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.

WILLIAM R SHARPE, JR HOSPITAL 936 SHARPE HOSPITAL ROAD WESTON, WV April 19, 2017
VIOLATION: NURSING SERVICES Tag No: A0385
Based on document review, record review, video review and staff interview it was determined the hospital failed to ensure nursing followed the administrative authority and delineation of responsibilities for patient care (see tag A 386); failed to ensure nursing and other personnel provided nursing care to patients as needed (see tag A 392); failed to ensure nursing supervised and evaluated care rendered to patients (see tag A 395); failed to ensure nursing developed and kept current a nursing care plan for each patient ( see tag A 396); and, failed to ensure contract nurses adhered to the hospital's policies and procedures, and failed to ensure they were adequately supervised (see tag A 398).
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
A. Based on document review, record review, video review and staff interview it was determined the Director of Nursing failed to ensure nursing personnel (Nurse Clinical Coordinator, Nurse Manager, Charge Nurse, Licensed Practical Nurses (LPN) #1 and 2 and Health Service Worker (HSW) #3) filed an Adult Protective Services (APS) form, in accordance with hospital policy, for one (1) of one (1) patients who were harmed during an allegation of abuse (patient #1). This failure has the potential for all patients who are abused to continue to be abused by their perpetrator.

Findings include:

1. Review of the policy titled "Allegations of Abuse and Neglect", effective date 6/08, revealed it states, in part: "All patients have the right to be free from abuse or neglect as well as the fear of being abused...All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may occur...All employees...are mandatory reporters for abuse and neglect. Individuals who witness or have knowledge of patient abuse/neglect shall immediately report it to the charge nurse or Nurse Clinical Coordinator (NCC)...Documentation in the form of an APS form...grievance form and/or written statements are to be completed within one hour of the allegation."

2. Review of the medical record for patient #1 revealed documentation by Registered Nurse (RN) #1 on 3/26/17 at 9:45 p.m. that the patient complained of left shoulder pain and slipped on towels in his room.

3. Review of the Adult Protective Services (APS) form revealed it was filed on 4/2/17, eight (8) days after the patient notified the hospital of the alleged incident, by the Nurse Clinical Coordinator (NCC).

4. Review of the hospital's investigation report revealed a signed statement from RN #1 on 4/2/17 which revealed patient #1 initially complained of a fall and later explained Health Service Worker (HSW) #1 had grabbed hold of him and pushed him into the wall and he fell .

5. On 4/17/17 at 1:27 p.m. a video tape (dated 3/26/17-date of incident) was reviewed in the presence of the Assistant Chief Operating Officer and Patient Safety Director. Beginning at 8:35 p.m., the video shows patients #1 and 2 standing in front of the nursing station. At 8:36 p.m. HSW #1 came down the hall, took his hand and moved patient #2 around and then put his hand to the back of her neck and took her to a patient room. He then came back up the hall at 8:39 p.m. and immediately placed his face in patient #1's face; HSW #1 was seen moving his mouth and patient #1 was trying to move out of his way but HSW #1 continued to keep the patient in the area where the medication pass was occurring. HSW #1 then began to walk away. Patient #1 was leaning against a wall with his back turned toward HSW #1 when HSW #1 came back to the patient and said something to the patient's back, turned him around and took him down the hall to his room. Patient #3 was seen outside of patient #1's room looking into the room and then moved to the room and touched the light switch. At 10:18 p.m. patient #1 exited the room holding his left arm and went to the nursing station and talked to RN #1. The video showed four (4) employees sitting at the nursing station.

During review of the video the Director of Nursing (DON) came in at 1:39 p.m. and saw the aggressive behavior from HSW #1 towards patients #1 and 2. When asked if she saw this aggressive behavior while investigating the abuse allegations, she stated, in part: "No, I did not. I watched four (4) days of videos and didn't see this. I feel nauseous at seeing this now."

6. An interview was conducted with patient #1 on 4/17/17 at approximately 9:00 a.m. during a tour of unit C-1. The patient requested RN #2 be present for the interview and the patient's representative was notified of the request for interview; the interview was granted by phone to RN #2. When asked to explain how his arm became injured, patient #1 stated, in part: "I was told by (HSW #1) to go to my room because he said I was acting up and I went to my room and then he shoved me when I got to my room and I fell over towels in my room." When asked if he told anyone about what happened, he stated, in part: "I told (RN #1) because I was in pain and then I told my doctor and almost everyone and I'm afraid of him because he told me if I told anyone he would hurt me."

7. A joint interview was conducted with Attending Physician #1 and Physician Assistant (PA) #1 on 4/17/14 at 12:45 p.m. When asked if they remembered patient #1 being injured, they both stated, "Yes." Attending Physician #1 stated, in part: "I was getting ready for work on the 27th and got a phone call that he fell and hurt his arm and told them I was getting ready to come in and I would see him in a couple of hours. When I came in I discussed the patient with the PA and she went to see him." The PA stated, in part: "When I talked to the patient he told me he was pushed down and fell over clothes and hit the wall and floor and hurt his arm and he refused to tell me who hurt him." When asked if they filed a complaint or an Adult Protective Services form on the patient's behalf, they stated, "No."

8. An interview was conducted with patient #3 (who was patient #1's roommate at the time of the incident) on 4/17/17 at approximately 4:00 p.m. When asked if he remembered the night patient #1 was injured, he stated, in part: "He (HSW#1) was aggressive to him (patient #1). Physical interaction is bad. He (HSW #1) is not nice to him (patient #1)."

9. An interview was conducted with RN #1 on 4/17/17 at 4:24 p.m. When asked if she remembered the night patient #1 was injured, she stated, "Yes." When asked what happened, she stated, in part: "Patient #1 came to the nursing desk and said he tripped over towels in his room and hurt his arm and wanted something for pain so I gave him an ice pack and medicated him. He later told me he was pushed by (HSW #1) and tripped over the towels in the floor and hit the wall and then the floor." When asked if she had ever seen HSW #1 become aggressive with patients, she stated, in part: "Yes, he was aggressive that night with (patient #1) and with other patients before. He's been aggressive with me and I told our NCC and she didn't do anything so I never said anything again since they don't seem to care." When asked if she filed a complaint for the patient or filed an Adult Protective Services form, she stated, "No, I told the NCC."

10. An interview was conducted with the Nurse Manager of unit C-1 on 4/18/17 at 8:17 a.m. When asked when she became aware of the incident of patient #1 she stated the PA told her the next morning about what patient #1 said. When asked if an Adult Protective Services form was completed, she stated, "No."

11. An interview was conducted with the Assistant Chief Executive Officer on 4/18/17 at 8:58 a.m. and she concurred with the above findings.

B. Based on document review, record review, video review and staff interview it was determined the Director of Nursing failed to ensure allegations of abuse were reported to Adult Protective Services, in accordance with hospital policy, in one (1) of one (1) allegations of abuse reviewed (patient #2). This failure has the potential for all patients who are allegedly abused to continue to be abused by the alleged perpetrator.

Findings include:

1. Review of the policy titled "Allegations of Abuse and Neglect", effective date 6/08, revealed it states, in part: "All patients have the right to be free from abuse or neglect as well as the fear of being abused...All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may occur...All employees...are mandatory reporters for abuse and neglect. Individual who witness or have knowledge of patient abuse/neglect shall immediately report it to the charge nurse or Nurse Clinical Coordinator (NCC)...Documentation in the form of an APS form...grievance form and/or written statements are to be completed within one hour of the allegation."

2. Review of the medical record for patient #2 revealed no documentation of physical abuse was documented on 3/26/17 at 8:36 p.m. by Health Service Worker (HSW) #1.

3. On 4/17/17 at 1:27 p.m. a video tape (dated 3/26/17-date of incident) was reviewed in the presence of the Assistant Chief Operating Officer and Patient Safety Director. Beginning at 8:35 p.m., the video shows patients #1 and 2 standing in front of the nursing station. At 8:36 p.m. HSW #1 came down the hall, took his hand and moved patient #2 around and then put his hand to the back of her neck and took her to a patient room. He then came back up the hall at 8:39 p.m. and immediately placed his face in patient #1's face; HSW #1 was seen moving his mouth and patient #1 was trying to move out of his way but HSW #1 continued to keep the patient in the area where the medication pass was occurring. HSW #1 then began to walk away. Patient #1 was leaning against a wall with his back turned toward HSW #1 when HSW #1 came back to the patient and said something to the patient's back, turned him around and took him down the hall to his room. Patient #3 was seen outside of patient #1's room looking into the room and then moved to the room and touched the light switch. At 10:18 p.m. patient #1 exited the room holding his left arm and went to the nursing station and talked to RN #1. The video showed four (4) employees sitting at the nursing station.

During review of the video the Director of Nursing (DON) came in at 1:39 p.m. and saw the aggressive behavior from HSW #1 towards patients #1 and 2. When asked if she saw this aggressive behavior while investigating the abuse allegations, she stated, in part: "No, I did not. I watched four (4) days of videos and didn't see this. I feel nauseous at seeing this now." During review of the video the DON acknowledged the facility was unaware of patient #2 being abused even though she investigated patient #1's abuse by video tape and failed to watch the correct time of the occurrence. The four (4) healthcare workers seen sitting at the nursing station were identified by the DON and Nurse Manager.

4. An interview was conducted with RN #1 on 4/17/17 at 4:24 p.m. When asked if she remembered the night patient #1 was injured, she stated, "Yes." When asked what happened, she stated, in part: "Patient #1 came to the nursing desk and said he tripped over towels in his room and hurt his arm and wanted something for pain so I gave him an ice pack and medicated him. He later told me he was pushed by (HSW #1) and tripped over the towels in the floor and hit the wall and then the floor." When asked if she had ever seen HSW #1 become aggressive with patients, she stated, in part: "Yes, he was aggressive that night with (patient #1) and with other patients before. He's been aggressive with me and I told our NCC and she didn't do anything so I never said anything again since they don't seem to care." When asked if she filed a complaint for the patient or filed an Adult Protective Services form, she stated, "No, I told the NCC and I did not contact the guardian until the next morning."

5. An interview was conducted with the Nurse Manager of unit C-1 on 4/18/17 at 8:17 a.m. When asked if she reviewed the video tape of the night of the alleged abuse she stated she had and was shocked because she never would have thought he would have the behavior she watched on the video.

6. An interview was conducted on 4/17/17 at 5:00 p.m. with HSW #1 in the presence of the Assistant Chief Executive Officer, at the request of HSW #1. When asked if he remembered the night patient #1 was injured, he stated, in part: "Yes, I had taken him to his room because he was acting up and throwing popcorn and before I could get out of the room I heard him fall and turned around and he was laying in the floor and his lip was bleeding. I helped him up and put him in bed and went to ask the nurse for an ice pack for his mouth because it was bleeding and she told me that takes a doctor's order so he didn't get one." It should be noted that when observing the above noted video HSW #1 came out of the patient's room and did not speak to any other health care worker or return to the patient's room. When asked if he knew the patient alleged he pushed him, he stated, in part: "Yes, the advocate asked me if I saw anything that night." When asked if he was ever removed from patient care during the investigation, he stated, "No, I've worked every day except one (1) and my daughter had a baby that night." The HSW was then made aware of a new allegation of abuse on the same night and time with patient #2 and when asked if he remembered anything unusual about the night with patient #2, he stated, in part: "Yes, she was laying in the floor and I was told to pick her up and take her to her room."

7. An interview was conducted on 4/17/17 at 5:30 p.m. with LPN #1. When asked if she knew about patient #1's injury to his arm and if so what information she had about it, she stated, in part: "Yes, I was told he fell and that HSW #1 pushed him and broke his arm." When asked if she was passing medication during the time the injury occurred she consulted her date calendar and said she didn't know because she worked a double. When shown the medication administration record on all patients for the time of the incident, she stated, "Then I guess I was." When asked if she heard any yelling or saw any abuse, she stated, "No, I did not."

8. An interview was conducted on 4/19/17 at 3:20 p.m. with HSW #2. When asked if she was aware of patient #1 being injured, she stated, in part: "Yes, I found out the next day when I came back and he had his arm in a sling." When asked if she heard or saw any abuse during the evening medication pass while she was sitting at the nursing station, she stated, in part: "I probably had my head down charting and if so I wouldn't hear because I am legally deaf and don't know if you are speaking unless you are looking at me. I have a medical note in my chart that says that." It should be noted review of the HSW's personnel record revealed the HSW is legally deaf.

9. An interview was conducted with the Assistant Chief Executive Officer on 4/18/17 at 8:58 a.m. and she concurred with the above findings.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on document review, record review, video review and staff interview it was determined the Director of Nursing failed to ensure the hospital's abuse policy was followed and failed to ensure supervision of care for one (1) of one (1) patients who did not receive medical care in a timely manner following an abuse allegation (patient #1). This failure has the potential for all patients to not be supervised by a qualified Registered Nurse.

1. Review of the policy titled "Allegations of Abuse and Neglect", effective date 6/08, revealed it states, in part: "All patients have the right to be free from abuse or neglect as well as the fear of being abused...All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may occur...All employees...are mandatory reporters for abuse and neglect. Individuals who witness or have knowledge of patient abuse/neglect shall immediately report it to the charge nurse or Nurse Clinical Coordinator (NCC)...Documentation in the form of an APS form...grievance form and/or written statements are to be completed within one hour of the allegation...Alleged perpetrator removed from the situation."

2. Review of the medical record for patient #1 revealed documentation by Registered Nurse (RN) #1 on 3/26/17 at 9:45 p.m. that the patient complained of left shoulder pain and slipped on towels in his room.

3. Review of the Adult Protective Services (APS) form revealed it was filed on 4/2/17, eight (8) days after the patient notified the hospital of the alleged incident, by the Nurse Clinical Coordinator (NCC).

4. Review of the hospital's investigation report revealed a signed statement from RN #1 on 4/2/17 which revealed patient #1 initially complained of a fall and later explained Health Service Worker (HSW) #1 had grabbed hold of him and pushed him into the wall and he fell .

5. On 4/17/17 at 1:27 p.m. a video tape (dated 3/26/17-date of incident) was reviewed in the presence of the Assistant Chief Operating Officer and Patient Safety Director. Beginning at 8:35 p.m., the video shows patients #1 and 2 standing in front of the nursing station. At 8:36 p.m. HSW #1 came down the hall, took his hand and moved patient #2 around and then put his hand to the back of her neck and took her to a patient room. He then came back up the hall at 8:39 p.m. and immediately placed his face in patient #1's face; HSW #1 was seen moving his mouth and patient #1 was trying to move out of his way but HSW #1 continued to keep the patient in the area where the medication pass was occurring. HSW #1 then began to walk away. Patient #1 was leaning against a wall with his back turned toward HSW #1 when HSW #1 came back to the patient and said something to the patient's back, turned him around and took him down the hall to his room. Patient #3 was seen outside of patient #1's room looking into the room and then moved to the room and touched the light switch. At 10:18 p.m. patient #1 exited the room holding his left arm and went to the nursing station and talked to RN #1. The video showed four (4) employees sitting at the nursing station.

During review of the video the Director of Nursing (DON) came in at 1:39 p.m. and saw the aggressive behavior from HSW #1. When asked if she saw this aggressive behavior while investigating the abuse allegations, she stated, in part: "No, I did not. I watched four (4) days of videos and didn't see this. I feel nauseous at seeing this now."

6. An interview was conducted with patient #1 on 4/17/17 at approximately 9:00 a.m. during a tour of unit C-1. The patient requested RN #2 be present for the interview and the patient's representative was notified of the request for interview; the interview was granted by phone to RN #2. When asked to explain how his arm became injured, patient #1 stated, in part: "I was told by (HSW #1) to go to my room because he said I was acting up and I went to my room and then he shoved me when I got to my room and I fell over towels in my room." When asked if he told anyone about what happened, he stated, in part: "I told (RN #1) because I was in pain and then I told my doctor and almost everyone and I'm afraid of him because he told me if I told anyone he would hurt me."

7. A joint interview was conducted with Attending Physician #1 and Physician Assistant (PA) #1 on 4/17/14 at 12:45 p.m. When asked if they remembered patient #1 being injured, they both stated, "Yes." Attending Physician #1 stated, in part: "I was getting ready for work on the 27th and got a phone call that he fell and hurt his arm and told them I was getting ready to come in and I would see him in a couple of hours. When I came in I discussed the patient with the PA and she went to see him." The PA stated, in part: "When I talked to the patient he told me he was pushed down and fell over clothes and hit the wall and floor and hurt his arm and he refused to tell me who hurt him." When asked if they filed a complaint or an Adult Protective Services form on the patient's behalf, they stated, "No."

8. An interview was conducted with patient #3 (who was patient #1's roommate at the time of the incident) on 4/17/17 at approximately 4:00 p.m. When asked if he remembered the night patient #1 was injured, he stated, in part: "He (HSW#1) was aggressive to him (patient #1). Physical interaction is bad. He (HSW #1) is not nice to him (patient #1)."

9. An interview was conducted with RN #1 on 4/17/17 at 4:24 p.m. When asked if she remembered the night patient #1 was injured, she stated, "Yes." When asked what happened, she stated, in part: "Patient #1 came to the nursing desk and said he tripped over towels in his room and hurt his arm and wanted something for pain so I gave him an ice pack and medicated him. He later told me he was pushed by (HSW #1) and tripped over the towels in the floor and hit the wall and then the floor." When asked if she had ever seen HSW #1 become aggressive with patients, she stated, in part: "Yes, he was aggressive that night with (patient #1) and with other patients before. He's been aggressive with me and I told our NCC and she didn't do anything so I never said anything again since they don't seem to care." When asked if she filed a complaint for the patient or filed an Adult Protective Services form, she stated, "No, I told the NCC."

10. An interview was conducted with the Nurse Manager of unit C-1 on 4/18/17 at 8:17 a.m. When asked when she became aware of the incident of patient #1 she stated the PA told her the next morning about what patient #1 said. When asked if an Adult Protective Services form was completed, she stated, "No." When asked if HSW #1 was removed from patient care she stated she would have to check. After checking the staffing sheets she stated he was at work when he was scheduled except for one (1) day when he called in.

11. An interview was conducted with the Assistant Chief Executive Officer on 4/18/17 at 8:58 a.m. and she concurred with the above findings.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on document review, record review, video review and staff interview it was determined the Director of Nursing failed to ensure supervision of care in one (1) of one (1) patients who alleged abuse with an injury (patient #1). This failure has the potential for all patients to not have qualified supervised care during injury caused by harm.

1. Review of the policy titled "Allegations of Abuse and Neglect", effective date 6/08, revealed it states, in part: "All patients have the right to be free from abuse or neglect as well as the fear of being abused...All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may occur...All employees...are mandatory reporters for abuse and neglect. Individuals who witness or have knowledge of patient abuse/neglect shall immediately report it to the charge nurse or Nurse Clinical Coordinator (NCC)...Documentation in the form of an APS form...grievance form and/or written statements are to be completed within one hour of the allegation...Alleged perpetrator removed from the situation."

2. Review of the medical record for patient #1 revealed documentation by Registered Nurse (RN) #1 on 3/26/17 at 9:45 p.m. that the patient complained of left shoulder pain and slipped on towels in his room.

3. Review of the Adult Protective Services (APS) form revealed it was filed on 4/2/17, eight (8) days after the patient notified the hospital of the alleged incident, by the Nurse Clinical Coordinator (NCC).

4. Review of the hospital's investigation report revealed a signed statement from RN #1 on 4/2/17 which revealed patient #1 initially complained of a fall and later explained Health Service Worker (HSW) #1 had grabbed hold of him and pushed him into the wall and he fell .

5. On 4/17/17 at 1:27 p.m. a video tape (dated 3/26/17-date of incident) was reviewed in the presence of the Assistant Chief Operating Officer and Patient Safety Director. Beginning at 8:35 p.m., the video shows patients #1 and 2 standing in front of the nursing station. At 8:36 p.m. HSW #1 came down the hall, took his hand and moved patient #2 around and then put his hand to the back of her neck and took her to a patient room. He then came back up the hall at 8:39 p.m. and immediately placed his face in patient #1's face; HSW #1 was seen moving his mouth and patient #1 was trying to move out of his way but HSW #1 continued to keep the patient in the area where the medication pass was occurring. HSW #1 then began to walk away. Patient #1 was leaning against a wall with his back turned toward HSW #1 when HSW #1 came back to the patient and said something to the patient's back, turned him around and took him down the hall to his room. Patient #3 was seen outside of patient #1's room looking into the room and then moved to the room and touched the light switch. At 10:18 p.m. patient #1 exited the room holding his left arm and went to the nursing station and talked to RN #1. The video showed four (4) employees sitting at the nursing station.

During review of the video the Director of Nursing (DON) came in at 1:39 p.m. and saw the aggressive behavior from HSW #1. When asked if she saw this aggressive behavior while investigating the abuse allegations, she stated, in part: "No, I did not. I watched four (4) days of videos and didn't see this. I feel nauseous at seeing this now."

6. An interview was conducted with patient #1 on 4/17/17 at approximately 9:00 a.m. during a tour of unit C-1. The patient requested RN #2 be present for the interview and the patient's representative was notified of the request for interview; the interview was granted by phone to RN #2. When asked to explain how his arm became injured, patient #1 stated, in part: "I was told by (HSW #1) to go to my room because he said I was acting up and I went to my room and then he shoved me when I got to my room and I fell over towels in my room." When asked if he told anyone about what happened, he stated, in part: "I told (RN #1) because I was in pain and then I told my doctor and almost everyone and I'm afraid of him because he told me if I told anyone he would hurt me."

7. A joint interview was conducted with Attending Physician #1 and Physician Assistant (PA) #1 on 4/17/14 at 12:45 p.m. When asked if they remembered patient #1 being injured, they both stated, "Yes." Attending Physician #1 stated, in part: "I was getting ready for work on the 27th and got a phone call that he fell and hurt his arm and told them I was getting ready to come in and I would see him in a couple of hours. When I came in I discussed the patient with the PA and she went to see him." The PA stated, in part: "When I talked to the patient he told me he was pushed down and fell over clothes and hit the wall and floor and hurt his arm and he refused to tell me who hurt him." When asked if they filed a complaint or an Adult Protective Services form on the patient's behalf, they stated, "No."

8. An interview was conducted with patient #3 (who was patient #1's roommate at the time of the incident) on 4/17/17 at approximately 4:00 p.m. When asked if he remembered the night patient #1 was injured, he stated, in part: "He (HSW#1) was aggressive to him (patient #1). Physical interaction is bad. He (HSW #1) is not nice to him (patient #1)."

9. An interview was conducted with RN #1 on 4/17/17 at 4:24 p.m. When asked if she remembered the night patient #1 was injured, she stated, "Yes." When asked what happened, she stated, in part: "Patient #1 came to the nursing desk and said he tripped over towels in his room and hurt his arm and wanted something for pain so I gave him an ice pack and medicated him. He later told me he was pushed by (HSW #1) and tripped over the towels in the floor and hit the wall and then the floor." When asked if she had ever seen HSW #1 become aggressive with patients, she stated, in part: "Yes, he was aggressive that night with (patient #1) and with other patients before. He's been aggressive with me and I told our NCC and she didn't do anything so I never said anything again since they don't seem to care." When asked if she filed a complaint for the patient or filed an Adult Protective Services form, she stated, "No, I told the NCC."

10. An interview was conducted with the Nurse Manager of unit C-1 on 4/18/17 at 8:17 a.m. When asked when she became aware of the incident of patient #1 she stated the PA told her the next morning about what patient #1 said. When asked if an Adult Protective Services form was completed, she stated, "No." When asked if HSW #1 was removed from patient care she stated she would have to check. After checking the staffing sheets she stated he was at work when he was scheduled except for one (1) day when he called in.

11. An interview was conducted with the Assistant Chief Executive Officer on 4/18/17 at 8:58 a.m. and she concurred with the above findings.

B. Based on document review, record review, video review and staff interview it was determined the Director of Nursing failed to ensure allegations of abuse were reported according to hospital policy in one (1) of one (1) allegations of abuse reviewed (patient #2). This failure has the potential for all patients who are allegedly abused to continue to be abused by the alleged perpetrator.

Findings include:

1. Review of the policy titled "Allegations of Abuse and Neglect", effective date 6/08, revealed it states, in part: "All patients have the right to be free from abuse or neglect as well as the fear of being abused...All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may occur...All employees...are mandatory reporters for abuse and neglect. Individuals who witness or have knowledge of patient abuse/neglect shall immediately report it to the charge nurse or Nurse Clinical Coordinator (NCC)...Documentation in the form of an APS form...grievance form and/or written statements are to be completed within one hour of the allegation."

2. Review of the medical record for patient #2 revealed no documentation of physical abuse was documented on 3/26/17 at 8:36 p.m. by HSW #1.

3. On 4/17/17 at 1:27 p.m. a video tape (dated 3/26/17-date of incident) was reviewed in the presence of the Assistant Chief Operating Officer and Patient Safety Director. Beginning at 8:35 p.m., the video shows patients #1 and 2 standing in front of the nursing station. At 8:36 p.m. HSW #1 came down the hall, took his hand and moved patient #2 around and then put his hand to the back of her neck and took her to a patient room. He then came back up the hall at 8:39 p.m. and immediately placed his face in patient #1's face; HSW #1 was seen moving his mouth and patient #1 was trying to move out of his way but HSW #1 continued to keep the patient in the area where the medication pass was occurring. HSW #1 then began to walk away. Patient #1 was leaning against a wall with his back turned toward HSW #1 when HSW #1 came back to the patient and said something to the patient's back, turned him around and took him down the hall to his room. Patient #3 was seen outside of patient #1's room looking into the room and then moved to the room and touched the light switch. At 10:18 p.m. patient #1 exited the room holding his left arm and went to the nursing station and talked to RN #1. The video showed four (4) employees sitting at the nursing station.

During review of the video the Director of Nursing (DON) came in at 1:39 p.m. and saw the aggressive behavior from HSW #1 towards patients #1 and 2. When asked if she saw this aggressive behavior while investigating the abuse allegations, she stated, in part: "No, I did not. I watched four (4) days of videos and didn't see this. I feel nauseous at seeing this now." During review of the video the DON acknowledged the facility was unaware of patient #2 being abused even though she investigated patient #1's abuse by video tape and failed to watch the correct time of the occurrence. The four (4) healthcare workers seen sitting at the nursing station were identified by the DON and Nurse Manager.

4. An interview was conducted with RN #1 on 4/17/17 at 4:24 p.m. When asked if she remembered the night patient #1 was injured, she stated, "Yes." When asked what happened, she stated, in part: "Patient #1 came to the nursing desk and said he tripped over towels in his room and hurt his arm and wanted something for pain so I gave him an ice pack and medicated him. He later told me he was pushed by (HSW #1) and tripped over the towels in the floor and hit the wall and then the floor." When asked if she had ever seen HSW #1 become aggressive with patients, she stated, in part: "Yes, he was aggressive that night with (patient #1) and with other patients before. He's been aggressive with me and I told our NCC and she didn't do anything so I never said anything again since they don't seem to care." When asked if she filed a complaint for the patient or filed an Adult Protective Services form, she stated, "No, I told the NCC and I did not contact the guardian until the next morning."

5. An interview was conducted with the Nurse Manager of unit C-1 on 4/18/17 at 8:17 a.m. When asked if she reviewed the video tape of the night of the alleged abuse she stated she had and was shocked because she never would have thought he would have the behavior she watched on the video and agreed abuse occurred with patients #1 and 2.

6. An interview was conducted on 4/17/17 at 5:00 p.m. with HSW #1 in the presence of the Assistant Chief Executive Officer, at the request of HSW #1. When asked if he remembered the night patient #1 was injured, he stated, in part: "Yes, I had taken him to his room because he was acting up and throwing popcorn and before I could get out of the room I heard him fall and turned around and he was laying in the floor and his lip was bleeding. I helped him up and put him in bed and went to ask the nurse for an ice pack for his mouth because it was bleeding and she told me that takes a doctor's order so he didn't get one." It should be noted that when observing the above noted video HSW #1 came out of the patient's room and did not speak to any other health care worker or return to the patient's room. When asked if he knew the patient alleged he pushed him, he stated, in part: "Yes, the advocate asked me if I saw anything that night." When asked if he was ever removed from patient care during the investigation, he stated, "No, I've worked every day except one (1) and my daughter had a baby that night." The HSW was then made aware of a new allegation of abuse on the same night and time with patient #2 and when asked if he remembered anything unusual about the night with patient #2, he stated, in part: "Yes, she was laying in the floor and I was told to pick her up and take her to her room."

7. An interview was conducted on 4/17/17 at 5:30 p.m. with LPN #1. When asked if she knew about patient #1's injury to his arm and if so what information she had about it, she stated, in part: "Yes, I was told he fell and that HSW #1 pushed him and broke his arm." When asked if she was passing medication during the time the injury occurred she consulted her date calendar and said she didn't know because she worked a double. When shown the medication administration record on all patients for the time of the incident, she stated, "Then I guess I was." When asked if she heard any yelling or saw any abuse, she stated, "No, I did not."

8. An interview was conducted on 4/19/17 at 3:20 p.m. with HSW #2. When asked if she was aware of patient #1 being injured, she stated, in part: "Yes, I found out the next day when I came back and he had his arm in a sling." When asked if she heard or saw any abuse during the evening medication pass while she was sitting at the nursing station, she stated, in part: "I probably had my head down charting and if so I wouldn't hear because I am legally deaf and don't know if you are speaking unless you are looking at me. I have a medical note in my chart that says that." It should be noted review of the HSW's personnel record revealed the HSW is legally deaf.

9. An interview was conducted with the Assistant Chief Executive Officer on 4/18/17 at 8:58 a.m. and she concurred with the above findings.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review, record review, video review and staff interview it was determined the hospital failed to ensure all patients were given the right to file a complaint (see tag A 118); failed to give a prompt resolution to a complaint (see tag A 119); failed to follow their grievance process (see tag A 120); failed to follow their investigation process and complete an accurate investigation (see tag A 122); failed to allow the patient/representative to be informed of a change of condition to make an informed decision of care (see tag A 131); failed to timely notify the patient's representative of injury (see tag A 132); failed to provide care in a safe setting (see tag A 144); and, failed to ensure patients remained free from all forms of abuse (see tag A 145).
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on document review, record review and staff interview it was determined the hospital failed to enforce a prompt resolution to a patient grievance in one (1) of ten (10) records reviewed in which a complaint was voiced by a patient (patient #1). This failure has the potential to negatively affect all patients who have a right to file a complaint.

Findings include:

1. Review of the policy titled "Allegations of Abuse and Neglect", effective date 6/08, revealed it states, in part: "All patients have the right to be free from abuse or neglect as well as the fear of being abused...All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may occur...A formal or informal written or verbal complaint may be initiated on behalf of the patient."

2. Review of the medical record for patient #1 revealed documentation by Registered Nurse (RN) #1 on 3/26/17 at 9:45 p.m. which stated, in part: "The patient complained of left shoulder pain and slipped on towels in his room and I notified the supervisor."

3. Review of the hospital's investigation report revealed a signed statement from RN #1 on 4/2/17 which revealed patient #1 initially complained of a fall and later explained Health Service Worker (HSW) #1 had grabbed hold of him and pushed him into the wall and he fell .

4. Review of the Adult Protective Services (APS) form revealed it was filed on 4/2/17, eight (8) days after the patient notified the hospital of the alleged incident, by the Nurse Clinical Coordinator (NCC).

5. An interview was conducted with patient #1 on 4/17/17 at approximately 9:00 a.m. during a tour of unit C-1. The patient requested RN #2 be present for the interview and the patient's representative was notified of the request for interview; the interview was granted by phone to RN #2. When asked to explain how his arm became injured, patient #1 stated, in part: "I was told by (HSW #1) to go to my room because he said I was acting up and I went to my room and then he shoved me when I got to my room and I fell over towels in my room." When asked if he told anyone about what happened, he stated, in part: "I told (RN #1) because I was in pain and then I told my doctor and almost everyone and I'm afraid of him because he told me if I told anyone he would hurt me."

6. A joint interview was conducted with Attending Physician #1 and Physician Assistant (PA) #1 on 4/17/14 at 12:45 p.m. When asked if they remembered patient #1 being injured, they both stated, "Yes." Attending Physician #1 stated, in part: "I was getting ready for work on the 27th and got a phone call that he fell and hurt his arm and told them I was getting ready to come in and I would see him in a couple of hours. When I came in I discussed the patient with the PA and she went to see him." The PA stated, in part: "When I talked to the patient he told me he was pushed down and fell over clothes and hit the wall and floor and hurt his arm and he refused to tell me who hurt him." When asked if they filed a complaint or an Adult Protective Services form on the patient's behalf, they stated, "No."

7. An interview was conducted with patient #3 (who was patient #1's roommate at the time of the incident) on 4/17/17 at approximately 4:00 p.m. When asked if he remembered the night patient #1 was injured, he stated, in part: "He (HSW#1) was aggressive to him (patient #1). Physical interaction is bad. He (HSW #1) is not nice to him (patient #1)."

8. An interview was conducted with RN #1 on 4/17/17 at 4:24 p.m. When asked if she remembered the night patient #1 was injured, she stated, "Yes." When asked what happened, she stated, in part: "Patient #1 came to the nursing desk and said he tripped over towels in his room and hurt his arm and wanted something for pain so I gave him an ice pack and medicated him. He later told me he was pushed by (HSW #1) and tripped over the towels in the floor and hit the wall and then the floor." When asked if she had ever seen HSW #1 become aggressive with patients, she stated, in part: "Yes, he was aggressive that night with (patient #1) and with other patients before. He's been aggressive with me and I told our NCC and she didn't do anything so I never said anything again since they don't seem to care." When asked if she filed a complaint for the patient or filed an Adult Protective Services form, she stated, "No, I told the NCC."

9. An interview was conducted with the Nurse Manager of unit C-1 on 4/18/17 at 8:17 a.m. When asked when she became aware of the incident of patient #1 she stated the PA told her the next morning about what patient #1 said. When asked if an Adult Protective Services form was completed, she stated, "No."

10. An interview was conducted with the Assistant Chief Executive Officer on 4/18/17 at 8:58 a.m. and she concurred with the above findings.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on document review, record review and staff interview it was determined the hospital failed to file a complaint in a timely manner and failed to include the patient's representative in the patient grievance process in one (1) of ten (10) complaints voiced by patients (patient #1). This failure has the potential to negatively affect all patients who have a right to know the outcome of a complaint.

Findings include:

1. Review of the policy titled "Allegations of Abuse and Neglect", effective date 6/08, revealed it states, in part: "All patients have the right to be free from abuse or neglect as well as the fear of being abused...All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may occur...A formal or informal written or verbal complaint may be initiated on behalf of the patient."

2. Review of the medical record for patient #1 revealed documentation by Registered Nurse (RN) #1 on 3/26/17 at 21:45 p.m. that the patient complained of left shoulder pain and slipped on towels in his room.

3. Review of the hospital's investigation report revealed a signed statement from RN #1 on 4/2/17 which revealed patient #1 initially complained of a fall and later explained Health Service Worker (HSW) #1 had grabbed hold of him and pushed him into the wall and he fell .

4. Review of the hospital's investigation revealed the patient received a letter from the hospital with a conclusion to the grievance process although the patient's representative was not notified of the Adult Protective Services (APS) report or the grievance filed on the patient's behalf.

5. Review of the APS form revealed it was filed on 4/2/17, eight (8) days after the patient notified the hospital of the alleged incident, by the Nurse Clinical Coordinator.

6. An interview was conducted with patient #1 on 4/17/17 at approximately 9:00 a.m. during a tour of unit C-1. The patient requested RN #2 be present for the interview and the patient's representative was notified of the request for interview; the interview was granted by phone to RN #2. When asked to explain how his arm became injured, patient #1 stated, in part: "I was told by (HSW #1) to go to my room because he said I was acting up and I went to my room and then he shoved me when I got to my room and I fell over towels in my room." When asked if he told anyone about what happened, he stated, in part: "I told (RN #1) because I was in pain and then I told my doctor and almost everyone and I'm afraid of him because he told me if I told anyone he would hurt me."

7. A joint interview was conducted with Attending Physician #1 and Physician Assistant (PA) #1 on 4/17/14 at 12:45 p.m. When asked if they remembered patient #1 being injured, they both stated, "Yes." Attending Physician #1 stated, in part: "I was getting ready for work on the 27th and got a phone call that he fell and hurt his arm and told them I was getting ready to come in and I would see him in a couple of hours. When I came in I discussed the patient with the PA and she went to see him." The PA stated, in part: "When I talked to the patient he told me he was pushed down and fell over clothes and hit the wall and floor and hurt his arm and he refused to tell me who hurt him." When asked if they filed a complaint or an Adult Protective Services form on the patient's behalf, they stated, "No."

8. An interview was conducted with patient #3 (who was patient #1's roommate at the time of the incident) on 4/17/17 at approximately 4:00 p.m. When asked if he remembered the night patient #1 was injured, he stated, in part: "He (HSW#1) was aggressive to him (patient #1). Physical interaction is bad. He (HSW #1) is not nice to him (patient #1)."

9. An interview was conducted with RN #1 on 4/17/17 at 4:24 p.m. When asked if she remembered the night patient #1 was injured, she stated, "Yes." When asked what happened, she stated, in part: "Patient #1 came to the nursing desk and said he tripped over towels in his room and hurt his arm and wanted something for pain so I gave him an ice pack and medicated him. He later told me he was pushed by (HSW #1) and tripped over the towels in the floor and hit the wall and then the floor." When asked if she had ever seen HSW #1 become aggressive with patients, she stated, in part: "Yes, he was aggressive that night with (patient #1) and with other patients before. He's been aggressive with me and I told our NCC and she didn't do anything so I never said anything again since they don't seem to care." When asked if she filed a complaint for the patient or filed an Adult Protective Services form, she stated, "No, I told the NCC."

10. An interview was conducted with the Nurse Manager of unit C-1 on 4/18/17 at 8:17 a.m. When asked when she became aware of the incident of patient #1 she stated the PA told her the next morning about what patient #1 said. When asked if an Adult Protective Services form was completed, she stated, "No."

11. An interview was conducted with the Assistant Chief Executive Officer on 4/18/17 at 8:58 a.m. and she concurred with the above findings.
VIOLATION: PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES Tag No: A0120
Based on document review, record review and staff interview it was determined the hospital failed to file a complaint in a timely manner and failed to include the patient's representative in the patient grievance process in one (1) of ten (10) complaints voiced by patients (patient #1). This failure has the potential to negatively affect all patients who have a right to know the outcome of a complaint.

Findings include:

1. Review of the policy titled "Allegations of Abuse and Neglect", effective date 6/08, revealed it states, in part: "All patients have the right to be free from abuse or neglect as well as the fear of being abused...All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may occur...A formal or informal written or verbal complaint may be initiated on behalf of the patient."

2. Review of the policy titled "Allegations of Abuse and Neglect", last reviewed 3/14, revealed it states, in part: "The CEO/designee will also assign a hospital staff member(s) to investigate...abuse and/or neglect...the investigation will be complete within fourteen (14) calendar days of the investigation."

3. Review of the medical record for patient #1 revealed documentation by Registered Nurse (RN) #1 on 3/26/17 at 9:45 p.m. that the patient complained of left shoulder pain and slipped on towels in his room.

4. Review of the Adult Protective Services (APS) form revealed the patient complained of abuse on 3/26/17; an investigation was not initiated and an APS form was not filed until 4/2/17 by the Nurse Clinical Coordinator.

5. Review of the hospital's investigation report revealed a signed statement from RN #1 on 4/2/17 which revealed patient #1 initially complained of a fall and later explained Health Service Worker (HSW) #1 had grabbed hold of him and pushed him into the wall and he fell .

6. Review of the hospital's investigation revealed the patient received a letter from the hospital with a conclusion to the grievance process although the patient's representative was not notified of the APS report or the grievance filed on the patient's behalf.

7. An interview was conducted with patient #1 on 4/17/17 at approximately 9:00 a.m. during a tour of unit C-1. The patient requested RN #2 be present for the interview and the patient's representative was notified of the request for interview; the interview was granted by phone to RN #2. When asked to explain how his arm became injured, patient #1 stated, in part: "I was told by (HSW #1) to go to my room because he said I was acting up and I went to my room and then he shoved me when I got to my room and I fell over towels in my room." When asked if he told anyone about what happened, he stated, in part: "I told (RN #1) because I was in pain and then I told my doctor and almost everyone and I'm afraid of him because he told me if I told anyone he would hurt me."

8. A joint interview was conducted with Attending Physician #1 and Physician Assistant (PA) #1 on 4/17/14 at 12:45 p.m. When asked if they remembered patient #1 being injured, they both stated, "Yes." Attending Physician #1 stated, in part: "I was getting ready for work on the 27th and got a phone call that he fell and hurt his arm and told them I was getting ready to come in and I would see him in a couple of hours. When I came in I discussed the patient with the PA and she went to see him." The PA stated, in part: "When I talked to the patient he told me he was pushed down and fell over clothes and hit the wall and floor and hurt his arm and he refused to tell me who hurt him." When asked if they filed a complaint or an Adult Protective Services form on the patient's behalf, they stated, "No."

9. An interview was conducted with patient #3 (who was patient #1's roommate at the time of the incident) on 4/17/17 at approximately 4:00 p.m. When asked if he remembered the night patient #1 was injured, he stated, in part: "He (HSW#1) was aggressive to him (patient #1). Physical interaction is bad. He (HSW #1) is not nice to him (patient #1)."

10. An interview was conducted with RN #1 on 4/17/17 at 4:24 p.m. When asked if she remembered the night patient #1 was injured, she stated, "Yes." When asked what happened, she stated, in part: "Patient #1 came to the nursing desk and said he tripped over towels in his room and hurt his arm and wanted something for pain so I gave him an ice pack and medicated him. He later told me he was pushed by (HSW #1) and tripped over the towels in the floor and hit the wall and then the floor." When asked if she had ever seen HSW #1 become aggressive with patients, she stated, in part: "Yes, he was aggressive that night with (patient #1) and with other patients before. He's been aggressive with me and I told our NCC and she didn't do anything so I never said anything again since they don't seem to care." When asked if she filed a complaint for the patient or filed an Adult Protective Services form, she stated, "No, I told the NCC."

11. An interview was conducted with the Nurse Manager of unit C-1 on 4/18/17 at 8:17 a.m. When asked when she became aware of the incident of patient #1 she stated the PA told her the next morning about what patient #1 said. When asked if an Adult Protective Services form was completed, she stated, "No."

12. An interview was conducted with the Assistant Chief Executive Officer on 4/18/17 at 8:58 a.m. and she concurred with the above findings.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on document review, record review and staff interview it was determined the hospital failed to file a complaint in a timely manner and failed to include the patient's representative in the patient grievance process in one (1) of ten (10) complaints voiced by patients (patient #1). This failure has the potential to negatively affect all patients who have a right to know the outcome of a complaint.

Findings include:

1. Review of the policy titled "Allegations of Abuse and Neglect", effective date 6/08, revealed it states, in part: "All patients have the right to be free from abuse or neglect as well as the fear of being abused...All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may occur...A formal or informal written or verbal complaint may be initiated on behalf of the patient."

2. Review of the policy titled "Allegations of Abuse and Neglect", last reviewed 3/14, revealed it states, in part: "The CEO/designee will also assign a hospital staff member(s) to investigate...abuse and/or neglect...the investigation will be complete within fourteen (14) calendar days of the investigation".

3. Review of the medical record for patient #1 revealed documentation by Registered Nurse (RN) #1 on 3/26/17 at 9:45 p.m. that the patient complained of left shoulder pain and slipped on towels in his room.

4. Review of the Adult Protective Services (APS) form revealed the patient complained of abuse on 3/26/17; an investigation was not initiated and an APS form was not filed until 4/2/17 by the Nurse Clinical Coordinator.

5. Review of the hospital's investigation report revealed a signed statement from RN #1 on 4/2/17 which revealed patient #1 initially complained of a fall and later explained Health Service Worker (HSW) #1 had grabbed hold of him and pushed him into the wall and he fell .

6. Review of the hospital's investigation revealed the patient received a letter from the hospital with a conclusion to the grievance process on 4/7/17 although the patient's representative was not notified of the APS report or the grievance filed on the patient's behalf.

7. An interview was conducted with patient #1 on 4/17/17 at approximately 9:00 a.m. during a tour of unit C-1. The patient requested RN #2 be present for the interview and the patient's representative was notified of the request for interview; the interview was granted by phone to RN #2. When asked to explain how his arm became injured, patient #1 stated, in part: "I was told by (HSW #1) to go to my room because he said I was acting up and I went to my room and then he shoved me when I got to my room and I fell over towels in my room." When asked if he told anyone about what happened, he stated, in part: "I told (RN #1) because I was in pain and then I told my doctor and almost everyone and I'm afraid of him because he told me if I told anyone he would hurt me."

8. A joint interview was conducted with Attending Physician #1 and Physician Assistant (PA) #1 on 4/17/14 at 12:45 p.m. When asked if they remembered patient #1 being injured, they both stated, "Yes." Attending Physician #1 stated, in part: "I was getting ready for work on the 27th and got a phone call that he fell and hurt his arm and told them I was getting ready to come in and I would see him in a couple of hours. When I came in I discussed the patient with the PA and she went to see him." The PA stated, in part: "When I talked to the patient he told me he was pushed down and fell over clothes and hit the wall and floor and hurt his arm and he refused to tell me who hurt him." When asked if they filed a complaint or an Adult Protective Services form on the patient's behalf, they stated, "No."

9. An interview was conducted with patient #3 (who was patient #1's roommate at the time of the incident) on 4/17/17 at approximately 4:00 p.m. When asked if he remembered the night patient #1 was injured, he stated, in part: "He (HSW#1) was aggressive to him (patient #1). Physical interaction is bad. He (HSW #1) is not nice to him (patient #1)."

10. An interview was conducted with RN #1 on 4/17/17 at 4:24 p.m. When asked if she remembered the night patient #1 was injured, she stated, "Yes." When asked what happened, she stated, in part: "Patient #1 came to the nursing desk and said he tripped over towels in his room and hurt his arm and wanted something for pain so I gave him an ice pack and medicated him. He later told me he was pushed by (HSW #1) and tripped over the towels in the floor and hit the wall and then the floor." When asked if she had ever seen HSW #1 become aggressive with patients, she stated, in part: "Yes, he was aggressive that night with (patient #1) and with other patients before. He's been aggressive with me and I told our NCC and she didn't do anything so I never said anything again since they don't seem to care." When asked if she filed a complaint for the patient or filed an Adult Protective Services form, she stated, "No, I told the NCC."

11. An interview was conducted with the Nurse Manager of unit C-1 on 4/18/17 at 8:17 a.m. When asked when she became aware of the incident of patient #1 she stated the PA told her the next morning about what patient #1 said. When asked if an Adult Protective Services form was completed, she stated, "No."

12. An interview was conducted with the Assistant Chief Executive Officer on 4/18/17 at 8:58 a.m. and she concurred with the above findings.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on record review, document review and staff interview it was determined the hospital failed to timely notify the patient's representative of an injury in one (1) of ten (10) records reviewed of patients receiving an injury (patient #1). This failure has the potential to delay medical care for all patients injured.

Findings include:

1. Review of the medical record for patient #1 revealed documentation by Registered Nurse (RN) #1 on 3/26/17 at 9:45 p.m. that the patient complained of left shoulder pain and slipped on towels in his room. The patient's health care surrogate (HCS) was not notified at the time of injury. Further review of the medical record revealed the Physician Assistant (PA) completed a medical exam on patient #1 on 3/27/17 at 12:41 p.m. and the patient had decreased movement to the left arm with swelling and bruising noted. The PA then notified patient #1's HCS of the patient's injuries and the need for X-rays. The patient was sent to Stonewall Jackson Memorial Hospital for an X-ray of the left arm; the patient was diagnosed with a fracture of the left shoulder.

2. Review of the hospital's injury report revealed a report was filed on 3/26/17 at 10:30 p.m. and the patient's representative was not notified until 6:40 a.m. on 3/27/17.

3. An interview was conducted on 4/17/17 at 4:24 p.m. with RN #1. When asked if she notified patient #1's representative, she stated, in part: "I waited to notify her until the next morning."

4. An interview was conducted with the Director of Nursing on 4/17/17 at 5:30 p.m. and she concurred with the above findings.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
Based on record review, document review and staff interview it was determined the hospital failed to timely notify the patient's representative of an injury in one (1) of ten (10) records reviewed of patients receiving an injury (patient #1). This failure has the potential to delay medical care for all patients injured.

Findings include:

1. Review of the medical record for patient #1 revealed documentation by Registered Nurse (RN) #1 on 3/26/17 at 9:45 p.m. that the patient complained of left shoulder pain and slipped on towels in his room. The patient's health care surrogate (HCS) was not notified at the time of injury. Further review of the medical record revealed the Physician Assistant (PA) completed a medical exam on patient #1 on 3/27/17 at 12:41 p.m. and the patient had decreased movement to the left arm with swelling and bruising noted. The PA then notified patient #1's HCS of the patient's injuries and the need for X-rays. The patient was sent to Stonewall Jackson Memorial Hospital for an X-ray of the left arm; the patient was diagnosed with a fracture of the left shoulder.

2. Review of the hospital's injury report revealed a report was filed on 3/26/17 at 10:30 p.m. and the patient's representative was not notified until 6:40 a.m. on 3/27/17.

3. An interview was conducted on 4/17/17 at 4:24 p.m. with RN #1. When asked if she notified patient #1's representative, she stated, in part: "I waited to notify her until the next morning."

4. An interview was conducted with the Director of Nursing on 4/17/17 at 5:30 p.m. and she concurred with the above findings.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
A. Based on document review, record review, video review and staff interview it was determined the hospital failed to ensure allegations of abuse and neglect were reported according to hospital policy in one (1) of one (1) allegations of abuse cases reviewed for injury (patient #1). This failure has the potential for all patients who are allegedly abused to continue to be abused by the alleged perpetrator.

Findings include:

1. Review of the policy titled "Allegations of Abuse and Neglect", effective date 6/08, revealed it states, in part: "All patients have the right to be free from abuse or neglect as well as the fear of being abused...All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may occur...All employees...are mandatory reporters for abuse and neglect. Individuals who witness or have knowledge of patient abuse/neglect shall immediately report it to the charge nurse or Nurse Clinical Coordinator (NCC)...Documentation in the form of an APS form...grievance form and/or written statements are to be completed within one hour of the allegation...Alleged perpetrator removed from the situation."

2. Review of the medical record for patient #1 revealed documentation by Registered Nurse (RN) #1 on 3/26/17 at 9:45 p.m. that the patient complained of left shoulder pain and slipped on towels in his room.

3. Review of the Adult Protective Services (APS) form revealed it was filed on 4/2/17, eight (8) days after the patient notified the hospital of the alleged incident, by the Nurse Clinical Coordinator (NCC).

4. Review of the hospital's investigation report revealed a signed statement from RN #1 on 4/2/17 which revealed patient #1 initially complained of a fall and later explained Health Service Worker (HSW) #1 had grabbed hold of him and pushed him into the wall and he fell .

5. On 4/17/17 at 1:27 p.m. a video tape (dated 3/26/17-date of incident) was reviewed in the presence of the Assistant Chief Operating Officer and Patient Safety Director. Beginning at 8:35 p.m., the video shows patients #1 and 2 standing in front of the nursing station. At 8:36 p.m. HSW #1 came down the hall, took his hand and moved patient #2 around and then put his hand to the back of her neck and took her to a patient room. He then came back up the hall at 8:39 p.m. and immediately placed his face in patient #1's face; HSW #1 was seen moving his mouth and patient #1 was trying to move out of his way but HSW #1 continued to keep the patient in the area where the medication pass was occurring. HSW #1 then began to walk away. Patient #1 was leaning against a wall with his back turned toward HSW #1 when HSW #1 came back to the patient and said something to the patient's back, turned him around and took him down the hall to his room. Patient #3 was seen outside of patient #1's room looking into the room and then moved to the room and touched the light switch. At 10:18 p.m. patient #1 exited the room holding his left arm and went to the nursing station and talked to RN #1. The video showed four (4) employees sitting at the nursing station.

During review of the video the Director of Nursing (DON) came in at 1:39 p.m. and saw the aggressive behavior from HSW #1 towards patients #1 and 2. When asked if she saw this aggressive behavior while investigating the abuse allegations, she stated, in part: "No, I did not. I watched four (4) days of videos and didn't see this. I feel nauseous at seeing this now." During review of the video the DON acknowledged the facility was unaware of patient #2 being abused even though she investigated patient #1's abuse by video tape and failed to watch the correct time of the occurrence. The four (4) healthcare workers seen sitting at the nursing station were identified by the DON and Nurse Manager.

6. An interview was conducted with patient #1 on 4/17/17 at approximately 9:00 a.m. during a tour of unit C-1. The patient requested RN #2 be present for the interview and the patient's representative was notified of the request for interview; the interview was granted by phone to RN #2. When asked to explain how his arm became injured, patient #1 stated, in part: "I was told by (HSW #1) to go to my room because he said I was acting up and I went to my room and then he shoved me when I got to my room and I fell over towels in my room." When asked if he told anyone about what happened, he stated, in part: "I told (RN #1) because I was in pain and then I told my doctor and almost everyone and I'm afraid of him because he told me if I told anyone he would hurt me."

7. A joint interview was conducted with Attending Physician #1 and Physician Assistant (PA) #1 on 4/17/14 at 12:45 p.m. When asked if they remembered patient #1 being injured, they both stated, "Yes." Attending Physician #1 stated, in part: "I was getting ready for work on the 27th and got a phone call that he fell and hurt his arm and told them I was getting ready to come in and I would see him in a couple of hours. When I came in I discussed the patient with the PA and she went to see him." The PA stated, in part: "When I talked to the patient he told me he was pushed down and fell over clothes and hit the wall and floor and hurt his arm and he refused to tell me who hurt him." When asked if they filed a complaint or an Adult Protective Services form on the patient's behalf, they stated, "No."

8. An interview was conducted with patient #3 (who was patient #1's roommate at the time of the incident) on 4/17/17 at approximately 4:00 p.m. When asked if he remembered the night patient #1 was injured, he stated, in part: "He (HSW#1) was aggressive to him (patient #1). Physical interaction is bad. He (HSW #1) is not nice to him (patient #1)."

9. An interview was conducted with RN #1 on 4/17/17 at 4:24 p.m. When asked if she remembered the night patient #1 was injured, she stated, "Yes." When asked what happened, she stated, in part: "Patient #1 came to the nursing desk and said he tripped over towels in his room and hurt his arm and wanted something for pain so I gave him an ice pack and medicated him. He later told me he was pushed by (HSW #1) and tripped over the towels in the floor and hit the wall and then the floor." When asked if she had ever seen HSW #1 become aggressive with patients, she stated, in part: "Yes, he was aggressive that night with (patient #1) and with other patients before. He's been aggressive with me and I told our NCC and she didn't do anything so I never said anything again since they don't seem to care." When asked if she filed a complaint for the patient or filed an Adult Protective Services form, she stated, "No, I told the NCC."

10. An interview was conducted with the Nurse Manager of unit C-1 on 4/18/17 at 8:17 a.m. When asked when she became aware of the incident of patient #1 she stated the PA told her the next morning about what patient #1 said. When asked if an Adult Protective Services form was completed, she stated, "No." When asked if HSW #1 was removed from patient care she stated she would have to check. After checking the staffing sheets she stated he was at work when he was scheduled except for one (1) day when he called in.

11. An interview was conducted with the Assistant Chief Executive Officer on 4/18/17 at 8:58 a.m. and she concurred with the above findings.

B. Based on record review, video review and staff interview it was determined the hospital failed to ensure allegations of abuse and neglect were reported according to hospital policy in one (1) of one (1) allegations of abuse cases reviewed (patient #2). This failure has the potential for all patients who are allegedly abused to continue to be abused by the alleged perpetrator.

Findings include:

1. Review of the medical record for patient #2 revealed no documentation of physical abuse was documented on 3/26/17 at 8:36 p.m. by HSW #1.

2. On 4/17/17 at 1:27 p.m. a video tape (dated 3/26/17-date of incident) was reviewed in the presence of the Assistant Chief Operating Officer and Patient Safety Director. Beginning at 8:35 p.m., the video shows patients #1 and 2 standing in front of the nursing station. At 8:36 p.m. HSW #1 came down the hall, took his hand and moved patient #2 around and then put his hand to the back of her neck and took her to a patient room. He then came back up the hall at 8:39 p.m. and immediately placed his face in patient #1's face; HSW #1 was seen moving his mouth and patient #1 was trying to move out of his way but HSW #1 continued to keep the patient in the area where the medication pass was occurring. HSW #1 then began to walk away. Patient #1 was leaning against a wall with his back turned toward HSW #1 when HSW #1 came back to the patient and said something to the patient's back, turned him around and took him down the hall to his room. Patient #3 was seen outside of patient #1's room looking into the room and then moved to the room and touched the light switch. At 10:18 p.m. patient #1 exited the room holding his left arm and went to the nursing station and talked to RN #1. The video showed four (4) employees sitting at the nursing station.

During review of the video the Director of Nursing (DON) came in at 1:39 p.m. and saw the aggressive behavior from HSW #1 towards patients #1 and 2. When asked if she saw this aggressive behavior while investigating the abuse allegations, she stated, in part: "No, I did not. I watched four (4) days of videos and didn't see this. I feel nauseous at seeing this now." During review of the video the DON acknowledged the facility was unaware of patient #2 being abused even though she investigated patient #1's abuse by video tape and failed to watch the correct time of the occurrence. The four (4) healthcare workers seen sitting at the nursing station were identified by the DON and Nurse Manager.

3. An interview was conducted with RN #1 on 4/17/17 at 4:24 p.m. When asked if she remembered the night patient #1 was injured, she stated, "Yes." When asked what happened, she stated, in part: "Patient #1 came to the nursing desk and said he tripped over towels in his room and hurt his arm and wanted something for pain so I gave him an ice pack and medicated him. He later told me he was pushed by (HSW #1) and tripped over the towels in the floor and hit the wall and then the floor." When asked if she had ever seen HSW #1 become aggressive with patients, she stated, in part: "Yes, he was aggressive that night with (patient #1) and with other patients before. He's been aggressive with me and I told our NCC and she didn't do anything so I never said anything again since they don't seem to care." When asked if she filed a complaint for the patient or filed an Adult Protective Services form, she stated, "No, I told the NCC and I did not contact the guardian until the next morning."

4. An interview was conducted with the Nurse Manager of unit C-1 on 4/18/17 at 8:17 a.m. When asked if she reviewed the video tape of the night of the alleged abuse she stated she had and was shocked because she never would have thought he would have the behavior she watched on the video.

5. An interview was conducted on 4/17/17 at 5:00 p.m. with HSW #1 in the presence of the Assistant Chief Executive Officer, at the request of HSW #1. When asked if he remembered the night patient #1 was injured, he stated, in part: "Yes, I had taken him to his room because he was acting up and throwing popcorn and before I could get out of the room I heard him fall and turned around and he was laying in the floor and his lip was bleeding. I helped him up and put him in bed and went to ask the nurse for an ice pack for his mouth because it was bleeding and she told me that takes a doctor's order so he didn't get one." It should be noted that when observing the above noted video HSW #1 came out of the patient's room and did not speak to any other health care worker or return to the patient's room. When asked if he knew the patient alleged he pushed him, he stated, in part: "Yes, the advocate asked me if I saw anything that night." When asked if he was ever removed from patient care during the investigation, he stated, "No, I've worked every day except one (1) and my daughter had a baby that night." The HSW was then made aware of a new allegation of abuse on the same night and time with patient #2 and when asked if he remembered anything unusual about the night with patient #2, he stated, in part: "Yes, she was laying in the floor and I was told to pick her up and take her to her room."

6. An interview was conducted on 4/17/17 at 5:30 p.m. with LPN #1. When asked if she knew about patient #1's injury to his arm, and if so what information she had about it, she stated, in part: "Yes, I was told he fell and that HSW #1 pushed him and broke his arm." When asked if she was passing medication during the time the injury occurred she consulted her date calendar and said I don't know, I worked a double." When shown the medication administration record on all patients for the time of the incident, she stated, "Then I guess I was." When asked if she heard any yelling or saw any abuse, she stated, "No, I did not."

7. An interview was conducted on 4/19/17 at 3:20 p.m. with HSW #2. When asked if she was aware of patient #1 being injured, she stated, in part: "Yes, I found out the next day when I came back and he had his arm in a sling." When asked if she heard or saw any abuse during the evening medication pass while she was sitting at the nursing station, she stated, in part: "I probably had my head down charting and if so I wouldn't hear because I am legally deaf and don't know if you are speaking unless you are looking at me. I have a medical note in my chart that says that." It should be noted a review of HSW #2's personnel record revealed the HSW is legally deaf.

8. An interview was conducted with the Assistant Chief Executive Officer on 4/18/17 at 8:58 a.m. and she concurred with the above findings.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
A. Based on document review, record review, video review and staff interview it was determined the hospital failed to ensure allegations of abuse and neglect were reported according to hospital policy in one (1) of one (1) allegations of abuse cases reviewed for injury (patient #1). This failure has the potential for all patients who are allegedly abused to continue to be abused by the alleged perpetrator.

Findings include:

1. Review of the policy titled "Allegations of Abuse and Neglect", effective date 6/08, revealed it states, in part: "All patients have the right to be free from abuse or neglect as well as the fear of being abused...All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may occur...All employees...are mandatory reporters for abuse and neglect. Individuals who witness or have knowledge of patient abuse/neglect shall immediately report it to the charge nurse or Nurse Clinical Coordinator (NCC)...Documentation in the form of an APS form...grievance form and/or written statements are to be completed within one hour of the allegation...Alleged perpetrator removed from the situation."

2. Review of the medical record for patient #1 revealed documentation by Registered Nurse (RN) #1 on 3/26/17 at 9:45 p.m. that the patient complained of left shoulder pain and slipped on towels in his room.

3. Review of the Adult Protective Services (APS) form revealed it was filed on 4/2/17, eight (8) days after the patient notified the hospital of the alleged incident, by the Nurse Clinical Coordinator (NCC).

4. Review of the hospital's investigation report revealed a signed statement from RN #1 on 4/2/17 which revealed patient #1 initially complained of a fall and later explained Health Service Worker (HSW) #1 had grabbed hold of him and pushed him into the wall and he fell .

5. On 4/17/17 at 1:27 p.m. a video tape (dated 3/26/17-date of incident) was reviewed in the presence of the Assistant Chief Operating Officer and Patient Safety Director. Beginning at 8:35 p.m., the video shows patients #1 and 2 standing in front of the nursing station. At 8:36 p.m. HSW #1 came down the hall, took his hand and moved patient #2 around and then put his hand to the back of her neck and took her to a patient room. He then came back up the hall at 8:39 p.m. and immediately placed his face in patient #1's face; HSW #1 was seen moving his mouth and patient #1 was trying to move out of his way but HSW #1 continued to keep the patient in the area where the medication pass was occurring. HSW #1 then began to walk away. Patient #1 was leaning against a wall with his back turned toward HSW #1 when HSW #1 came back to the patient and said something to the patient's back, turned him around and took him down the hall to his room. Patient #3 was seen outside of patient #1's room looking into the room and then moved to the room and touched the light switch. At 10:18 p.m. patient #1 exited the room holding his left arm and went to the nursing station and talked to RN #1. The video showed four (4) employees sitting at the nursing station.

During review of the video the Director of Nursing (DON) came in at 1:39 p.m. and saw the aggressive behavior from HSW #1 towards patients #1 and 2. When asked if she saw this aggressive behavior while investigating the abuse allegations, she stated, in part: "No, I did not. I watched four (4) days of videos and didn't see this. I feel nauseous at seeing this now." During review of the video the DON acknowledged the facility was unaware of patient #2 being abused even though she investigated patient #1's abuse by video tape and failed to watch the correct time of the occurrence. The four (4) healthcare workers seen sitting at the nursing station were identified by the DON and Nurse Manager.

6. An interview was conducted with patient #1 on 4/17/17 at approximately 9:00 a.m. during a tour of unit C-1. The patient requested RN #2 be present for the interview and the patient's representative was notified of the request for interview; the interview was granted by phone to RN #2. When asked to explain how his arm became injured, patient #1 stated, in part: "I was told by (HSW #1) to go to my room because he said I was acting up and I went to my room and then he shoved me when I got to my room and I fell over towels in my room." When asked if he told anyone about what happened, he stated, in part: "I told (RN #1) because I was in pain and then I told my doctor and almost everyone and I'm afraid of him because he told me if I told anyone he would hurt me."

7. A joint interview was conducted with Attending Physician #1 and Physician Assistant (PA) #1 on 4/17/14 at 12:45 p.m. When asked if they remembered patient #1 being injured, they both stated, "Yes." Attending Physician #1 stated, in part: "I was getting ready for work on the 27th and got a phone call that he fell and hurt his arm and told them I was getting ready to come in and I would see him in a couple of hours. When I came in I discussed the patient with the PA and she went to see him." The PA stated, in part: "When I talked to the patient he told me he was pushed down and fell over clothes and hit the wall and floor and hurt his arm and he refused to tell me who hurt him." When asked if they filed a complaint or an Adult Protective Services form on the patient's behalf, they stated, "No."

8. An interview was conducted with patient #3 (who was patient #1's roommate at the time of the incident) on 4/17/17 at approximately 4:00 p.m. When asked if he remembered the night patient #1 was injured, he stated, in part: "He (HSW#1) was aggressive to him (patient #1). Physical interaction is bad. He (HSW #1) is not nice to him (patient #1)."

9. An interview was conducted with RN #1 on 4/17/17 at 4:24 p.m. When asked if she remembered the night patient #1 was injured, she stated, "Yes." When asked what happened, she stated, in part: "Patient #1 came to the nursing desk and said he tripped over towels in his room and hurt his arm and wanted something for pain so I gave him an ice pack and medicated him. He later told me he was pushed by (HSW #1) and tripped over the towels in the floor and hit the wall and then the floor." When asked if she had ever seen HSW #1 become aggressive with patients, she stated, in part: "Yes, he was aggressive that night with (patient #1) and with other patients before. He's been aggressive with me and I told our NCC and she didn't do anything so I never said anything again since they don't seem to care." When asked if she filed a complaint for the patient or filed an Adult Protective Services form, she stated, "No, I told the NCC."

10. An interview was conducted with the Nurse Manager of unit C-1 on 4/18/17 at 8:17 a.m. When asked when she became aware of the incident of patient #1 she stated the PA told her the next morning about what patient #1 said. When asked if an Adult Protective Services form was completed, she stated, "No." When asked if HSW #1 was removed from patient care she stated she would have to check. After checking the staffing sheets she stated he was at work when he was scheduled except for one (1) day when he called in.

11. An interview was conducted with the Assistant Chief Executive Officer on 4/18/17 at 8:58 a.m. and she concurred with the above findings.

B. Based on record review, video review and staff interview it was determined the hospital failed to ensure allegations of abuse and neglect were reported according to hospital policy in one (1) of one (1) allegations of abuse cases reviewed (patient #2). This failure has the potential for all patients who are allegedly abused to continue to be abused by the alleged perpetrator.

Findings include:

1. Review of the medical record for patient #2 revealed no documentation of physical abuse was documented on 3/26/17 at 8:36 p.m. by HSW #1.

2. On 4/17/17 at 1:27 p.m. a video tape (dated 3/26/17-date of incident) was reviewed in the presence of the Assistant Chief Operating Officer and Patient Safety Director. Beginning at 8:35 p.m., the video shows patients #1 and 2 standing in front of the nursing station. At 8:36 p.m. HSW #1 came down the hall, took his hand and moved patient #2 around and then put his hand to the back of her neck and took her to a patient room. He then came back up the hall at 8:39 p.m. and immediately placed his face in patient #1's face; HSW #1 was seen moving his mouth and patient #1 was trying to move out of his way but HSW #1 continued to keep the patient in the area where the medication pass was occurring. HSW #1 then began to walk away. Patient #1 was leaning against a wall with his back turned toward HSW #1 when HSW #1 came back to the patient and said something to the patient's back, turned him around and took him down the hall to his room. Patient #3 was seen outside of patient #1's room looking into the room and then moved to the room and touched the light switch. At 10:18 p.m. patient #1 exited the room holding his left arm and went to the nursing station and talked to RN #1. The video showed four (4) employees sitting at the nursing station.

During review of the video the Director of Nursing (DON) came in at 1:39 p.m. and saw the aggressive behavior from HSW #1 towards patients #1 and 2. When asked if she saw this aggressive behavior while investigating the abuse allegations, she stated, in part: "No, I did not. I watched four (4) days of videos and didn't see this. I feel nauseous at seeing this now." During review of the video the DON acknowledged the facility was unaware of patient #2 being abused even though she investigated patient #1's abuse by video tape and failed to watch the correct time of the occurrence. The four (4) healthcare workers seen sitting at the nursing station were identified by the DON and Nurse Manager.

3. An interview was conducted with RN #1 on 4/17/17 at 4:24 p.m. When asked if she remembered the night patient #1 was injured, she stated, "Yes." When asked what happened, she stated, in part: "Patient #1 came to the nursing desk and said he tripped over towels in his room and hurt his arm and wanted something for pain so I gave him an ice pack and medicated him. He later told me he was pushed by (HSW #1) and tripped over the towels in the floor and hit the wall and then the floor." When asked if she had ever seen HSW #1 become aggressive with patients, she stated, in part: "Yes, he was aggressive that night with (patient #1) and with other patients before. He's been aggressive with me and I told our NCC and she didn't do anything so I never said anything again since they don't seem to care." When asked if she filed a complaint for the patient or filed an Adult Protective Services form, she stated, "No, I told the NCC and I did not contact the guardian until the next morning."

4. An interview was conducted with the Nurse Manager of unit C-1 on 4/18/17 at 8:17 a.m. When asked if she reviewed the video tape of the night of the alleged abuse she stated she had and was shocked because she never would have thought he would have the behavior she watched on the video.

5. An interview was conducted on 4/17/17 at 5:00 p.m. with HSW #1 in the presence of the Assistant Chief Executive Officer, at the request of HSW #1. When asked if he remembered the night patient #1 was injured, he stated, in part: "Yes, I had taken him to his room because he was acting up and throwing popcorn and before I could get out of the room I heard him fall and turned around and he was laying in the floor and his lip was bleeding. I helped him up and put him in bed and went to ask the nurse for an ice pack for his mouth because it was bleeding and she told me that takes a doctor's order so he didn't get one." It should be noted that when observing the above noted video HSW #1 came out of the patient's room and did not speak to any other health care worker or return to the patient's room. When asked if he knew the patient alleged he pushed him, he stated, in part: "Yes, the advocate asked me if I saw anything that night." When asked if he was ever removed from patient care during the investigation, he stated, "No, I've worked every day except one (1) and my daughter had a baby that night." The HSW was then made aware of a new allegation of abuse on the same night and time with patient #2 and when asked if he remembered anything unusual about the night with patient #2, he stated, in part: "Yes, she was laying in the floor and I was told to pick her up and take her to her room."

6. An interview was conducted on 4/17/17 at 5:30 p.m. with LPN #1. When asked if she knew about patient #1's injury to his arm, and if so what information she had about it, she stated, in part: "Yes, I was told he fell and that HSW #1 pushed him and broke his arm." When asked if she was passing medication during the time the injury occurred she consulted her date calendar and said I don't know, I worked a double." When shown the medication administration record on all patients for the time of the incident, she stated, "Then I guess I was." When asked if she heard any yelling or saw any abuse, she stated, "No, I did not."

7. An interview was conducted on 4/19/17 at 3:20 p.m. with HSW #2. When asked if she was aware of patient #1 being injured, she stated, in part: "Yes, I found out the next day when I came back and he had his arm in a sling." When asked if she heard or saw any abuse during the evening medication pass while she was sitting at the nursing station, she stated, in part: "I probably had my head down charting and if so I wouldn't hear because I am legally deaf and don't know if you are speaking unless you are looking at me. I have a medical note in my chart that says that." It should be noted a review of HSW #2's personnel record revealed the HSW is legally deaf.

8. An interview was conducted with the Assistant Chief Executive Officer on 4/18/17 at 8:58 a.m. and she concurred with the above findings.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on record review and staff interview it was determined the hospital failed to ensure the patient's nursing care plan was updated with a change of condition for one (1) of one (1) patients with a change of condition of injury (patient #1). This failure has the potential for all patients with an injury to have an inadequate care plan to ensure patients' needs are met.

Findings include:

1. Review of the medical record for patient #1 revealed documentation by Registered Nurse (RN) #1 on 3/26/17 at 9:45 p.m. that the patient complained of left shoulder pain and slipped on towels in his room. There was no update noted in the patient's care plan regarding his injury.

2. An interview was conducted with Nurse Manager of unit C-1 on 4/18/17 at 8:17 a.m. When asked the expectation if a change of condition would normally be documented in the patient's care plan, she stated, in part: "Yes, it should be updated with the injury."

3. An interview was conducted with the Assistant Chief Executive Officer on 4/18/17 at 8:58 a.m. and she concurred with the above findings.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on document review, record review, video review and staff interview it was determined the Director of Nursing failed to ensure a non-employee (contracted) Registered Nurse (RN) followed hospital policy when a patient alleged abuse, and the nurse visualized the abuse, in one (1) of one (1) records reviewed of patients who complained of abuse (patient #1). This failure has the potential for all patients to be abused by hospital staff.

Findings include:

1. Review of the policy titled "Allegations of Abuse and Neglect", effective date 6/08, revealed it states, in part: "All patients have the right to be free from abuse or neglect as well as the fear of being abused...All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may occur...All employees...are mandatory reporters for abuse and neglect. Individuals who witness or have knowledge of patient abuse/neglect shall immediately report it to the charge nurse or Nurse Clinical Coordinator (NCC)...Documentation in the form of an APS form...grievance form and/or written statements are to be completed within one hour of the allegation...Alleged perpetrator removed from the situation."

2. Review of the medical record for patient #1 revealed documentation by RN #1 on 3/26/17 at 9:45 p.m. that the patient complained of left shoulder pain and slipped on towels in his room.

3. Review of the Adult Protective Services (APS) form revealed it was filed on 4/2/17, eight (8) days after the patient notified the hospital of the alleged incident, by the Nurse Clinical Coordinator (NCC).

4. Review of the hospital's investigation report revealed a signed statement from RN #1 on 4/2/17 which revealed patient #1 initially complained of a fall and later explained Health Service Worker (HSW) #1 had grabbed hold of him and pushed him into the wall and he fell .

5. On 4/17/17 at 1:27 p.m. a video tape (dated 3/26/17-date of incident) was reviewed in the presence of the Assistant Chief Operating Officer and Patient Safety Director. Beginning at 8:35 p.m., the video shows patients #1 and 2 standing in front of the nursing station. At 8:36 p.m. HSW #1 came down the hall, took his hand and moved patient #2 around and then put his hand to the back of her neck and took her to a patient room. He then came back up the hall at 8:39 p.m. and immediately placed his face in patient #1's face; HSW #1 was seen moving his mouth and patient #1 was trying to move out of his way but HSW #1 continued to keep the patient in the area where the medication pass was occurring. HSW #1 then began to walk away. Patient #1 was leaning against a wall with his back turned toward HSW #1 when HSW #1 came back to the patient and said something to the patient's back, turned him around and took him down the hall to his room. Patient #3 was seen outside of patient #1's room looking into the room and then moved to the room and touched the light switch. At 10:18 p.m. patient #1 exited the room holding his left arm and went to the nursing station and talked to RN #1. The video showed four (4) employees sitting at the nursing station.

During review of the video the Director of Nursing (DON) came in at 1:39 p.m. and saw the aggressive behavior from HSW #1. When asked if she saw this aggressive behavior while investigating the abuse allegations, she stated, in part: "No, I did not. I watched four (4) days of videos and didn't see this. I feel nauseous at seeing this now."

6. An interview was conducted with patient #1 on 4/17/17 at approximately 9:00 a.m. during a tour of unit C-1. The patient requested RN #2 be present for the interview and the patient's representative was notified of the request for interview; the interview was granted by phone to RN #2. When asked to explain how his arm became injured, patient #1 stated, in part: "I was told by (HSW #1) to go to my room because he said I was acting up and I went to my room and then he shoved me when I got to my room and I fell over towels in my room." When asked if he told anyone about what happened, he stated, in part: "I told (RN #1) because I was in pain and then I told my doctor and almost everyone and I'm afraid of him because he told me if I told anyone he would hurt me."

7. A joint interview was conducted with Attending Physician #1 and Physician Assistant (PA) #1 on 4/17/14 at 12:45 p.m. When asked if they remembered patient #1 being injured, they both stated, "Yes." Attending Physician #1 stated, in part: "I was getting ready for work on the 27th and got a phone call that he fell and hurt his arm and told them I was getting ready to come in and I would see him in a couple of hours. When I came in I discussed the patient with the PA and she went to see him." The PA stated, in part: "When I talked to the patient he told me he was pushed down and fell over clothes and hit the wall and floor and hurt his arm and he refused to tell me who hurt him." When asked if they filed a complaint or an Adult Protective Services form on the patient's behalf, they stated, "No."

8. An interview was conducted with patient #3 (who was patient #1's roommate at the time of the incident) on 4/17/17 at approximately 4:00 p.m. When asked if he remembered the night patient #1 was injured, he stated, in part: "He (HSW#1) was aggressive to him (patient #1). Physical interaction is bad. He (HSW #1) is not nice to him (patient #1)."

9. An interview was conducted with RN #1 (a contracted nurse) on 4/17/17 at 4:24 p.m. When asked if she remembered the night patient #1 was injured, she stated, "Yes." When asked what happened, she stated, in part: "Patient #1 came to the nursing desk and said he tripped over towels in his room and hurt his arm and wanted something for pain so I gave him an ice pack and medicated him. He later told me he was pushed by (HSW #1) and tripped over the towels in the floor and hit the wall and then the floor." When asked if she had ever seen HSW #1 become aggressive with patients, she stated, in part: "Yes, he was aggressive that night with (patient #1) and with other patients before. He's been aggressive with me and I told our NCC and she didn't do anything so I never said anything again since they don't seem to care." When asked if she filed a complaint for the patient or filed an Adult Protective Services form, she stated, "No, I told the NCC."

10. An interview was conducted with the Nurse Manager of unit C-1 on 4/18/17 at 8:17 a.m. When asked when she became aware of the incident of patient #1 she stated the PA told her the next morning about what patient #1 said. When asked if an Adult Protective Services form was completed, she stated, "No." When asked if HSW #1 was removed from patient care she stated she would have to check. After checking the staffing sheets she stated he was at work when he was scheduled except for one (1) day when he called in.

11. An interview was conducted with the Assistant Chief Executive Officer on 4/18/17 at 8:58 a.m. and she concurred with the above findings.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
Based on document review, record review and staff interview it was determined the hospital failed to ensure medical staff notified Adult Protective Services of their physical assessment in one (1) of one (1) patients that complained of physical abuse (patient #1). This failure has the potential for all patients who complain of alleged physical abuse to not receive adequate medical treatment.

1. Review of the policy titled "Allegations of Abuse and Neglect", effective date 6/08, revealed it states, in part: "All patients have the right to be free from abuse or neglect as well as the fear of being abused...All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may occur...All employees...are mandatory reporters for abuse and neglect. Individuals who witness or have knowledge of patient abuse/neglect shall immediately report it to the charge nurse or Nurse Clinical Coordinator (NCC)...Documentation in the form of an APS form...grievance form and/or written statements are to be completed within one hour of the allegation...Alleged perpetrator removed from the situation ...physical and psychological findings will be placed in the patient's medical record."

2. Review of the Medical Staff By-Laws titled "Rules and Regulations Governing Patient Management", last reviewed 10/16, revealed it states, in part: "Progress notes must include a chronological record of patient's clinical course, including a description of change in the patient's condition."

3. Review of the medical record for patient #1 revealed documentation by Registered Nurse (RN) #1 on 3/26/17 at 9:45 p.m. that the patient complained of left shoulder pain and slipped on towels in his room.

4. A joint interview was conducted with Attending Physician #1 and Physician Assistant (PA) #1 on 4/17/14 at 12:45 p.m. When asked if they remembered patient #1 being injured, they both stated, "Yes." Attending Physician #1 stated, in part: "I was getting ready for work on the 27th and got a phone call that he fell and hurt his arm and told them I was getting ready to come in and I would see him in a couple of hours. When I came in I discussed the patient with the PA and she went to see him." The PA stated, in part: "When I talked to the patient he told me he was pushed down and fell over clothes and hit the wall and floor and hurt his arm and he refused to tell me who hurt him." When asked if they filed a complaint or an Adult Protective Services form on the patient's behalf, they stated, "No."

5. An interview was conducted with the Assistant Chief Executive Officer on 4/18/17 at 8:58 a.m. and she concurred with the above findings.