The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on staff interviews, personnel file review, review of facility abuse policy, review of facility internal abuse investigation and medical record reviews, the facility failed to ensure administrative staff implemented the facility abuse policy to protect patients.. 1 of 4 sampled Swing Bed patients (Patient 3) was abused. The patient was physically abused by Registered Nurse (RN) A. The facility census was 3 (Patient ' s 2, 3, and 36) during the night shift beginning on 3/21/15 at 5:00 AM and ending on 3/22/15 at 5:00 AM when the abuse occurred. RN A continued to finish the shift providing patient care after the abuse was reported to the Director of Nursing (DON).This finding placed all patients at risk for potential abuse by RN A.

Findings are:

A. On 2/25/15 the State Agency received the facility internal investigation of physical and verbal abuse of Patient 3 by RN A on 3/21/15. The report identified RN 'C' and Nurse Aide (NA) ''B' as having witnessed the abuse. The report states the employee was "placed on suspension".

B. Staff interview with RN C on 3/24/15 at 3:00 PM revealed he/she was assigned to Patient 3 on the night shift. The shift began on 2/21/15 at 5:00 PM and ended at 5:00 AM on 3/22/15. RN C stated Patient 3 was "disoriented and hallucinating angrily grabbing at what [gender] was seeing." RN C reported he/she was working with 2 other staff, RN A and NA B. The 3 staff were attempting to get Patient 3 from a recliner into a wheelchair for transport back to the patient's room a little after Midnight. RN C said the time was around 12:20 AM to 12:40 AM. RN C stated Patient 3 would not keep his/her feet on the wheelchair pedals and kept sliding out of the wheelchair. RN C stated "several times we boosted the patient up then [name of RN A] got frustrated and slapped the patient's left leg and poked [his/her] finger in [name of Patient 3's] chest, gritted her teeth and said 'Now you stop that, you are not even trying'." RN C stated RN A was "clearly angry." RN C stated that RN A did not go into Patient 3's room the rest of the night. RN C did confirm that RN A continued to finish working the remainder of the shift taking care of Patient 2 after the witnessed abuse took place.
RN C stated he/she reviewed the facility abuse policy and recalls seeing the directive to report immediately. RN C stated "I called the DON around an hour after the incident, the DON said it would be addressed and did not give me any other instructions."

C. Telephone interview with NA B on 3/25/15 at 4:55 PM revealed that on 2/21/15 Patient 3 was in the recliner at the nurses ' station late in the evening "around 10 or 11 PM." The patient's nurse was RN C. The 3 staff, RN A, RN C and NA B were trying to get Patient 3 into a wheelchair to return to the room to go to bed. The patient kept kicking his/her legs off the wheelchair. RN C was behind the wheelchair. RN A was on the right and NA B was on the left side of the patient. The patient was being uncooperative. NA B recalled seeing RN A strike the patient's leg with the palm of the hand and stated RN A " was irritated and agitated with [name of Patient 3]. " NA B stated " I was at eye level so I could see it clearly. " The NA said RN A ' s tone was " threatening. "

D. Medical record review of Patient 3's medical record on 3/24/15 revealed he/she was admitted for acute psychosis on 2/17/15. Psychosis is a symptom or feature of a mental illness typically characterized by radical changes in personality, impaired functioning, and a distorted or nonexistent sense of objective reality. Patient 3 was changed from inpatient status on admission to Swing Bed on 2/21/15 at 10 AM. RN C documented that on 2/22/15 at 12:40 AM "Staff assists pt [patient] to pivot transfer from chair to wheelchair, pt has difficulty standing" and further notes "Pt disoriented to person, time, and place, unable to be reoriented. Hallucinations continue, pt grabs @ the air."

E. Review of facility provided census records for the night shift 2/21 -2/22/15 from 5:00 PM to 5:00 AM revealed a census of 3 (Patient 2, 3, and 36). Record review of Patient 2's medical record on 3/25/15 revealed documentation entered by RN A on 2/22/15 at 2:00 AM, 3:30 AM, 4:45 AM further confirming RN A continued to care for patients after the witnessed abuse took place. Review of Patient 36's medical record identified the patient was discharged ,d+[DATE] at 8:35 AM. The record revealed no documentation by RN A.

F. Interview with the DON on 3/24/15 at 2:30 PM confirmed the charge nurse, RN C, called and reported the abuse of Patient 3 by RN A around 2 AM on 2/22/15. The DON stated RN A continued to work "even after the abuse of [name of Patient 3] occurred and stated [Name of RN A] should not have been doing patient care." The DON stated RN A was suspended on 2/22/15 and " never worked here again. " On 3/16/15 RN A was given the option to resign or be terminated. RN A resigned on 3/16/15.

G. Record review of the personnel file for RN A on 3/25/15 revealed the RN had a written notice of verbal counseling on 7/19/13 for pinching a patient on 7/17/13. The last education taken on abuse was 2/25/15. The program title was "Identifying and Assessing Elder Abuse and Neglect. The file notes the nurse was terminated 3/16/15.

H. Record review of undated facility policy titled "Swing Bed/LTC [Long Term Care] Patient Rights" states under the section titled "Abuse" that "You have the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion."

I. Record review of facility policy titled "Abuse and Neglect" last revised July 2009 and last reviewed March 2015 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 "G" the policy states that "After intervention or if abuse is suspected, the staff member must report it to their charge nurse immediately. The charge nurse will take any immediate action necessary and report the incident to the DON, who is responsible to contact the Administrator. If the DON is not available, the administrator should be contacted immediately. Under section "H' the policy directs that the administrator or DON is to respond with interventions needed for the protection of the resident. The interventions include "prevention of contact with individual involved if appropriate by removing suspected staff from schedule or patient care related duties."