 6/11/2021, Patient #1, an 89-year-old male presented to the facility from ECF (Extended care facility) for evaluation. Within 5 hours of arrival, patient #1 became violent and hit a registered nurse (RN) . The report indicated RN requested assistance to restrain patient. While restraining patient, RN placed pillow over head of patient and punched patient in the face. 2nd RN threatened patient and used excessive force on patient's neck causing significant bruising. 3rd RN who observed assault reported incident to leadership on 6/18/2021. The report indicated Investigation initiated, staff suspended pending investigation, 2 RN's were terminated and reported to the (State Agency).

Review of Patient #1's record, the patient of concern, revealed he was an 89-year-old male who had been brought to the emergency department via ambulance on 6/11/2021 and was triaged at 1304 with a chief complaint of psych evaluation, more aggressive at adult foster care home. Per emergency room (ER) physician note dated 6/11/2021 at 1500, Patient #1 had no swelling or bruising. Nursing noted dated 6/11/2021 at 1620 indicated Patient #1 was agitated and orders were received for Ativan 1milligram (mg) which was given intravenously (IV). Per nursing note 6/11/2021 at 1740, Patient #1 continued to be agitated with orders for Haldol 5 mg which was given intramuscularly (IM). Per nursing note on 6/11/2021 at 100 Patient #1 was assisted with dinner by his daughter. Nursing note 6/11/2021 at 1850 patient #1 with increased agitation and given Ativan 1mg IV. Nursing note on 6/11/2021 at 1905 indicated patient #1 punched at staff and at 1930 was placed in 4-point hard restraints. Nursing Note at 0010 reports Patient #1 with increased swelling/bruising to right face and right hand with physician notified and no new orders. Nursing noted dated 6/12/2021 at 0930, with no staff signature, indicated Patient #1 was not following commands, attempted got out of bed, striking chin on bed rail, doctor to bedside for assessment, no new orders. Nursing note 6/12/2021 at 1910 revealed Patient #1 was still awaiting bed placement for admission, Patient #1 right side of face was still bruised, missing teeth, black and blue in color and also on lower lip. According to nursing note dated 6/15/2021 at 1942, Patient was transferred to medical floor for admission.

In an interview with Staff N on 8/19/2021 at 1610, She stated she witnessed Staff BB forcefully hold Patient #1's face into the rail of the bed and Staff AA put a pillow over Patient #1's face and punch him in the face. Staff N stated Staff BB was calling Patient #1 terrible names during this time and Patient #1 was saying "that hurts". Staff N stated she waited a day or two to reported it because she was afraid of the two staff members and afraid she may lose her job. She stated after thinking about it she knew her patients' needs came first so she reported it. Staff N stated there had been no negative repercussions from reporting the incident.

Review of Staff N's written statement, provided to the surveyor by the facility in their investigation packet, revealed Staff N was attempted to find a posey belt for Patient #1 when she was instructed by Staff AA to tie a sheet around Patient #1 and his wheelchair. Staff N indicated in her statement she left the room to assist another patient, heard Staff AA cry out and stated patient #1 had hit her, and to "get restraints". The statement indicated Staff N, Staff AA and Staff BB were in Patient #1's room together when Staff N witnessed Staff BB push the right side of Patient #1's face into the bed, and tell the patient he was "a piece of shit for hitting women". Staff N indicated she was instructed by Staff AA (charge nurse) to close the curtain. Staff N indicated in her statement she then witnessed Staff BB using excessive force and body weight to hold Patient #1's face to the bed while Staff AA placed a pillow over Patient #1's turned head and punched the pillow/Patient #1's face. The statement indicated at that time Security entered the room to assist with restraints and Staff BB continued to hold Patient #1's face to the bed with more force than necessary and tell Patient #1 he is a "piece of shit", while the patient cried out that his nose was being hurt. The statement indicated while all staff were leaving the room, Staff BB told Patient #1 if he wasn't working he would take him out to the parking lot and beat the shit out of him. The statement was signed by staff N.

Review of Staff CC's written statement, provided to the surveyor by the facility in their investigation packet, revealed he heard Staff AA discuss the incident with another co-worker. The statement indicated Staff AA stated Patient #1 had hit Staff AA and Staff BB "fucked him up". The statement revealed Staff AA said out loud to another co-worker "his face was mess up and his teeth got knocked out". Staff CC's written statement stated Staff AA was going to make it look like Patient #1 fell.

Review of the facility investigation provided to the surveyor on 8/17/2021 at 1015 revealed Staff N reported the allegation to the facility leadership on 6/18/2021, all staff involved in allegation were immediately suspended pending investigation. Investigation completed on 6/28/2021, with disclosure made to Patient #1's daughter and termination of Staff AA and BB on 6/28/2021 and report to the State Agency.

During the investigation the surveyor requested the facility abuse policy. The surveyor was provided the facility's policies for reporting suspected abuse of adult and child when presenting for care at the facility. The surveyor provided clarification and again requested the hospital wide abuse prevention, recognition and reporting policy. The facility provided an abuse policy for the Behavioral Health Unit specific for the prevention of abuse for the Abuse and Neglect of recipients of Mental Health Services.

During an interview on 08/18/2021 at 10:15, Staff Z, the Vice President of Patient Care, stated the hospital does not have a hospital wide abuse policy, but they will get one.