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EASTERN STATE HOSPITAL 1350 BULL LEA ROAD LEXINGTON, KY Aug. 21, 2013
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and review of the facility's policy. it was determined the facility failed to ensure an allegation abuse was investigated in a timely manner and failed to ensure the patient was protected from further alleged abuse for one (1) of ten (10) sampled patients, Patient #1.

The findings include:

Review of the facility's policy, "General Hospital Policies, Section 3, Risk Management and Safety Policies, Subsection A.4.a.," revised 08/2012, revealed abuse was defined as the willful (not accidental) infliction of injury that resulted in physical or mental pain; and mental or psychological abuse included the mental harm or injury which occurred when the victim was humiliated, harassed, threatened, punished, deprived, coerced or intimidated. The policy also revealed the facility would seek to protect patients from all forms of abuse.

Review of Patient #1's clinical record revealed an admission date of [DATE] at 7:30 PM with diagnoses which included, Schizoaffective Disorder, Diabetes, wrist and Back Pain and Chronic mental illness. Continued review revealed Patient #1's admission type was involuntary via a seventy two (72) hour court order. Review of the Admissions History dictated 08/08/13 at 7:23 PM revealed, " The patient also makes statements about a staff member, saying that he touched his genitals and then opened her carton of milk and that she/he was going to get AIDS from this and asks to go to the bathroom and wash her /face".

Review of the facility's investigation of the allegation of abuse revealed an incident report was completed the morning of on 08/09/13 when Patient #1 reported inappropriate behaviors by a Mental Health Associate (MHA) #1 to the MHA leader. Continued review of the facility's investigation revealed staff members from the Central Triage Center from the evening shift had been interviewed by a risk manager, who had taken statements which indicated none of the staff were aware of the alleged abuse.

Interview with MHA #1, on 08/20/13 at 1:45 PM, revealed he was on duty when Patient #1 was admitted to CTC. He stated he was assigned to day room monitoring and chart assembly. He stated Patient #1 was in the dayroom complaining of being hungry and diabetic. He stated he had went to the nutrition room and got Patient #1 a tray and a carton of milk. He stated he handed Patient #1 the tray with an unopened milk carton. Continued interview with MHA #1 revealed later the Physician told him Patient #1 stated he had masturbated in the milk and Patient #1 wanted to go to the bathroom and wash her/his mouth out to keep from getting AIDS. He stated the Physician told him to stay back from Patient #1.

Interview with the MHA leader, on 08/20/13 at 2:00 PM, revealed when Patient #1 saw him the morning of 08/09/13, Patient #1 reported to him the incident of the night before. He stated he immediately notified the shift coordinator and notified risk management.

Interview with the Physician who had admitted Patient #1, on 08/21/13 at 3:10 PM via telephone, revealed she was aware of Patient #1's allegation related to MHA #1, she stated the whole unit was aware. The Physician stated Patient #1 had told multiple staff members and had been loud when telling when telling it. She stated she thought she had had abuse training, but could not remember when nor could she remember what the policy was for an allegation of abuse.

Interview with the risk manager who had investigated the allegation, on 08/20/13 at 2:26 PM, revealed if Patient #1 had made the statement to staff the evening of 08/08/13, someone should have filled out an incident report, notified the shift coordinator and notified risk management. He stated a risk manager would have come in to initiate the investigation. He stated he had been unaware the Physician had documented the alleged incident in the Patient #1's Admission History.

Interview with Patient #1, on 08/20/13 at 4:20 PM, revealed she/he had been treated well during her/his admission, other than when she was admitted to CTC. Patient #1 stated while on the CTC unit a black man had ejaculated on her/his milk carton then given it to her/him to drink. When asked if she/he had reported the incident to anyone, Patient #1 stated, "God".

Interview with Licensed Practical Nurse #1, on 08/21/13 at 9:50 AM, via telephone revealed he was aware of what Patient #1 had been said. He stated he knew the patient and he/she was paranoid and he knew MHA #1 would never do anything like that.

Interview with MHA #2, on 08/21/13 at 11:03 AM, revealed he had worked the evening Patient #1 was admitted . He stated he was told by MHA #1 what Patient #1 had said.

Interview with MHA #3, on 08/21/13 at 11:55 AM, revealed she had worked the evening Patient #1 was admitted , but was unaware of the allegation.

Interview with the Interim Director of Nursing Services, on 08/21/13 at 4:15 PM, revealed every staff member has the responsibility to report allegations of abuse whether they think the incident occurred or not.