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Based on document review, video review and staff interview it was determined the hospital failed to ensure patient # 11 was provided a safe environment. This failure has the potential to have a negative impact on any patient receiving the services of this hospital.

Findings include:

1. A review of the medical record for patient #11 revealed the patient was admitted to the hospital on 10/20/20 with a diagnosis Attention Deficit Hyperactivity Disorder (ADHD), Intellectual or Developmental Disability (IDD) and Traumatic Brain Injury (TBI). The record indicated on 9/7/21 at 10:44 a.m. an APS (Adult Protective Services) was reported due to an altercation with HSW (Health Service Worker) #4 that had occurred on 9/6/21. The patient was ordered CCO (Close Constant Observation) and ordered to wear mittens due to his/her history of hitting patients and staff. The record indicated the patient has an IQ (Intelligence Quotient) of fifty (50) and a third grade education.

2. A review of the APS report filed states, "Patient #11 was trying to go to his/her room, nurse was yelling that he/she was not and getting in his/her face. Patient #11 hit the nurse, nurse pushed him/her, he/she fell into the door, stumbled and fell."

3. An interview was conducted with the Chief Nursing Officer (CNO) on 9/8/21 at approximately 11:15 a.m. The CNO stated that an incident with a patient on G-2 had occurred on 9/6/21. Housekeeping had witnessed an altercation between patient #11 and HSW #4. He/she stated as soon as nursing was made aware of the incident on 9/7/21, HSW #4 was suspended pending the investigation. The APS was filed and the investigation had begun. The physician had been notified and an exam had been performed on patient #11 to assess for injuries. The guardian was notified of the alleged incident. The CNO stated, "Staff is required to immediately report any concerns to the Registered Nurse (RN) over the unit or the NCC (Nurse Clinical Coordinator). He/she stated they had identified the issue and planned to reeducate housekeeping on the importance of reporting any suspected or witnessed abuse. He/she concurred that policy was not followed.

4. A review of the hospital document entitled "Reporting and Investigating Verbal, Physical, and Sexual Abuse of Patients, and Neglect," effective date 10/11/2019, states, ''Individuals who witness, have knowledge of patient abuse/neglect, or have reason to believe patient abuse/neglect occurred shall immediately report it to the RN and/or Nurse Manager assigned to the unit where the patient resides or to the Nurse Clinical Coordinator (NCC), unless said individuals are the alleged perpetrators."

5. A review of video from 9/6/21 was conducted on 9/8/21 at 1:23 p.m. with the Information System Specialist and Survey Coordinator present. At 10:34.33 patient #11 can be visualized on video with HSW #5 monitoring the patient on CCO. The housekeeping cart could be seen in the video at this time with HSW #6 monitoring the cart. At 10:34:44 patient #11 can be seen with mittens on walking towards his/her room. 10:34:50 CCO #5 is handing off CCO monitoring duties to HSW #4. At this time, HSW #4 and #5 are not able to visualize patient #11. At 10:34:54 HSW #4 starts walking towards patient #11. At 10:35:18 you can see HSW #4 in the face of patient #11. At 10:35:26 HSW #4's arms are extending, touching patient #11's upper body, backing the patient into the room and the door partially closes.

6. A review of the hospital document entitled "Levels of Observation," effective date 7/15/19 states under the CCO, "A patient on this level of observation must always be in view of the staff member assigned to the observation."

7. An interview was conducted with the survey coordinator on 9/8/21 at approximately 1:30 p.m. The survey coordinator concurred HSW #4 and 5 did not follow hospital policy.

8. An interview was conducted with the lead nurse on G-2. The lead nurse stated, "On 9/7/21 I was informed that housekeeping had witnessed an alleged incident with patient #11 and HSW #4. I informed them that an APS report needed filed and assisted the housekeeper with filing the APS report. I told them if they had concerns about anything an APS report needed to be filed."

9. An interview was conducted with housekeeper #1 on 9/8/21 at approximately 2:50 p.m. Housekeeper #1 stated, "I was in the bathroom cleaning and could hear a thud and looked and saw patient #11 come stumbling through the door and land on his/her butt and HSW #4 was standing overtop of him/her. I knew he/she had been pushed. Patient #11 was sitting up against the wall with his/her knees drawn up. I asked if he/she was alright. I looked up and saw other HSWs in the doorway and thought they were taking care of it. We told my supervisor at the end of the day and he/she said that was an APS report and said we would deal with it the next day."

10. An interview was conducted with housekeeper #2 on 9/8/21 at approximately 3:00 p.m. Housekeeper #2 stated, "I was standing in the hallway in front of patient #11's room when I saw him/her on the other side of the housekeeping cart. I was watching him/her. The next thing I know HSW #4 was mumbling something to patient #11 and was really close to his/her face. The next thing I know is patient #11 had hit the HSW. HSW #4 put his/her hands on the patient and shoved him/her and told him/her, "You are not going to hit me in the face." I let housekeeper #1 know something was going on because he/she was in that room." He/she stated that no one intervened and support was not called. Housekeeper #2 stated, "HSW #4 was down in his/her face. You know [patient #11] is a hitter. Why would you get in his/her face?"

11. An interview was conducted with Environmental Services Supervisor on 9/9/21 at approximately 11:40 a.m. He/she stated he/she was leaving for the day when housekeeper #1 and 2 told him/her they thought they saw something but wasn't for sure what they saw. I told them we would review the video in the morning and see if they saw what they thought they saw. After we reviewed the video we notified the NCC and did the paperwork. He/she stated, "I know we should have let the nurse know that day."

12. A review of the staffing sheet N-2 on 9/6/21 revealed HSW #4 continued to monitor the CCO for patient #11 from 10:30 a.m. to 11:30 a.m. that day and was scheduled to monitor him/her on 9/7/21 but was suspended pending the investigation.

13. A review of the education provided to housekeeper #1 revealed he/she was educated on his/her "APS Competency" on 3/30/21.

14. A review of the education provided to housekeeper #2 revealed he/she was educated on his/her "APS Competency" on 7/21/21.

15. An interview was conducted with the CNO on 9/9/21 at approximately 8:35 a.m. The CNO concurred the incident involving HSW #4 and patient #11 should have been handled differently.

Based on document review, video review and staff interview it was revealed the hospital failed to ensure nursing staff followed their policy entitled "Reporting and Investigating Verbal, Physical, and Sexual Abuse of Patients, and Neglect" and their "Levels of Observation" policy. This failure has the potential to negatively impact anyone receiving the services of this hospital.

Findings include:

1. A review of the hospital document entitled "Reporting and Investigating Verbal, Physical, and Sexual Abuse of Patients, and Neglect," effective date 10/11/2019, states, ''Individuals who witness, have knowledge of patient abuse/neglect, or have reason to believe patient abuse/neglect occurred shall immediately report it to the Registered Nurse (RN) and/or Nurse Manager assigned to the unit where the patient resides or to the Nurse Clinical Coordinator (NCC), unless said individuals are the alleged perpetrators."

2. A review of the hospital document entitled "Levels of Observation," effective date 7/15/19, states under the Close Constant Observation (CCO), "A patient on this level of observation must always be in view of the staff member assigned to the observation."

3. A review of the medical record for patient #11 revealed the patient was admitted to the hospital on 10/20/20 with a diagnosis Attention Deficit Hyperactivity Disorder (ADHD), Intellectual or Developmental Disability (IDD) and Traumatic Brain Injury (TBI). The record indicated on 9/7/21 at 10:44 a.m. an APS (Adult Protective Services) was reported due to an altercation with HSW (Health Service Worker) #4 that had occurred on 9/6/21. The patient was ordered CCO (Close Constant Observation) and ordered to wear mittens due to his/her history of hitting patients and staff. The record indicated the patient has an IQ (Intelligence Quotient) of fifty (50) and a third grade education.

4. A review of video from 9/6/21 was conducted on 9/8/21 at 1:23 p.m. with the Information System Specialist and Survey Coordinator present. At 10:34.33 patient #11 can be visualized on video with HSW #5 monitoring the patient on CCO. The housekeeping cart could be seen in the video at this time with HSW #6 monitoring the cart. At 10:34:44 patient #11 can be seen with mittens on walking towards his/her room. 10:34:50 CCO #5 is handing off CCO monitoring duties to HSW #4. At this time, HSW #4 and #5 are not able to visualize patient #11. At 10:34:54 HSW #4 starts walking towards patient #11. At 10:35:18 you can see HSW #4 in the face of patient #11. At 10:35:26 HSW #4's arms are extending, touching patient #11's upper body, backing the patient into the room and the door partially closes.

5. An interview was conducted with the Chief Nursing Officer (CNO) on 9/8/21 at approximately 11:15 a.m. The CNO stated that an incident with a patient on G-2 had occurred on 9/6/21. Housekeeping had witnessed an altercation between patient #11 and HSW #4. He/she stated as soon as nursing was made aware of the incident on 9/7/21, HSW #4 was suspended pending the investigation. The APS was filed and the investigation had begun. The physician had been notified and an exam had been performed on patient #11 to assess for injuries. The guardian was notified of the alleged incident. The CNO stated, "Staff is required to immediately report any concerns to the Registered Nurse (RN) over the unit or the NCC (Nurse Clinical Coordinator). He/she stated they had identified the issue and planned to reeducate housekeeping on the importance of reporting any suspected or witnessed abuse. He/she concurred that policy was not followed.

6. An interview was conducted with the survey coordinator on 9/8/21 at approximately 1:30 p.m. The survey coordinator concurred HSW #4 and 5 did not follow hospital policy regarding CCO.

7. An interview was conducted with housekeeper #1 on 9/8/21 at approximately 2:50 p.m. Housekeeper #1 stated, "I was in the bathroom cleaning and could hear a thud and looked and saw patient #11 come stumbling through the door and land on his/her butt and HSW #4 was standing overtop of him/her. I knew he/she had been pushed. Patient #11 was sitting up against the wall with his/her knees drawn up. I asked if he/she was alright. I looked up and saw other HSWs in the doorway and thought they were taking care of it. We told my supervisor at the end of the day and he/she said that was an APS report and said we would deal with it the next day."

8. An interview was conducted with housekeeper #2 on 9/8/21 at approximately 3:00 p.m. Housekeeper #2 stated, "I was standing in the hallway in front of patient #11's room when I saw him/her on the other side of the housekeeping cart. I was watching him/her. The next thing I know HSW #4 was mumbling something to patient #11 and was really close to his/her face. The next thing I know is patient #11 had hit the HSW. HSW #4 put his/her hands on the patient and shoved him/her and told him/her, "You are not going to hit me in the face." I let housekeeper #1 know something was going on because he/she was in that room." He/she stated that no one intervened and support was not called. Housekeeper #2 stated, "HSW #4 was down in his/her face. You know [patient #11] is a hitter. Why would you get in his/her face?"

9. An interview was conducted with Environmental Services Supervisor on 9/9/21 at approximately 11:40 a.m. He/she stated he/she was leaving for the day when housekeeper #1 and 2 told him/her they thought they saw something but wasn't for sure what they saw. I told them we would review the video in the morning and see if they saw what they thought they saw. After we reviewed the video we notified the NCC and did the paperwork. He/she stated, "I know we should have let the nurse know that day."

10. A review of the staffing sheet N-2 on 9/6/21 revealed HSW #4 continued to monitor the CCO for patient #11 from 10:30 a.m. to 11:30 a.m. that day and was scheduled to monitor him/her on 9/7/21 but was suspended pending the investigation.

11. An interview was conducted with the CNO on 9/9/21 at approximately 8:35 a.m. The CNO concurred the incident involving HSW #4 and patient #11 should have been handled differently.