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VIOLATION: ABUSE (483.13(B)) Tag No: C0382

Based on record review of facility policies and procedures to protect patients from abuse/neglect, staff interview and review of the facility internal investigation for 1 of 1 incident of staff to patient alleged physical abuse (Patient 1), the facility administrative staff failed to take steps to prevent and protect patients. Facility census was 4 swing bed and 0 acute inpatients. The total sample was 4.

Findings are:

A. Review of the Medical Record Nursing Notes for Patient 1 dated 7/17/13 at 9:25 PM by Registered Nurse (RN)-A stated "staff did try to reason with pt [patient] --no success. Staff did pinch back only when she would pinch you. Staff never did spit in pt's face, when she did ours. Staff did hold pt's face when she hit at staff's face and hit glasses." Record review of the Discharge Summary for Patient 1 noted she was admitted on [DATE] from a nursing home with diagnosis of delirium, urinary tract infection and pneumonia. She was discharged back to the nursing home on 7/23/13.

B. Interview with RN-A on 9/25/13 at 2:15 PM revealed, "[Patient 1] became very combative. Not liking anyone taking care of [gender]. We get a lot of elderly and confused patients, just not someone this combative usually. I tried to work with [gender], all [gender] would say is "I can't hear you" when you tried to talk with [gender]. [Patient 1] pulled hair, scratched, kicked and tried to knock off my glasses. If we have patients with this kind of behaviors we send them out to someplace that deals with this kind of person....I guess no one would take [gender] because of the physical illness going on. It was after midnight about 2:00 AM (on 7/17/13) and I and a Nurse Aide went into change [gender] wet brief. [Gender] knocked my glasses off, I took [gender] by the chin (to get her attention) and said "Don't knock off my glasses they are costly. [Patient 1] stopped for a minute then started scratching, hitting, pinching and tried to bite us. I was at my wits end and I pinched her skin on top of her hand. [Gender] said, 'Ouch, that hurts me." I said, "That hurts us when you do that too." "All the staff had trouble dealing with this patient, not just the night shift. I think it would be good for all of us to have a refresher on how to deal with people like this."

Director of Nursing (DON) talked to me the next afternoon when I came in. I was told that this could be viewed as abuse and that they may have to report it. "I told [gender], you have to do what you have to do. I was honest, I didn't do it as abuse, I was just at my wits end." "I worked that night and then was on vacation. [Gender] called me about the disciplinary action and I came in when got back from vacation. I was suspended the 2nd week in September, I think." (9/9/13 through 9/15/13).

C. Review of the staffing schedule from 7/17/13 through 9/8/13 revealed that RN-A worked the following night shifts (5:00 PM-5: 00 AM) before the suspension took place:
- 7/18/13, 7/30/13
- 8/2/13, 8/3/13, 8/5/13, 8/6/13, 8/7/13, 8/15/13, 8/17/13, 8/20/13, 8/21/13, 8/22/13, 8/28/13, 8/29/13, 8/30/13, 8/31/13
- 9/4/13, 9/5/13, 9/7/13, 9/8/13

D. Interview with the DON on 9/25/13 at 9:25 AM, "I came in the next day [RN-A] was scheduled to work which was 7/18/13. I counseled [RN A] that could not do that to a patient and it could be looked at as abuse. I informed [gender] that I may have to report it to the State. I told [gender] just step away, get more help or have someone else try it. I told [RN-A] to have limited contact with that patient that night and not to be alone with the patient. [RN-A] went ahead and worked that night." [RN-A] started vacation the next 10 days after this shift. By the time the vacation was done the investigation was completed. I called [gender] in and did a verbal warning, performance improvement plan, education and a suspension. We didn't set a date that the suspension or education needed to be done." When asked if the DON tried to replace RN-A for the 7/18/13 shift, the DON stated, "Honestly I didn't try to get anyone else to work." "We have a cross of swing bed patients, observation patients and acute inpatients here."

E. Record review of undated facility policy titled "Abuse and Neglect" states (under section F) that "When any of the facility staff discovers or witnesses abuse, the first action must be to intervene to protect the vulnerable party." Under section H the policy states that "In cases of abuse/neglect the person representing the facility (administrator, DON) is to respond in the following manner:
1. Determine and implement further interventions that may be needed for the protection of the resident. Interventions may include:
a. termination, suspension or reassignment of staff involved ....... d. prevention of contact with individual involved."

The facility allowed the suspected abuser, RN-A to continue to care for the patient after the DON knew of the alleged physical abuse (pinching) by RN-A to Patient 1 before determination and investigation/remedial action had occurred to ensure the protection of patients.