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Based on document review, observation and interview, the facility failed to provide the patient with reasonable protection from abuse for 1 of 1 patient incident reviewed (P1) and allowed an employee to continue shift after episode of abuse toward a patient.

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review, observation and interview, the facility failed to provide the patient with reasonable protection from abuse for 1 of 1 patient incident reviewed (P1) and allowed an employee to continue shift after episode of abuse toward a patient.

Findings include:

1. Review of policy/procedure "Patient Rights and Responsibilities," PolicyNo.: RE 09, last revised 07/2018; indicated under: You have the right to: 6. Reasonable protection from physical or emotional abuse or harassment.

2. Review of policy/procedure titled, "Assaultive/Combative Patients - Management Of," PolicyNo.: CC.13, last revised 09/2024; indicated under Purpose: (d) ensure that patients received the least restrictive available intervention as warranted by their behavior. Procedure: (2) Do not attempt to approach the patient until adequate help is available.

3. Review of policy/procedure titled, "Recognizing And Reporting Suspected Abuse/Neglect/Exploitation," PolicyNo.: CC.07, Revised 09/2024; indicated under Policy: Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. Indicated under types of abuse: 2. Physical Abuse:
A willful infliction of injury by using physical force that may result in bodily injury, physical pain, or bodily function impairment. Examples of physical abuse include, but are not limited to, striking (with or without an object), kicking, hitting, pushing, shoving, shaking, beating, slapping, pinching, and rough handling. The Hospital shall protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff members, students, volunteers, other patients, visitors or family members.

4. Review of disciplinary action form for A11 (Certified Nurse Aide) regarding their suspension and termination. A11's suspension form dated 1/16/2025 indicated they failed to intervene appropriately and provide a timely intervention with a patient which resulted in a fall. A11 was unable to work until review with an outcome occurred. A11's termination form dated 1/20/2025 concluded A11 was found to be negligent in the care of a patient resulting in the patient hitting the floor and remaining on the floor without assistance while A11 remained in a chair.

5. On 02/05/25 at approximately 4:30 p.m., this surveyor, accompanied by A1 (Chief Executive Officer), viewed video footage of an incident on 01/16/25 at approximately 12:15 a.m. The incident involving P1 indicated they opened the refrigerator located in the milieu and at that point A11 got up from the chair and attempted to get P1 away from the refrigerator. P1 became aggressive, A11 pushed P1 into the wall, and then down to the floor. A11 walked away from P1 and sat back down in the chair.

6. Interview with A1, on 02/05/25 at approximately 2:45 p.m., A1 confirmed they thought A11 was too aggressive with P1 during an incident on 01/16/25. A1 confirmed A11 was not sent home after the 01/16/25 incident occurred and they completed their shift.

Based on document review, observation and interview, nursing services failed to ensure the provider was notified within 1 hour of an incident for 1 of 1 incident reviewed (P1).


Findings include:

1. Review of policy/procedure titled, "Incident Reports," PolicyNo.: NR.11, Revised 03/2024; indicated under: Taking Action And Completing The Incident Report: Provider is notified within 1 hour of an incident/injury.

2. Review of Incident Report (IR) on 01/16/25, indicated (P1) was seen trying to open the refrigerator on 1/16/2025 at approximately 12:15 a.m., staff were redirecting P1 from the refrigerator and in the process P1 fell and sustained a skin tear. P1 denied any other injury. The physician was notified of IR at 5:00 a.m.

3. Review of disciplinary action form for A11 (Certified Nurse Aide) regarding their suspension and termination indicated they failed to intervene appropriately and provide a timely intervention with a patient which resulted in a fall. A11 was unable to work until review with an outcome occurred. A11's termination form concluded, A11 was found to be negligent in the care of a patient resulting in the patient hitting the floor and remaining on the floor without assistance while A11 remained in a chair.

4. On 02/05/25 at approximately 4:30 p.m., this surveyor, accompanied by A1 (Chief Executive Officer), viewed video footage of an incident on 01/16/25 at approximately 12:15 a.m. The incident involving P1 indicated they opened the refrigerator located in the milieu and at that point A11 got up from the chair and attempted to get P1 away from the refrigerator. P1 became aggressive, A11 pushed P1 into the wall, and then down to the floor. A11 walked away from P1 and sat back down in the chair.

5. Interview with A1, on 02/05/25 at approximately 2:45 p.m., confirmed they thought A11 was too aggressive with P1 during an incident on 01/16/25.

6. Interview with A12 (Certified Nurse Aide), on 02/06/25 at approximately 11:55 a.m., indicated they were working in a different zone when an incident on 01/16/25 took place. They indicated they observed P1 becoming combative. A12 indicated A11 tried to lower P1 to the floor but P1 fell. A12 indicated another staff member asked them to help get P1 off the floor. A12 indicated they observed P1 bleeding, and the nurse was evaluating them.