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Based on staff interviews it was determined the facility staff failed to protect Patient #3 against abuse while bathing on 2/25/13.

The findings:

Employee #10, a Certified Nurse's Aide (CNA) was interviewed in person on 4/11/13 at 1:48 p.m. The surveyor asked the CNA to recall the events of 2/25/13 related to bathing Patient #3. She acknowledged she was not assigned to provide care to Patient #3 that day. After hearing a commotion coming from the tub room, Employee #10 said she entered the room and witnessed Patient #3 trying to bite, spit and hit one of the four employees bathing him. The CNA indicated she was familiar with Patient #3, had bathed him many times and knew him to have unpredictable behavior. After entering the tub room and seeing the patient's behavior, she went to the cabinet and got a towel to use as a spit shield and help keep the patient from biting someone. She said, "When I put it in front of his face, I got it too close and he bit it. He started hitting with his left arm so I let go of the towel with both hands, held it with one hand to help with his left arm. I held it loosely because he was biting it." She added, "At no time was it my intention to harm." The CNA acknowledged she had been trained to hold a towel away from the face as a spit shield, "but I got it too close." When asked how long she held the towel too close, she stated it was maybe a couple of minutes. Employee #10 said Patient #3 was able to talk while she held the towel and said she asked him, "(Patient's name) are you going to quit hitting, spitting and biting so we can get you out of here?" and the patient answered, "Yes, (CNA's name)." Employee #10 told the surveyor she wished she had called a code or gone to the desk to ask for more help. The CNA added, "It was an impulse thing, it just happened. I didn't go in there thinking I'm going to put a towel over his face. You don't put a towel over anyone's face."

Three of the four CNA's who were bathing Patient #3 on 2/25/13 were interviewed separately on 4/11/13 (Employees #6, #8, and #9). The fourth CNA was not interviewed due to being on leave during the investigation.

Employee #6 was interviewed via phone on 4/11/13 at 12:47 p.m. The CNA acknowledged she'd had lots of experience with Patient #3 and knew how unpredictable his behavior was at times but 2/25/13 was the first time she'd assisted with that patient's bath. The CNA said that while bathing Patient #3 on 2/25/13, she saw the patient swing at another employee who was also bathing him. She recalled another aide coming into the tub room and putting a towel around Patient #3's mouth and holding the towel behind him. She recalled that Patient #3 said, "Get it off my mouth" and that she (Employee #6) asked that aide, "What are you doing that for?" The aide replied that she had the towel because the patient will bite and spit. Employee #6 estimated the aide held the towel approximately 2 to 3 minutes and stated that she had never seen this happen before 2/25/13 or since.

Employee #8 was interviewed in person on 4/11/13. She stated she was one of four employees bathing Patient #3 on 2/25/13 and was familiar with the patient's behavior and made sure to "stay out of arm's reach." The CNA said she was at the foot of the tub and recalled the patient attempting to hit another CNA who was at the head of the tub. She remembered that although Employee #10 was not originally in the tub room assisting with Patient #3's bath, she did see Employee #10 at the head of the tub and saw a towel at the head of the tub but did not see the towel on the patient's head. "I can't say the towel touched the face or not." Employee #8 indicated she was focused on keeping the patient from getting pinched while putting him in the sling for the lift to assist him out of the tub.

Employee #9 was interviewed in person on 4/11/13 at 11:10 a.m. The CNA acknowledged being one of four employees bathing Patient #3 on 2/25/13. She stated it was the second time she'd bathed the patient and that she was shaving him. Employee #9 recalled seeing the patient try to hit another CNA and looking up to see Employee #10 there. She stated she knew there was a towel there but could not recall any other detail related to the towel. She could not recall how long the towel was present and said that they just finished the bath and took Patient #3 to his room.

Along with the 4 employees who bathed Patient #3 on 2/25/13, there were 3 students in the tub room observing. At the time of the investigation, those three students were employed at the facility and interviewed separately via phone (Employees #4, #5, and #7).

Employee #4 was interviewed via phone on 4/11/13 at 9:55 a.m. That employee (a student at the time of the incident) recalled seeing an aide grab a towel and putting it over Patient #3's mouth after the patient swung at another aide. Employee #4 stated the aide readjusted the towel after the top of the towel was in his mouth and that the towel remained until the bath was complete.

Employee #5 (a student at the time of the incident) was interviewed via phone on 4/11/13 at 10:09 a.m. Employee #5 recalled while observing Patient #3's bath on 2/25/13, someone opened the door and asked if they could help and then grabbed a towel and pulled it hard across the patient's face with her foot on the tub. Employee #5 recalled the person repositioned the towel after someone said it was too tight but then held it tight again.

Employee #7 (a student at the time of the incident) was interviewed via phone on 4/11/13 at 10:18 a.m. recalled observing 4 aides performing Patient #3's bath on 2/25/13. Employee #7 acknowledged she was not paying close attention and did not see the patient swing at the aide but did notice the aide jerk back. The employee said that then a girl got a towel and draped it across the patient's face, on his nose and mouth. She said they pulled the towel off his nose after something was said about it being there and remembered someone saying the patient had spit. Employee #7 said the towel remained until after the bath. She acknowledged they (the students) had been informed of the patient's history of hitting and spitting prior to entering the tub room.

Patient #3 was interviewed by the surveyor along with the unit manager on 4/11/13 at 3:30 p.m. The patient was difficult to understand at times but when asked if there was anything about his bath time that he was upset about, the patient responded in a broken sentence and said that they won't let him have the purple gloves. Patient #3 did not offer any other response to the question; He did not mention anything placed over his face. The unit manager later explained that the patient gets upset when the staff will not give him purple gloves and the patient had been reported to pull gloves out of staff's pockets.

Patient #3's medical record was reviewed on 4/11/13 at 1:05 p.m. There was no evidence of the incident during the bath on 2/25/13 found in the medical record.