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.

FLAGET MEMORIAL HOSPITAL 4305 NEW SHEPHERDSVILLE ROAD BARDSTOWN, KY 40004 Nov. 27, 2017
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have a system in place that ensured nursing staff effectively evaluated patient care to prevent abuse for one (1) of ten (10) sampled patients, Patient #1.

Staff interviews revealed staff witnessed contract Security Guard (SG) #2 call Patient #1 a "M-----r F-----r" and display aggressive body language while interacting with the patient. Instead of evaluating the need to remove SG #2 from patient care, staff left the room. A short time later, the Charge Nurse walked past Patient #1's room, witnessed the SG grab Patient #1 by the neck and forcefully pushed the patient back down on the stretcher. At that time, the Charge Nurse determined it was necessary to remove SG #2 from the patient's room; however, the Charge Nurse allowed SG #2 to continue to work in other patient care areas until the end of his shift.

Refer to A 0395.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have a system in place that ensured nursing staff effectively evaluated patient care to prevent abuse for one (1) of ten (10) sampled patients, Patient #1. Interviews revealed staff witnessed contracted Security Guard (SG) #2 call Patient #1 a "M----r F----r" and display aggressive body language while interacting with Patient #1. However, instead of evaluating the need to remove SG #2 from patient care, staff left the room. A short time later, the Charge Nurse walked past Patient #1's room and witnessed the SG grab Patient #1 by the neck, and forcefully pushed the patient back down on the stretcher. At that time, the Charge Nurse determined it was necessary to remove SG #2 from the patient's room; however, the Charge Nurse allowed SG #2 to continue to work in other patient care areas until the end of his shift.

The findings include:

Review of the facility's Charge Nurse Job Description, not dated, revealed the Charge Nurse was responsible for the direct supervision of personnel practicing on the nursing units. The Charge Nurse would use logical, systematic approach to problems and problem solving. In addition, to maintain unit professional standards and hold staff accountable for behaviors and attitudes.

Review of the facility's Director of Nursing/Director of Emergency Services Job Description, not dated, revealed the Director was responsible for directing, planning, coordinating, monitoring, and evaluating nursing care and patient outcomes. Further review revealed the director was responsible for maintaining and evaluating employee performance and staff development. The Director was also responsible for the oversight of staff education, supervision, and evaluation that included nursing, technicians, billing, and documentation specialists.

Review of the facility's Chief Nursing Officer (CNO) Job Description, not dated, revealed the CNO was responsible for hospital patient care, overseeing nursing and other clinician care in a way that strategically created value to the system and the community.

Review of the facility's policy, Patient Rights and Patient Responsibilities, revised December 2016, revealed patients had the right to receive treatment in a safe environment free from neglect, exploitation, abuse, and to be assisted in accessing Protective Services and/or Advocacy Services, as appropriate.

Review of the facility's policy, Abuse, Exploitation, Human Trafficking of Patients, revised February 2016, revealed verbal abuse was defined as the use of oral, written, or gestured language that included disparaging and derogatory terms. Examples of verbal abuse included threats of harm, saying things to frighten a person, degrading remarks and name-calling. Physical abuse included hitting, slapping, kicking, shoving, choking, biting, pinching, and assault with an object or weapon. It also included controlling behavior through corporal punishment. If suspicion or known abuse was identified, the employee would notify the hospital social worker, immediate supervisor, house supervisor, or administrator on call, who would in turn assure a referral was made to the Department of Community Based Services. If suspicion or known abuse were identified in the emergency department, staff would make the referral to community-based services. Any employee suspected of abuse would be removed from providing direct patient care during the pending investigation. All alleged violations of abuse, mistreatment, injuries of unknown source, or misappropriation of patients property would be immediately reported to the Administrator or their designee for required investigation. The results of the investigation would be reported to the Administrator within five (5) working days of the incident. The Chief Operating Officer or designee would initiate follow-up corrective action and notification of appropriate state licensing agencies. All new employees would receive training on the facility's Abuse Policy and ongoing in-service through learning modules on what constituted abuse, neglect, and exploitation, methods to report allegations of abuse without fear of reprisal, and how to recognize signs of burnout and stress that may lead to abuse. According to the policy, screening of new employees criminal background checks would be conducted through the State Police. Skilled Nursing employees would have screening through the Nurse Aide Registry.

Review of Patient #1's Emergency Department documentation, dated 09/21/17, revealed the patient arrived at the hospital by ambulance. The patient was unarousable and staff used an ammonia capsule to arouse the patient. The physician noted Patient #1 was intoxicated and ordered a blood alcohol test, which resulted 173 milligrams per deciliter (normal findings: 0-50 milligrams per deciliter).

Interview with Registered Nurse (RN) #4, on 11/17/17 at 11:50 AM, revealed Patient #1 entered the Emergency Department via ambulance and was unresponsive. Staff used an ammonia capsule to arouse the patient and the patient awakened from a drunken sleep and began cursing for staff to get the ammonia capsule away from him/her. RN #4 stated contracted SG #2 was in the room along with several other staff tending to the patient. She stated she left the room but heard SG #2 and the patient yelling at each other and once SG #2 left the room, the patient calmed down and went back to sleep. RN #4 stated she did not witness SG #2 lay his hands on the patient but believed the Charge Nurse was in the room at the time. She stated she did not determine the need to intervene to prevent or protect Patient #1 from further abuse.

Interview with the Certified Nursing Assistant (CNA), on 11/17/17 at 12:10 PM, revealed she heard Patient #1 and SG #2 yelling at each other. She stated she heard the SG say to Patient #1 "you want a piece of me you little d--k". However, she did not determine the need to intervene. The CNA stated she saw the SG put his hands on the patient's throat and it was very upsetting to her.

Interview with Registered Nurse (RN) #3, on 11/17/17 at 11:57 AM, revealed he witnessed Patient #1 and the SG #2 cussing each other; however did not determine the need to intervene. He stated the patient told SG #2 he/she was going to beat him up. RN #3 witnessed the SG put his hands around Patient #1's throat and then the SG told the patient to "shut the f--k up." He stated the Charge Nurse told the SG to leave the room and for staff to remove the SG before he went off. According to RN #3, the facility protected patients from abuse by removing the perpetrator from the area.

Interview with the Charge Nurse, on 11/17/17 at 3:39 PM, revealed he supervised the care nursing staff provided to patients. He stated nursing staff was responsible for ensuring patients received safe patient care and if staff witnessed abuse, they should intervene to protect the patient. He stated on 09/21/17, Patient #1 arrived via ambulance for treatment related to alcohol intoxication. Staff used an ammonia capsule to arouse Patient #1 and the patient became verbally abusive. The Charge Nurse stated SG #2 was in the room assisting with patient care at that time and the patient and the SG were cursing at each other. He heard the SG call Patient #1 a "M----r F----r" and displayed excessive and aggressive body language while interacting with the patient. In addition, the Charge Nurse stated the SG told the patient "if you do not lay down I will put you down"; however, he did not determine the need to remove the SG from patient care at that time or address his inappropriate behavior with Patient #1. The Charge Nurse stated he left the room to perform other duties and later walked past Patient #1's room, witnessed the SG grab Patient #1 by the neck and forcefully pushed the patient back down on the stretcher, while continuing to curse at the patient. He stated, at that time, he assessed SG #2's behavior as inappropriate and removed him from the patient's room and felt the issue was over after he told the SG #2 not to return to the patient's room. The Charge Nurse stated he informed the House Supervisor of the SG's behavior sometime after the incident occurred; however, after he informed the House Supervisor she did not determine the need to remove the SG from patient care. The Charge Nurse stated he did not escalate the witnessed abuse to the Administrator on call because in his nursing judgement, he had addressed the issue by not allowing the SG back into the patient's room, even though the SG still had contact with other patients in the facility.

Interview with the contracted security company's Regional Manager, on 11/21/17 at 11:35 AM, revealed the company did not perform routine abuse registry checks on their potential employees. She stated the company only completed background checks on employees. The contracted security company's Regional Manager verified SG #2 had previously employment as a nursing assistant.

Review of the Kentucky Board of Nursing On-Line Validation results, dated 11/27/17, for contracted Security Guard (SG) #2, revealed the SG was a State Registered Nursing Assistant and listed on the California Abuse Registry.

Review of the California Department of Public Health Verification on 11/27/17, revealed SG #2 was a Certified Nurse Assistant and the status of his certification was listed as Revoked, Not Employable.

Interview with the SG #2, on 11/17/17 at 4:08 PM, revealed on 09/21/17, nursing staff was having a hard time providing medical care to Patient #1 due to his/her behavior. He stated he went to the room to assist and did not remember cursing at the patient but a nurse told him he had cursed the patient. The SG stated he was aware staff was not to curse at the patients. He stated the patient cursed at staff and sat up on the stretcher and because he did not want things to escalate out of hand, he pushed the patient back down on the stretcher. He stated he placed his hands on the patient's neck/shoulder area to push the patient back down on the stretcher. The SG stated the Charge Nurse told him to leave the room, so he left and continued to finish out his duties by making rounds inside and outside the facility. SG #2 stated the facility did not interview him regarding the incident in order to get his side of the story; however, the next day his contracted company supervisor directed him not to return to the facility. He stated his contracted company supervisor interviewed him and then fired him.

Interview with House Supervisor (HS), on 11/17/17 at 1:31 PM, revealed she supervised the care nursing staff delivered to patients. She stated the Charge Nurse informed her on 09/21/17, during the time she was rounding in the Emergency Department that SG #2 had aggravated, cursed, and put his hands on Patient #1. The HS stated because she assumed the SG was just restraining the patient due to the patient's belligerent behavior, there was no need to remove the SG from patient care. She stated SG #2 remained in the facility and continued to perform his routine duties until his shift ended. She stated she found out from the Chief Nursing Officer, on 11/17/17, that staff reported the SG had choked the patient during the incident. According to the HS, she would have removed the SG from the facility and called the Administrator on call in order to protect patients from abuse, if she had identified the SG actions as verbal and physical abuse. She stated she did not assess or determine the need to re-educate staff on the facility's abuse policy and procedure requirements.

Interview with the Emergency Department Director (EDD), on 11/17/17 at 2:39 PM, revealed she supervised the nursing care staff provided to patients; however, had not identified staff lacked knowledge of the facility's abuse policy and procedure prior to the incident on 10/21/17. She stated after review of the incident between the security guard and Patient #1, it was determined staff failed to remove SG #2 promptly from patient care after they witnessed him verbally and physically abuse Patient #1. She stated staff lacked the knowledge of the abuse policy and procedure in order to act accordingly. She stated it was important for nursing leaders to supervise patient care in order to ensure staff reported abuse timely and removed the alleged perpetrator from the building promptly.

Interview with the Chief Operating Officer/Chief Nursing Officer (COO/CNO), on 11/27/17 at 11:25 AM, revealed she supervised the nursing care provided to patients in the facility. She stated nursing staff did not notify her immediately regarding the allegation of abuse, which was concerning, and found out about the allegation after reading the facility incident reports on the morning of 09/21/17. She stated it was determined staff did not report the incident timely or remove the security guard from the building to protect patients from further potential abuse. The CCO/CNO stated the facility did not have abuse allegations often and believed that influenced the staff's behavior of not reporting timely. In addition, she stated the facility should have re-educated staff on the facility's abuse policy and procedure, since staff did not follow it accordingly. The COO/CNO stated she was not involved in the development or review of the security company's contracts to ensure contracted staff, assigned to her facility, was not listed on an abuse register. She stated she was not aware SG #2 was listed on the California Abuse Registry and in order to protect patients from abuse; she would not have allowed him to work in the facility, if she had known.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, interview, record review, and review of the facility's policy, it was determined the governing body failed to ensure the facility evaluated their contracted security services. The facility's governing body failed to implement an effective system to ensure contracted security staff, that delivered services in patient care areas, did not have a history of patient abuse. Interview with the contracted security company's Regional Manager, verified SG #2 had previously employment as a nursing assistant. Review of the Kentucky Board of Nursing On-Line Validation results, dated 11/27/17, for contracted Security Guard (SG) #2, revealed the SG was a State Registered Nursing Assistant and listed on the California Abuse Registry. Review of the California Department of Public Health Verification on 11/27/17, revealed SG #2 was a Certified Nurse Assistant and the status of his certification was listed as Revoked, Not Employable.

In addition, the facility's governing body failed to ensure contracted employees were trained on the facility's abuse policy and procedures in order for patients to receive services in a safe and effective manner for one (1) of ten (10) sampled patients, Patient #1.

Refer to A 084.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on observation, interview, record review, and review of the facility's policy, it was determined the facility's governing body failed to evaluate and implement an effective system to ensure contracted security staff, that delivered services in patient care areas, did not have a history of patient abuse for one (1) of ten (10) sampled patients, Patient #1.

Interview with the contracted security company's Regional Manager, verified SG #2 had previous employment as a nursing assistant.

Review of the Kentucky Board of Nursing On-Line Validation results, dated 11/27/17, for contracted Security Guard (SG) #2, revealed the SG was a State Registered Nursing Assistant and listed on the California Abuse Registry.

Review of the California Department of Public Health Verification on 11/27/17, revealed SG #2 was a Certified Nurse Assistant and the status of his certification was listed as Revoked, Not Employable.

Interview with the Charge Nurse revealed Patient #1 arrived via ambulance on 09/21/17, for treatment related to alcohol intoxication. Staff used an ammonia capsule to arouse Patient #1 and the patient became verbally abusive. Security Guard (SG) #2 was in the room assisting with patient care at that time, and the patient and the SG were cursing at each other and the Charge Nurse heard the SG call Patient #1 a "M----r F----r". He stated the SG also displayed excessive and aggressive body language while interacting with Patient #1. The Charge Nurse left the room to perform other duties, later walked past Patient #1's room and witnessed the SG grab Patient #1 by the neck and forcefully pushed the patient back down on the stretcher.

Interview with Governing Body Board of Director #1, on 11/27/17 at 1:10 PM, revealed he could not remember any data regarding contracted services being evaluated during a board meeting or the incident with Patient #1 and Security Guard #2. If the incident had been brought to the Governing Body's attention, he would have wanted more information and directed leaders to address the situation. He stated patient safety was very important and this incident was concerning to him.

In addition, the facility's governing body failed to ensure contracted employees were trained on the facility's abuse policy and procedures, in order for patients to receive services in a safe and effective manner.

The findings include:

Review of the facility's Quality, Safety, and Performance Improvement (QAPI) Policy, revised June 2016, revealed the Governing Body had the ultimate responsibility and accountability for the quality, safety of care, treatment, and services; therefore, the existence of the Quality, Safety and Performance Improvement Plan. The goals of the plan were to consistently measure, monitor, evaluate, and improve the delivery, effectiveness, efficiency, and outcomes of clinical care, treatment, and services. The scope of the plan encompassed the current quality and safety related regulatory requirements and accrediting standards under each hospital license. Data would be collected from many sources, including employees, patients, volunteers, contract staff, and licensed independent practitioners. Data would be compiled in usable formats and through data analysis, current performance, and performance over time, would be evaluated to identify patterns, trends, and casual variances. The administration and leaders would be directly responsible for the safety and quality of care, treatment, and services, which included may factors such as the provision of competent staff and other care providers, identifying educational needs, and ensuring that education and facility wide learning for quality improvement took place.

Review of the facility's policy, Patient Rights and Patient Responsibilities, revised December 2016, revealed patients had the right to receive treatment in a safe environment free from neglect, exploitation, abuse, and to be assisted in accessing Protective Services and/or Advocacy Services, as appropriate.

Review of the facility's policy, Abuse, Exploitation, Human Trafficking of Patients, revised February 2016, revealed verbal abuse was defined as the use of oral, written, or gestured language that included disparaging and derogatory terms. Examples of verbal abuse included threats of harm, saying things to frighten a person, degrading remarks, and name-calling. Physical abuse included hitting, slapping, kicking, shoving, choking, biting, pinching, and assault with an object or weapon. It also included controlling behavior through corporal punishment. If suspicion or known abuse was identified, the employee would notify the hospital social worker, immediate supervisor, house supervisor, or administrator on call, who would in turn assure a referral was made to the Department of Community Based Services. If suspicion or known abuse were identified in the emergency department, staff would make the referral to community-based services. Any employee suspected of abuse would be removed from providing direct patient care during the pending investigation. All alleged violations of abuse, mistreatment, injuries of unknown source, or misappropriation of patients property would be immediately reported to the Administrator or their designee for required investigation. The results of the investigation would be reported to the Administrator within five (5) working days of the incident. The Chief Operating Officer or designee would initiate follow-up corrective action and notification of appropriate state licensing agencies. All new employees would receive training on the facility's Abuse Policy and ongoing in-service through learning modules on what constituted abuse, neglect, and exploitation, methods to report allegations of abuse without fear of reprisal, and how to recognize signs of burnout and stress that may lead to abuse. According to the policy, screening of new employees criminal background checks would be conducted through the State Police, and Skilled Nursing employees would have screening through the Nurse Aide Registry.

Review of Patient #1's Emergency Department documentation, dated 09/21/17, revealed the patient arrived at the hospital by ambulance. The patient was unarousable and staff used an ammonia capsule to arouse the patient. The physician noted Patient #1 was intoxicated and ordered a blood alcohol test. The results were 173 milligrams per deciliter (normal findings: 0-50 milligrams per deciliter).

Interview, on 11/17/17 at 3:39 PM, with the Charge Nurse, revealed the facility used contracted Security Guards in the emergency department. He stated their role was to sit with patients that were suicidal, help with crisis-situations, monitor the registration desk to help with patient flow, and perform safety rounds inside and outside the facility. He stated Patient #1 arrived via ambulance on 09/21/17, for treatment related to alcohol intoxication and staff used an ammonia capsule to arouse the patient and he/she became verbally abusive. The Charge Nurse stated Security Guard (SG) #2 was in the room assisting with patient care, and the patient and the SG were cursing at each other and he heard the SG call Patient #1 a "M----r F----r". He stated the SG also displayed excessive and aggressive body language while interacting with Patient #1. In addition, the Charge Nurse stated the SG told the patient "if you do not lay down, I will put you down". He stated he did not remove the SG from patient care at that time or address his inappropriate behavior with Patient #1. The Charge Nurse stated he left the room to perform other duties and later walked past Patient #1's room and witnessed the SG grab Patient #1 by the neck and forcefully pushed him/her back down on the stretcher, while cursing at the patient. He stated this behavior was inappropriate and he removed the SG from the patient's room. According to the Charge Nurse, he felt the issue was over and told SG #2 not to return to the patient's room. The Charge Nurse stated he informed the House Supervisor sometime after the incident occurred and the House Supervisor did not remove the SG from patient care, and the SG continued his routine duties until the end of his shift. The Charge Nurse stated he did not escalate the witnessed abuse to the Administrator on call because he believed the incident was addressed by not allowing the SG back into the patient's room.

Interview, on 11/21/17 at 10:45 AM, with the Risk Manager (RM), revealed on 09/21/17, she reviewed facility incident reports and found an incident of verbal and physical abuse by SG #2 that occurred in the Emergency Department around 3:20 AM. The RM stated interviews with staff revealed the SG cursed and choked the patient; however, staff did not promptly remove the security guard from the building and failed to notify the Administrator on call of the incident. According to the RM, SG #2 was a contracted Security Guard and she let the contracted company interview the guard about the incident. She stated the hospital staff and contracted security guards were not re-educated on the facility's abuse policy and procedure after the incident. The RM stated leadership did not develop an action plan that addressed staff's failure to report the abuse timely, remove the SG promptly from patient care, or provide re-education on the abuse policy and procedure. She stated it was important for patient safety that staff report abuse and remove the alleged perpetrator from patient care immediately.

Interview, on 11/21/17 at 11:35 AM, with the contracted security company's Regional Manager, revealed the company did not perform routine abuse registry checks on their potential employees, only criminal background checks. The Regional Manager stated the facility identified in February 2017, that the contracted staff, that she employed, had not received abuse training, but did not evaluate the practice of not performing abuse registry checks. She stated the facility began requiring their contracted staff attend hospital orientation after hire in order to receive abuse training, in February 2017. However, she could not say if the contracted employees hired before February 2017 received abuse training. The Regional Manager revealed the company did not have evidence they had provided abuse training to three (3) of their officers contracted to work in the facility, hired before February 2017. She stated the facility had not requested to audit their employee files to ensure contracted staff did not have a history of abuse in order to ensure patients received safe care and services. She stated on 9/21/17, facility staff informed her SG #2 had verbally, and possibly physically, abused a patient in the Emergency Department. According to the Regional Manager, she interviewed SG #2; however, his story did not match the information staff reported, so they fired him. She stated the guard should have removed himself from the situation. The RM stated after the incident with SG #2, the company had discussions with the facility about the possibility of allowing contracted security guards access to the annual facility computer based learning module on abuse so they could receive on going abuse education. She stated no decision had been made. The contracted security company's Regional Manager verified SG #2 had previously employment as a nursing assistant.

Review of the Kentucky Board of Nursing On-Line Validation results, dated 11/27/17, for contracted Security Guard (SG) #2, revealed the SG was a State Registered Nursing Assistant and listed on the California Abuse Registry.

Review of the California Department of Public Health Verification on 11/27/17, revealed SG #2 was a Certified Nurse Assistant and the status of his certification was listed as Revoked, Not Employable.

Review of the Board of Directors meeting minutes, dated February, May, August, and October 2017, revealed the minutes did not include an agenda item for the governing body to review QAPI's evaluation of contracted services.

Interview with the Director of Quality, on 11/27/17 at 2:18 PM, revealed she had not collected data or reported findings to the Governing Body related to contracted services. She stated the facility determined, on 11/27/17, the contracted security guards, hired before February 2017, had not received abuse training. In addition, the contracted security company had not ensured employees assigned to work in the facility did not have a history of abuse. The Director of Quality stated the role of the Quality Department and the Quality Assurance Performance Improvement Plan was to ensure the facility was evaluating services and providing quality care that was safe.

Interview with Governing Body Board of Director #1, on 11/27/17 at 1:10 PM, revealed he could not remember any data regarding contracted services being evaluated during a board meeting or the incident with Patient #1 and SG #2. He stated if the incident had been brought to the Governing Board's attention, he would have wanted more information and would have directed leaders to address the situation. He stated patient safety was very important and the incident was concerning to him.

Interview with Governing Body Board of Director #2/President/ Interim Chief Operating Officer, on 11/27/17 at 1:00 PM, revealed the incident with SG #2 and Patient #1 had not been discussed during the Governing Body's meetings; however, it would be discussed at the next meeting. He stated the contracted security services had not been evaluated, as far as he could remember, to ensure contracted staff did not have a history of abuse. He stated quality and patient safety was important.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview, record review and review of the facility policy it was determined the facility failed to have an effective system in place to ensure patients were protected from verbal and physical abuse for one (1) of ten (10) sampled patients, Patient #1.

Per interviews, the facility used contracted Security Guards in the emergency department and on 09/21/17, Patient #1 arrived via ambulance for treatment related to alcohol intoxication and Security Guard (SG) #2 was in the room assisting with patient care and he and the patient were cursing at each other. SG #2 called Patient #1 a "M----r F----r" and displayed aggressive body language while interacting with Patient #1. The SG told the patient "if you do not lay down I will put you down". Staff did not remove the SG from patient care at that time or address his inappropriate behavior with Patient #1. Staff later walked past Patient #1's room, witnessed the SG grab Patient #1 by the neck, and forcefully push him/her back down on the stretcher while cursing at the patient. Staff told the Security Guard to leave the patient's room but did not immediately inform the House Supervisor of the incident. After reporting the incident to the House Supervisor, she did not remove the SG from patient care to prevent further abuse and the SG continued his routine duties until the end of his shift. Per continued interviews, the facility did not audit the contracted security company employee files to determine if the company was completing abuse registry checks.

Interview with the contracted security company's Regional Manager, verified SG #2 had previous employment as a nursing assistant.

Review of the Kentucky Board of Nursing On-Line Validation results, dated 11/27/17, for contracted Security Guard (SG) #2, revealed the SG was a State Registered Nursing Assistant and listed on the California Abuse Registry.

Review of the California Department of Public Health Verification on 11/27/17, revealed SG #2 was a Certified Nurse Assistant and the status of his certification was listed as Revoked, Not Employable.


Refer to A 0145.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure patients were protected from verbal and physical abuse for one (1) of ten (10) sampled patients, Patient #1.

Interview with the Charge Nurse revealed on 09/21/17, Patient #1 arrived via ambulance for treatment related to alcohol intoxication. Contracted Security Guard (SG) #2 was in the room assisting with patient care, and the patient and the SG were cursing at each other and he heard the SG call Patient #1 a "M----r F----r". He stated the SG also displayed aggressive body language while interacting with Patient #1. The Charge Nurse stated the SG told the patient "if you do not lay down I will put you down". The Charge Nurse did not remove the SG from patient care at that time or address his inappropriate behavior with Patient #1. The Charge Nurse stated he left the room and later walked past Patient #1's room and witnessed the SG grab Patient #1 by the neck and forcefully pushed the patient back down on the stretcher and told SG #2 to leave the patient's room. The Charge Nurse stated he did not immediately inform the House Supervisor of the incident and after reporting the incident to the House Supervisor, she did not remove the SG from patient care and the SG continued his routine duties until the end of his shift.

Interview with the Chief Operating Officer/Chief Nursing Officer (COO/CNO) revealed she found out about the allegation of abuse after reading the facility incident reports on the morning of 09/21/17. She stated it was determined staff did not report the incident timely or remove the security guard from the building to protect patients from further potential abuse. She stated the facility should have developed an action plan and re-educated staff on the facility's abuse policy and procedure, since staff did not follow it accordingly. The COO/CNO was not involved in the development of the contracts for the security guards and assumed the contracted company completed abuse registry checks on all potential employees since they worked in a healthcare facility.

Interview with the Quality Director and the facility's Human Resources Business Partner revealed they did not audit the contracted security company's employee files to determine if the company was completing abuse registry checks. They stated completing an abuse registry check ensured the employee was eligible to work in the facility and protected patients from potential abuse.

Interview with the contracted security company's Regional Manager, verified SG #2 had previous employment as a nursing assistant.

Review of the Kentucky Board of Nursing On-Line Validation results, dated 11/27/17, for contracted Security Guard (SG) #2, revealed the SG was a State Registered Nursing Assistant and listed on the California Abuse Registry.

Review of the California Department of Public Health Verification on 11/27/17, revealed SG #2 was a Certified Nurse Assistant and the status of his certification was listed as Revoked, Not Employable.

The findings include:

Review of the facility's policy, Patient Rights and Patient Responsibilities, revised December 2016, revealed patients had the right to receive treatment in a safe environment free from neglect, exploitation, abuse, and to be assisted in accessing Protective Services and/or Advocacy Services, as appropriate.

Review of the facility's policy, Abuse, Exploitation, Human Trafficking of Patients, revised February 2016, revealed verbal abuse was defined as the use of oral, written, or gestured language that included disparaging and derogatory terms. Examples of verbal abuse included threats of harm, saying things to frighten a person, degrading remarks, and name-calling. Physical abuse included hitting, slapping, kicking, shoving, choking, biting, pinching, and assault with an object or weapon. It also included controlling behavior through corporal punishment. If suspicion or known abuse was identified, the employee would notify the hospital social worker, immediate supervisor, house supervisor, or administrator on call, who would in turn assure a referral was made to the Department of Community Based Services. If suspicion or known abuse were identified in the emergency department, staff would make the referral to community-based services. Any employee suspected of abuse would be removed from providing direct patient care during the pending investigation. All alleged violations of abuse, mistreatment, injuries of unknown source, or misappropriation of patients property would be immediately reported to the Administrator or their designee for required investigation. The results of the investigation would be reported to the Administrator within five (5) working days of the incident. The Chief Operating Officer or designee would initiate follow-up corrective action and notification of appropriate state licensing agencies. All new employees would receive training on the facility's Abuse Policy and ongoing in-service through learning modules on what constituted abuse, neglect, and exploitation, methods to report allegations of abuse without fear of reprisal, and how to recognize signs of burnout and stress that may lead to abuse. According to the policy, screening of new employees criminal background checks would be conducted through the State Police. Skilled Nursing employees would have screening through the Nurse Aide Registry.

Interview with the contracted security company's Regional Manager, on 11/21/17 at 11:35 AM, revealed the company did not perform routine abuse registry checks on their potential employees, only background checks. She stated SG #2's background check came back with a misdemeanor for resisting arrest and the SG was questioned about the circumstances surrounding the arrest. The SG informed them he had an argument with his wife, neighbors heard them, called the police and once the police arrived, they arrested him. She stated the SG told them as he turned around for the police to handcuff him, he tripped and fell , and the police officer fell on top of him. Therefore, he was convicted for resisting arrest. The Reginal Manager stated a waiver was obtained to hire the SG after reviewing his explanation of the circumstances. Continued interview with the Regional Manager revealed the company did not have evidence they had trained three (3) of their security guards on the facility's abuse policy and procedures. The contracted security company's Regional Manager verified SG #2 had previously employment as a nursing assistant.

Review of the Kentucky Board of Nursing On-Line Validation results, dated 11/27/17, for contracted Security Guard (SG) #2, revealed the SG was a State Registered Nursing Assistant and listed on the California Abuse Registry.

Review of the California Department of Public Health Verification on 11/27/17, revealed SG #2 was a Certified Nurse Assistant and the status of his certification was listed as Revoked, Not Employable.

Review of Patient #1's Emergency Department documentation, dated 09/21/17, revealed the patient arrived at the hospital by an ambulance, was unarousable, and staff used an ammonia capsule to arouse the patient. The physician noted Patient #1 was intoxicated and ordered a blood alcohol test. The results were 173 milligrams per deciliter (normal findings: 0-50 milligrams per deciliter)

Interview with the Risk Manager (RM), on 11/21/17 at 10:45 AM, revealed she arrived to work on 09/21/17, and reviewed her incident reports. She stated staff documented an incident of verbal and physical abuse by SG #2, in the Emergency Department, around 3:20 AM on 09/21/17. The RM stated she conducted staff interviews of those present at the time; however, she did not interview the House Supervisor or the alleged perpetrator. The RM stated several staff told her the SG cursed and choked the patient. However, staff did not promptly remove the security guard from the building and failed to notify the Administrator on call of the incident. The RM stated the alleged perpetrator was a contracted security guard and she let the contracted company handle the matter internally. She stated staff and contracted security guards were not re-educated on the facility's abuse policy and procedure after the incident. In addition, leadership did not develop an action plan that addressed staff's failure to report the abuse timely, remove the SG promptly from patient care, or provide re-education on the abuse policy and procedure. According to the RM, it was important for patient safety that staff report abuse and remove the alleged perpetrator from patient care immediately.

Interview with Registered Nurse (RN) #4, on 11/17/17 at 11:50 AM, revealed Patient #1 entered the Emergency Department via an ambulance and was unresponsive. She stated staff used an ammonia capsule to arouse the patient and the patient awakened from a drunken sleep and began cursing for staff to get the ammonia capsule away from him/her. RN #4 stated contracted SG #2 was in the room along with several other staff tending to the patient. She stated she left the room but heard SG #2 and the patient yelling at each other, once SG #2 left the room, the patient calmed down and went back to sleep. RN #4 stated she did not witness SG #2 laying his hands on the patient but believed the Charge Nurse was in the room at the time.

Interview with Registered Nurse (RN) #3, on 11/17/17 at 11:57 AM, revealed he witnessed Patient #1 and SG #2 cussing each other. He stated the patient told SG #2 he/she was going to beat him up. RN #3 stated he witnessed the SG put his hands around Patient #1's throat and then the SG told the patient to "shut the f--k up." The Charge Nurse told the SG to leave the room and for staff to remove the SG before he went off. He stated the facility protected patients from abuse by removing the perpetrator from the area.

Interview with the Certified Nursing Assistant (CNA), on 11/17/17 at 12:10 PM, revealed she heard Patient #1 and SG #2 yelling at each other and the SG told Patient #1 not to talk to the medical staff like that. The CNA stated she heard the SG say to Patient #1 "you want a piece of me you little d--k". The CNA stated she saw the SG put his hands on the patient's throat and it was very upsetting to her. According to the CNA, she did not receive additional re-education on the facility's abuse policy and procedure after the incident with Patient #1 and the SG.

Interview with the Charge Nurse, on 11/17/17 at 3:39 PM, revealed the contracted security guards' role was to sit with patients that were suicidal at times, help with crisis-situations, monitor the registration desk to help with patient flow, and perform safety rounds inside and outside the facility. He stated Patient #1 arrived via ambulance on 09/21/17, for treatment related to alcohol intoxication. Staff used an ammonia capsule to arouse Patient #1 and the patient became verbally abusive. The Charge Nurse stated SG #2 was in the room assisting with patient care, the patient and the SG were cursing at each other and he heard the SG call Patient #1 a "M----r F----r". He stated the SG also displayed excessive/aggressive body language while interacting with Patient #1. In addition, the Charge Nurse stated the SG told the patient "if you do not lay down I will put you down". He stated he did not remove the SG from patient care at that time or address his inappropriate behavior with Patient #1. He left the room to perform other duties, later walked past Patient #1's room and witnessed the SG grab Patient #1 by the neck and forcefully pushed the patient back down on the stretcher, while continuing to curse at the patient. The Charge Nurse stated the behavior was inappropriate, and he removed the SG from the patient's room and felt the issue was over after he told the SG #2 not to return to the patient's room. The Charge Nurse informed the House Supervisor sometime after the incident occurred; however, after he informed the House Supervisor, she did not remove the SG from patient care, and the SG continued his routine duties until the end of his shift. The Charge Nurse stated he did not escalate the witnessed abuse to the Administrator on call because he believed the incident was addressed by not allowing the SG back into the patient's room; however, the SG still had contact with other patients in the facility. According to the Charge Nurse, he did not receive re-education on the facility abuse policy and procedure requirements after the incident with Patient #1.

Interview with House Supervisor (HS), on 11/17/17 at 1:31 PM, revealed the Charge Nurse informed her on 09/21/17, during the time she was rounding in the Emergency Department that SG #2 had aggravated, cursed, and put his hands on Patient #1. She stated because she assumed the SG was just restraining the patient, due to the patient's belligerent behavior, there was no need to remove the SG from patient care. She stated she did not review the incident report completed by staff nor did she investigate the situation. SG #2 remained in the facility and continued to perform his routine duties until his shift ended. The HS stated she did not notify the Administrator on call about the verbal abuse or that the SG had put his hands on the patient. According to the HS, she did not find out until the Chief Nursing Officer notified her on 11/17/17, that staff reported the SG had choked the patient during the incident. The HS stated after the incident occurred, she was informed during a meeting that she should have removed the SG from the facility and contacted the Administrator on call after staff reported an allegation of abuse. She stated she would have removed the SG from the facility and called the Administrator on call in order to protect patients from abuse, if she had identified the SG actions as verbal and physical abuse.

Interview with SG #2, on 11/17/17 at 4:08 PM, revealed on 09/21/17, nursing staff was having a hard time providing medical care to Patient #1 due to his/her behavior. He went to the room to assist; however, he stated he did not remember cursing at the patient but a nurse told him he had cursed the patient. The SG stated he was aware staff was not to curse at patients. He stated the patient cursed at staff and sat up on the stretcher and because he did not want things to escalate out of hand, he pushed the patient back down on the stretcher. SG #2 stated he placed his hands on the patient's neck/shoulder area to push the patient back down on the stretcher. The SG stated the Charge Nurse told him to leave the room, so he left and continued his duties of making rounds inside and outside the facility. SG #2 stated the facility did not interview him regarding the incident in order to get his side of the story; however, the next day his contracted company supervisor directed him not to return to the facility. He stated his contracted company supervisor interviewed him and then fired him.

Interview with the Emergency Department Director (EDD), on 11/17/17 at 2:39 PM, revealed it was determined staff did not immediately remove SG #2 from patient care after staff witnessed him verbally and physically abuse Patient #1. In addition, staff did not notify the Administrator on call after the incident to obtain further direction. She stated staff lacked the knowledge of the abuse policy and procedure to act accordingly. After the incident occurred, a nursing leadership meeting was held and the Quality Director reminded nursing leaders and House Supervisors of the importance of removing an alleged perpetrator of abuse from the building and notifying the Administrator on call immediately after an incident was witnessed. However, neither nursing leadership nor the Quality Director provided an action plan or directed leaders to re-educate staff regarding the abuse policy and procedure to ensure timelier reporting and removal of alleged perpetrators. She stated it was important for patient safety to report abuse and remove the alleged perpetrator from the building promptly.

Interview with the Quality Director, on 11/17/17 at 2:39 PM, revealed staff did not follow the abuse policy and procedure, which required them to remove SG #2 from the facility immediately after they witnessed him verbally abusing Patient #1. She stated they did not report the incident timely to the House Supervisor (HS) and the HS did not remove the SG promptly from the building to promote patient safety. In addition, the Risk Manager did not perform a thorough investigation because she failed to interview all parties involved. She stated a meeting with leaders was held on 10/10/17, in which she briefly provided information to the attendees about the importance of timely reporting of abuse and the removal of the alleged perpetrator from the building for patient safety. She stated during the meeting, she did not direct leaders to re-educate staff on the abuse policy, nor did she develop, or discuss an action plan regarding the identified findings in order to prevent them from occurring again.

Further interview with the Quality Director, on 11/27/17 at 12:00 PM, revealed she did not audit the contracted security company's employee files to determine if the company was completing abuse registry checks, or if all contracted staff assigned to the facility had received abuse training. She stated she would have never had thought to audit the facility contracted company's services to determine if they were meeting regulatory requirements. According to the Quality Director, the role of the quality assurance department was to audit services to determine if the facility was doing things right and promoting safe patient care.

Interview with the Chief Operating Officer/Chief Nursing Officer (COO/CNO), on 11/27/17 at 11:25 AM, revealed she found out about the allegation of abuse after reading the facility incident reports on the morning of 09/21/17. She stated it was determined staff did not report the incident timely or remove the security guard from the building to protect patients from further potential abuse. The CCO/CNO stated the facility did not have abuse allegations often and believed that influenced the staff's behavior of not reporting timely. She stated the facility could have done a better job investigating the incident and should have developed an action plan. In addition, the facility should have re-educated staff on the facility's abuse policy and procedure, since staff did not follow it accordingly. The COO/CNO stated she was not involved in the development of the contracts for the security guards and assumed the contracted company completed abuse registry checks on all potential employees and trained their staff on abuse since they worked in a healthcare facility. According to the COO/CNO, she was not aware SG #2 was listed on the California Abuse Registry and in order to protect patients from abuse, if she had known, she would not have allowed him to work in the facility.

Interview with the facility's Human Resources Business Partner, on 11/27/17 at 10:50 AM, revealed she did not complete audits of the contracted security company's employee files to ensure security guards providing services in the facility were not on an abuse registry list. She stated that was not part of her normal process even though she conducted abuse registry checks on all facility employees. She stated completing an abuse registry check ensured the employee was not on an abuse registry and was eligible to work in a healthcare facility, which was important for patient safety.
VIOLATION: QAPI Tag No: A0263
Based on observation, interview, record review, and review of the facility's policy, it was determined the governing body failed to have an effective system in place to ensure the Quality Assurance Performance Improvement program performed an evaluation of its contracted services to ensure services were provided in a safe manner for one (1) of ten (10) sampled patients, Patient #1.

Staff interviews revealed contracted Security Guard (SG) #2 call Patient #1 a "M----r F----r" and displayed excessive and aggressive body language while interacting with Patient #1. Staff interviews also revealed later, the Charge Nurse walked past Patient #1's room and witnessed the SG grab Patient #1 by the neck and forcefully pushed the patient back down on the stretcher and staff removed the SG from the patient's room.

Interview with the contracted security company's Regional Manager, verified SG #2 had previous employment as a nursing assistant.

Review of the Kentucky Board of Nursing On-Line Validation results, dated 11/27/17, for contracted Security Guard (SG) #2, revealed the SG was a State Registered Nursing Assistant and listed on the California Abuse Registry.

Review of the California Department of Public Health Verification on 11/27/17, revealed SG #2 was a Certified Nurse Assistant and the status of his certification was listed as Revoked, Not Employable.

In addition, review of the Board of Directors meeting minutes, dated February, May, August, and October 2017, revealed the minutes did not reflect a review of the QAPI evaluation of contracted services to ensure services were delivered in a safe manner.

Interview with the System Vice President of Quality revealed the organization did not perform a documented evaluation of their contracted services. She stated leaders at the facility level had an informal meeting with contracted companies to perform a vendor survey of services; however, no documentation of the meeting or survey was completed. She stated she attended Governing Body Board meetings; however, had not provided data to the board regarding contracted services and/or received direction from the board to do so.

Refer to A 0308.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on observation, interview, record review, and review of the facility's policy, it was determined the governing body failed to have an effective system in place to ensure the Quality Assurance Performance Improvement (QAPI) program performed an evaluation of its contracted services to ensure services were provided in a safe manner for one (1) of ten (10) sampled patients, Patient #1.

Interview with the Charge Nurse revealed he witnessed contracted Security Guard (SG) #2 call Patient #1 a "M----r F----r" and display excessive and aggressive body language while interacting with Patient #1. The Charge Nurse stated he left the room to perform other duties and later walked past Patient #1's room and witnessed the SG grab Patient #1 by the neck and forcefully pushed the patient back down on the stretcher. The Charge Nurse removed the SG from the patient's room.

Interview with the contracted security company's Regional Manager, verified SG #2 had previous employment as a nursing assistant.

Review of the Kentucky Board of Nursing On-Line Validation results, dated 11/27/17, for contracted Security Guard (SG) #2, revealed the SG was a State Registered Nursing Assistant and listed on the California Abuse Registry.

Review of the California Department of Public Health Verification on 11/27/17, revealed SG #2 was a Certified Nurse Assistant and the status of his certification was listed as Revoked, Not Employable.

In addition, review of the Board of Directors meeting minutes, dated February, May, August, and October 2017, revealed the minutes did not reflect a review of the QAPI evaluation of contracted services to ensure services were delivered in a safe manner.

Interview with the System Vice President of Quality revealed the organization did not perform a documented evaluation of their contracted services. She stated leaders at the facility level had an informal meeting with contracted companies to perform a vendor survey of services; however, no documentation of the meeting or survey was completed. She stated she attended Governing Body Board meetings; however, had not provided data to the board regarding contracted services and/or received direction from the board to do so.

The findings include:

Review of the facility's policy, Patient Rights and Patient Responsibilities, revised December 2016, revealed patients had the right to receive treatment in a safe environment free from neglect, exploitation, abuse, and to be assisted in accessing Protective Services and/or Advocacy Services, as appropriate.

Review of the facility's policy, Quality, Safety, and Performance Improvement Plan 2017, revised June 2017, revealed The Governing Body had the ultimate responsibility and accountability for the quality and safety, care, treatment, and services; therefore, the existence of the Quality, Safety and Performance Improvement Plan. The primary objective of the Quality, Safety, and Performance Improvement Plan was to consistently measure, monitor, evaluate, and improve the delivery, effectiveness, efficiency, and outcomes of clinical care, treatment, and service. The plan would include all departments and services, including those services furnished under contract or arrangement, focusing on indicators related to improved health outcomes. The plan would ensure education and resources was provided to enhance knowledge and skills related to quality improvement, safety, risk reduction, and regulatory requirements.

Review of the facility's policy, Leadership Plan of Care, revised August 2016, revealed the facility leadership consisted of the Board of Directors, Executive Team Members, and facility specific executive teams. The Board of Directors was responsible for the overall operation of the facility. The Board of Directors would ensure adequate resources were available to ensure patients received safe, quality care and services. Responsibilities of the Executive Team included oversight for all operations within the organization. The operations included government, legal affairs, and patient safety and rights. The Chief Operating Officer/Chief Nursing Officer (COO/CNO) was responsible for the daily operations and accountability for the oversight of nursing care at the facility and responsible for the nursing organizational plan, goal setting, policymaking, and program development. The COO/CNO would attend meetings and committees related to finance, performance improvement, patient safety, and clinical care.

Review of the Board of Directors meeting minutes, dated February, May, August, and October 2017, revealed the minutes did not include an agenda item for the governing body to review regarding QAPI's evaluation of contracted services.

Review of Patient #1's Emergency Department documentation, dated 09/21/17, revealed the patient arrived at the hospital by an ambulance. The patient was unarousable and staff used an ammonia capsule to arouse the patient. The physician noted Patient #1 was intoxicated and ordered a blood alcohol test, which resulted 173 milligrams per deciliter (normal findings: 0-50 milligrams per deciliter).

Interview, on 11/17/17 at 3:39 PM, with the Charge Nurse, revealed the facility used contracted security guards in the emergency department and their role was to sit with patients that were suicidal, help with crisis-situations, monitor the registration desk to help with patient flow, and perform safety rounds inside and outside the facility. He stated Patient #1 arrived via ambulance on 09/21/17, for treatment related to alcohol intoxication. Staff used an ammonia capsule to arouse Patient #1 and the patient became verbally abusive. The Charge Nurse stated SG #2 was in the room assisting with patient care, and the patient and the SG were cursing at each other and he heard the SG call Patient #1 a "M----r F----r". He stated the SG also displayed excessive and aggressive body language while interacting with Patient #1. In addition, the SG told the patient "if you do not lay down I will put you down". The Charge Nurse stated he left the room to perform other duties and later walked past Patient #1's room and witnessed the SG grab Patient #1 by the neck and forcefully pushed him back down on the stretcher, while cursing at the patient. He stated that behavior was inappropriate and he removed the SG from the patient's room at that time. He stated he felt the issue was over after he told SG #2 not to return to the patient's room and informed the House Supervisor sometime after the incident occurred of the SG behavior. However, the House Supervisor did not remove the SG from patient care and the SG continued his routine duties until the end of his shift. According to the Charge Nurse, patients had the right to be free from abuse and staff should follow the facility abuse policy and procedure.

Interview with the Director of Quality, on 11/27/17 at 2:18 PM, revealed she had not collected data or provided findings to the Governing Body related to contracted services. She stated the facility determined on 11/27/17, the contracted security guards, hired before February 2017, had not received abuse training and the facility had not ensured contracted employees assigned to work in the hospital, did not have a history of abuse. She stated the role of the Quality Department and the Quality Assurance Performance Improvement Plan was to ensure the facility had a process in place to evaluate services in order to provide quality care that was safe; however, the department failed to evaluate their contracted services.

Interview with the System Vice President of Quality, on 11/21/17 at 3:00 PM, revealed the organization did not perform a documented evaluation of their contracted services. She stated leaders at the facility level had an informal meeting with contracted companies to perform a vendor survey of services; however, no documentation of the meeting/survey was completed and any actions taken from the meeting were not documented. The System Vice President of Quality stated in hindsight, meeting minutes should have been taken. She stated she attended Governing Body Board meetings; however, she had not provided any data to the board regarding contracted services and had not received direction from the board to do so.

Interview with Board of Director #1, on 11/27/17 at 1:10 PM, revealed he could not remember any data regarding contracted services being evaluated during a board meeting or the incident with Patient #1 and SG #2. He stated if the incident had been brought to the Governing Body's attention, he would have wanted more information and would have directed leaders to address the situation. He stated patient safety was very important and was concerning to him.