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Based on medical record reviews, nursing assessments, eye witness assessments, incident report, policy procedure reviews and interviews, the facility failed to promote one of six sampled patient's (P#1) rights. The facility clinicians failed to immediately evaluate and treat P#1's injuries she sustained when she was allegedly abused by a staff member.

Findings:

A review of Patient (P) #1's medical record revealed that P#1 presented at the facility on 5/26/21 at 11:20 a.m. on a 1013 (involuntary treatment). P#1 was admitted to the facility due to major depressive disorder with suicidal ideations.


On 5/27/21 at 11:00 p.m., RN HH documented that P#1 reported she was abused by a staff member but did not know the staff member's name. RN HH noted P#1 proceeded to show her multiple bruises and stated they were done by the staff. RN HH documented she verified that many marks P#1 reported were documented on intake and the bruises on P#1's right hand were noted to have occurred from P#1 punching the wall before admitted to the facility.


On 5/28/21 at 6:00 a.m., RN HH documented when P#1 described the alleged abuse, P#1 physically grabbed her face, skin and squeezed it very hard. RN HH noted P#1 punched her knees as she described the alleged abuse by staff. RN HH documented that on the back of P#1's right and left hands were multiple dime-sized bruises. RN HH documented three fingertip-sized bruises on the back of P#1's left arm. The three fingertip-size bruises were new bruises.

On 5/28/21 at 11:45 p.m. RN HH noted that an X-ray order was obtained, and an X-ray was done for P#1's right hand. P#1 received PRN pain medication.

A review of the facility's document titled "consultation" revealed that on 5/29/21 P#1 had a medical consult related to her right-hand injury and pain. The X-ray report obtained revealed a mildly displaced right-hand fracture. Further review of the record revealed that P#1 was ordered to be transferred to the Emergency Department (ED) to evaluate and treat P#1's hand injury.
A review of the facility's document titled "Radiology Report" revealed on 5/29/21 at 12:09 p.m., P#1's x-ray results were as follows:
1. Mandible (Jaw)
Result: No fracture is seen and no dislocation of the temporomandibular joint (jaw).
2. Right Hand
Result: There is a fracture involving the 5th metacarpal (little finger) with moderate callus. Stable old moderately healed right-hand fracture, findings were unchanged since 10/3/20.
A review of the treatment summary revealed P#1 had a discharge diagnosis of major depressive disorder and attention deficit hyperactive disorder. P#1 was discharged from the facility on 6/2/21. P#1's discharge and safety plan were completed.


An interview took place with RN DD on 6/16/21 at 11:00 a.m. in the conference room. RN DD said that she had been working at the facility about three years. RN DD said she was not at the facility when the incident occurred. RN DD said she was made aware of the incident the next day by RN BB. RN DD said she immediately did a skin assessment, incident report and took pictures of the bruises on P#1. RN DD said she asked P#1 to touch her shoulder and one of the bruises on her back was beyond P#1's reach. RN DD explained that she also observed what resembled a hand print on P#1. RN DD said she compared the scars and bruises on P#1 to her initial assessment and some of the scars seemed to have been present before she was admitted to the facility. RN DD stated she was concerned of P#1's bruises on her back and the hand print.


An interview took place with the Director of Compliance and Risk Management (DCR) (FF) on 6/16/21 at 1:03 p.m. DCR FF acknowledged that he recalled the incident with P#1. DCR FF explained that he was made aware of the incident by RN DD. DCR FF said they immediately suspended BHA KK pending the investigation and she was removed from the facility however, she resigned (6/9/21) before the investigation was completed. DCR FF said the RN DD documented the incident report, took a statement from BHA CC who said she witnessed the alleged assault, and spoke with the staff that had allegedly assaulted P#1 (BHA KK). DCR FF explained that BHA KK stated she didn't lay hands on P#1. DCR FF further explained that BHA KK said she was positioned in the doorway and the door to P#1's room was slightly open during the time of the incident. DCR FF said the conclusion after the investigation was that BHA CC's statement was credible, based on the pictures from P#1's reassessment something had happened in P#1's room but they are not aware of what occurred. DCR FF explained that he went through the whole surveillance video of the unit but could not see any video that was concerning because the incident had occurred in P#1's room. DCR FF said that there were no videos in the patient's room due to privacy concerns. DCR FF acknowledged that the allegation was substantiated during their internal investigation. DCR FF explained that whenever there was an allegation that a staff assaulted a patient his expectation is for the witness to report right away to the supervisor, department leader, and himself. DCR FF acknowledged that the patient room door should have remained open while P#1 was on a 1-1 observation with the staff. DCR FF said that the facility staff was trained on crisis prevention intervention (CPI) annually and during orientation. DCR FF further explained they intended to retrain all staff on CPI by 7/1/21 to prevent such an incident from happening again.

On 6/17/21 at 2:07 p.m. in a second interview with DCR FF to explain what the facility's policies meant by "All allegation for patient abuse, neglect and exploitation be reported immediately". DCR FF said his expectations were for the staff who witnessed abuse to report the allegation of patient abuse to the charge nurse within an hour and they should be investigated up through to the leadership.


A review of the facility's policy titled "Alleged Patient Abuse, Neglect and Sexual Exploitation", Policy Number RI. 009, last reviewed 1/20, revealed that it is the policy of the facility that all allegation of patient abuse, neglect, and exploitation be reported immediately and investigated within twenty-four (24) hours of the time the incident occurred.

Purpose:
1. To ensure patients are treated with dignity and respect in accordance with the patient's bill of rights and other applicable law
2. To ensure that incidents or allegations concerning patient neglect and or abuse are handled fairly, thoroughly, and expeditiously.
3. To protect the professional integrity of the hospital and its staff members.
Procedures.
1. Protocol- Alleged Abuse or Neglect Occurring within the Hospital setting.

An employee who hears from a patient or visitor or who observes a potential case of patient neglect and/ or abuse will immediately report it to the charge nurse. An incident report must also be completed regarding the incident. If an allegation has been made against a specific staff member, that individual will, at a minimum be reassigned to another unit. Depending upon the circumstance, the employee may also be suspended until an investigation can be completed.
The human resources director will be notified of the allegation against a specific employee and will review the employee's file for clearances and previous complaints.
The Director of Nursing (DON), Director of Clinical Services, and Risk Manager are to be notified of the allegation and will begin the initial investigation, including interviews with the patient, alleged abuser, patient witness, and staff witnesses.

The patient is to be interviewed by the DON, DCS, or risk manager and assessed for injuries by the charge nurse or DON. This assessment will be documented in the progress note. Any injuries are to be reported to the attending or on-call physician for further assessment and treatment.

Review of the facility's policy number RI-010, titled 'Abuse and/or Neglect of Patients', last reviewed 08/17, reveals it is established to prevent and rectify misconduct in a just and constructive manner to reduce the likelihood of recurrence and to protect patients from abuse. The organization supports and conforms to all state and federal guidelines for the protection of patients 'rights. No employee or intern will mistreat and/or neglect a patient. Further review reveals that any staff, student, or intern suspected of any of the above infractions will be investigated under this policy. If it is determined that the staff member physically, sexually, or verbally abused the patient in question or willfully neglected the patient(s), disciplinary actions will be enacted against him/her, up to and including termination of employment. Employees are informed of this policy by the speaker at the new employee and annual employee orientation, provided with a copy of the policy, and must sign an "Employee Acknowledgement of Abuse Policy" statement. Patient alleging (or staff suspecting) Abuse/Neglect will immediately notify administrator, Director of Clinical Services, and/ or Director of Nursing.

Review of the facility's incident report documented the alleged incident occurred on 5/27/21 at approximately 12:00 p.m. regarding P#1 and BHA KK. P#1 received a skin assessment by RN HH on 5/27/11 at 11:00 p.m. Further review of the incident report documented P#1's family was not contacted, but P#1's physician and a state agency were notified of the alleged abuse.

Based on medical record reviews, nursing assessments, eye witness assessments, incident report, policy procedure reviews and interviews, it was determined the facility clinicians failed to immediately evaluate and treat P#1's injuries she sustained when she was allegedly abused by a staff member. The clinical staff failed to timely investigate P#1's allegation of abuse in accordance to the facility policy, titled "Alleged Patient Abuse, Neglect, and Sexual Exploitation", #RI.009, last reviewed 1/2020. This policy indicated that all allegation of patient abuse, neglect, and exploitation be reported immediately and investigated within 24 hours of the time the incident occurred.


Findings:


A review of Patient (P) #1's medical record revealed that P#1 presented at the facility on 5/26/21 at 11:20 a.m. on a 1013 (involuntary treatment). P#1 was admitted to the facility due to major depressive disorder with suicidal ideations. P#1 had planned to overdose, was disorganized (disorganized thoughts) and hypersexual (exhibiting inappropriate sexual behaviors). P#1's past medical history included Attention Deficit Hyperactive Disorder (ADHD) (a disorder that makes it difficult for a person to pay attention and control impulsive behaviors ), Major Depressive Disorder (Depression), Bipolar (high and low moods, changes of sleep pattern). The plan of care for P#1 was to treat for psychiatric management. P#1 had no known drug allergies.

A review of the initial nursing assessment revealed on 5/26/21 at 11:30 p.m. that P#1 had bruises on her hands and shoulders. The assessment revealed P#1 reported scratching herself and punching walls before admission.


On 5/27/21 at 11:00 p.m., RN HH documented that P#1 reported she was abused by a staff member but did not know the staff member's name. RN HH noted P#1 proceeded to show her multiple bruises and stated they were done by the staff. RN HH documented she verified that many marks P#1 reported were documented on intake and the bruises on P#1's right hand were noted to have occurred from P#1 punching the wall before admitted to the facility.

On 5/28/21 at 6:00 a.m., RN HH documented when P#1 described the alleged abuse, P#1 physically grabbed her face, skin and squeezed it very hard. RN HH noted P#1 punched her knees as she described the alleged abuse by staff. RN HH documented that on the back of P#1's right and left hands were multiple dime-sized bruises. RN HH documented three fingertip-sized bruises on the back of P#1's left arm. The three fingertip-size bruises were new bruises.

On 5/28/21 at 6:55 p.m. RN BB documented P#1 slept most of the day, did not eat lunch, and reported allegation of abuse. RN BB noted that a facility staff came forward as a witness. RN BB documented there were multiple bruises and lacerations on P#1's body.

On 5/28/21 at 11:45 p.m. RN HH noted that an X-ray order was obtained, and an X-ray was done for P#1's right hand. P#1 received PRN pain medication.

A review of the facility's document titled "consultation" revealed that on 5/29/21 P#1 had a medical consult related to her right-hand injury and pain. The X-ray report obtained revealed a mildly displaced right-hand fracture. Further review of the record revealed that P#1 was ordered to be transferred to the Emergency Department (ED) to evaluate and treat P#1's hand injury.
A review of the facility's document titled "Radiology Report" revealed on 5/29/21 at 12:09 p.m., P#1's x-ray results were as follows:
1. Mandible (Jaw)
Result: No fracture is seen and no dislocation of the temporomandibular joint (jaw).
2. Right Hand
Result: There is a fracture involving the 5th metacarpal (little finger) with moderate callus. Stable old moderately healed right-hand fracture, findings were unchanged since 10/3/20.
A review of the treatment summary revealed P#1 had a discharge diagnosis of major depressive disorder and attention deficit hyperactive disorder. P#1 was discharged from the facility on 6/2/21. P#1's discharge and safety plan were completed.

A review of the facility's witness statement from Behavioral Health Assistant (BHA CC) documented that on 5/28/21, BHA CC documented she witnessed P#1 was mishandled by BHA KK. BHA CC documented that P#1 cried and screamed from behind the closed doors. BHA CC wrote that P#1's cries and screams were heard by the entire unit. The other patients were escorted to the group room because the scream triggered them. BHA CC noted P#1 kept saying "stop abusing me". BHA CC noted that P#1 came to her and other staff members to show them the bruises on her hand where P#1 claimed BHA KK continuously hit her. BHA CC noted she attempted to get P#1 a bag of ice and was advised by BHA KK not to worry about it. BHA CC noted she did not see what went wrong in the room with the door closed but P#1 fought to get out of her room unsuccessfully. BHA CC documented that BHA KK picked up P#1 several times and slung her back into the room closing the door each time. BHA CC documented that P#1 maintained she had been abused and complained other body areas were sore. BHA CC noted that upon examination, RN BB validated everything P#1 stated the previous day. BHA CC documented P#1 had a swollen jaw, nail marks on her back, handprints on her shoulder, and an extremely bruised hand.

A review of the incident report log from 12/1/20 to 6/8/21 revealed there were 2 allegations (P#1 P#2) of patients that were physically abused by staff.

A review of the incident report revealed that P#1 was allegedly abused by staff on 5/27/21 at 12:00 p.m. P#1 was admitted to the facility on 5/26/21 and was on suicide precautions at the time of the incident. Further review of the report revealed, that BHA CC documented she reportedly witnessed P#1 mishandled. BHA CC noted that P#1 fought to get out of her room and BHA KK picked her up several times and flung her back in her room. BHA CC noted that P#1 maintained she was abused and complained that other areas of her body were sore. The incident report revealed that BHA CC saw the nurse's examination and it was consistent with what she reported. According to the nurse assessment, P#1 had bruises on her knees and superficial lacerations on her back, and bruising on her right hand. P#1 also had redness and swelling to her jaw. BHA KK was interviewed and denied putting hands-on P#1. BHA KK said that P#1 hit the wall in her bathroom several times. P#1 had an X-ray taken for her jaw and hand and noted no new fractures.


A telephone interview was initiated with the Behavioral Health Assistant (BHA) CC on 6/15/21 at 11:34 a.m. BHA CC explained there was a code purple (evacuation) and she had to take other patients to the common room. BHA CC explained that while she was taking the girls to the room, she heard P#1 yelling from her room that BHA KK was assaulting her and she needed help. BHA CC said the staff was on a 1-1 observation with P#1 in her room and the door was closed. BHA CC said there were nurses on the floor who heard P#1 requesting help, but she was not aware if any staff went into her room to help P#1. BHA CC said when she saw P#1 later in the day she showed her bruises, but she was told P#1 had the bruises before P#1 was admitted to the facility and the bruises were present during intake assessment. BHA CC said they had training on crisis prevention intervention but it was more like defense training. BHA CC said they were not allowed to restrain a patient without physician consent. BHA CC said it is not common for staff to be behind a closed door with a patient during a 1-1 observation. BHA CC explained that staff were to be seen at all times with a patient during a 1-1 observation.

A telephone interview was conducted with the Registered Nurse (RN) BB on 6/15/21 at 12:36 p.m. RN BB explained that P#1 told her when she was at the nursing station that a staff member assaulted her. RN BB further explained that she was not working at the facility the day the incident occurred but when she came in the next day, P#1 got up from her bed, came to her, and complained that staff had assaulted her. RN BB said that she spoke to BHA CC who witnessed the incident and BHA CC said it was accurate. RN BB explained that BHA CC stated she saw BHA KK picked up P#1, pulled her into the room, and shut the door. RN BB said P#1 had bruises that resembled fingerprints and she immediately notified her supervisor and physician. RN BB said the physician ordered an X-ray and her supervisor stated she would notify the state agencies. RN BB acknowledged that the fingerprints looked like someone had grabbed P#1. RN BB explained that BHA KK was placed on leave and not allowed to be around P#1. RN BB explained that if a patient was agitated, they were trained to make sure the patient was isolated and there was no audience, keep the milieus safe and secure. If the patient was combative, she would get an order for a PRN medication. RN BB said they were never taught to assault any patient.

An interview was conducted with the Registered Nurse (RN) HH on 6/15/21 at 1:53 p.m. RN HH explained that she arrived at the facility for her shift. P#1 reported that she was abused by a staff member but did not know the name of the staff. RN HH said that P#1 proceeded to show her multiple bruises and scratches she stated were done by the staff that assaulted her. RN HH explained that most of the bruises P#1 pointed out were recorded on intake. RN HH said however, there was a fingerprint bruising on P#1's back and a scratch on P#1's jaw. RN HH explained that while P#1 was describing the incident, P#1 punched her knees to the wall and squeezed her face tightly with her hands. RN HH said she was not present when the incident occurred. RN HH further explained the incident occurred during the day and she worked during the night shift. RN HH said she told the nurse working with her on the night shift to notify the doctor about the allegation, but she did not until 6:00 a.m. the next day. RN HH said the physician ordered an X-ray for P#1. RN HH said if a patient was screaming about being assaulted in her room, she would expect the staff who heard it to immediately go to the room.

A telephone interview was initiated with the Registered Nurse (RN) II on 6/16/21 at 10:00 a.m. RN II explained that she was one of the nurses on the floor. RN II said that P#1 was hyper-sexual and wanted to talk to her family. RN II said they attempted to contact P #1's family, but P#1's family did not want to talk to her. RN II explained when they told P#1 the family's response, she became upset and started throwing tantrums. RN II explained that P#1 was kicking at the day area and hitting BHA KK. RN II explained the medication nurse obtained a medication order and a code purple (evacuation) was called. RN II said the staff (staff member not identified by RN II) carried P#1 into her room and the medication Ativan (medication to reduce anxiety) 1 mg was administered to P#1. RN II explained that she left P#1 with BHA KK in the room. RN II said she heard P#1 crying in the room and went into the room to ask BHA KK if she wanted a break or support from another tech. RN II said BHA KK stated she was doing fine observing P#1. RN II said she notified the supervisor to ask BHA KK if she needed assistance. RN II explained that the supervisor said if BHA KK was okay she does not have to switch. RN II said she was not aware of any allegation of abuse or neglect until later in the evening at the end of her shift around 8:00 p.m.
RN II said she heard that P#1 was hurt from the night shift report. RN II said she told the night shift RN HH to handle the situation. RN II said the tech (RN II could not identify the name of the tech whom was female, because she did not know the tech's name) came to tell all the nurses that P#1 told the tech that she was abused by BHA KK while the nurses conducted end of shift reports. RN II said BHA CC did not tell her about P#1 allegation of abuse during her shift. RN II said she heard P#1 crying and thought P#1 only wanted to get out of her room. RN II said she went to check on her and did not witness P#1 assaulted. RN II stated that P#1 calmed down and did not notify her she was assaulted. RN II said she did not remember how to handle an agitated patient, but she was aware it is not right to put hands on a patient.

An interview took place with RN DD on 6/16/21 at 11:00 a.m. in the conference room. RN DD said that she had been working at the facility about three years. RN DD explained she had numerous roles and responsibilities at the facility that included supervisory and auditing medical records. RN DD said she was not at the facility when the incident occurred. RN DD said she was made aware of the incident the next day by RN BB who said P#1 alleged she was assaulted by staff at the facility. RN DD said she immediately did a skin assessment, incident report and took pictures of the bruises on P#1. RN DD said she asked P#1 to touch her shoulder and one of the bruises on her back was beyond P#1's reach. RN DD explained that she also observed what resembled a hand print on P#1. RN DD said she compared the scars and bruises on P#1 to her initial assessment and some of the scars seemed to have been present before she was admitted to the facility. RN DD stated she was concerned of P#1's bruises on her back and the hand print.
RN DD said she did an incident report, included her findings and a statement from BHA CC. RN DD explained she submitted the information to the facility's administration. RN DD explained that she trained the facility staff on crisis prevention intervention (CPI) and it is not a common practice at the facility to hold agitated patients. RN DD said if a patient is blowing off steam they would try to talk to the patient and move other patients to the group room. RN DD said the facility staff were trained on crisis prevention intervention during their orientation and annually. RN DD said the physician was notified about P#1 alleged assault and the physician ordered an X-ray. RN DD said the images revealed there were calluses and the fractures were old. RN DD said once she heard about the allegation, she immediately told BHA KK to leave the facility until the investigation was completed. RN DD said she would expect the facility's staff to immediately assess P#1 and start the process of investigating an alleged assault especially if the patient was in pain. RN DD said she would expect the staff to document on the progress note if a code purple was called. RN DD said that an order is needed from a physician before a patient can be placed on a 1-1 observation and documented on the patient medical record.

An interview with RN EE took place on 6/16/21 at 11:52 a.m. in the conference room. RN EE acknowledged she remembered P#1. RN EE explained that P#1 was not re-directable, combative, aggressive, hyper-sexual, and unpredictable. RN EE said that P#1 had to be monitored twenty-four (24) hours and her mental state had regressed since P#1's last admission. RN EE said she recalled P#1 was in her room on 5/27/21 at around 12:30 p.m. screaming at the staff and P#1 got a standing order PRN medication. RN EE said there were 2 nurses on the unit and she was the medication nurse and another staff member was the charge nurse (RN II). RN EE acknowledged they had no shift schedule on the unit and both nurses were in charge of the unit. RN EE explained that her role was to calm the patient down by administering the medication. RN EE said that when she went to P#1's room to administer medication she heard P#1 crying but did not witness an assault to P#1 by a staff member. RN EE stated that P#1 was not screaming because she got beaten up but was just agitated. RN EE said she did not see any bruises on P#1 when she administered the medication. RN EE said after she administered the medication she went back into the medication room and was not aware of any other incident that occurred. RN EE acknowledged that a code purple was called on the day the incident occurred, and she said it should have been documented in P#1's medical record.

A telephone interview was conducted with RN JJ on 6/16/21 at 12:41 p.m. RN JJ acknowledged she recalled P#1 and heard that P#1 harmed herself. RN JJ said she was the supervisor on the unit when the incident occurred. RN JJ explained her job responsibilities includes completing rounds in the building and making sure everything was okay. RN JJ acknowledged there was a code purple but she stated she arrived later and was not aware of any allegation of assault from P#1. RN JJ said the staff was attempting to get medications for P#1 because she was agitated and screaming. RN JJ said she could not recall if P#1 was on a 1-1 observation. RN JJ said if there was an allegation that a staff assaulted a patient, the patient had to be examined immediately, an incident report and statement from the staff had to be documented and the physician, patient's family, and state agencies had to be notified. RN JJ said that she didn't hear that staff hurt P#1 during the code purple and the allegation of assault only came out during the evening shift. RN JJ explained that it was unusual for staff to close a patient room while on a 1-1 observation. RN JJ said she was not aware if P#1's door was closed while being observed.


An interview took place with the Director of Compliance and Risk Management (DCR) (FF) on 6/16/21 at 1:03 p.m. DCR FF acknowledged that he recalled the incident with P#1. DCR FF explained that he was made aware of the incident by RN DD. DCR FF said they immediately suspended BHA KK pending the investigation and she was removed from the facility however, she resigned (6/9/21) before the investigation was completed. DCR FF said the RN DD documented the incident report, took a statement from BHA CC who said she witnessed the alleged assault, and spoke with the staff that had allegedly assaulted P#1 (BHA KK). DCR FF explained that BHA KK stated she didn't lay hands on P#1. DCR FF further explained that BHA KK said she was positioned in the doorway and the door to P#1's room was slightly open during the time of the incident. DCR FF said the conclusion after the investigation was that BHA CC's statement was credible, based on the pictures from P#1's reassessment something had happened in P#1's room but they are not aware of what occurred. DCR FF explained that he went through the whole surveillance video of the unit but could not see any video that was concerning because the incident had occurred in P#1's room. DCR FF said that there were no videos in the patient's room due to privacy concerns. DCR FF acknowledged that the allegation was substantiated during their internal investigation. DCR FF explained that whenever there was an allegation that a staff assaulted a patient his expectation is for the witness to report right away to the supervisor, department leader, and himself. DCR FF acknowledged that the patient room door should have remained open while P#1 was on a 1-1 observation with the staff. DCR FF said that the facility staff was trained on crisis prevention intervention (CPI) annually and during orientation. DCR FF further explained they intended to retrain all staff on CPI by 7/1/21 to prevent such an incident from happening again.

On 6/17/21 at 2:07 p.m. in a second interview with DCR FF to explain what the facility's policies meant by "All allegation for patient abuse, neglect and exploitation be reported immediately". DCR FF said his expectations were for the staff who witnessed abuse to report the allegation of patient abuse to the charge nurse within an hour and they should be investigated up through to the leadership.


A review of the facility's policy titled "Alleged Patient Abuse, Neglect and Sexual Exploitation", Policy Number RI. 009, last reviewed 1/20, revealed that it is the policy of the facility that all allegation of patient abuse, neglect, and exploitation be reported immediately and investigated within twenty-four (24) hours of the time the incident occurred.

Purpose:
1. To ensure patients are treated with dignity and respect in accordance with the patient's bill of rights and other applicable law
2. To ensure that incidents or allegations concerning patient neglect and or abuse are handled fairly, thoroughly, and expeditiously.
3. To protect the professional integrity of the hospital and its staff members.
Procedures.
1. Protocol- Alleged Abuse or Neglect Occurring within the Hospital setting.

An employee who hears from a patient or visitor or who observes a potential case of patient neglect and/ or abuse will immediately report it to the charge nurse. An incident report must also be completed regarding the incident. If an allegation has been made against a specific staff member, that individual will, at a minimum be reassigned to another unit. Depending upon the circumstance, the employee may also be suspended until an investigation can be completed.
The human resources director will be notified of the allegation against a specific employee and will review the employee's file for clearances and previous complaints.
The Director of Nursing (DON), Director of Clinical Services, and Risk Manager are to be notified of the allegation and will begin the initial investigation, including interviews with the patient, alleged abuser, patient witness, and staff witnesses.

The patient is to be interviewed by the DON, DCS, or risk manager and assessed for injuries by the charge nurse or DON. This assessment will be documented in the progress note. Any injuries are to be reported to the attending or on-call physician for further assessment and treatment.

Review of the facility's policy number RI-010, titled 'Abuse and/or Neglect of Patients', last reviewed 08/17, reveals it is established to prevent and rectify misconduct in a just and constructive manner to reduce the likelihood of recurrence and to protect patients from abuse. The organization supports and conforms to all state and federal guidelines for the protection of patients 'rights. No employee or intern will mistreat and/or neglect a patient. Further review reveals that any staff, student, or intern suspected of any of the above infractions will be investigated under this policy. If it is determined that the staff member physically, sexually, or verbally abused the patient in question or willfully neglected the patient(s), disciplinary actions will be enacted against him/her, up to and including termination of employment. Employees are informed of this policy by the speaker at the new employee and annual employee orientation, provided with a copy of the policy, and must sign an "Employee Acknowledgement of Abuse Policy" statement. Patient alleging (or staff suspecting) Abuse/Neglect will immediately notify administrator, Director of Clinical Services, and/ or Director of Nursing.

Review of the facility's incident report documented the alleged incident occurred on 5/27/21 at approximately 12:00 p.m. regarding P#1 and BHA KK. P#1 received a skin assessment by RN HH on 5/27/11 at 11:00 p.m. Further review of the incident report documented P#1's family was not contacted, but P#1's physician and a state agency were notified of the alleged abuse.