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Based on review of medical records, policy and procedure and interviews, the hospital failed to thoroughly investigate patient falls, consistently document falls and post fall vital signs in the medical records. Staff also failed to maintain Line of Sight Precautions for Patient Identifier (PI) # 8 on 10/29/17. This affected Patient Identifier (PI) # 9, # 8, # 3 and # 1, five of nine sampled patients. In addition, the hospital failed to follow their own policy for conducting an investigation regarding allegations of patient abuse. This affected Patient Identifier (PI) # 1 and PI # 2, and had the potential to affect all patients served.

Findings include:

Refer to A - 0144 and A - 0145 for findings.

Based on review of medical records, Occurrence Investigation Statements, Interdisciplinary Occurrence Investigation Worksheet, Physical Therapy Log, policy and procedure and interviews, the hospital failed to thoroughly investigate patient falls, consistently document falls and post fall vital signs in the medical records. Staff also failed to maintain Line of Sight Precautions for Patient Identifier (PI) # 8 on 10/29/17. This affected Patient Identifier (PI) # 9, # 8, # 3 and # 1, five of nine sampled patients and had the potential to affect all patients served by the hospital.

Findings include:

1). A review of the medical record revealed PI # 9 was admitted on 10/26/17 with diagnosis to include Major Neurocognitive Disorder, Alzheimer's type, severe with behavioral disturbances. Plan includes: Fall precautions and every 15 minute safety checks.

A review of the care plan for PI # 9 dated 10/26/17 revealed a plan for Fall risk, High. PI # 9's Morse fall risk score was 65 (high risk for fall) on 10/26/17. Interventions initiated on 10/26/17 included: monitor for a minimum of every 30 minutes, fall sticker to indicate high risk and application of appropriate footwear.

A review of the Nurse Event Note dated 11/1/17 at 12:10 AM revealed PI # 9 had an unobserved fall in the patient room. Vital signs after the fall were not documented.

Documented in the section of the form titled, "Detailed Description of Occurrence" was the following: MHT (Mental Health Technician) heard alarm sounding in room 103, entered to find PI # 9 "laying" on the floor, c/o (complained of) pain in Right leg, otherwise no injuries noted, called MD (Medical Doctor), received order to transfer to hospital..."

Interventions Implemented to Prevent Reoccurrence: Encourage to call nurse for assistance to bathroom.

A review of the Patient Care Notes dated 11/1/17 at 12:10 AM revealed PI # 9, "Fell in pt. (patient) room. C/o r (right) leg pain. Sent to (initials of hospital) ED (Emergency Department) for further evaluation." There is no documentation to indicate an attempt was made by staff to interview PI # 9.

During a tour of the patient's rooms on 11/7/17 it was noted that the patient call lights are located on the wall above the patient's headboard.

A review of the Interdisciplinary Occurrences Investigation Worksheet revealed the root cause of the occurrence is, "MHT (Mental health Technician) heard alarm (bed) sounding in room...Nurse/MHT entered to find patient lying on the floor. C/o (complained of) pain to r (right) leg. Otherwise, no injuries were noted by the charge nurse...). Impaired cognition was a contributing factor to PI # 9's fall. However, "encourage patient to call nurse for assistance to the bathroom" is documented as a post fall intervention. The location of the call bell and/or PI # 9's ability to use the call bell was not documented.

The Transfer Form revealed PI # 9 was confused at the time of transfer.

An Occurrence Investigation statement that was not signed or dated by the witness revealed PI # 9 was found to have BM (bowel movement) on his/her body. There is no documentation to indicate toileting was considered by staff as a potential contributing factor in the fall on the Interdisciplinary Occurrences Investigation Worksheet dated 11/1/17. There was no documentation hospital staff were interviewed regarding patient toileting.

Comments documented on the worksheet revealed PI # 9 sustained a right femur fracture and is now requiring right hip replacement surgery.


Policy and Procedure: Fall Prevention Program
Revised 7/2015...

...3. A fall without an injury is still a fall.

Procedure:
A. Fall Risk Assessment
1. The Registered Nurse (RN)/Licensed Practical Nurse (LPN) will complete Morse Fall Risk Assessment (MFS)...
2. Initiate interventions based on MFS score (low, moderate, high risk)...

B. Interventions: Fall Risk Score determines level of fall prevention interventions warranted.

Score: 0-24
Orient patient to environment on admission.
Clutter free environment.
Application of appropriate footwear.

Score: 25-45
All previous interventions.
Safety alarm (chair/bed/body) as appropriate.
Fall precautions every 30 minutes.
Bed in lowest position at H.S. (Hour of Sleep)...
Non-skid sock at H.S. (May also wear in the day).

Score: 46 +
All previous interventions.
Fall sticker added to patient identification bracelet.
Restorative therapy.

The facility failed to assure vitals signs were taken and/or documented after PI # 9 fell on 11/1/17.

2). A review of the medical record revealed PI # 8 fell on 10/29/17 at 12:30 AM.

A review of the medical record revealed PI # 8 was admitted on 9/12/17 with diagnoses to include Major Neurocognitive Disorder, Alzheimer's type moderate with behavioral disturbances and Schizoaffective Disorder, bipolar type.

Mental Status Examination:
Insight and Judgement: Poor

Gait and station: Unsteady related to muscle weakness. Patient uses a walker.

A Morse Fall Scale dated 10/25/17 revealed PI # 8's score was 95 indicating PI # 8 was at high risk for falls.

Post fall evaluation comments include: history of falls and underlying acute and chronic medical problems. "Patient (PI # 8) was in the bed. RN was called to the room. Nurse witnessed patient lying face down on the floor. Body audit was completed by charge nurse...no injuries were noted. Intervention: ensure bed alarm on and remain LOS (Line of Sight)." LOS: Staff must be able to see the person served and hear any verbal or potential action the person may be attempting to do that could be harmful...as defined in the Special Precautions Policy dated 4/2016.

A review of the Interdisciplinary Occurrences Investigation Worksheet revealed:

a. "Patient Name: PI # 8 Date of Incident: 10/29/17

b. The incident was: on the floor.

c. Did the fall result in injury? No.

d. Review the environment for possible contributing factors. Place a check mark in the box to identify contributing factor (s): N/A (Not applicable) was selected. Although Call Light (on dominant side within reach, appropriate for patient) is an option, it was not selected.

e. List includes alarms, but it was not selected. There is no documentation to note if the bed alarm was sounding at the time of the fall.

f. Review factors related to the resident for possible contributing factor. Place a check mark in the box to identify contributing factor (s): Impaired cognition was selected. Toileting needs is as option, but it was not selected as a factor.

g. Medication dose was changed in the last 24 hours. Types of medications: Antipsychotics, Narcotics, Antianxiety Agents, Cardiovascular and Laxatives.

h. 'Restless' was identified as a behavior that may have contributed to the fall.

i. Physical function problems that may have contributed to the fall: N/A. Muscle weakness is an option, but it was not selected even though muscle weakness was identified on admission PI # 8.

j. Conclusion and Action Plan:

The root cause of the Occurrence is: Pt. (Patient) was lying in bed. RN called to pt. room. Charge nurse witnessed pt. lying face down on the floor. Body audit...revealed no injury.

Intervention (s) put in place: Neuro (Neurological) checks, VS (Vital Signs), Remain LOS (Line of Sight). Bed alarm on."

A review of The Patient Care Notes revealed no documentation about PI # 8's fall.

A review of the Special Precautions - Special Monitoring Form dated 10/28/17 revealed PI # 8 was in the shower at 12:15 AM, 12;30 AM and 12:45 AM as documented by the Mental Health Technician (MHT). However, the fall was documented as occurring at 12:30 AM in PI # 8's room. The form also revealed PI # 8 was on 1:1 precautions.

During an interview on 11/8/17 at 10:15 AM, the Risk Manager / EI # 1 was asked about PI # 8's bed alarm. EI # 1 verified there was no documentation to indicate if PI # 8's bed alarm was functioning at the time of the fall. EI # 8 said, "That's what should have alerted them (staff) in the first place." EI # 1 stated she could not identify the root cause of PI # 8's fall. The Risk Manager / EI # 1 was asked if she interviewed PI # 8 and she replied, "No. I probably should have." EI # 1 verified there was no documentation regarding PI # 8's fall in the nursing notes (also know as Patient Care Notes) or by the physician in the medical progress notes. EI # 1 confirmed the MHT documented PI # 8 was in the shower at the time of the fall (12:30 AM on 10/29/17).

During an interview on 11/8/17 at 12:05 PM, the Interim Administrator / EI # 3 was asked if staff reviewed video at the time of the fall to attempt to determine the location of staff (the fall occurred in PI # 8's room). EI # 3 replied he did not have the capability to view the video.


3. A review of the medical record revealed PI # 3 was admitted to the hospital on 9/1/2017
with a diagnosis of Major Neurocognitive disorder, Alzheimer's type, severe with behavioral disturbances.

A review of PI # 3's care plan dated 9/1/17 revealed a care plan for high fall risk. PI # 3's gait was documented as unsteady with poor balance. A bed alarm was documented as an intervention.

A review of PI # 3's Morse Fall Scale revealed a score of 64 (high risk) on admission (9/1/17) and a score of 80 on 10/13/17.

A review of the Nurse Event Note revealed PI # 3 had an unobserved fall with no apparent injury on 10/29/17 at 12:30 AM. PI # 3's blood pressure was not documented as required on the note.

A review of the Interdisciplinary Occurrences Investigation Worksheet revealed the section on the sheet titled "Equipment" was documented as N/A (Not Applicable). However, the care plan documented PI # 3 had a bed alarm. There was no documentation that indicated if the alarm was working at the time of the fall. Additionally, there was no documentation to reveal PI # 3's IV was considered as a potential contributing factor in the fall.

The Patient Care Note dated 10/28/17 at 10:00 PM revealed PI # 3 had an IV (intravenous infusion) infusing in the right arm and "safety measures in place line of sight monitoring." According to the Special Precautions policy, Line of Sight means staff must be able to see the person served and hear any verbal or potential action the person may be attempting to do that could be harmful.

A review of the Patient Care Notes dated 10/28/17 revealed no documentation about PI # 3's fall.

During an interview on 11/8/17 at 9:12 AM the Risk Manager, EI # 1, verified PI # 3's fall was not documented in the Patient Care Notes. EI # 1 also confirmed PI # 3's blood pressure was not documented on the Nurse Event Note dated 10/29/17.


Policy and Procedure: Special Precautions Revised: 4/2016...

Description of Precaution Levels:

..c. Line of Sight: Precautions are documented every 15 minutes along with specific instructions (when indicated) that the person served is within eyesight and hearing (eye shot / ear shot) of a clinical staff member. Staff must be able to see the person served and hear any verbal or potential action the person may be attempting to do that could be harmful...




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4. Patient Identifier (PI) # 1 was admitted to the hospital on 10/07/17 with diagnosis to include Alzheimer's disease.

A review of the care plan for PI # 1 revealed a care plan for fall risk dated 10/07/17. PI # 1 scored a 75 (high risk for fall) on the Morse fall scale. Interventions put in place on 10/07/17 included: monitor for a minimum of every 30 minutes and chair alarm. On 10/25/17 new interventions listed were: Physical Therapy consult.

A review of the medical record revealed a nurse event note dated 10/24/17 at 3:55 PM. The event note documented PI # 1 had an unobserved fall in the dinning room. Documented in the section of the form titled, "Detailed Description of Occurrence" was the following: family member stated PI # 1 got up to walk and after a few steps PI # 1 slid down to the floor, landing on her right elbow and right hip. It was noted PI # 1 had a clip (chair) alarm attached to her shirt and the tab string was separated from the alarm box, but the alarm did not sound.

Under the section of the note titled, "Interventions Implemented to Prevent Reoccurrence" the following was documented: Tab (chair) alarm and box changed out with another tab alarm that does sound when the string is separated from the alarm box.

There was no other intervention documented and no documentation why the first alarm box failed to function properly.

A review of the medical record revealed another nurse event note dated 10/25/17 at 6:50 AM. The event note documented PI # 1 had an observed fall in the dinning room. Documented in the section of the form titled, "Detailed Description of Occurrence" was the following: PI # 1 was in a wheelchair with a chair alarm on. PI # 1 attempted to get out of the chair without assistance and fell. The physician was notified, no further orders were received.

Under the section of the note titled, "Interventions Implemented to Prevent Reoccurrence" the following was documented: Physical Therapy (PT) referral done 10/24/17 and again on 10/25/17.

There was no documentation the family was notified of the fall on 10/25/17.

A review of the physician orders revealed an order dated 10/25/17 at 11:40 AM for a Physical Therapy consult, due to recent fall.

A review of the therapy section of the medical record revealed a referral for therapy services dated 10/25/17 that was faxed to the therapy department. A second referral for therapy services was dated 11/07/17 that was also faxed to the therapy department.

A review of the physical therapy log was completed. The physical therapy staff sign in on the log each time they make a visit and list the date, patient name and reason for the visit. The only entry on the physical therapy log for PI # 1 was dated 11/8/17. The reason documented was for a Physical Therapy evaluation.

A review of the therapy notes documented a Physical Therapy evaluation was completed on 11/7/17, thirteen (13) days after the physician order was written for PI # 1 to be evaluated. The Physical Therapy plan of care included a frequency for Physical Therapy every day for two to three weeks.

The facility failed to assure a chair alarm for PI # 1 was working properly and follow the physician order for a physical therapy evaluation on 10/25/17. The physical therapy evaluation was not completed until thirteen (13) days after the order was written.

Based on hospital policy and procedure review, personnel file review, medical record documentation and interviews and review of video footage, the hospital failed to follow their own policy for conducting an investigation regarding allegations of patient abuse. This affected Patient Identifier (PI) # 1 and PI # 2, and had the potential to affect all patients served.

Findings include:

Policy and procedure: Abuse and Neglect

To have an internal procedure to investigate abuse and/or neglect allegedly committed by an employee of this hospital or by a family member/caretaker of a patient. All staff members will be trained and given a copy of the provider's policies and procedures on reporting suspected cases of abuse and neglect.

Definitions:

Abuse: The willful inflection of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish.

Verbal abuse: Is defined as oral, written, or gestured language that willfully includes disparaging and/or derogatory terms to patients or their families, or within hearing distance, regardless of age, ability to comprehended, or disability.

Physical abuse: Includes hitting, slapping, pinching, pushing, and kicking. It also includes controlling behavior through corporal punishment.

Mental abuse: Includes, but is not limited to humiliation, harassment, threats of punishment or deprivation.

Procedure:

1. Reporting procedure of abuse or neglect where abuser is believed to be an employee.

a. Reporting of abuse or neglect where the abuser is believed to be an employee of BHC (Behavioral Healthcare Center) shall be immediately reported to the administration and proper authorities for investigation. Anytime abuse is suspected, an employee should report to their immediate supervisor. Reporting will be done immediately upon discovery. The reported accounting shall be transcribed into written form, signed and dated by those reporting and witnessing such incident.

b. Individuals under investigation are not permitted to be a part of the investigation team.

c. Individuals under investigation due to accusable or suspicion for afflicting abuse, neglect, or misappropriation of patient property, shall be questioned about the alleged incident by the Administrator in the presence of a witness. Accused employees who comply with the interrogation proceedings and who deny accusations of abuse, neglect or misappropriation of patient property shall be under immediate suspension (without pay). Visitation to the hospital except to pick up payroll check due to the employee is restricted until investigation is finalized. Continued employment of such suspended employee will be determined based on results of investigation.

d. Findings will be reviewed and forwarded to the Board of Directors. All allegations of abuse, neglect, and misappropriation of patient property will be reported to the Department of Human Resources. Substantiated allegations of abuse, neglect, or misappropriation will be reported to the Alabama Department of Public Health and law enforcement when necessary.

Policy: Abuse Protection Policy

To operate this facility where all of our patients are free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion and misappropriation of patient property. Policy and procedure will include screening, training, prevention, identification, investigation, and reporting/response.

Procedure:

5. Investigation: Complete an investigation on all occurrences to include appropriate information.

6. Protection:
a. The patient will be protected from harm during the investigation process.
b. Evaluation and appropriate intervention will be taken to ensure patient safety.

7. Reporting/Response
a. Abuse must be reported to the Administrator. The Administrator then reports all alleged violations and all substantiated incidents to the State Agency and to all licensure agencies within 24 hours. Internal investigation will be faxed to appropriate agencies within 72 hours.

Alabama State Agency complaint intake.

On 11/6/17 the Alabama State Survey Agency received an allegation of patient abuse to PI # 1 and PI # 2 via the complaint hotline. The caller alleged that Employee Identifier (EI) # 4, Mental Health Tech (MHT), physically abused PI # 1 by "pinching" PI # 1 on the arm. EI # 4 also allegedly verbally abused PI # 2 by telling PI # 2 when the patient asked where he/she was, EI # 4 allegedly told PI # 2, "You are in hell."

According to the complaint intake the caller alleged these abuse incidents were reported to the hospital Administrator, witness statements received and no investigation was conducted.

A review of PI # 1's medical record revealed the patient was admitted to the hospital on 10/07/17 for dementia related behavior disturbances.

PI # 2 was admitted to the hospital on 10/13/17 with a diagnosis of Dementia with behavioral disturbance.

Interviews:

On 11/8/17 at 12:45 PM, EI # 6 (Employee Identifier) / Discharge Planner, was interviewed. During the interview EI # 6 was asked about the allegation of abuse by EI # 4 to PI # 1. EI # 6 stated she was at the nursing station getting report and she heard a "commotion" in the dinning room. When EI # 6 looked she stated she saw PI # 1 "swatting" at EI # 4 . EI # 6 stated she saw EI # 4 "swatting" PI # 1's hands down and grabbing PI # 1's right arm in what looked like a pinch. EI # 6 stated the patient (PI # 1) immediately grabbed his / her right arm. EI # 6 stated PI # 1 was taken to the exam room and the patient's arm was examined. EI # 6 confirmed PI # 1's arm had no redness or obvious injury and no skin was broken. EI # 6 stated she reported the incident to EI # 5, Administrator, who serves as the hospital abuse coordinator. EI # 6 was told by EI # 5 to write a statement. EI # 6 stated she asked EI # 5 to review the camera (video footage) and EI # 5 told EI # 6 he did not have access and he cannot review past video footage.

On 11/8/17 at 1:30 PM, EI # 5 confirmed no video footage review of the alleged physical abuse of PI # 1 was conducted.

On 11/8/17 at 1:35 PM, EI # 5 was interviewed. During the interview, EI # 5 stated he would be the one to investigate allegations of abuse along with Human Resources, but no one has told him he was the abuse coordinator for the hospital. EI # 5 was asked during this interview if he had received any complaints or allegations of abuse and he stated, no. EI # 5 went on to say he was notified of a patient (PI # 1) "swatting" at staff and the way it was described staff "grabbed" the patient's arm to stop the patient from swinging. EI # 5 stated he was given two written descriptions. One of EI # 4 "yelling" too loudly at a patient. EI # 5 stated he gave the statements to the former Director of Nursing (DON), who left the early part of November. EI # 5 stated he had no copy of any of the documentation and he was told by the former DON EI # 4 received a written warning. EI # 5 stated the incident was not presented to him as abuse and if he thought it was abuse he would have removed EI # 4. EI # 5 stated he did not see EI # 4 "grabbing" PI # 1's arm as abuse. EI # 5 stated telling a patient they are in hell was a concern and he gave that concern to the former DON and the former DON counseled the staff and gave them a written warning. EI # 5 stated the incident report should have gone to the former DON and if an issue was identified the report should have been forwarded to him.

On 11/8/17 at 2:45 PM, EI # 5, Administrator, was furthered interviewed. During the interview EI # 5 stated he notified the former Director of Nursing (DON) by telephone of the allegations of abuse. EI # 5 stated when the former DON returned to work she discussed the allegations with EI # 8, Human Resources, and decided to do a written reprimand for EI # 4. EI # 5 stated he did not know if an investigation was done. EI # 5 was asked if the allegation was considered abuse and EI # 5 stated he did not know if the former DON and EI # 8 considered the allegations abuse. EI # 5 confirmed that EI # 4 was never pulled from staffing and that a written reprimand was given to EI # 4.

On 11/9/17 at 9:05 AM, EI # 8, Human Resources, was interviewed. During the interview EI # 8 was asked when and how she was notified of an allegation of abuse allegedly committed by EI # 4. EI # 8 stated she was notified after the incident because she was not on-site when the incident happened. EI # 8 stated she was told the incident was unfounded. EI # 8 was asked if a statement was obtained from EI # 4 and EI # 8 stated in this case a statement was not obtained and EI # 8 did not know why. EI # 8 was asked if the allegation was considered to be abuse and EI # 8 stated, yes. EI # 8 was asked if the hospital had a designated abuse coordinator and EI # 8 stated yes, EI # 5, Administrator. EI # 8 stated EI # 5 would handle the investigation. EI # 8 was asked if she had a role in the abuse investigation process and EI # 8 stated, no.

On 11/9/17 at 10:15 AM, EI # 4, MHT, accused of abuse was interviewed. EI # 4 was asked to describe the allegation made against her. EI # 4 stated she did not know anything until she was pulled in to the office and given a "write up." EI # 4 stated the write up documented she said a patient was in hell. EI # 4 stated she was never given the patient's names (PI # 1 or PI # 2). EI # 4 stated she was never asked to tell her side of the events and there was no investigation. EI # 4 was asked if anyone ever told her the allegations could be considered abuse and EI # 4 stated, yes the former DON told her that.

On 11/9/17 at 1:15 PM, EI # 3, Interim Administrator/Consultant, was interviewed. During the interview with EI # 3 he confirmed an incident report would be completed if there was an allegation of abuse. EI # 3 was asked to define abuse and stated anything between two individuals that has the potential to harm psychologically or physically. EI # 3 was asked if an investigation was completed for an allegation of abuse to PI # 1 by a staff member. EI # 3 stated he did not know. EI # 3 was asked what process staff should follow if they suspected abuse. EI # 3 responded staff would go back and review video footage, talk to all individuals involved, talk to the patient, and have the patient examined immediately after alleged abuse. EI # 3 stated staff are to report abuse or suspected cases of abuse to the charge nurse. The charge nurse would report up through the chain of command and if severe enough, the charge nurse can send a staff person home or get the staff person off the unit.

On 11/9/17 at 2:00 PM, EI # 2, Assistant Director of Nursing, was interviewed. EI # 2 was asked about the process when there is an allegation of abuse and how the abuse allegation would be investigated. EI # 2 stated if the allegation was brought to her she would notify the Director of Nursing, Administration and Human Resources. EI # 2 stated she would discuss the allegation with Administration and Human Resources Director and that Human Resources then directs the staff in what steps to take. EI # 2 stated interviews with the accused staff member would be done and staff would be separated from the victim until the investigation was completed. EI # 2 was asked to define abuse and stated abuse can be physical, verbal or mental. Anything that causes harm. Being rough, aggressive, yelling at patients or saying negative things. EI # 2 was asked if an investigation was completed for an allegation of physical abuse to PI # 1 and EI # 2 stated she did not know if an actual investigation was done. EI # 2 was asked if an allegation of physical abuse was reported to her and she stated yes, by EI # 5, Administrator. EI # 2 stated EI # 5 brought her two written allegations from EI # 6, Discharge Planner and EI # 7, Social Worker Director. EI # 2 stated EI # 5 asked her to read the allegations and then give EI # 5 her thoughts. EI # 2 stated she notified the former Director of Nursing (DON). At the time of the survey the hospital did not have a DON, the former DON resigned. EI # 2 stated the former DON was given the two written statements and the next thing that happened EI # 2 was asked to sit in as a witness for the written reprimand for EI # 4. EI # 2 stated that EI # 4 denied the allegation of physical abuse that was alleged toward PI # 1. EI # 2 was asked if she would define the written allegations she received from EI # 5 as abuse and she stated, yes. EI # 2 was asked what process staff should follow if the staff suspect patient abuse. EI # 2 stated staff should immediately go to their supervisor and report it, fill out a written statement, complete an incident report, and if physical abuse the nurse should remove the accused staff member.

On 11/9/17 at 2:35 PM, EI # 1, Risk Manager was interviewed. During the interview EI # 1 was asked to describe the process when an allegation of abuse is reported. EI # 1 stated it would be reported to Administrator, DON, statements would be taken and an investigation completed. Part of the investigation would include talking to the accused and the persons making the claim. EI # 1 was asked to give examples of abuse and stated hitting, yelling, neglect. EI # 1 was asked if an investigation for an abuse allegation involving PI # 1 was done and EI # 1 stated she did not know. EI # 1 stated she did not even know statements existed until asked by the surveyor on 11/08/17. EI # 1 was asked the process staff should follow if staff suspect patient abuse. EI # 1 stated talk to administration immediately, speak to person accused of abusing patient and obtain written statements.

A review of the EI # 4's personnel file revealed a personnel form dated 10/23/17. The form documented EI # 4 had an improper conduct infraction. Under the remarks section it was documented: "Reported use of harsh tone with patients on multiple occasions; aggressive and rushed transferring of patients observed; patient asked 'where am I' - overheard telling the patient 'you're in hell.'" Corrective actions documented were as follows: "Writing warning and employee / supervisor in-service on appropriate conduct and transferring of geriatric patients. Violation of this warning will result in further disciplinary action, including termination." There were three staff signatures on the personnel action form. Signature of Supervisor, former DON; Signature of employee, EI # 4; and Signature of Administrator, EI # 5.

Attached to the personnel action form were two written statements.

Statement one was dated 10/19/17 and signed by EI # 6. In the written statement by EI # 6 it stated, "This writer (EI # 6) turned around and observed a patient (PI# 1) hitting (EI # 4). The MHT then turned around and what looked like his/her pinching the patient. The patient immediately grabbed his/her arm like she was in pain. This writer and another nurse took the patient in the treatment room to look at the patient's arm. There were no noticeable marks on this patient other than old bruising. This patient is unable to voice what had happened..."

Statement two was dated 10/19/17 and signed by EI # 7, Social Worker Director. The written statement did allege EI # 4 using "...a harsh tone with patients several times throughout group sessions. (EI # 4's) affect and demeanor often appears callous and annoyed when interacting with patients. I (EI # 7) have observed (EI # 4) using harsh tones and aggressive transfers of patients. When one patient (PI # 2) asked 'where am I', (EI # 4) responded harshly 'you're in Hell.'

On 11/9/17 at 10:55 AM, surveyors reviewed video footage for 10/19/17 with EI # 9, Business Office Manager. This was the first time any of the hospital staff viewed the video footage of the dates and times that EI # 4 allegedly abuse PI # 1 and PI # 2. During the review of the video footage, there was no visible evidence on the recordings to confirm that EI # 4 physically abused PI # 1 as alleged. The video footage does not have audio recordings. Therefore, there was no video / audio footage evidence to confirm EI # 4 verbally abused PI # 2.

The hospital failed to conduct a thorough and complete investigation for allegations of abuse by EI # 4 towards PI # 1 and PI # 2.

Based on medical record review, interviews and review of policy and procedure, the hospital failed to assure medications were given on the date and time ordered, documented as given by nursing staff to the patient, document directions for medication administration and document the correct start time for an IV (intravenous fluid). This affected (Patient Identifier) PI # 4, 7, 6, 5 and 2, five of nine sampled patients and has the potential to affect all patients served by the facility.


Findings include:


1). PI # 4 was admitted to the hospital on 10/27/17 with a diagnosis of Alzheimer's Dementia with behavioral disturbance. On 11/6/17, a diagnosis of Bronchitis versus Pneumonia was added.

The physician's progress note dated 11/6/17 revealed PI # 4 has a cough and some increasing bilateral lower lobe (lung) atelectasis (part of the lung collapses or doesn't inflate. exchange.www.nhlbi.nih.gov). The atelectasis was confirmed by x-ray.

A review of PI # 4's Medication Administration Record (MAR) on 11/7/17 revealed, "Z-pac to use as directed" was written on the MAR on 11/6/17. ( Z-pac / Z-pak is Zithromax, an antibiotic used to treat bacterial infections, www.drugs.com). There was no signature on the MAR to indicate the medication was given to PI # 4 on 11/6/17 and no specific directions for administration of the medication to include times of administration and dose.

During a review on 11/7/17, no physician's order for a Z-pak was found on the physician's order form in PI # 4's medical record for the date of 11/6/17.

During an interview on 11/7/17 at 1:45 PM, the Assistant Director of Nursing (ADON) / Employee Identifier (EI # 2) verified the medication was not given on 11/6/17 and the start time was not documented. EI # 2 said, "The RN (Registered Nurse) apparently forgot to put the order on the chart." EI # 2 confirmed the order was received by the pharmacy.

During an interview on 11/8/17 at 8:30 AM, the ADON / EI # 2, verified
PI # 4's physician order for the Z-pak was not placed in the patient's medical record. The ADON confirmed the Z-pak arrived at the facility between 7:00 PM and 8:00 PM on 11/6/17.

EI # 2 explained the process for medication orders:
1. The physician uses a computer to write an order.
2. The order is printed out and given to the RN.
3. The RN gives the printed order sheet to the LPN (Licensed Practical Nurse) / medication nurse.
4. The medication nurse faxes the order to the pharmacy and writes the order on the MAR.
5. The RN checks the order and the MAR to ensure the order is correct and matches the order written on the MAR.

2). PI # 7 was admitted to the hospital on 10/26/17 with a diagnosis of Dementia with behavior disturbance.

A review of the physician's progress note dated 11/6/17 revealed PI # 7 was wheezing, had chest congestion and sinusitis.

A review of the physician order dated 11/6/17 at 2:54 PM revealed an order was written for a "Z-pak to take as ordered."

A review of PI # 7's MAR revealed a Z-pak was transcribed on the MAR on 11/6/17. There was no documentation to indicate the medication was given to PI # 7 on 11/6/17.

During an interview on 11/8/17 at 8:30 AM, the ADON / EI # 2, verified PI # 7's Z-pak (antibiotic) was not given as ordered by the physician on 11/6/17 and the directions for administration of the medication were not documented on the MAR.


3). PI # 6 was admitted to the hospital on 10/26/17 with a diagnosis of Cognitive impairment with behavior disturbance.

A physician's order dated 10/27/17 at 4:33 PM revealed an order for Melatonin 4.5 milligrams (mg.) po (orally) hs (hour of sleep).

A review of PI # 6's MAR revealed Melatonin 4.5 mg. po was not documented as given as ordered at the hour of sleep on 11/6/17.

During an interview on 11/8/17 at 8:30 AM, the ADON / EI # 2, verified Melatonin was not documented as given to PI # 6 on 11/6/17.


4). PI # 5 was admitted to the hospital on 10/23/17 with diagnoses to include Dementia with behavior disturbance and Hyperlipidemia.

A physician's order dated 10/24/17 at 1:00 PM revealed Simvastatin 20 mg. was to be given q (every) hs (hour of sleep). (Simvastatin: medication used to lower types of fat in the blood, www.drugs.com).

A review of PI # 5's MAR revealed Simvastatin 20 mg. was not documented as given to PI # 5 on 11/6/17.

5). PI # 2 was admitted to the hospital on 10/13/17 with a diagnosis of Dementia with behavioral disturbance.

A physician's order dated 10/23/17, but not timed, revealed an IV (Intravenous) of D5 1/2 NS (Dextrose 5% and 1/2 normal saline @ 75 L (Liters) / hr (hour) x 3 Liters was to be started on PI # 2. The order was noted by an LPN at 4:45 PM.

A review of PI # 2's MAR revealed the IV was to be started at 7:00 PM on 10/23/17. A nurse initialed the MAR at 7:00 PM to indicate the IV fluid was started. However, the nurses note dated 10/23/17 revealed the IV was not started until 11:30 PM. Additionally, the signatures of the nurses on the MAR do not reflect the times the other two liters of fluid were administered.

During an interview on 11/8/17 at 2:25 PM, the Risk Manager / EI # 1, stated there should be a nursing note explaining the reason the IV was not started when ordered. EI # 1 verified the times when the remaining bags of IV fluid were started were not documented on PI # 2's MAR.

During an interview on 11/8/17 at 2:30 PM, the ADON / EI # 2, verified
the IV was initiated at 11:30 PM on 10/23/17. EI # 2 stated, "We have the IV solution. There is no reason it wasn't started."

Although the order was not timed by the practitioner, it was noted by an LPN at 4:45 PM. The IV was initiated at 11:30 PM, six hours and 45 minutes after staff was aware of the order.


Policy and Procedure: Medication Administration, revised 12/2006:
Policy: Medication is to be administered...as ordered.

Procedure:
...3. when medications are administered, the medication and dosage must be checked against the orders.

4. Each dose must be recorded in the clinical record.

Based on review of the recommendations of the CDC (Centers for Disease Control and Prevention) and interviews, it was determined the facility failed to ensure:

1). There was a system in place for the treatment of an outbreak of Scabies.

2). Hospital staff were educated about the treatment of Scabies and

3). CDC recommendations for the treatment of Scabies was followed.

As a result of these failures, all patients were treated twice.

This affected all of the patients in the hospital and has the potential to affect new admissions to the hospital.

Findings include:

The following documentation was provided by the Risk Manager / Employee Identifier (EI) # 1 as evidence of actions taken by the hospital to treat patients for Scabies and the CDC guidelines used by the facility:

A review of the Step by Step Instructions for Prophylactic Scabies Treatment as recommended by the CDC (confirmed by the Risk Manager / EI # 1 on 11/8/17 at 3:30 PM) revealed:

"It is imperative that the following procedure and timeline be followed exactly. If you have any questions about anything, ASK!

Day 1

Tuesday, 11/7/2017

- Remove all patient clothing from rooms, place in sealed plastic bag to be sent to laundry. Do not forget to wear gloves and wash hands thoroughly.

- Laundry will pick up patient clothing...

- Laundry will return clothes as soon as possible.

- Clothes are to be kept in the clean laundry room when they return...

- Permethrin cream to arrive at facility on routine shipment of medication.

- Staff to begin signing for their tube of cream...Do not apply until Wednesday night. It is imperative that ALL patient and staff treatments are done at the same time (with the exception of housekeeping).

Day 2

Wednesday, 11/8/2017

- Prior to bedtime, Permethrin cream will be applied to all patients.

- Cream should be left on overnight.

- Staff should be treating themselves tonight in the same manner...

- Document on MARS (Medication Administration Records) that Permethrin was applied. Document a short nursing note that Permethrin 5 % cream was applied per M.D. (Medical Doctor) order with date and time.

- Put any clothing taken off of the patients today in a sealed plastic bag to be re-laundered.

Day 3

Thursday, 11/9/2017

- Wake patients, and take directly to the shower room. Shower them thoroughly, including washing their hair. Put on clean clothing in the laundry room.

- A short nursing note should be documented on every patient that Permethrin cream was removed by shower and hair washed...

- Lock the patient's room...Do not allow the patient back into their room at this time.

- Housekeeping will...strip the beds, remove and place linens in a sealed bag and thoroughly clean the beds and the rooms.

- All bagged linens to be sent to the laundry.

- Housekeeping will treat themselves after all cleaning has been completed.

- Room doors can be unlocked after all cleaning has been completed.

- All patient clothing may now be taken form the clean laundry room and put back in each of the patient's rooms.

Note: An in-service is being provided to ALL staff with information form the CDC regarding Scabies Prevention, Treatment, etc. It is MANDATORY that ALL STAFF members read and sign that you understand the information being provided. it will be located at the nurses's desk for your review...
Signed by the Risk Manager, Employee Identifier (EI # 1)."

Steps to use Permethrin Cream was attached to the information noted above.


10/30/17 at 10:00 AM: Permethrin x 35 doses for patients and employee use.

11/6/17 at 10:40 AM: Permethrin x 45 doses for patients and employee use.


III. Interviews:

During an interview on 11/8/17 at 3:30 PM, the Risk Manager / EI # 1, stated a staff member noticed a rash. On 10/25/17, this employee received a diagnosis of scabies from a physician.
EI # 1 said this information was not reported to her until 10/30/17. According to EI # 1, she was advised the DON (Director of Nursing) was notified of the situation sometime between 10/18/17 and 10/25/17, but the DON never discussed it with the Risk Manager. The Risk Manager said she consulted the CDC (Centers for Disease Control and Prevention) website for guidance regarding the treatment for scabies and provided this information to the DON on 10/30/17. EI # 1 said she received no occurrence reports about the suspected or confirmed scabies. EI # 1 spoke to the Medical Director, the Administrator and the Interim Administrator about the concerns. EI # 1 gave instructions for the application of the Permethrin cream to the DON. The DON was to develop a sign out sheet for staff to sign for their tube of cream and application instructions. Later, EI # 1 said she was informed the instructions were never put with the sign out sheet. (The DON resigned and was not available for interview).

On 10/30/17 EI # 1 stated she ordered 35 tubes of Permethrin cream and it was received on 10/31/17. EI # 1 reiterated staff did not receive application instructions for the Permethrin cream. The Risk Manager asked the Assistant Director of Nursing (ADON) for a list of the patients who were treated with Permethrin and was informed the patients were not treated because none of the patients had symptoms. "Now we are treating everybody all over again."

Later, an employee reported one half of the patients were treated on one shift and the remainder were treated on another shift. According to Employee Identifier (EI # 1) all of the patients were supposed to be treated at the same time because of the one confirmed employee case of scabies. The Risk Manager was asked if she saw the confirmation of the scabies diagnosis and she said, "No." The employee's diagnosis was reported to her. The DON and ADON have the confirmation. EI # 1 said she discussed the concern about the patients not being treated at the same time and not knowing how staff applied Permethrin cream with the Administrator. It was decide to repeat the Permethrin correctly. "We had so many statements from staff. (regarding rashes and itching)." The Medical Director agreed. The Medical Director did not say it was necessary for every patient to be evaluated for scabies by a physician. It was felt it was appropriate to treat all patients due to the one confirmed employee case of scabies." All of the patients are to be treated tonight (11/08/17) with Permethrin.

A review of the Statement for Inservice Training for Employees dated 11/8/17 revealed no employees had signed the training form. "The following areas of instructions were covered: Please review the attached information on scabies from the CDC. Make a copy for yourself for future reference. If you have any questions, please ask Risk Management. Review of this information is mandatory." The form was signed by the Administrator and the Risk Manager.

The following information from the CDC was attached to the Statement for Inservice Training for Employees:

Scabies is a skin condition cased by mites. It commonly leads to intense itching and a...rash. Scabies is contagious and can spread quickly in areas where people are in close physical contact.

How can I get scabies?
Scabies us spread by skin to skin contact with a person who has scabies. It is sometimes spread indirectly by sharing items such as clothing, towels or bedding used by an infested person. Scabies can spread easily under crowded conditions where close body contact and and skin contact is common.

Common symptoms of itching and a pimple like rash may affect much of the body or be limited to places such as: between the fingers, wrist, elbow, armpit, genitals, nipple, waist, buttocks and shoulder blades.

When a person is first infested with scabies mites, it usually takes 2-6 weeks for symptoms to appear after infestation. If the person has had scabies before, symptoms appear 1-4 days after exposure.

Any infested person can transmit scabies, even if they do not have symptoms, until they are treated and the mites and eggs are destroyed.

Scabies should be treated with topical creams. In addition to the infested person, treatment is also recommended for people they have been in contact with.

Possible complications: The intense itching of scabies leads to scratching that can lead to skin sores. The sore sometimes become infected with bacteria on the skin. Sometimes the bacterial skin infection can lead to inflammation of the kidneys.

There was no documentation provided by the Risk Manager to indicate which patients had been treated with Permethrin during the first round of treatment.

There was no system in place and no follow through by staff regarding prevention and treatment of the patients and staff for Scabies. The in-service was only a review of the information obtained from the CDC website and no actual teaching was provided to staff.