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Based on observation, interviews, record review, and review of policies, the hospital failed to protect and promote hospital patients' rights. Immediate Jeopardy was identified related to patient abuse. The Condition of Participation of Patient Rights was found to be out of compliance based on the following findings:

I. The facility failed to ensure patients were free from abuse and harassment. The facility failed to develop and implement policies to ensure hospital staff identified, reported, and investigated allegations of abuse. Immediate Jeopardy was identified regarding freedom from abuse. Refer to A0145.

II. The facility failed to ensure Patient #8 was informed of his/her rights at the time of admission. Refer to A0117

III. The facility failed to provide information to Patient #8 upon admission, regarding how to file a grievance and failed to inform the patient who to contact to file a grievance. Refer to A0118

IV. The facility failed to ensure multiple grievances voiced to staff by Patient #9 were filed and resolved. Refer to A0118

Based on observation, interview, and record review, the hospital failed to inform 1 of 1 inpatients (Patient #8) of his patient rights.

Findings include:

Admission records showed 41 year old Patient #8 was admitted to the hospital on 10/8/19 at 4:30 PM for intravenous antibiotic administration due to osteomyelitis (bone infection). Patient #8 was alert and oriented and signed the inpatient consent at 4:43 PM 10/8/2019.

On 10/9/19 at 2:30 PM, Patient #8 was interviewed about the admission process. Patient #8 said he did not receive a booklet about patient rights and no one talked to him about his rights. Patient #8 said he did not have information on who to contact and was not given a telephone number to call if he needed help or had concerns about his care.

In an interview on 10/9/19 at 2:35 PM, Staff 16 said the hospital provided the booklet on patient rights to the patient at time of admission. Staff 16 said the ADON (Assistant Director of Nursing) or Staff 17 was supposed to provide the information on patient rights to the patient on admission. Staff 16 said it must have been missed.

In an interview on 10/9/19 at 2:35 PM, Staff 17 said she talked to patients about their POAs (power of attorney) and advanced directives. Staff 17 said she goes through the booklet with the patient but she does not fill out the last page information related to "Who can help you." Staff 17 said she goes over the booklet and just tells them if they have concerns or complaints, they can ask the nurse who they should contact. Staff 17 said she did not discuss patient rights with Patient #8.

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Based on interview and record review, the hospital failed to inform Patient #8 who to contact to file a grievance within the hospital and with other agencies. The facility failed to ensure Patient #9's voiced grievances regarding care were filed in the hospital. Patient #9 had repeated unresolved grievances. These failures placed all patients at risk to have unresolved grievances.

Findings include:

The facility's admission department provided a copy of a booklet titled "Understanding Patient Rights". Page three stated the patient had the right to resolve conflict that may arise and directed the patient to "Ask your healthcare provider and/or your patient representative for more information." The last page of the booklet had a fill-in box labeled "Who you can call for help" with headings that included: Your patient representative and telephone number; The ethics consultant/committee and telephone number; and Other sources and telephone number. All fill-in spaces were left blank.

In an interview on 10/9/19 at 2:35 PM, Staff 17 said she was an admitting nurse and she went over paperwork with new patients. Staff 17 said she went over the Patient Rights booklet with the patient about Advance Directives and POA (power of attorney) but she said she did not fill out the "Who Can Help You" section. Staff 17 said she just tells the patient they can contact anyone.

Admission records showed 41 year old Patient #8 was admitted to the hospital on 10/8/19 at 4:30 PM for intravenous antibiotic administration due to osteomyelitis (bone infection). Patient #8 was alert and oriented and signed the inpatient consent at 4:43 PM 10/8/2019.

On 10/9/19 at 2:30 PM, Patient #8 was interviewed about the admission process. Patient #8 said he did not receive a booklet about patient rights. Patient #8 said he was not provided information on who to contact or how to file a grievance. Patient #8 said he was not provided a telephone number to call if he had concerns about his care.

In a progress note dated 5/21/19 as a late entry for 5/14/19, the DON (Director of Nursing ) documented Dr.2 reported concerns voiced by Patient #9 about a couple of staff nurses. Patient #9 told Dr. 2 that her leg was bruised by a nurse. The DON documented she spoke with Patient #9 who stated a couple of the nurses acted like they did not have time and were in a hurry.

An undated and unsigned typed statement by ADON (Assistant DON) documented that ADON and DON spoke to Patient #9 on July 8th. Patient #9 requested assurance Staff 6 would not take care of her anymore. The statement read in part; "Patient #9 said Staff 6 was mean to her, rough with her, yelled at her on numerous occasions, and called her a liar."

A review of the Grievance Log found no entry regarding the allegation made by Patient #9 on 5/14/19 or the grievance voiced by Patient #9 on 7/8/19.

In an interview on 10/9/19 at 9:40 AM, the DON and the ADON said they did not fill out a grievance form for Patient #9 and did not assist Patient #9 to file a grievance regarding the complaints/grievances reported verbally on 5/14/19 and 7/8/19. The DON reviewed the grievance log and confirmed no grievance was filed for Patient #9 for either voiced concern. Refer to A0145 for additional information.

Based on observation, interview, and record review, the hospital failed to implement measures to ensure Patient #9 was free from repeated incidents of abuse/harassment. The hospital did not develop and implement policies and procedures to provide staff information and direction to identify, report, respond to, and investigate allegations of potential or actual abuse. Patient #9 reported allegations of abuse on 5/14/19, 7/8/19, and 8/27/19, but there was no evidence to show actions were taken to protect the patient and to investigate the allegations until 8/30/19. As of 10/9/19, the hospital had not implemented abuse and neglect policies and procedures and had not trained staff to recognize, report, and investigate abuse, neglect and harassment. The findings constituted immediate jeopardy for the ill, injured, and vulnerable adults and children cared for in the hospital, emergency department, and clinics.

Findings include:

Admission records showed Patient #9 was admitted to the hospital inpatient unit on 5/1/19 for care related to end-stage cancer. Patient #9 expired on 9/22/19 in the hospital.

Staff 4 reported he was the Safety Officer and provided a loose leaf binder titled "Grievances" with a four page document Policy ID: 4465790 last approved 05/2018 and with the next review due 05/2019, and a Grievance reporting System (GRS) log. In an interview on 10/8/19 at 9:30 AM, Staff 4 said he was responsible for review and closure of grievances and Webcident reports. Staff 4 said he was to send a letter to the patient to acknowledge receipt of the grievance within 10 days and a close out letter within 30 days.

Staff 4 said Webcident was an online reporting system. Staff could use Webcident to report slips, trips, falls, near misses, blood borne pathogen concerns, and medication errors. Staff 4 said he was notified by e-mail each time a Webcident report was filed. Staff 4 said he reviewed and closed out the Webcident reports.

Staff 4 described the flow in Webcident. Staff 4 said he and Quality Assessment (QA) both got an e-mail when an entry was made in Webcident. Staff 4 said he "Checked to see where it falls, meaning "significant or non-significant". Staff 4 said he reviewed significant reports right away. When asked if QA reviewed grievances and Webcident, he said "Sometimes".

The Webcident instruction poster indicated Webcident was an electronic incident reporting system that could be used by all personnel working for IHS at any IHS-affiliated facility for *collecting and maintaining occupational injury and illness data, visitor injury data and patient safety error and adverse event data *reporting security events, property damage, and hazardous conditions *Conducting trend analysis and producing reports. Once submitted, the Webcident is reviewed by the Risk Manager/Safety Officer and Department Supervisor. Based on the type of incident, the team will use the information to help ensure that a similar safety event will not occur in the future.

Staff 4 demonstrated how to enter an incident into Webcident. It was observed that there was no category to check for abuse. Staff 4 said there was a check box for 'other' but then the employee would have to explain the circumstances.

In a progress note dated 5/21/19 as a late entry for 5/14/19, the DON (Director of Nursing ) documented Dr. 2 reported concerns voiced by Patient #9 about a couple of staff nurses. Patient #9 told Dr. 2 that her leg was bruised by a nurse. The DON documented she spoke with Patient #9 who stated a couple of the nurses acted like they did not have time and were in a hurry. The DON said she told Patient #9 she would talk to the nurses and Patient #9 responded that she did not want to cause trouble. The DON documented she did not find a bruise, only a mark on the skin in the area of the urinary catheter. Dr. 2 wrote in a progress note on 5/14/19 that Patient #9 was feeling down and was tearful stating she felt unwanted here at times and felt like she was a burden to us.

In an interview on 10/9/19 at 9:40 AM, the DON confirmed she examined Patient #9 and found no bruise. The DON said the two nurses (Staff 6 and Staff 7) who gave care to Patient #9 on 5/14/19 both said they did not feel that they were mean or aggressive in any way. The DON said she documented the patient exam in the medical record.

When asked about documentation of the discussion with Staff 6 and Staff 7, the DON said she documented such conversations with staff in her DON calendar book. The DON checked her calendar and said she documented the date but not the content of the conversation. The DON stated, "I should have documented this as a corrective talk, but I did not." The DON explained for a 'corrective talk' she typed a note and put it in her DON file cabinet. The DON said "If it turned into a reprimand, then the note would go in the personnel file and she would send the information to risk management or QA".

The DON said she did not fill out a grievance form, did not assist Patient #9 to complete a grievance form, and did not make an entry into Webcident regarding the allegations made by Patient #9 on 7/8/19.

An undated and unsigned typed statement by the ADON (assistant DON) documented that ADON and DON spoke to Patient #9 on July 8th. Patient #9 requested assurance Staff 6 would not take care of her anymore. The statement read in part; "Patient #9 said Staff 6 was mean to her, rough with her, yelled at her on numerous occasions, and called her a liar."

The ADON said she did not fill out a grievance form, did not assist Patient #9 to file a grievance, and did not make an entry in Webcident regarding Patient #9's 7/9/19 allegations.

A statement dated 8/30/19 and signed by the DON indicated on July 8, 2019 at 7:30 AM, Patient #9 requested she not have Staff 6 as her nurse anymore. Patient #9 said Staff 6 was her nurse all weekend and was mean, treated her like she was a burden, and acted like she didn't have time for her.

The DON said Patient #9 was frustrated with Staff 6 so she (DON) "pulled out the patient's rights and made everyone in-house do training on patient rights." The DON said she offered EAP (Employee Assistance Program) to Staff 6 and they discussed overtime work. The DON documented that Staff 6 was informed of Patient #9's concerns and was reminded of patient rights. Staff 6 denied that she was mean to Patient #9. The DON wrote that Staff 6 verbalized understanding when the DON stated "you are not allowed in patient's room alone." The DON said she told Staff 6 she could only be in Patient #9's room to assist another nurse when requested by the other nurse.

When asked if the hospital staffing could support having Staff 6 not provide care to Patient #9 who was at times the only inpatient in the hospital, the DON said the nurses were all in an uproar and texted her asking "How will this work, how can it be that she (Staff 6) will not do inpatient?", but the DON said the hospital had adequate staff to manage.

The DON said she did not fill out a grievance form for Patient #9, did not assist the patient to file a grievance, and did not make an entry in Webcident regarding the allegations Patient #9 reported on 7/8/19.

The DON was asked if there were any other incidents involving Patient #9 and Staff 6. The DON said on 8/14/19 she discovered Staff 6 was going to provide care to Patient #9 after she had been directed that she was not to provide Patient #9's care.

The DON referred to a DON 'calendar note' dated 8/14/19 that indicated the DON called Staff 6 to her office to discuss the directive that Staff 6 not provide care for Patient #9. The DON explained on 8/14/19 she observed no nurse on the inpatient unit and three RNs Staff 6, Staff 8, and Staff 11 at the ER (emergency room). The DON asked which nurse would be assigned to inpatient care and Staff 6 said she was. DON said she responded "absolutely not". The DON said she then asked Patient #9 if she wanted Staff 6 to provide care and Patient #9 confirmed she still did not want Staff 6 to care for her. The DON said she told Staff 6 "no" and told Staff 8 to do inpatient care.

When asked what she did to address Staff 6's apparent disregard of her instruction to not provide care to Patient #9, the DON said she and the ADON called Staff 6 into her office and talked with her. The DON said Staff 6 responded "I know, I know, but no one else liked to take care of her (Patient #9)." The DON said she had the pastor come in and talk with the staff because Patient #9 had a lot of needs, she had cancer and was dying. The DON confirmed no change was made to Patient #9's plan of care.

When asked how the hospital handled concerns with staff performance, the DON said if there was some question with staff performance, she opened an ER\LR (employee relation\labor relation) report. The DON said she did not open an ER\LR in this case because she did not think the patient statement; "Always makes me feel rushed, makes me feel like a burden" warranted it. The DON said she knew Staff 6 for several years and did not believe any of the nurses would be abusive to any patient.

The DON said she did not fill out a grievance form for Patient #9, did not assist Patient #9 to file a grievance, and did not make an entry in Webcident.

Review of the grievance log revealed no entries regarding the allegation made by Patient #9 on 5/14/19 or the grievance voiced by Patient #9 on 7/8/19. The log listed a grievance on 8/23/19 for Patient #5 regarding care the ED (Emergency Department) involving Staff 6. A grievance for Patient #6 on 8/26/19 regarding care in the ED involving Staff 6. A grievance for Patient #9 on 8/29/19 listed as care inpatient involving Staff 6. A grievance entered 9/5/19 by Dr. 2 indicating an ED patient left due to Staff 6.

A grievance report dated 8/28/19 asked the question; Does your grievance involve patients, staff, or an interaction between patients and staff? Staff was checked and Staff 6 was named as "the person this grievance involves". The grievance form directed to check the option(s) which best provide a general description of the grievance reported and choices included physical assault, and verbal abuse. Other was selected with an entry "alleged hit by nurse"'. The grievance form directed: please provide some guidance on what corrective action you would recommend to SRSU for resolution of this grievance. The recommended solution: "Staff 6 not be allowed to be my nurse", and "Staff 6 not to enter my room alone." The grievance form was signed by the DON for patient #9.

A Webcident Report noted date of incident as 8/27/18 at 11:00 AM and the report was filed 8/28/19 at 3:10 PM involving Patient #9, occurred in patient room. Description of the incident "Patient stated on 8/27/19 around 11:00 AM I put my call light on, Staff 6 came into my room and asked what I needed. I asked Staff 6: "where is my nurse?" and Staff 6 stated: "she's helping the other patient." I then tell Staff 6 my back hurts and asked to be turned. Staff 6 turned me and I felt like I got hit and it felt like her fist was being twisted into my back. I asked her to stop, she wouldn't stop per patient. The Webcident report suggested Prevention of the Incident: Staff 6 not entering patient's room and noted no injuries and/or illness documented.

The Grievance Reporting Form and the Webcident both identified a preventive measure (staff 6 not to enter Patient #9's room) that was already in place and was demonstrated to be ineffective to protect Patient #9.

A Behavioral Health Therapy Note written by Dr. 1 indicated Dr. 1 saw Patient #9 on 8/28/19. Dr. 1 wrote; during the session, DON entered to discuss an incident from the day prior. Patient #9 verbally authorized Dr. 1 to remain in the room. Patient #9 indicated she was "hit" in the back by a shift nurse, when the nurse was assisting her to shift her position in bed. DON took notes and informed her she would turn the report in to the Safety Officer. Patient #9 concurred. Dr. 1 documented Patient #9 was well oriented to person, place, and circumstances. Her memory appeared intact and she appeared competent to make decisions involving her medical care. She was alert. Judgment is fair. Insight was fair, as she is aware of problems, consequences, and causes. Attention and concentration was appropriate and focused.

Staff 12 wrote a statement dated 9/5/19 indicating at the beginning of the evening shift on 8/27/19, Patient #9 was upset and yelling stating "I need you to be my witness. Staff 6 punched me." Staff 12 cautioned the patient that was a big accusation to make and asked her if she was sure. Patient #9 responded that she was sure and wanted to talk to DON right now. Staff 12's statement indicated during shift report, Staff 10 reported she requested Staff 6 assist with Patient #9 and stated she (Staff 10) stood outside the room the entire time. Staff 12 contacted DON and as directed, assessed the skin on Patient 9's back to find no redness, irritation, or trauma. Staff 12 asked Patient #9 again later what happened and she continued to say, "She punched me."

Dr. 2 wrote a statement dated 8/29/19 indicating Patient #9 reported that Staff 6 came in to help and became upset with her (patient 9) for how she spoke to Staff 10. Patient #9 reported they were alone in the room and Staff 6 unnecessarily grinded the pillow into her low back which caused pain. This caused her to yell out. She (Patient# 9) stated that she does not feel safe with Staff 6 as her nurse.

On a typed statement dated 8/27/19, Staff 10 documented Staff 10 provided care for Patient #9 and at 4:45 PM requested assistance of Staff 13. However, Staff 6 responded to assist her (Staff 10) with care and then left the patient room. Staff 10 indicated the patient became agitated and ordered her out of the room stating "leave this room and don't come back in here again tonight." Staff 10 wrote that she informed Staff 6 of the patient statement so Staff 6 answered patient's call at 5:00 PM. Staff 10 wrote "I followed Staff 6 but stood outside door because I wasn't allowed back in the room, I heard a loud voice but didn't know where or who it came from. I had full view of Staff 6 and did not see anything happen. Staff 6 came out and said she's asking for you. Staff 6 said: "I told her (Patient #9) well you kicked her out." Staff 10's statement indicated at 6:37 PM she went into Patient #9's room and she (Patient #9) started apologizing saying she was so sorry.

Review of a typed one-page document: Observation of Patient #9's conversation with her doctor; dated 8/29/19 at 3:40 PM and signed by Staff 5 indicated Staff 5 observed and recorded a conversation between Patient #9 and her doctor regarding the allegation that Staff 6 hit Patient #9 on 8/27/19. Patient #9 stated after she received care, Staff 6 came back into her room on 8/27/19 and made the statement "We are understaffed and need two people to care for her" and "Gee I wish you wouldn't be treating the nurses like this." Patient #9 said she asked Staff 6 "How am I treating the nurses?" then Staff 6 left the room. Patient #9 said she lay in the same position for more than an hour and wanted to move and Staff 6 was the nurse who came back into the room by herself. Patient #9 said she asked for Staff 10 and reported Staff 6's response was "Why would she be coming back in here after you treated her like that?" Patient #9 said she tried to turn to her side. Staff 6 grabbed a pillow and grinded it into her back. Patient #9 made a closed hand and turning motion with her hand when she explained. Patient #9 said she told Staff 6 to stop and asked her "Why are you doing that?" Patient #9 said Staff 6 responded "Why not, look at how you made Staff 10 feel and had a smirk on her face." Patient #9 said she put her light on again and Staff 6 came into her room and asked her "What do you want and why are you doing that?" Patient #9 said she told Staff 6 she was trying to apologize to her. Patient #9 reported Staff 6 made her feel bad and she was in the room by herself when Staff 6 was in the room. Patient #9 said she was afraid to ask for things such as a wash. She said she had never been treated like that verbally before when she was a patient in the hospital. Patient #9 said she did not feel safe with Staff 6 as her nurse.

Staff 6 wrote an e-mail to the Safety Officer dated 9/6/19. Staff 6 indicated she was asked to assist Patient #9 by Staff 10. Staff 6 indicated she and Staff 10 proceeded to the patient room. Staff 6 went in the room to assist Patient #9 and Staff 10 remained by the door and was in line of sight for both Staff 6 and the patient. Staff 6 wrote that as she was turning Patient #9 she started to say, Stop, Ouch" so she (Staff 6) stopped what she was doing immediately. Staff 6 wrote that she did not know what the complaint consisted of but the only thing he did was to help her turn. Staff 6 wrote "I never put my hands on her in a malicious manner. All this was witnessed by Staff 10 as she was standing at the door and had a clear view of me interacting with the patient."

On 9/10/19 Staff 10 provided information that was not consistent with prior statements when she wrote that she did not recall the time she heard the yell or loud noise she thought came from the patient's (Patient #9) room so she ran to see and Staff 6 was in the room with Patient #9. Staff 10 wrote that she did not see anything and was not sure where the sound even came from. Staff 10's statement indicated when Staff 6 came out of her room she stated "she wants you back in the room" and also stated she told the patient "well you kicked her out." Staff 10's statement noted the call light rang, so she went into the room and Patient #9 apologized stating "I'm sorry, I'm really sorry for doing that."

A written statement dated 8/30/19 at 2:00 PM, documented the DON informed acting CEO Staff 14 about Patient #9's allegations. Staff 14 directed the DON to fill out a grievance form, enter incident in track-it, and file an ER/LR. DON filled out the grievance form and read it back to Patient #9 who concurred and DON submitted Webcident. DON wrote that she submitted the grievance form to Staff 4 on 8/29/19 and submitted an ER/LR on 8/29/19. On 8/29/9 DON sought guidance from the Area Nurse Consultant who informed DON to contact Board of Nursing, OIG (Office of Attorney General) and submit an ER/LR for immediate investigative leave which were completed on 8/29/19. A report was made to the local police.

During an interview on 10/9/19 at 8:30 AM, Staff 5 stated she was responsible for coordination of QAPI (Quality Assessment and Performance Improvement) and for investigation of risk management and quality complaints and grievances. Staff 5 stated the ED (Emergency Department) manager, Dr. 2, was responsible for quality and complaints in the ED. Staff 5 said they worked closely together and spoke daily.

Staff 5 stated she recalled an allegation regarding Patient #9 reported by Dr. 2 on 5/14/19. Staff 5 said she was out of town at the time so she telephoned DON and Dr. 2 and told them the complaint needed to be followed up on to see if there was a bruise as alleged by Patient #9. Staff 5 said the patient had no bruise and after she talked with the patient she (Staff 5) said it was OK; so no further investigation was conducted. Staff 1 added, "But it was not OK". Staff 1 also noted a patient could be hurt or abused even if there were no physical signs such as a bruise. Staff 1 said a verbal complaint was a grievance and should be thoroughly investigated to rule out abuse and to track and trend.

When asked about investigations regarding allegations made by Patient #9 on 7/8/19 about rough handling and the 8/14/19 DON finding that Staff 6 did not comply with directives put in place regarding care of Patient #9; Staff 5 said she did not investigate because she was not notified until statements were submitted 8/30/19 during the course of the current ongoing investigation. Staff 5 stated she would have identified abuse if she had received the 7/8/19 statement timely.

The hospital had multiple forms of documentation for patient complaints and staff issues. Examples included; DON calendar entries, DON corrective action file, reprimands, ER\LR reports, grievance reports and grievance log, and Webcident. These documents and forms were not integrated into one system and there was no way for staff to cross reference them. This created confusion and contributed to the information not made available to QA and /or Safety Officer in a timely manner. Dr. 2 said the Webcident system was not adequate for reporting patient grievances and potential abuse.

Regarding the investigation into the allegation that Staff 6 hit Patient #9, Staff 5 said it was a very difficult investigation. Staff 5 confirmed during the course of the investigation, staff gave false statements and staff were not cooperative with the investigation. Staff 5 said "Staff were not talking." Staff 5 said the hospital had video that showed inconsistencies with staff statements. Staff 5 said the first time she saw the video "there were red flags all over." Staff 5 said the video showed Staff 6 was in Patient #9's room alone several times and Staff 10 did not have Staff 6 or Patient #9 in her line of sight as indicated in statements. When confronted with the video evidence, staff said they could not remember anything.

On 10/9/19 from 11:30 AM to 12:00 PM, a video tape (no audio) of the nursing station and inpatient unit was viewed by hospital administrative staff and surveyors. The tape viewed covered the time period before and after Patient #9 made the allegation on 8/27/19. The video showed Staff 6 walked from the nurse's station to Patient #9's room. Her posture was stiff and her gait was rapid, purposeful, and suggestive of anger and it appeared as if she "stomped" down the hall. Staff 6 entered patient #9's room alone and Staff 10 did not follow to stand at the door as she wrote in her statement. Staff 10 and a housekeeper Staff 17 stood and talked at the nurse station. Staff 6 and Patient #9 were not in her line of sight. Staff 10 appeared anxious and paced in front of the nurse station. At one point Staff 10 and Staff 17 simultaneously turned their heads abruptly and looked toward Patient #9's room. Staff 10 moved closer to the room but stayed in the corridor and Staff 17 entered the empty room next door to Patient #9's room.

Following the video viewing, Staff 1 said something definitely happened. Staff 1 confirmed staff were not talking about it. Staff 1 said even shortly after the incident, nurses denied knowledge and said they could not remember what happened. Staff 1 said "Nursing is a very tight group and would not speak about another nurse even after made aware of the video evidence. Staff 5 said she did not know what to do because this had never happened before. Staff 5 said she just could not believe that something like this could happen. Staff 5 said the hospital sought guidance from IHS.

Staff 5 confirmed the alleged incident (patient alleged Staff 6 hit her) occurred on 8/27/19 and Staff 6 continued to work with patients on August 27, 28, and 29.

Staff 5 said "The last straw happened when Staff 6 was in the room asking the patient and staff for statements and seeking support for herself. Staff 6 asked Staff to make late or amended entries in Patient #9's medical record. Staff 5 said it was very disturbing to the hospital so at that point she sought permission from IHS to suspend Staff 6. Staff 5 said Staff 6 was officially placed on leave at 5:25 PM on 8/29/19 and was not allowed to complete her shift.

Staff 1 said she is the CEO (Chief Executive Officer) and there have been no abuse allegations, no sexual, and no physical abuse, only a few patient-to employee since she started in January 2015 except for the current ongoing investigation. Staff 1 said things were discussed in morning report like transfers and clinical issues. Staff 1 said the quality person, Staff 5 attended and they met as QA after the regular morning meeting if needed. Staff 1 said the concerns with Staff 6 should have been identified for investigation by this group.

The DON said she has been the DON at the hospital since 2013 and has never had training on abuse of inpatients by staff. The DON said when the allegation of abuse came up she "had no idea what to do." The DON said the hospital had no policy and procedures to direct what to do. The DON said she had to call the nurse consultant for direction.

The ADON said abuse never came up in her tenure at the hospital, no patient-to-patient or staff-to-patient abuse. The ADON said she did not know how to proceed when Patient #9 alleged Staff 6 hit her. The ADON said the hospital provided training to staff on what to do if someone from the community presented to the ED or hospital with signs of abuse. The ADON said all IHS employees are mandatory reporters. The ADON said in the last few months there was a big push within IHS to report abuse. The ADON said the hospital did training on abuse for all staff.

The ADON provided the abuse training for review. Review found the training materials focused on what to do if someone from the community, especially a child, presented to the ED or admitted to the hospital with signs of abuse. The training covered identification and reporting of abuse that occurred in the community. The training was titled "Protecting Children from Sexual Abuse in Health Care Settings-Supporting a Culture of Community Safety. The training did not address patient to patient abuse or staff to patient abuse in the hospital.

The ADON explained that the hospital utilized online programming for staff training. She said some programs in the system were updated but some were quite old. The ADON said very few staff completed the mandatory abuse training in 2018 and she had not yet, as of 10/9/19, sent out the list of mandatory online training for 2019.

The ADON said in response to the allegations, she put out articles in August 2019 for staff to read and sign that they read them. The ADON said the staff were not cooperative, the articles disappeared from the nurse station, and she had to re-issue them on 9/3/19. An email dated 9/13/19 from the ADON to nursing staff again directing nursing staff to complete the training.

An e-mail dated 8/8/19 subject: etiquette from the ADON to the nursing staff read in part: "It has come to our attention that the work environment has become an unhealthy environment at times. Unhealthy work environments can affect patient care and outcomes. Please read attached documents and ensure you fully understand their contents. Any repeated negative behavior that affects patient care or patient outcomes may be reprimanded.

The articles were reviewed and included a four-page article from Nursing 2017 "Nurse-To-Patient It's more than good manners. The article discussed professionalism including professional appearance, smiling and avoiding body language that conveys impatience, boredom, or annoyance. Followed by a 14 question test. An article titled "Business Etiquette: focused on office and employee to employee interactions in a business office. The articles did not discuss verbal abuse, threats, intimidation, harassment, or physical abuse recognition and reporting, or staff to patient abuse.

In a meeting on 10/10/19, when asked about the grievances regarding Staff 6 and Patients #5, #6, and #7, Staff 5 said the grievances were not abuse. Staff 5 explained that Staff 6 was handing out urine cups during triage for drug testing without a physician order or medical reason. Staff 5 agreed this issue involved patient rights and professional standards. Staff 5 stated a work order for an ER\LR report was submitted 8/29/19 that indicated "Staff 6 was given a directive to not have contact with Patient #9 per patient's request and Staff 6 disobeyed directive. And Staff 6 was given a written memo to not hand out urine cups in ER during triage. Nurse handed cups out prior to triage."

Hospital systemic failures including: no policies and procedures to ensure prevention, identification, thorough investigation, and timely reporting of potential staff to patient abuse; lack of training program for management and nursing staff regarding staff to patient abuse; no integration of multiple means of documentation of patient grievances including allegations of abuse; and lack of staff cooperation with potential abuse investigations led to failure to recognize escalation of abusive staff behavior with repeated staff to patient abuse allegations, lack of thorough and timely documentation and investigation of patient grievances and allegation of abuse contributed to conditions of immediate jeopardy and placed all patients at risk for physical, emotional, or psychological injury related to abuse.

Refer to A0283 for information related to fear of retaliation.

The hospital CEO, DON, and IHS officials were notified of the determination of immediate jeopardy on 10/9/19 at 6:10 PM.

On 10/10/19 at 9:30 AM the hospital management staff presented a detailed plan to remove the immediacy. Surveyor reviewed facility documentation which included new policies and mandatory training provided to all hospital staff prior to providing patient care. Interviews conducted with management and patient care staff showed evidence of training and understanding of the new policies and expectations with regard to patient abuse prevention, recognition, reporting, and investigation. The implementation of the hospital immediacy removal plan was validated.

The hospital CEO, DON, and IHS officials were notified of the removal of immediacy on 10/10/19 at 11:15 AM.

Based on interview, document review, review of facility policy, and review of the facility's Quality Assurance and Performance Improvement (QAPI) program, the facility failed to develop an action plan in response to reports by staff' that the fear of retaliation and harassment from co-workers was a barrier to reporting potential abuse by co-workers.

Findings include:

Review of the facility's, "Root Cause Analysis and Action Plan Framework Template" completed by Staff 3, dated 08/29/19 revealed, "The following framework is intended to provide a template for answering the analysis questions and aid organizing the steps in a root cause analysis. Plan of action should be answered 'Yes' for any finding that can reasonably be considered for a risk reduction strategy. Each item checked in this column should be addressed later in the action plan."

Further review of the document revealed under the section titled, "Detailed Event Description" Staff 3 documented, "Patient in room [number] reports nurse [name] hit [his/her] on [his/her] back when turning [him/her]. Nurse was alone in the room. Nurse [name] was not to provide care to the patient per previous agreement between patient, nurse, and DON [Director of Nurses]. Incident was reported to the night supervisor [name], who notified the DON [name]." Under the section titled, "Analysis," in response to "Question #20" regarding the presence of any barriers to communication among caregivers identified by the organization, and the measures being taken to break down those barriers, the documentation revealed, "There is some fear of retaliation by co-workers for reporting co-workers. Some staff worry about harassment by co-workers if [they] report." Review of the section titled, "Organization Plan of Action Risk Reduction Strategies" revealed the following "Action Items" were documented, "Action Item #1: Follow reporting rules for hospitals on allegations of Patient Rights and Abuse form 8/27/2019. Action Item #2: Nursing staff to use buddy system (two staff in room) when caring for patient. Action Item #3: Follow up on Nursing Home applications and status on waiting list." The facility failed to identify the communication barrier caused by the staffs' fear of retaliation by other staff as a barrier to reporting incidents of abuse as an action item that required a plan of action to reduce the risk of patient abuse.

During an interview on 10/09/19 at 1:10 PM, Staff 3 said he/she was notified of Patient 9's allegations of staff abuse on 08/29/19, and he/she then asked for all documents and conversations with the staff. When Staff 3 read all the statements, he/she stated the Office of Inspector General was notified. Staff 3 said the allegations raised a "Red flag" and a "Root Cause Analysis and Action Plan Framework Template" was initiated. During the process of completing the root cause analysis, staff reported being afraid to report co-workers of alleged abuse due to a fear of retaliation and harassment. Staff 3 said an action plan for the fear of retaliation was not implemented because there was only one staff member involved. Staff 3 said the facility provides education on safety culture and thought that was enough.

During an interview on 10/09/19 at 2:00 PM, Staff 1 said he/she was aware of Patient 9's alleged abuse and his/her responsibility was to ensure the hospital reported the incident to the appropriate agencies.

Review of the "Standing Rock Service Unit Quality Assessment and Performance Improvement Program" last reviewed 12/2018 documented, "The Chief Executive Officer assists in identifying performance measures. . . . The QAPI Committee membership includes these key members: QAPI Manager, Chief Executive Officer, and Director of Nursing. . . . For the purposes listed above, the QAPI Committee will select key performance measures and projects. . . . The QA/PI [sic] program shall meet the intent of the standards of improving organizational performance as stated in the CMS [Centers for Medicare and Medicaid] conditions of participation and independent accreditation standards including, but not limited to: To recognize and minimize the potential for patient harm and clinical error and to ensure high quality care is provided in a safe responsible manner. . . . The activity documentation should include: a. Planning- A summary of the performance improvement activity conducted. b. Analysis- An interim result of data collection and recommendations. c. Change/Action- The final reporting of data, graphic displays and improvement made. d. Evaluation and Follow up- Completed by the QAPI Committee which documents the review and approval of the performance improvement activity and determines the need for follow up."