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Based on observation, interview, and document review, the facility failed to protect and promote each patient's rights by failing to ensure patients receive care in a safe setting and are free from abuse and neglect (impacts all patients at the hospital).

The cumulative effect of the facility's failure to promote and protect all patient's rights placed all patients at risk of receiving care in an unsafe setting, having their rights violated, and developing mistrust of the hospital staff.

Findings Include:

The hospital failed to provide care in a safe setting by failing to remove ligature hazards in the environment (Refer to A-0144).

The hospital failed to ensure patients are free from abuse and neglect by failing to respond to and investigate two allegations of patient abuse by hospital staff. (Refer to A-0145).

Based on interview, record review, and policy and procedure review the hospital failed to ensure each patient was informed of their Patient Rights upon admission for 2 of 11 records reviewed (patients #1 and #2) and 3 of 5 patients interviewed (patients #13, #15 and #16). The hospital also failed to ensure the document titled "Patient's Rights and Responsibilities" included all of the required patient's rights including the following: 1. the patient has the right to participate in the development and implementation of his or her care plan. This deficient practice puts all patients at risk for failing to have input and a voice in their care, treatments, medications, outcomes and discharge; 2. the patient or his or her representative has the right to make informed decisions regarding his or her care. This deficient practice puts all patient at risk for receiving care, treatments and medications that may conflict with their personal choices, benefit, understanding, ethical, and spiritual beliefs; 3. the patient has the right to formulate an Advanced Directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) to direct health care professionals to comply with their directives. This deficient practice puts all patient at risk for receiving care, treatments and medications when they are no longer able to make a sound decision on their own that is against their personal/ethical wish or desire; 4.the patient has the right to personal privacy. This deficient practice puts all patients at risk for ensuring their personal dignity and privacy is respected and observed; 5. the patient has the right to receive care in a safe setting. This deficient practice puts patients at risk for self harm; and 6. the patient has the right to be free from all forms of abuse, neglect or exploitation. This deficient practice places all patients at risk for mistreatment by staff or other patients.

Findings include:

Patient #1's medical record review on 8/22/17 revealed the patient was unable to sign for Patient Rights due to his/her psychiatric behavior. The patient had an admission date of 7/26/17 and the hospital staff failed to provide documentation of follow up to ensure the patient received a copy of his/her Patient Rights during their admission.

- Patient #2's medical record review on 8/22/17 revealed the patient was unable to sign for Patient Rights due to his/her psychiatric behavior. The patient had an admission date of 8/11/17, and the hospital staff failed to provide documentation of follow up to ensure the patient received a copy of his/her Patient Rights during their admission.

Staff K, Administration interviewed while reviewing finding of the records on 8/22/17 and verified the Patient Rights failed to be given and signed for Patients #1 and 2.

Patient #15 interviewed outside in the courtyard of the CSU (Crisis Stabilization Unit) unit on 8/22/17 at 2:14 PM acknowledged he/she failed to receive a copy of Patient Rights upon admission.

Patient #16 interviewed outside in the courtyard of the CSU unit on 8/22/17 at 2:14 PM acknowledged he/she failed to receive a copy of Patient Rights upon admission.

Staff P RN interviewed outside in the courtyard of the CSU unit on 8/22/17 at 2:26 PM indicated he/she would provide patients #15 and 16 with a copy of their Patient Rights.

Patient #13 interviewed outside in the courtyard of the West unit on 8/22/17 at 1:14 PM explained s/he failed to receive a copy of Patient Rights upon admission and requested a copy.

Staff F, Administration interviewed outside in the courtyard on the West unit on 8/22/17 at 1:25 PM indicated s/he will provide patient #13 with a copy of Patient Rights.


- The hospital's document titled "Patients' Rights and Responsibilities" reviewed on 8/22/17 failed to include the patient has the right to participate in the development and implementation of his or her care plan.

- The hospital's document titled "Patients' Rights and Responsibilities" reviewed on 8/22/17 failed to include the patient or his or her representative has the right to make informed decisions regarding his or her care.

- The hospital's document titled "Patients' Rights and Responsibilities" reviewed on 8/22/17 failed to include the patient has the right to formulate an Advanced Directive to direct health care professionals to comply with their directives.

- The hospital's document titled "Patients' Rights and Responsibilities" reviewed on 8/22/17 failed to include the patient has the right to personal privacy.

- The hospital's document titled "Patients' Rights and Responsibilities" reviewed on 8/22/17 failed to include the patient has the right to receive care in a safe setting.

- The hospital's document titled "Patients' Rights and Responsibilities" reviewed on 8/22/17 failed to include the patient has the right to be free from all forms of abuse, neglect, or exploitation.

- Document titled "Patient Handbook" (revised 7/18/17) reviewed on 8/22/17 revealed the hospital failed to include a copy of the Patient Rights.

Staff K, Administration interviewed in the team conference room on 8/22/17 at 8:16 AM verified the facility failed to include a copy of the Patient Rights in the new patient handbook. Staff K explained the new patient handbook was revised and completed during her scheduled time off work, and patients admitted after 7/18/17 failed to receive a copy of the Patient Rights. Staff K verified Patient Rights were included in the old patient handbook prior to 7/18/17. Staff K explained the facility has a separate copy of the Patient Rights available if someone needs one.

Staff H, Administration interviewed in the administration office on 8/23/17 at 8:26 AM verified the facility failed to include in the Patient Rights that the patients have the rights to be free from abuse, neglect, or exploitation, and the Patient Rights failed to be included in the Patient Handbook revised 7/18/19.

- The Hospital's policy titled "Informing Patients of Their Rights and Responsibilities Upon Admission" reviewed on 8/22/17 directed, " ...upon admission, the Registered Nurse (RN) will educate the patient, both orally and in writing, of his/her rights and responsibilities and document on the Acknowledgment of Education ...a copy of the ...Patient's Rights and Responsibilities ...shall be given to each patient upon admission ...in the event a patient's mental status, at the time of admission, prohibits Patient's Rights and Responsibilities education ...it shall be reviewed with the patient by the assigned Social Worker, at least weekly. The Social Worker will document this education on the Acknowledgment of Education.

Based on document review and interview the hospital failed to provide written response of grievance investigation outcomes and dates of resolution in two of six complaint/grievance reports reviewed (Patient #24 and Patient #27). Failure to provide documentation of a response to patients can create feelings of distrust and insignificance by the patients and discourages them from submitting legitimate future concerns, therefore denying them the ability to practice their rights fully.

Findings Include:

-Complaint filed by patient #24 on 3/3/2017, against Physician Staff TT stating s/he felt her/his breast and lifted her/his bra without need. Grievance investigation revealed no evidence an exam was performed by Physician Staff TT. Documentation of a physical and neurological exam was performed by APRN Staff U on 2/25/2017. There was no evidence to indicate hospital staff provided a written response to the complainant.

-Complaint filed by patient #27 on 7/24/2017, regarding patient #6. Review of the complaint revealed "(Unknown staff) screamed at us to get into our room. She said "I am the boss". She called security and 4 officers roughed patient #6 up pretty bad." Customer Service Specialist Staff OO reviewed the grievance on 7/25/2017. The review revealed Customer Service Staff OO forwarded the complaint to nursing department leaders for their awareness and appropriate follow up with documentation noted in patient #6's medical record. There was no evidence to indicate hospital staff provided a written response to the complainant.

Customer Service Specialist Staff OO interviewed 8/23/2017 at 8:30 AM acknowledge the patient complaint and grievance report system and stated "I am a patient advocate and I respond to grievances submitted by the patients. I try to investigate and respond to the patient within 24 hours. I like to close the investigation out or send it on to the appropriate staff to handle if I am unable to complete it. If the grievance involves staff abuse, it is directed to Risk Management (RM), if it involves staff/patient interactions, it is sent to the Unit Leader (UL), and if the grievance is about the treatment, care, concerns or objections, then it is directed to the treatment team for response. The grievance policy does not specifically state that I will always respond. I normally send all of the grievances to the treatment team so they can respond or are aware of a grievance and can plan for a response if necessary.
There is a grievance box on each hall of the Psychiatric Service Program (PSP) and staff are encouraged to help patients complete the grievance forms. A grievance occasionally comes through a phone call, usually from family. Patients are told about the grievance process at admission, either through intake or the Social Worker will review the process with the patient. Complaints often come through the 1st or 2nd day of the stay. The forms are not readily available, patients have to request them and staff are educated that a form has to be made available if a patient requests it. I only handle employee grievances if they are advocating on behalf of another employee."


Policy "Patient Grievance-Suggestion Process" directed in part "...Prompt review and response to complaints enhances customer service and patient satisfaction and results in improved quality of care... ...Action by LSH Customer Services Department:... ...Compiles summary of staff decision or action into a memo/letter of final response to the patient or representative. Sends final memo/letter of resolution to patient..."

Based on staff interview and policy review, the hospital failed to ensure accurate language translation is provided for all patients in their native language. This deficient practice puts all patients at risk for failing to have their physical, emotional and medical needs understood and met.

Findings Include:

Staff Q, Mental Health Developmental Disabled Technician (MHDDT) was interviewed in the visitation room in the West wing on 8/23/17 at 8:53 AM. Staff Q does not usually work on this unit, s/he was picking up overtime at the time of our interview. Staff Q's husband is Hispanic and s/he speaks Spanish at home with him. Staff Q clarified that s/he speaks Spanish to some of the patients while at work so that they can speak their primary language. Staff Q feels that there is a better rapport with patient care when s/he speaks the patient's primary language. Staff Q clarified s/he does not like to do interpretation for patients and other staff. Staff Q will not do it for the department of corrections, but has interpreted for administrative staff. Most of the staff do not use the translation phone line as they know the patients and can communicate with them well enough. Staff Q did say that usually each shift has someone who can speak Spanish.

Staff R, Registered Nurse (RN) was interviewed in the visitation room in the West wing on 8/23/17 at 9:18 AM. Staff R told this surveyor of two patients on the unit who speak Spanish. S/he told me that one of the clients used to speak English, and will only speak Spanish now due to an illness 1-2 years ago. Staff R explained the other patient does not say a whole lot. Staff R explained most staff know the patient's needs and can meet the patient's needs. The facility has picture charts and a white board for the patients to use if they desire. Staff R disclosed that a list of Spanish speaking staff that can help with translation is located in the Crisis Stabilization Unit (CSU), and that there are two physicians who can speak Spanish if they are needed. S/he explained the facility does use the interpretation phone line for the Vietnamese speaking patients, at treatment team meetings and with any difficult medications.

On 8/23/2017 at 9:44 AM, Staff S, MHDDT reports regarding patients who speak a language other than English: I have been here about a year and a half and I work first shift. One of the patients speaks Spanish, and not much English. She uses body language. She has been here for about a month. Another patient speaks some English, but he likes to be by himself. He just shakes his head. I'm not sure he really understands English. He has been refusing things lately.

Patient #22 (a Spanish speaking patient) was asked for an interview on 8/22/17 at 9:55 AM and refused.
Patient #21 (a Spanish speaking patient) was asked for an interview on 8/22/17 at 9:57 AM and refused.

- The Hospital's policy titled "Language Translators/Interpreters" directed, " ...clinical staff identifies the patients' oral and written communication needs, including the patients' preferred language for discussing health care ...the facility provides translators/interpreters to ensure effective communication concerning a patient's treatment, legal status, patient rights, and other issues as determined by the patient's Treatment Team ...The treatment team will call Optimal Phone Interpreters (OPI) for language translation ...when possible, and with supervisory approval, personnel may provide translation/interpretive services to individual patients ...personnel who are utilized as translators/interpreters must be deemed competent by using the ...Personnel Translators/Interpreters Competency.

Staff K, Administration was interviewed in the team conference room on 8/24/17 at 10:43 AM. Staff K verified that the facility has a list of employees who speak Spanish on the units, and that two physicians also speak Spanish. The staff uses their clinical decision making process to decide if an interpreter is needed. Staff K also verified the facility has a translator option called Optimal Phone Authorization (OPI) that is available 24/7 for all staff and all languages needed. Staff K clarified the policy that directs staff will be deemed competent by using the facilities competency course was a topic at the last board meeting, as the facility fails to have staff that have completed the competency at this time.

Based on observation, interview, and document review, the hospital failed to provide a safe environment to all patients by removing all possible ligature risks; failed to ensure all unsafe items are securely locked; and failed to remove lightweight furniture which could be used as a weapon. Failure to provide care in a safe setting places all patients and employees at risk of injury and possible death.

Findings Include:

- Hospital Psychiatric Services Program (PSP) consists of a building with three distinct sections. Each section consists of 3 wings.

Tours of the Crisis Stabilization Unit (CSU), the acute short stay inpatient unit of the Adult Treatment Center (ATC) and the Adult Treatment Center (ATC) were conducted 8/21/2017 at 10:30 AM and 8/23/2017 at 3:00PM.
The CSU unit consists of 28 beds with 17 inpatients at the time of the 8/21/2017 tour.
The ATC unit consists of 28 beds with an unknown number of patients at the time of the 8/23/2017 tour.

Observations resulted in the following findings:

- Classroom #2, Art Room, A134, Hallway door with over door hinge and flat top plastic box covering exit sign above the exit door (these are examples of a ligature point that is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation) two supply cabinets with locks that were unsecured (the supply cabinet could have harmful chemicals or cleaning supplies that a patient could use to harm themselves) and one wooden wall covering for an ironing board and iron mounted to the wall failing to be secured (this practice gives patients access to an iron which could be used to harm themselves or others and the ironing board and woden cover are examples of a ligature point that is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation).

Staff K, Administration in the patient art room interviewed on 8/21/17 at 10:54 AM verified the 2 art room supply cabinets that were unsecured and the 1 wooden wall covering for the ironing board and iron unsecured.


- Seclusion room bathroom with regular non-ligature proof shower curtains, non- ligature proof shower head with long neck, and toilet with handle flushing device (these are examples of a ligature point that is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation).

- Day Room, with one unsecured round light-weight table (a patient can use lightweight furniture as an object to throw at another patient or staff member) and one cabinet with a lock on it that was unsecured (an unsecured cabinet can contain harmful chemicals or cleaning solutions).

Staff K, Administration interviewed in the day room/TV room on 8/21/17 at 11:01 AM verified the unsecured cabinet.


- Shelter tornado room (used for CSU treatment room) with an empty bed frame, two bathrooms with non-ligature proof sink faucets and turn knobs,a toilet with handle flushing device, and non-ligature proof door knobs on both sides of door (these are examples of a ligature point that is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation), one large unsecured plastic trash can, one large unsecured plastic rolling utility cart (with 3 levels)(these are examples of lightweight furniture which a patient can use as an object to throw at another patient or staff member and examples of a ligature point that is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation).

Staff K, Administration interviewed in the tornado/activity room on 8/21/17 at 11:04 AM verified the large plastic trash can, large utility cart and metal bed frame as ligature risks.


- Nursing station med room with one of five unlocked cabinets containing syringes and various medication supplies (the unlocked cabinets could have supplies that a patient could use to harm themselves).

Staff F, Nursing interviewed in the CSU medication room on 8/21/17 at 11:22 AM verified the unsecured medication supply cabinet.


- One day room hallway bathroom with non-ligature proof door knobs on both sides of door (this is an example of a ligature point that is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation).

- Patient dining room door between the staff and patient dining room unlocked, and 2 unsecured cabinets with locks containing cleaning supplies, plastic bags and wash clothes (the unlocked cabinets have chemicals, cleaning supplies, and materials to make a cord or rope that a patient could use to harm themselves).

Staff K, Administration interviewed in the patient dining room on 8/21/17 at 11:30 AM verified the unlocked door between the patient and staff dining rooms, and the two unsecured cabinets in the patient dining room containing plastic bags, wash cloths, and cleaning supplies.


- Patient room C140 with one soap container (this is an examples of a ligature point that is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation)..

Staff K, Administration interviewed in room C140 verified the soap container as a ligature risk.


- West wing examination room with four cabinets containing various medical supplies with unsecured locks (the unlocked cabinets could have chemicals, cleaning supplies, and material to make a cord or rope that a patient could use to harm themselves).

Staff K, Administration interviewed in the West wing examination room on verified the four unsecured cabinets


- Forty-eight of forty-eight observed patient rooms with non-ligature proof door handles on both sides of each exterior door (these are examples of a ligature point that is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation).; Forty-eight light weight, metal, movable bed frames (these are examples of a ligature point that is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation and these are examples of lightweight furniture which a patient can use as an object to throw at another patient or staff member).

-Exit doors in six of six sunrooms observed with exposed and accessible non-ligature proof door hinges (this is an example of a ligature point that is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation).

-Exit doors in four of four observed hallways with non-ligature proof door hinges (this is an example of a ligature point that is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation).

-Double doors in two of two activity rooms observed with non-ligature proof door hinges (this is an example of a ligature point that is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation).

-Five sets of light weight window curtains approximately 6 feet in length and five feet in width attached at the top of the window frame with Velcro (these are an example of materials a patient could use to make a cord, rope or other material for hanging or strangulation).

- Forty-six of forty-six rooms observed withnon-ligature proof door knobs on both sides of the exterior door (these are an example of a ligature point that is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation).

- All hand rails in observed hallways were attached to the wall with an approximate 4" gap between the rail and the wall (these are an example of a ligature point that is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation).

Based on staff interview, document review, policy and procedure review the hospital failed to ensure patients were free from all forms of abuse, neglect or exploitation (the act of treating someone unfairly)(ANE). During this on-site survey, the hospital administration was notified of an Immediate Jeopardy (IJ - A situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) by representatives of the Kansas Department of Health and Environment (KDHE) on behalf of the Centers for Medicare and Medicaid Services (CMS) on 8/23/2017 at 7:40pm. The IJ was called as a result of the hospital's failure to ensure their patients were free from abuse when the hospital failed to review an incident involving alleged verbal abuse against a patient (patient #30) by an employee (RN Staff AA) and failed to review an incident of alleged physical abuse against a patient (patient #16) by an employee (Mental Health/Developmental Disability Technician (MHDDT) BB). Review of the staff schedule revealed both employees involved in these incidents were scheduled to work within the next 24 hours. At 8:40pm on 8/23/2017, the hospital provided a credible plan of correction to remove the IJ prior to the survey exit. The hospital placed both employees identified as the alleged perpetrators of these incidents on immediate administrative leave. Additionally, they placed an administrator on 24 hour surveillance of the Crisis Stabilization Unit with the sole purpose of making rounds and ensuring that hospital staff treat patients with dignity and respect. The hospital's failure to ensure patients who cannot protect themselves are free from physical, verbal, and emotional abuse, neglect and exploitation puts all patients at risk for harm and imminent danger to their health, safety and welfare.

Findings Include:

- Document titled "Incident Report LSH 412 72017015" stamped received on 7/7/2017 and not reviewed until 8/23/2017 revealed reported details of an event occurring on the ATC unit (adult treatment center) on the west south hallway on 7/5/2017 at 8:25 PM. The document revealed the reporter (Mental Health Disability Technician (MHDDT) UU) was attending to a patient (patient #16) who had a wash cloth that they were trying to tear into pieces. When the patient would not stop the behavior, the reporter pulled their screecher (a body alarm to alert others to come help). Other staff members including MHDDT Staff BB came to the reporter's aid. It was reported that Staff BB came up from behind the patient and without any warning and suprised them by pulling the patient's pants down at which point they took the washcloth from the patient. The patient was agitated and shoved Staff BB. Staff BB in turn, shoved the patient back.

- Document titled, "PLX Leave Request" schedule for Staff BB reviewed on 8/23/2017 revealed Staff BB has remained on the schedule and working since the incident occurred on 7/7/2017.

On 8/23/2017 at 5:02 Risk Manager Staff M reported they investigate abuse, neglect and exploitation. Staff can report issues by emails, grievances, or they can bring them in to the risk management office. Staff can call the risk management staff's cell phone and there can be immediate action if needed. Any abuse substantiated, would be reported; also to the state board of nursing. Once they have substantiate it, they report it. As soon as they identify the staff member, they talk to HR and have them removed from patient care. They also make recommendations to the Superintendent and HR. Staff M reports they have a large case load for all of Larned State Hospital. Staff M is the only one in the risk management department for the entire state hospital, so bruises would take precedence before verbal abuse cases. HR is responsible for investigating unlicensed staff.

Human Resources (HR) Director Staff KK interview on 8/23/2017 at 6:50 PM reported they have not had abuse training except for what they receive in new employee orientation. They review the incidences and may have to kick back to the nurse manager. Risk management first gets the reports and then gives them to me to investigate. They usually do staff to staff altercations, 'HR stuff'; but now they complete investigations involving staff- patient issues for unlicensed staff. They report they have done no active work on this investigation, and it did not get sent to nursing. They state they have had minimal training, and only recently received training on what forms to fill out, as well as interrogative questioning training for incident investigations.


- Document titled, "Incident Report LSH 412 82017081" (no time stamp available when it was received by risk management) reviewed on 8/23/2017 revealed reported details of an event occurring on the CSU (crisis stabilization unit) medication window and lobby area on 8/18/2017. The document revealed a patient (patient #30) approached RN Staff AA at the medication window and asked for a band aid to hold on a medication patch. The patient then told Staff AA that the band aid was too small, and Staff AA raised their voice, asking "do you have a f---ing problem?" Staff AA continued to use foul and confrontational language with the patient, including "she could take him". The nurse left the unit promptly after the altercation.

- Document titled, "PLX Leave Request" schedule for Staff AA reviewed on 8/23/2017 revealed Staff AA has remained on the schedule and working since the 5/31/2017 and 8/18/2017 incidents occurred.

On 8/23/2017 at 4:39 PM Staff F reported Staff AA is an RN on night shift on CSU and is full time. The event happened recently, it was a Friday (8/18/2017) morning. The patient was going to be discharged on Monday (8/21/2017). I did not witness the event but heard a patient and the staff member were in a shouting match and security was called. Staff AA was sent home by her direct supervisor immediately and security settled down the patient. I was not concerned about Staff AA returning to work because the patient had discharged home before they worked on that unit again. The risk management report was sent, and I think security was going to do one also. Normally, when these things occur, we send staff to another unit or send them home. Staff AA worked the night following the incident, 8/18/17 on the triage unit, and was not allowed back on the unit because the patient was still there. Yes, Staff AA resumed work after her normal days off - Saturday (19th) and Sunday (20th). They worked Monday (21st) and Tuesday (22nd) but was in a training class, and did not have contact with patients. They are scheduled to work tonight on CSU where she will have contact with patients.

Staff F continued, I have not witnessed any ANE with patients before, nor have I heard of any incidents. I have had complaints of rude behavior from other staff, but no reports of hands-on or any threats have been reported. Using foul language in this case is a possibility, given Staff AA's past behavior. If there was report of foul language or abuse, they would go home until they hear from HR and go back for re-training. I would be proactive, not reactive.

Interview on 8/23/2017 at 5:02 Risk Manager Staff M revealed the report came in on the 21st (of August). The patient had discharged before I could interview them. I have called the call center to confirm there is a staff member that has the name. This is an open case. I have a sheet with questions on what I need to ask when I interview. Once the patient lands (location is established) and I know where they are going after discharge, I will interview them. I am going to interview this 'Staff AA'-use identifier. I am assuming this happened and have to confirm the identity of the Staff AA involved. I could probably get to this investigation tomorrow. I would investigate this as an abuse case. When asked how the facility was keeping patients safe from further abuse from Staff AA, Staff M stated "I would say we are not protecting them".

- The hospital's policy "Abuse, Neglect or Exploitation of Patients" reviewed on 8/22/17 directed, " ...it is the responsibility of every ...employee to immediately report abuse, neglect, or exploitation (suspected or confirmed). Any employee who willfully fails to report such an incident where there is reason to believe abuse, neglect, or exploitation has occurred can potentially be found guilty of a crime and/or be subject to disciplinary action ...action by Employee: provide for patient's immediate safety ...action by Unit Leader/Shift Leader: provides for patient's safety as indicated and notifies the medical staff of the alleged abuse ...ensures that the employee identified as the alleged perpetrator of the abuse, neglect, or exploitation is immediately removed from patient contact until a decision is made if the employee should be temporarily reassigned, placed on administrative leave, or returned to normal assignment ...action by Risk Manager/Designee: makes a recommendation as to whether or not the employee should be temporarily reassigned pending completion of an investigation ...conducts a timely and credible investigation ...reports confirmed cases of abuse, neglect, exploitation to the appropriate state and licensing agency."