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.

RESEARCH MEDICAL CENTER 2316 E MEYER BLVD KANSAS CITY, MO 64132 Aug. 30, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interviews, record review and policy review the facility failed to:
- Protect one discharged patient (#23) on the Rehabilitation Unit from physical abuse and continued abuse by a staff member.
- Follow the facility's internal policy and procedure related to abuse and neglect and to report incidents/events to proper facility administration in a timely manner when allegations of abuse are suspected and/or witnessed.
- Complete a physical examination and notify the physician after the alleged physical assault/abuse from staff had taken place with a discharged patient (#23).
- Ensure staff was competent and trained to prevent, recognize and respond to all forms of abuse by co-workers.
- Ensure staff was immediately educated/re-educated about abuse, to include steps to take if staff witnessed abuse, after the substantiated allegation of staff to patient abuse occurred between staff and a discharged patient (#23).
- Report to the appropriate State Agency staff abuse towards Patient #23, when staff physically assaulted the patient. Refer to A-0145 for additional information.
- To obtain either verbal and/or written consent of discharged Patient #7's legal guardian, (a legal relationship created when a person or institution is assigned by a court to take care of minor children or incompetent adults), when informed consent was required for a care decision, when the facility allowed Patient #7 to sign herself out of inpatient hospital care Against Medical Advice (AMA) without prior authorization from her legal guardian.
- Immediately remove staff from patient care after an allegation of abuse was identified/witnessed by two co-workers. Refer to A-0144 for additional information.

These failures created an unsafe environment and had the potential to place all patients admitted to the facility at an increased risk for their safety. The facility census was 285.

The severity and cumulative effect of these failed systematic practices resulted in the overall non-compliance with 42 CFR 482.23 Condition of Participation: Patient's Rights that resulted in a condition of Immediate Jeopardy (IJ).

As of 08/30/18, at the time of the survey exit, the facility provided an immediate action plan sufficient to remove the IJ by implementing the following:
Abuse/Neglect:
- Action Item #1: Immediate action to be taken on Wednesday, 08/29/18 - Re-educate all clinical and non-clinical personnel prior to the start of their next shift (current day shift staff on 08/29/18 prior to them leaving shift) on the following:
- Timely reporting of alleged and/or confirmed patient, staff and/or visitor abuse or neglect; and
- Abuse and Neglect Policy (reporting process and signs of abuse).
- Action Item #2: As of 08/29/18 Human Resources (HR) to report all allegations, disciplinary actions and terminations involving alleged or confirmed abuse/neglect of patient, co-worker, and/or visitors to Risk Department.
- Action Item #3: Alleged abuse substantiated by PCT (Patient Care Technician) admission during termination investigation. Termination date 04/03/18 by Director Clinical Operations. On 8/29/18, immediate action taken - The two Registered Nurses (RNs) neglecting to report suspected/witnessed abuse received a written warning in compliance with HR disciplinary policy.
Durable Power Of Attorney DPOA (A type of advance medical directive in which legal documents provide the power of attorney to another person in the case of an incapacitating medical condition) and Guardianship:
- Action Item #1: Immediate action to be taken on Wednesday, 08/29/18 - Re-educate all clinical personnel prior to the start of their next shift (current day shift staff on 08/29/18 prior to them leaving shift) on the following:
- DPOA/Guardianship;
- AMA Policy; and
- Arrival/Admission Assessment of DPOA/Guardianship.
- Action Item #2: Immediate action to be taken on Wednesday, 08/29/18 - All Nursing Unit Leaders received Transferring Patient Report Form. As of 08/29/18 form is to be utilized for all patients transferring to our facility from an outside facility to ensure referring facility provides guardianship status/documentation during report to Charge Nurse.
- Action Item #3: AMA Policy updated 08/29/18 to require confirmed guardianship during AMA process.
- Action Item #4: Added DPOA/Guardianship education to New Employee Orientation (NEO). Next facility NEO scheduled for 08/31/18.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on observation, interview, record review and policy review, the facility failed to provide accurate and complete information to patients with regards to patient rights and the required contact information to file a grievance. This failure had the potential to affect all patients in the facility who may have needed to file a grievance related to their care. The facility census was 285.

Findings included:

Review of the facility's policy titled, "Guidelines for the Management of Patient Complaints and Grievances," dated 11/2015 directed staff to inform the patient in writing that he/she may lodge a grievance with the State of Missouri, Department of Health and Senior Services, 1617 Southridge Drive, PO Box 570, Jefferson City, MO regardless of whether he/she had first used the hospital's grievance process. The facility failed to provide the correct address.

During an interview on 08/27/18 at 3:36 PM, Patient #1 stated that he did not know if he received information on how to contact the state agency if he had concerns. He stated that he would report his concerns to Staff Q, Director of Patient Safety and Risk Management, however, he did not know what her job was or what she did.

During an interview on 08/27/18 at 3:55 PM, Patient #2 stated he did not know if he received information on how to file a complaint or grievance with the facility or how to contact the state agency if he had concerns. He stated he did not know who to contact at the facility with concerns.

During an interview on 08/28/18 at 10:42 AM, Staff Q, Director of Patient Safety and Risk Management, stated that patients are given the brochure and leaders round to check with the patients to see if they have any questions.

Record review of the patient brochure showed that the following was listed on the back of the brochure: Missouri Department of Health (not the Missouri Department of Health and Senior Serivces) Complaint Hotline: 573-751-6303 or 800-392-0210. The facility failed to list an address.

Observation on 08/27/18 through 08/29/18 showed varied versions of Patient's Rights signage posted throughout the facility. None of the signage contained the contact information for the Missouri Department of Health and Senior Services.

The facility failed to provide accurate and consistent information for patients with regard to filing a complaint or grievance.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview, record review and policy review, facility staff failed to ensure a safe environment for two discharged patients (#7 and #23) of two patients reviewed when:
- Proper documentation of legal guardianship (someone legally responsible for a person who is unable to care for and make appropriate decision for self) was not completed.
- The patient was allowed to leave against medical advice (AMA) without notification to the guardian.
- The patient was provided transportation by cab without notification to the guardian.
- Immediately remove staff from patient care after an allegation of abuse was identified/witnessed by two co-workers.
These failures had the potential to lead to deterioration, injury, or death when policies and procedures to protect patients were not utilized, and could affect all patients in the facility with guardianship status.

The facility census was 285.

Findings included:

1. During an interview on 08/29/18 at 1:45 PM, Staff AA, Regulatory Manager, stated the facility did not have a policy or procedure for notification of patients' family or representative upon admission.

Review of a History & Physical (H&P) dated 07/21/18 at 8:51 AM, showed Patient #7 was transferred by ambulance from the nursing home in which she resided, with a medical history of Chronic Obstructive Pulmonary Disease (COPD, lung disease that makes it difficult to breath) and schizoaffective disorder (mental health disorder that makes someone feel extremely excited and then extremely sad). Patient #7 was admitted to the hospital at 10:14 AM, and the patient's guardian was not notified.

Review of nursing home documentation provided to the Emergency Department (ED) on 07/21/18, showed the name of the patient's guardian, relationship, and home telephone number. Included in the paperwork, was a Psychiatric Inpatient Note that documented the court granted Patient #7 a temporary guardian on 05/22/18, for a six month period (valid through 11/22/18).

During a telephone interview on 08/28/18 at 7:48 PM, Staff CC, Registered Nurse (RN), stated she was not aware Patient #7 had a guardian, and did not review the nursing home paperwork that was transferred with the patient.

During an interview on 08/29/18 at 9:20 AM, Staff DD, RN, Director of Nursing Operations (DNO), stated that when a patient was admitted from the ED, the transfer paperwork from the nursing home was placed in the paper medical record, and it stayed with the patient when they went to the inpatient floor. The admission nurse entered patient information (such as guardianship) from the transfer paperwork, into the patient's electronic medical record (EMR) during the patient's admission, in the admission assessment.

During an interview on 08/28/18 at 9:40 AM, Staff K, Health Information Management Director, stated if a patient had a guardian, and the guardian's information was entered into the patient's EMR, it was visible to staff every time a patient was admitted , and added that there was no documentation of a guardian for Patient #7.

The facility failed to ensure staff were aware of the patient's legal guardianship, and failed to ensure staff appropriately documented guardianship in the EMR.

2. Review of the facility's policy titled, "AMA - Leaving Against Medical Advice," dated 02/2018, showed the facility failed to have a procedure in place that required confirmation of patient guardianship status for patients that wished to leave AMA.

Review of Discharge Summary Report dated 07/24/18 at 7:32 AM, showed Staff PP, Physician, documented that Patient #7 discharged from the facility AMA on 07/23/18.

Review of a form titled, "Refusal of Transfer, Left Without Being Seen, or Leaving AMA," dated 07/23/18, showed Patient #7 left AMA, refused to sign the completed form, and showed no documentation that the patient's guardian was contacted. The document was witnessed by Staff FF, RN, Charge Nurse.

3. Review of a Case Management Report by Staff OO, Caseworker, dated 07/23/18 at 10:20 AM, showed that Patient #7 required a cab voucher for transportation at discharge.

The facility failed to consult or notify the guardian when Patient #7 requested to discharge AMA, and failed to consult or notify the guardian when the patient, with a history of psychiatric illness, was provided cab fare when she left.

3. Review of the facility's policy titled, "Patient Abuse and Neglect," revised 08/2016, showed directives for staff to place on administrative leave, any staff that was suspected to have committed an act of abuse or neglect until a determination was made. This allows time to conduct an investigation, while keeping in mind the protection of the patient, the facility and staff involved.

Review of Patient #23's discharged electronic medical record (EMR) showed that he was admitted to the facility's Rehabilitation Unit on 12/28/17 for rehabilitative care and treatment following a motor vehicle collision (MVC) and status post-traumatic brain injury (TBI - a disruption in the normal function of the head that can be caused by a bump, blow, or a jolt to the head, or penetrating head injury).

Review of the facility's list of staff that was terminated from employment over the past six months showed Staff NN, Patient Care Technician (PCT), was terminated on 04/03/18.

Review of Staff NN, PCT's personnel file showed that a Disciplinary/Corrective Action Form dated 04/03/18 was given to Staff NN, PCT, and showed:
- Category of Disciplinary Action:
- Conduct/behavior;
- Performance;
- Ethics; and
- Patient safety.
- Level of Disciplinary Action: Termination.
Detailed Summary of Offense(s) Leading To This Action:
- Staff NN, PCT, allegedly abused Patient #23 on 01/22/2018. Staff NN, PCT, was assisting the patient back to his room and he was complaining that she was hurting him and began to yell. Staff MM, Registered Nurse (RN), came out into the hall when she heard the commotion and witnessed Staff NN, PCT, hitting the patient on the back of his head. Staff LL, RN, also witnessed Staff NN, PCT, hitting the patient. Staff LL, RN, screamed at Staff NN, PCT, to move away from the patient. Staff NN, PCT, moved away from the patient while Staff LL, RN, and Staff MM, RN, took the patient back to his room. Staff LL, RN, went to get the patient's medications and Staff MM, RN, left the patient's room to attend to another patient. Staff NN, PCT, re-entered the patient's room, pushed him to the floor, and got on top of him. Staff MM, RN, told Staff LL, RN, to call security. Security came to the room and witnessed the patient on the floor. Staff MM, RN, and Staff LL, RN, helped the patient up off the floor. Security questioned the patient if he was alright and he stated that his chin was sore but otherwise alright (the patient had a fractured left leg that resulted from the MVC).
- On 03/21/2018, Staff NN, PCT, was questioned (by Staff DD, RN, Director of Nursing Operations) about the alleged abuse towards Patient #23 on 01/22/2018. Staff NN, PCT, admitted to "hitting" the patient in the back of his head on multiple occasions and demonstrated how she hit him by hitting one hand into the other. Staff NN, PCT, also stated that she "wrestled" the patient to the ground.
- Staff NN, PCT, did not follow "Code White" (a code called when staff needed assistance to handle an out of control/disruptive and/or violent behavior by a person) policy.
- Staff NN, PCT, did not de-escalate (reduce the intensity of a conflict or potentially violent situation) the situation or call for assistance.
- Staff NN, PCT, violated I-CARE Values of Integrity, Compassion and Respect by hitting the patient and pushing him to the ground.
- Staff NN, PCT, was suspended on 02/16/18, the date Staff DD first became aware of the incident.
- Termination was recommended.

Review of Staff NN, PCT's Time Sheet showed that:
- She was allowed to finish her scheduled 12-hour night shift on 01/22/18 after the alleged physical assault/abuse of Patient #23 had occurred.
- She was allowed to work 13 additional scheduled 12-hour night shifts from 01/22/18 to 02/16/18.
The facility failed to remove Staff NN, PCT, from patient care after allegations of physical assault/abuse occurred to Patient #23 on 01/22/18 and she was allowed to work and provide patient care for 13 additional scheduled 12-hour night shifts which placed all patients she cared for at increased risk for abuse.

During an interview on 08/29/18 at 9:20 AM, Staff DD, RN, Director of Nursing Operations (DNO), acknowledged that Staff NN, PCT, was allowed to continue working until the end of her scheduled 12-hour night shift on 01/22/18 after the alleged physical assault/abuse to Patient #23. Staff DD acknowledged that Staff NN, PCT, was allowed to work 13 additional scheduled 12-hour night shifts from 01/22/18 to 02/16/18.

During a telephone interview on 09/04/18 at 5:06 PM, Staff MM, RN, stated that:
- She worked a 12-hour night shift on the Rehabilitation Unit on 01/22/18.
- Staff NN, PCT, pushed Patient #23 to the floor in his room and was standing over him and was hitting him in the back of his head.
- She told Staff NN, PCT, to get off the patient and she (Staff MM) assisted him up off the floor.
- Staff NN, PCT, reported that the patient had "punched" her, so she "hit" him back and she admitted that she had "pushed" the patient onto the floor.
- She requested the patient's primary assigned nurse (Staff LL, RN) to call for security to come to the unit because of the altercation between Staff NN, PCT, and Patient #23.
- She did not know what the facility's policy and procedure instructed staff to do for witnessed staff to patient abuse, but since she had security called she thought that was all she needed to do.
- Staff NN, PCT, was not allowed to care for Patient #23 after the incident but was allowed to finish working until the end of her scheduled 12-hour night shift on 01/22/18.

During a telephone interview on 09/05/18 at 10:49 AM, Staff NN, PCT, stated that:
- Patient #23 hit her in the chest, so she restrained him and put him on the floor.
- Denied she ever "punched or hit" the patient in the back of his head multiple times.
- She continued to work after the altercation with Patient #23 and finished her scheduled 12-hour night shift on 01/22/18 but did not care for the patient after the altercation.

During a telephone interview on 09/05/18 at 4:22 PM, Staff LL, RN, stated that:
- She was working a 12-hour night shift on 01/22/18.
- She was newly hired and had only worked at the facility for approximately two weeks when the incident occurred between Staff NN, PCT, and Patient #23.
- She recalled the events that transpired between Staff NN, PCT and Patient #23 on 01/22/18.
- She was Patient #23's primary assigned nurse for the 12-hour night shift on 01/22/18.
- Staff NN, PCT, was walking with the patient and had the back of his pants "balled" up in her hand and was pulling his pants up and she (Staff NN, PCT) refused to release her hold on the back of his pants even after the patient informed her she (Staff NN, PCT) was "hurting" him.
- The patient had a cast on his right arm and swung it at Staff NN, PCT, when she (Staff NN, PCT) would not let go of the back of his pants. He tried to get Staff NN, PCT, to let go of his pants because it was hurting him the way she (Staff NN, PCT) held onto him but she (Staff NN, PCT) refused to let go.
- When the patient swung his casted arm towards Staff NN, PCT, she "pushed" the patient to the floor and stood over him and "hit" him multiple times in the back of his head.
- She visually observed Staff NN, PCT, "hit" the patient on his head between three to four times.
- She yelled at Staff NN, PCT, to get off the patient and Staff MM, RN, responded and had to pull Staff NN, PCT, off the patient.
- She called the facility's security to come to the floor to assist with the altercation and physical assault from Staff NN, PCT, toward the patient.
- She did not notify the House Supervisor because she thought Staff MM, RN, had notified them of the incident.
- Security arrived and asked how the patient got on the floor and she informed him that Staff NN, PCT, had put him on the floor and was "hitting" him.
- Staff NN, PCT was removed from caring for Patient #23 but was allowed to finish her 12-hour scheduled night shift on 01/22/18.
- She did not recall any abuse/neglect education/training when she started and she had a lot of policies and other information to complete during orientation but did not recall the abuse/neglect information.

The facility failed to:
- Protect Patient #23 from physical assault and abuse by Staff NN, PCT.
- Staff NN, PCT, was allowed to continue to abuse Patient #23 when she was allowed to hurt him while walking with him, then when she "wrestled" him to the floor and began to hit him multiple times in the head.
- Staff NN, PCT, was allowed to not only finish her scheduled 12-hour night shift on 01/22/18 but was allowed to work 13 additional scheduled 12-hour night shifts between 01/22/18 and 02/16/18.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interviews, record review and policy review the facility failed to:
- Protect one discharged patient (#23) from physical abuse and continued abuse by a staff member, of one patient reviewed for abuse.
- Follow the facility's internal policy for abuse and neglect when they failed to report the abuse of one discharged patient (#23) to administration in a timely manner, of one patient reviewed for abuse.
- Complete a physical assessment and notify the physician after the alleged abuse for one patient (#23) of one patient reviewed for abuse.
- Ensure staff were trained and competent to prevent, recognize and respond to all forms of abuse by co-workers, and failed to ensure staff were immediately re-educated about abuse and reporting, after allegation of staff to patient abuse occurred.
- Report allegations of abuse to the appropriate State Agency.
These failed practices by the facility placed all patients admitted to the facility at increased risk for their safety. The facility census was 285.

Findings included:

1. Review of the facility's policy titled, "Patient Abuse and Neglect," revised 08/2016, showed directives for staff:
- Patient abuse and neglect by employees shall be grounds for disciplinary action, up to and including termination.
-All reports of alleged abuse will be taken seriously, and will be investigated immediately.
- It was the responsibility of all employees who may witness, suspect patient abuse or receive report of same from the patient, or other staff, to report this suspected abuse and/or neglect to their supervisor immediately. This can include physical, sexual, emotional, verbal and/or social abuse.
- Any witnessed or un-witnessed incident of patient abuse or neglect or exploitation was initially reported to the Department Director or House Supervisor immediately.
- Any health care provider who knowingly fails to make an abuse report may be subject to disciplinary action up to, and including, termination.
- Upon receipt of an allegation of suspected abuse and/or neglect, it was the responsibility of the Department Director or House Supervisor to initiate investigation of the situation.
- Reports of suspected abuse or neglect will be referred to the appropriate agencies within 24-hours of determination.
- Verbal report shall be made immediately to the Missouri Department of Human Services Abuse Hotline and/or police.
- Staff having reasonable cause to suspect that abuse was committed on the grounds of the facility, shall contact the Chief Nursing Officer (CNO), or Director of Risk Management and security department if needed.

Review of Patient #23's discharged electronic medical record (EMR) showed that he was admitted to the facility's Rehabilitation Unit on 12/28/17 for rehabilitative care and treatment after a motor vehicle collision with traumatic brain injury (a disruption in normal brain function caused by injury to the head).

Review of the facility's list of terminated staff showed that Staff NN, Patient Care Technician (PCT), was terminated on 04/03/18.

Review of Staff NN, PCT's, Disciplinary/Corrective Action Form dated 04/03/18, showed she was terminated on 04/03/18, after Staff MM, Registered Nurse (RN) and Staff LL, RN, witnessed her repeatedly hit Patient #23 on 01/22/18. Later, after she hit the patient, she went to the patient's room and pushed the patient to the floor and got on top of him (the patient had a fractured left leg that resulted from the motor vehicle collision). On 03/21/18, Staff NN admitted that she hit the patient on multiple occasions, as well as wrestled the patient to the ground.

During a telephone interview on 09/04/18 at 5:06 PM, Staff MM, RN, stated that:
- She worked night shift on the Rehabilitation Unit on 01/22/18.
- Staff NN, PCT, pushed Patient #23 to the floor in his room and stood over him and hit him in the back of the head.
- She was shocked by Staff NN's behavior and told Staff NN, PCT, to get off the patient,
- Staff NN, PCT, reported that the patient had "punched" her, so she "hit" him back and admitted that she had "pushed" the patient onto the floor.
- She requested Staff LL, RN to call security to come to the unit because of the altercation.

During a telephone interview on 09/05/18 at 4:22 PM, Staff LL, RN, stated that:
- She worked night shift on 01/22/18 as Patient #23's primary nurse.
- Staff MM, RN, worked as Charge Nurse on 01/22/18.
- Staff NN, PCT, walked the patient, had the back of his pants "balled" up in her hand and pulled his pants up.
- The patient stated she was "hurting" him, but she refused to release her hold on his pants.
- The patient swung his casted arm at Staff NN, PCT.
- She observed Staff NN, PCT, push the patient to the floor, stood over him, and hit him three to four times in the back of his head.
- She yelled at Staff NN, PCT, to get off the patient and Staff MM, RN, responded and pulled Staff NN, PCT, off the patient.
- She called security to come to the floor to assist with the altercation.
- Security arrived and she informed security that Staff NN, PCT put the patient on the floor and hit him.
- She did not know if the patient's physician was notified after the physical assault/abuse.

During a telephone interview on 09/05/18 at 10:49 AM, Staff NN, PCT, stated that:
- Patient #23 hit her in the chest, so she restrained him and put him on the floor.
- She denied that she "punched or hit" the patient in the back of his head multiple times.
- She was terminated because she was accused of attacking the patient.

This showed that the facility failed to protect Patient #23 from repeated physical abuse by Staff NN.

2. During an interview on 08/29/18 at 9:20 AM, Staff DD, RN, Director of Nursing Operations (DNO), stated that:
- Staff LL, RN, and Staff MM, RN, came to her with concerns they had while working with Staff NN, PCT (believed to be on or around 02/16/18, more than 20 days after the alleged abuse).
- On 02/16/18, she called Staff NN, PCT, Staff LL, RN, and Staff MM, RN, in for a meeting.
- Staff LL, RN, reported that Staff NN, PCT, had "hit" a patient and put him "down" on the floor and was on top of him.
- Staff LL, RN, and Staff MM, RN, reported to her that they had called security on 01/22/18 because of Staff NN, PCT's behavior towards Patient #23.
- This was the first time staff had reported to leadership, that Staff NN, PCT, had hit a patient.
- Risk Management informed her not to contact the State Agency regarding the allegation of alleged staff to patient abuse.

During an interview on 08/29/18 at 12:30 PM, Staff GG, Security Officer (SO), Safety Coordinator, stated that when he responded to a request for help on 01/22/18 on the Rehabilitation Unit, Staff GG found Patient #23 on the floor. Staff LL and Staff MM, RNs, reported that Staff NN, PCT, was aggressive with Patient #23, and so Staff GG completed an incident report and gave it to his supervisor.

During an interview on 08/29/18 at 12:30 PM, Staff HH, Security Director (not the Security Director/Supervisor on 01/22/18), stated that when a SO filled out a report, it was the Security Director's responsibility to send the report with allegations of abuse and/or neglect to the Risk Manager and Nursing Director of the Unit involved, and the Nursing Director would forward the report accordingly to appropriate leadership as needed.

During a telephone interview on 09/05/18 at 4:22 PM, Staff LL, RN, stated that she did not notify the House Supervisor or complete an incident report for the abuse of Patient #23.

During an interview on 08/30/18 at 9:25 AM, Staff II, RN, Director of Nursing (DON), Rehabilitation Unit, stated that Staff LL, RN, admitted that she did not report Patient #23's abuse immediately.

During a telephone interview on 09/04/18 at 5:06 PM, Staff MM, RN, stated that she did not recall if she reported the abuse to the charge nurse, did not know what the policy instructed her to do, but since security was called, she thought that was all she needed to do.

During a telephone interview on 09/05/18 at 8:55 AM, Staff QQ, Interim Director, Rehabilitation Unit, stated that Staff LL, RN, and Staff MM, RN, did not immediately report the altercation between Staff NN, PCT, and Patient #23 to leadership, and when the incident was disclosed to her, "way after" the incident had occurred, Staff DD, RN, DNO, informed her that she was taking care of the situation.

This showed that the facility failed to immediately report the abuse of Patient #23 to leadership.

3. Review of Nurses Notes dated 01/22/18 and 01/23/18, showed no notes of the incident that occurred on 01/22/18 between Patient #23 and Staff NN, PCT, no physical examination of the patient after the abuse and no documentation of notification to the physician.

During an interview on 08/29/18 at 4:16 PM, Staff G, RN, Informatics Director, stated that Patient #23's EMR:
- Did not contain Nurse's Notes related to Staff NN, PCT's, altercation and physical assault/abuse toward the patient.
- Did not contain any documented nursing assessment of the patient after the altercation/physical assault/abuse from Staff NN, PCT.
- Did not contain any documentation that the patient's physician was notified of the physical assault/abuse of the patient by Staff NN, PCT.

During a telephone interview on 09/05/18 at 4:22 PM, Staff LL, RN, stated that she did not know if Patient #23's physician was notified after the abuse.

During a telephone interview on 09/04/18 at 5:06 PM, Staff MM, RN, stated that she did not know if the patient's physician was contacted after the event.

During an interview on 08/30/18 at 9:28 AM, Staff JJ, Physician, Rehabilitation Unit Medical Director, stated that he did not recall receiving notification of the altercation and alleged physical abuse by Staff NN, PCT, towards Patient #23.

This showed that the facility failed to assess and immediately notify the physician after the abuse of Patient #23.

4. During an interview on 08/30/18 at 10:29 AM, Staff Z, Vice President of Quality, stated that Staff NN, PCT, did not receive any abuse/neglect training in 2016 or in 2018.

During an interview on 08/29/18 at 9:20 AM, Staff DD, RN, Director of Nursing Operations (DNO), stated that she did not formally provide staff with abuse and neglect education after she learned of the alleged abuse, and after staff failed to immediately notify leadership of the abuse.

During an interview on 08/29/18 at 12:30 PM, Staff GG, SO, Safety Coordinator, stated he did not recall any abuse education/training after the alleged patient abuse that occurred on 01/22/18.

This showed that the facility failed to ensure staff were adequately educated in abuse, and that the facility failed to immediately re-educate staff about abuse, after staff to patient abuse had occurred.