William R Sharpe, Jr Hospital

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50550 Based on document reviews, medical record review, and staff interviews, it was determined the facility failed their policies and procedures for zone monitoring and by not notifying the provider of a change of condition for four (4) out of ten (10) patients, Patient #1, 2, 3, and 4. This failure has the potential to negatively affect all patients receiving care from the facility. Findings include: The policy was reviewed titled “Unit Zone Monitoring” effective 4/5/24. The policy states, in part, “Policy Statement: Non-Suicidal Zone Monitor observations are utilized to enhance observation of patients within a specific area of the unit. Purpose of Policy: To provide unit safety, patient support, and monitor patient behaviors across all areas of the unit. Procedures: ... 4. Zone Monitor Assignment ...c. Zone Monitors will provide general observation and interaction with patients in their assigned areas. d. Zone Monitor is to be walking throughout the zone, monitoring patients, patient interactions, as well as interacting with patients ...g. Zone Monitors will assist with support calls in their area and aid in their neighboring zone until additional support arrives to relieve them. Once relieved, Zone Monitor will return to the assigned area.” An observation of the videos was conducted on 11/18/24. Video #1 dated 11/11/24, start time at 7:42:36 p.m. At 7:46:15 p.m. Staff #9 (assigned to Zone 1 watcher per assignment) was sitting watching the hallway, then moved away from the zone into the nurse’s station to get hygiene supplies for a Patient. At 7:46:52 p.m. Patients alert staff about an incident in Staff #9’s zone. An interview was conducted on November 19, 2024, at 7:42 a.m., with Staff #7. Staff #7 stated, “I was in Zone 2. [Patient #1] was walking towards me saying you’re dead, pointing [their] finger at me. I was talking to [them] when [Patient #4] came up and put [Patient #1] in a chokehold. I separated them and [they] walked away. About fifteen (15) to twenty (20) minutes later I heard yelling and found [Patient #1] on the floor. [Patient #4] was kicking [them] in the gut. I pulled Patient #4 away. As soon as we got hold of [Patient #4], [they] stopped and walked away. [Staff #13] was there. [Staff #6] was the first nurse down there. I don’t remember who was in Zone 2. The second time, I was really surprised that [Patient #4] did that. In the zone, you don’t walk away from the zone. We monitor two (2) zones, and we switch zones watching every hour.” A phone interview was conducted with Staff #9 on 11/19/24 at Staff #9 states, “I briefly remember, another Patient was agitated, making noise, I was getting shower stuff for another patient, one of the staff asked me for the shower stuff for a Patient, this Patient was on one on one (1:1). In some circumstances we leave the zone, we aren’t supposed to; I don’t remember if another staff member was at the nursing station. Afterwards, nobody talked to me about the incident on 11/11/24, no nurse manager, nobody at all.” Failure to notify the provider: A review of the policy titled “Incident Reporting and Review” effective date 08/26/24. The policy states, in part, “...Procedure: 1. Reporting Patient Incidents: The Charge Nurse must assure that the attending provider or designee has been notified, family contacts have been made, Progress Notes completed, and the Incident Report form is accurately completed and signed ... 4. Rules to Remember: All sections of the report must be completed ...Do not place the report in the patient ’ s medical record. Document a complete description of the incident in the progress notes. Do not use a co-patient name or patient medical record number in the patient’s chart.” A medical record review was conducted for Patient #1. The patient was admitted to the facility on 10/09/2022. A “Behavior Note” 11/11/24 at 9:24 a.m. states, “[Patient #1] was in the breakfast line with peer. [Patient #1] was “in his peer space”. [Patient #1] allegedly would not leave peer alone and was pushing them in line. [Patient #1] was struck by a peer in the face, and they quickly separated. De-escalated by staff. Patients remained separated until after breakfast. No injuries on physical assessment. Slight redness on [Patient #1]’s cheek.” A review of a document titled “Addendum Status Completed” 11/11/24 at 5:40 p.m. states, “[Patient #1] and this same peer had another altercation this evening around 1600 [4:00 p.m.] They were both between the quiet room and the day area talking back and forth. Allegedly [Patient #1] had provoked [his/her] peer repeatedly all day and had threatened [him/her]. [Patient #1] had been having altercations with staff and had threatened staff all day as well. This peer struck [Patient #1] in the day room. No injuries present on either patient. Physical assessment WNL (with normal limits). Patients separated and deescalated successfully.” May it be noted, there was no documentation in the medical record a provider was notified after the above incidents. A medical record was reviewed for Patient #2. Patient #2 was admitted on 08/24/24 to George (G) two (2) then transferred to Nancy (N) one (1) on 09/15/24. Patient #2’s ninth (9th) admission to the facility, eloped from [other facility], with history of violence and diagnoses: Bipolar II disorder/Autistic disorder/ borderline personality disorder. A “Behavior Note” 11/11/24 at 7:09 p.m. states, in part, “At approximately 1600 (4:00 p.m.) this patient was standing in quiet room talking to two (2) [states gender] peers [states gender] peer #1, [states gender] peer #2, staff observed these patients talking for approximately 10 (ten) minutes, then a [gender] health service worker (HSW) observed this patient strike [states gender] peer #1, [states gender] peer #1 was observed stumbling backwards, and exited from quiet room. Where another [states gender] peer [states gender] peer #4 that was sitting in day area struck the [gender] peer #1. This patient came out of quiet room and began yelling at staff telling them about [states gender] peer #1 ‘get this [expletive] person off this unit, they aren’t safe, and I will [expletive] them up’ this patient was asked to step away from the situation, staff attempted to verbally de-escalate but this patient continued being verbally aggressive and threatening. No injuries were observed, on-call provider notified.” May it be noted, there was no documentation in the medical record which provider was contacted, or if a response was received. A medical record review was conducted for Patient #3. The Patient was transferred to the facility on 11/08/24 after a probable cause for being a harm to themself and/or others, rambling speech, and aggressive behaviors. The Patient was diagnosed with Bipolar Disorder (with psychotic features) and admitted to the facility on unit Nancy One (N1). On 11/11/24 at 8:38 a.m., a “Behavior Note” by Staff #3 states, “[Patient #3] was in the breakfast line with peer. Peer was in ’[his/her] space’. This peer in particular has been in multiple altercations in the past couple of days. Peer allegedly would not leave [Patient #3] alone, and was pushing [him/her] in line. [Patient #3] struck peer in the face and they were quickly separated. De-escalated by staff. Patients remain separated until after breakfast.” On 11/11/24 at 5:31 p.m., a “Behavior Note” by Staff #3 states, “[Patient #3] and the same peer had another altercation this evening around 1600 (4:00 p.m.). They were both between the quiet room and the day area talking back and forth. Allegedly [his/her] peer had provoked [him/her] repeatedly all day and had threatened [him/her]. This particular peer had been having altercations with staff and had threatened staff all day as well. [Patient #3] struck this peer in the day room. No injuries present on either patient. Physical assessment WNL. Patient separated and de-escalated successfully.” May it be noted, there is no documentation in the Patient’s medical record that the provider was notified of the above incidents. A medical record review was completed on 11/18/24, for Patient #4. Patient #4 was admitted on September 18, 2024, as a probable forensic cause (PFC) commitment. The Patient has a diagnosis of Intellectual Disability Disorder (IDD) and Attention Deficient Hyperactivity Disorder (ADHD). Patient #4 was admitted to the (Nancy) N-1 unit. A video review was completed on 11/9/24, of an incident that took place with Patient #4 and Patient #1, on November 11, 2024, at 7:43 p.m. on the N1 unit. The video revealed that the Patient entered the right side of the day area, where Patient #1 was standing. Patient #4 immediately came up behind the Patient #1 and got the patient in a choke hold. Staff #3 and Staff #7 were able to separate the two (2) patients. A video review was completed on 11/19/24, of the hallway in the N1 unit for the day of November 11, 2024. The video showed that at 7:48 p.m. on November 11, 2024, three minutes after the initial altercation with Patient #1. Patient #1 was walking down the hall, when Patient #4 approached the patient and was hitting the patient. Patient #1 went down to the floor and Patient #4 began stomping on them. Patient #4 was stopped when staff arrived and escorted back down the hall. May it be noted, there is no documentation in the Patient’s medical record of the above incidents. An interview was conducted with Staff #8 on 11/19/24 at 8:25 a.m. Staff #8 states, in part, “I was on call on 11/11/24. I was told [Patient #1] was attacked by another patient, other peer had [Patient #1] in a choke hold, then the Patient was kicked and stomped on. I came to the unit and saw [Patient #1]...This was the only call I received regarding this patient that day. [Patient #4] immediately was put on two to 1 (2:1) did not ask me about moving [him/her] out of the unit.” An interview was conducted with Staff #2 on 11/19/24 at 9:50 a.m. Regarding notification of the provider for incidents on 11/11/24 involving Patient #1, Patient #2, and Patient #4, Staff #2 states, “I know I talked to the provider three (3) or four (4) times that day. After the 4:00 p.m. incident with [Patient #1] and [Patient #2], I called the provider and left a message. I don’t remember who the zone watchers were at shift change, but I do know there wasn’t any more assigned after the incident with [Patient #1] around 8:00 p.m.” An interview was conducted with Staff #3 on 11/19/24 at 10:13 a.m. Regarding notification of the provider for incidents on 11/11/24 involving Patient #1 and Patient #3, Staff #2 states, “I don’t remember how I contacted the provider or what they said. I would continue to call if the provider didn’t call back if it was urgent. I wouldn’t consider either incident that day urgent. I don’t send text messages to the provider; I would call them directly or leave a message.” An interview was conducted with Staff #12 on 11/19/24 at 9:33 a.m. Regarding notification of providers, Staff #12 states, “There would be no way of knowing if the provider is notified unless it would be on the NCC log, the switchboard log, or documented by nursing.” An interview was conducted with Staff #10 at 11:25 a.m. Regarding telephone logs, Staff #10 explained there was no log from the switchboard for 11/11/24 from unit N1 to be transferred to the provider on call. An interview was conducted with Staff #11 on 11/19/24 at 11:40 a.m. Regarding the day of 11/11/24, Staff #11 states, “During that day we got the Patient-to-Patient incident reports. We had gotten a few. The unit called us at one (1) point and told us that [Patient #1] was in [Patient #4]’s face and getting in [his/her] perimeter. This was an ongoing situation from the weekend. I would not know if the unit called the doctor. Unless the Patient needs a PRN (as needed medication), or needs immediate attention, they may not call the doctor. It depends on who the nurse is, if they called, I would’ve called. I would like to know the game plan for the Patient if [he/she] has any behaviors. I didn’t witness any of the behavior. If it was just antagonizing other patients, I would not necessarily call, but if it started getting out of control I would.””

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 46199 Based on observations, review of medical records (MR) and facility documents, and interviews with staff (EMP), it was determined that the nursing services was not provided in accordance with acceptable standards of practice as evidence by failing to ensure that controlled medications were monitored and administered to prevent drug diversion (A0405). Cross Reference: §482.23(c) Standard: Preparation and Administration of Drugs”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 46199 Based on observations, review of medical records (MR) and facility documents, and interviews with staff (EMP), it was determined that controlled medications were not monitored and administered to prevent drug diversion for six out of 14 medical records (MR1, MR2, MR3, MR10, and MR12). Findings include: A review of facility policy, “Safe Use of Opioids in the Hospital,” effective June 1, 2022, revealed “ ... Monitoring should be individualized for each patient based on his or her response to medications.” A review of “Medication Guide” for Suboxone, a controlled sublingual medication used to treat opiate addition, revised June 2022, revealed “ ... Suboxone may cause serious and life-threatening breathing problems. ... Do not stop taking Suboxone suddenly. You could become sick and have withdrawal symptoms because your body has become used to the medicine (physical dependence). ... Never give anyone else your Suboxone sublingual film. They could die from taking it. Selling or giving away Suboxone sublingual film is against the law. ...” Review of MR1 “Behavior Note,” dated August 7, 2024, revealed that the patient reported to EMP16 that another patient was giving them their prescribed Suboxone. Patient indicated that they had been taking about “a quarter strip” of the medication for about two weeks. The provider was notified. Review of MR1 “Medical Staff Progress Note,” dated August 8, 2024, revealed that the treatment team met with the patient and that the patient refused a urine drug screen and indicated that they would come up as positive as they had been taking Suboxone not prescribed to them. Review of MR2 “Medical Staff Progress Note,” dated August 6, 2024, revealed “ ... Last evening, [patient] was found with what appeared to be a sublingual film that was concealed in a small piece of paper. [Patient] identified this as Suboxone ...”. Further review of the note revealed that the patient indicated that they received the medication, during recreation, from another patient located on another unit. It was indicated that the patient would be placed in “state clothing” so that their personal clothing could be laundered to ensure that there were no other films present. In addition, it was indicated that the patient would undergo random drug screening due to “significant history of diversion and/or contraband possession.” Review of MR3 “Physician Orders,” dated May 31, 2024, revealed an order to check the patient’s mouth after medication administration and to keep the patient in an open area for “15 minutes after medications.” Review of MR3 “Behavior Note,” dated June 2, 2024, revealed that the patient was reminded to sit in the day area for twenty minutes while their Suboxone medication fully dissolved in their mouth. The note indicated that two staff observed the patient removing the Suboxone film from their mouth and tucking it into their sleeve. Nursing approached the patient and subsequently the patient provided the medication back to the nurse. The patient’ s provider was notified of the incident and the provider gave the approval to administer the medication to the patient, but to monitor the patient “very closely, until completely dissolved.” Further review of the note revealed “Unit RN sat with [patient] as instructed until medication was completely dissolved.” Review of MR10 revealed that on August 12, 2024, the patient reported not feeling well. A review of “Cumulative Vital Report,” dated August 12, 2024, revealed that the patient’s blood pressure was elevated, had an elevated temperature and pain level was rated as a “10.” Review of MR10 “Behavior Note,” dated August 13, 2024, revealed that the provider was notified of the patient’s vitals and that the provider ordered a medication to treat the patient’ s high blood pressure and ordered a urine drug screen. The provider was notified that the patient tested positive for Buprenorphine (medication used to treat opiate addiction, like Suboxone). Further review of the patient’s medical record revealed that the patient did not have an order for this medication. Further review of MR10 “Behavior Note,” revealed that the patient indicated that they were getting “Suboxone” from another patient on another Unit. Patient was prescribed Naltrexone, a medication to help with individuals with opioid use disorder, who have stopped taking opiates, manage their cravings and remain drug-free. Interview on August 16, 2024, at 3:03 PM, with MR10, revealed that they previously received Suboxone from another patient, but did not disclose as to which patient provided it to them. MR10 indicated that there were other areas in the facility in which patients could obtain Suboxone from other patients. On August 19, 2024, at 10:29 AM, with EMP14, a review of video footage of medication administration was performed. Review of the footage, dated August 5, 2024, showed MR3 receiving their Suboxone. At 8:14:22 AM, the patient is observed walking away from the window, removing their Suboxone and placing at the top of their sweatpants. At 8:29:16 AM, the is not observed to receive a check of their mouth but the medication monitor provides a “thumbs up” and the patient walks away. EMP14 revealed that the patient’s mouth is supposed to be check to ensure that the Suboxone film is in the gum area. EMP14 indicated that the patient is then to wait in the day area while being monitored for at least twenty minutes. The patient’s mouth is then to be checked again to ensure that the film/strip is dissolved. EMP14 confirmed that the medication process was not followed. On August 20, 2024, at 11:35 AM, with EMP1, a review of video footage of medication administration was performed. Review of the footage, dated August 19, 2024, revealed that at 8:20 AM, MR12 received their medication, identified as Suboxone. At 8:20:05 AM, MR12 is observed walking away from the medication administration window with what is identified as Suboxone films in their hand. At 8:20:11 AM, MR12 appears to look around and then walks out of sight of the video. EMP1 confirmed that the patient was not administered the medication in accordance with medication administration protocols. The facility failed to administer controlled medications in accordance with accepted standards of practice, failing to visualize the medication being placed into the patient’s mouth before leaving the medication administration area and failing to adequately monitor the patient to ensure that the patient did not leave the area until medication was fully dissolved in order prevent diversion to another patient. In addition, the facility failed to adequately investigate incidents of drug diversion to prevent reoccurrence.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 32177 Based on observations, review of facility policies and procedures, and interviews with staff (EMP), it was determined that the hospital failed to have an effective governing body as evidence by failing to ensure electronic devices, utilized for audio and video monitoring and communications, were acquired and utilized in accordance with facility policy and were secure and monitored to ensure that the devices were restricted from unauthorized access. In addition, the Governing Body failed to ensure that a patient’s injuries were adequately investigated to rule out abuse, including neglect (A0145- Cross Reference 482.13(c)(3) Patient Rights: Free From Abuse/Harassment). Findings include: During a tour on March 11, 2024, at 8:15 AM, an electronic video doorbell (a type of doorbell that has an ability to display and record images when movement is detected within its range. It also requires an account and subscription to store and access video recordings) was observed located at the door of the facility’s carport area. On the right side of the facility’s entrance door was an intercom system which is utilized to gain access inside the building. Another electronic device, a “smart” speaker with a screen display that was voice activated and contained a built-in virtual assistant that could perform various tasks, such as answering questions, monitoring purchases, and connecting to other compatible electronic devices- such as video doorbells, etc. was observed at the admission’s window. This device was paired with the electronic video doorbell giving the device access to see outside the facility, in the carport area. An interview at 8:35 AM, with EMP5, revealed that they didn’t know who had access to video footage that may have been recorded and stored by the electronic video doorbell. Interview at 8:45 AM, with EMP1, the Chief Executive Officer, revealed that after a State Licensure survey, in June 2023, they purchased the items to address Emergency Medical Treatment and Active Labor Act (EMTALA) concerns and law enforcement activity. They would utilize the devices to communicate to law enforcement after hours if needed. EMP1 further indicated that they couldn’t remember their passwords for the accounts, and they didn’t know who had access to the video footage that may have been stored by the electronic video doorbell nor did they know who maintained the account for the devices. Interview on March 11, 2024, at 9:55 AM, with EMP2, the Assistance Chief Executive Officer, indicated that EMP2 did not know who had access to the video doorbell or footage acquired by the video doorbell. EMP2 indicated that they had the application to access the devices but deleted it once they were notified, by Admissions, that their personal purchases were viewable. Interview on March 11, 2024, at 12:49 PM, with EMP1 and EMP2, indicated that neither knew who maintained the account or had access to the accounts for these devices. A review of facility document, “Request for Purchase”, dated July 11, 2023, revealed that the head of security submitted a request for a “video doorbell for admissions.” This request was documented as approved and authorized by EMP2. The request contained an order for an electronic video doorbell and “smart” speaker. Review of a purchase order, dated July 14, 2023, revealed that the electronic video doorbell and “smart” speaker was ordered through an online retailer. The order was stamped by EMP7 on July 19, 2023, stating “I hereby certify that the items listed heron have been received and approved for payment.” On the receipt it was stamped “I hereby certify that the items listed heron have been received and approved for payment.” Interview on March 12, 2024, at 7:02 AM, with EMP9, revealed that they learned that a patient had attempted to elope upon arrival to facility grounds; the patient tried to run away through the carport area after returning from an acute care hospital. However, EMP9 reported that no one could obtain access to the electronic video doorbell’s account to see if the incident was recorded by the device. EMP9 also indicated that one night, while in the admissions area, the “smart” speaker started to speak and was reading out recently purchased items from an online retailer. EMP9 indicated that they were later informed that the purchases belonged to EMP2. Interview on March 12, 2024, at 11:05 AM, with EMP7, revealed that a “couple of weeks ago” they heard the “smart” speaker speaking and it was reading out ordered items and when the items were delivered. In addition, it provided the name and address of an employee, EMP2, when one of the items was preparing to ship. EMP7 indicated that they notified EMP2 that the device was providing verbal alerts regarding personal items that they [EMP2] were ordering and when they were preparing to ship. Review of facility policy, “Video Monitoring”, effective March 25, 2022, revealed “ ... The video monitoring system is installed and in use in certain areas in hospital facilities to help monitor observation/seclusion rooms, day rooms, corridors, admissions ... Monitors are placed at nursing stations and at the Hospital’s front desk. ... The video monitoring system includes a recording feature that stores images in a digital format for a limited period of time. ... Copes of records from the archived data may be made and stored separately when authorized by this policy or when litigation or any other legal action is anticipated ... Hospital employees who are within range of the video monitoring system have no expectation of privacy regarding any of their activities that are recorded. All images and records of whatever sort generated by the system may be used in investigations or complaints and or respect to disciplinary action. ... With the exception of those doing regulatory required investigations, requesting review of or access to video monitoring system records must obtain authorization from the hospital administrator or the administrator’s designee ... Safety and Security Departments will maintain the video monitoring system and as authorized by the hospital administrator or the administrator’s designee, produce secondary records from the system’s archival capacity.” There was no evidence that the Safety and Security Departments were monitoring or maintaining the electronic video doorbell or the “smart” speaker and there was no evidence that the facility was managing any audio or video footage that may have been recorded by the devices. Review of facility document, “Bylaws of the Governing Board of William R Sharpe, Jr. Hospital (Sharpe Hospital)”, revised May 3, 2023, revealed “ ... The term CEO means the hospital’s Chief Executive Officer who is qualified by education and experience, and is appointed by the Secretary of the Department of Health and Human Resources and represents the Governing Board, acting as its agent in the overall administration of Sharpe Hospital ... Responsibilities: ... the CEO will be responsible for the management of Sharpe Hospital. The Governing Board will hold the CEO accountable for the application and implementation of established policies to the operation of the hospital and for providing liaison between the Governing Board and the departments of the hospital. ... The CEO shall ensure effective communication (through committee membership, distribution of minutes, reports and effective organizational structure) between members of the Governing Board, the Medical Staff and Hospital Administration. A review of the Governing Board meeting minutes from July 2023 through January 2024 revealed no mention of the addition of an electronic video doorbell and the “smart” speaker device to the facility’s video monitoring/surveillance system. In addition, there was no documented evidence that the Governing Body ensured that the electronic video doorbell or “smart” speaker was installed and utilized in accordance with facility policy and that it was secure and monitored to ensure that the devices were restricted from unauthorized access.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 43434 Based observations, review of medical records (MR) and facility documents, and interviews with staff (EMP), it was determined that the facility failed to adequately investigate a patient’s injury to rule out abuse, including neglect for one out of ten medical records reviewed (MR6). Findings include: Review of MR6 revealed that the patient was admitted to the facility in October 2020 as a transfer from another facility. Further review of MR6 revealed that the patient was diagnosed with intellectual developmental delays, intermittent explosive disorder, and autism spectrum disorder. Review of “Mental Health Therapist Progress Note,” dated March 4, 2024, timed 12:28 PM, by EMP18, indicated that the patient was in a “good mood interacted positively.” Further review of the note indicated that upon the end of the session, the patient stood up and said their foot was “hurting” and “fell forward landing on [their] hands and knees” but “did not appear to be hurt.” Patient was assisted back to the gym and then returned to their Unit. The note did not identify which foot. Review of “Nursing Shift Evaluation,” dated March 4, 2024, timed 1:05 PM, by EMP19, revealed “ ... Irritable. Monitored every 15 minutes for safety. Neurological evaluation: Awake, Alert, and oriented to person, place, time, speech clear, face symmetrical. Moves all extremities. No seizure activity.” Further review of the nurse’s evaluation revealed no mention of the incident that occurred earlier that day as the patient was leaving their therapy session. Review of “Nursing Note,” dated March 4, 2024, timed 6:33 PM, by EMP20, indicated that the patient was in the day area and reported that they were unable to walk. EMP20 documented that the patient was unable to put weight on their right leg and was assisted back to their room. The on-call provider was contacted and ordered a medical consult with the medical team to evaluate the patient in the morning. The provider wrote an order for ice pack for 15 minutes every two hours and to evaluate the right foot for two days. Review of “Nursing Note,” dated March 5, 2024, timed 9:00 AM, by EMP21, revealed “Patient seen on the Unit. Left ankle swelling with bruising. The ankle is tender to touch, and palpation movements are restricted. Send to local hospital for possible fracture.” Review of MR6’s x-ray report, dated March 5, 2024, timed 1:57 PM, revealed “ ... some soft tissue swelling about the great toe and toenail. ... no displaced fracture is demonstrated. Recommend follow-up if there is persistent pain or concern for occult fracture.” Later that day the patient was returned to the hospital, with complaints of bilateral foot pain, and the hospital took additional x-rays. Further review of the patient’s medical record revealed that the patient had closed fractures of the left fibula and tibia (the two long bones in the leg that connect the knee and ankle). Interview on March 12, 2024, at 9:30 AM, with EMP24 (a health service worker), revealed that on the day of the incident they reported being in the hallway and being asked, by EMP18, to help get the patient up from the floor as the patient was sitting on the floor. I asked if the patient had fallen and EMP18 indicated no and that the patient “sat down.” I assisted the patient back to the gym and the patient indicated that their foot “hurts” and was favoring their left leg. EMP25 (another health service worker) came over and was speaking with the patient. EMP24 indicated that they did not complete an incident report. Interview on March 12, 2024, at 10:40 AM, with EMP25, indicated that EMP25 was in the hallway when EMP18 and EMP24 “yelled” for me. EMP25 indicated that when they went over to the patient, the patient was in the gym sitting down and that the patient had a seizure. EMP25 reported that EMP18 indicated that the patient fell. I asked the patient if they could walk back to their Unit and the patient replied “yes.” EMP25 reported that they have not known the patient to have seizures. EMP25 indicated that when they returned the patient back to their Unit that they informed Unit staff of the fall, but that they couldn’t remember who they told, but stated it may have been EMP20. EMP25 indicated that they did not complete an incident report. Interview on March 12, 2024, at 11:10 AM, with EMP18, indicated that on March 5, 2024, they walked the patient to their group therapy and that the patient was the only one in the session. They indicated that the patient did not voice any complaints of pain in their foot when going to their session. EMP18 indicated that the only time the patient voice a complaint of foot pain was when the patient went to stand up and then fell forward on their hands and knees. I saw EMP24 in the hallway and asked for help getting the patient off the floor. EMP18 indicated that the patient said that they had a seizure. EMP18 indicated that there were no signs of a seizure and no indication that the patient appeared hurt. EMP18 indicated that EMP25 took the patient back to their unit. EMP18 indicated that they did write a note in the patient’s medical record and “tagged” the “treatment team”. EMP18 indicated that the health service worker informed the nurse as they took the patient back to the Unit. Review of video footage, dated March 4, 2024, shows EMP25 assisting MR6 back to their Unit. The patient is observed walking with a limp while staff hold the patient’s arm for support. Review of facility policy, “Patient Care: Incident Reporting and Review,” dated March 30, 2021, stated “ ... Employees that witness or are aware of an incident are responsible for completing and signing an Incident Report form at the time they become aware of the incident. Reporting must be completed and submitted prior to the end of the current shift or within 8 hours of the incident, whichever is earlier. ...”. Review of facility policy, “Reporting and Investigation Verbal Abuse, Physical Abuse, Neglect and Sexual Harassment of Patient,” dated April 21, 2023, stated “ ... All patients have the right to be free from all forms of abuse or neglect. It is the responsibility of staff to identify and report ... neglect and to promote and environment free of abuse or neglect consistent with prevailing standard and the exercise of staff professional judgement. ... B. Mandatory Reporting of Neglect, Physical Abuse ... 1. Facility Mandatory Reporters shall make a Good Faith Report as soon as practicable to the RN and/or Nurse Manager assigned to the unit where the patient resides ... C. Response to Good Faith Report; 1. The RN/Nurse Clinical Coordinator shall take all precautions and implement all reasonably necessary interventions to ensure the patient or patients, against Neglect, Physical Abuse ... occurred or likely occurred are safe and that the risk of such further conduct is redressed. ... E. Investigation ... The facility investigator will review any available video. 7. The initial APS response completed by the Nurse Clinical Coordinator (NCC) will be submitted to the Chief Executive Officer (CEO) within (1) working day. NCC or administration personnel shall IMMEDIATELY suspend the alleged perpetrator pending completion of the investigation into the allegations, the findings are reviewed by the Administrator, and the alleged perpetrator is approved by the Administration to return to work or entry into the facility.” Review of facility documentation, dated March 6, 2024, revealed that EMP18 reported that the patient had an “unanticipated fall” and that the patient reported that their foot was hurting when they stood up and that there was “no apparent injury.” Further review of the document revealed that on March 7, 2024, EMP4 assigned an ACA (Apparent Cause Analysis) and APS (Adult Protective Services) filed. It was indicated that EMP18 failed to call for a rapid response after the patient’s fall, failed to follow the hand off communication to nursing and reporting process protocols. Interview on March 12, 2024, at 1:09 PM, with EMP26, revealed that they, along with the staff on the Unit, were unaware of the incident until the patient was observed with complaints of foot pain. EMP26 indicated that they were instructed to file an APS report for neglect on EMP18 and that nothing was said about the other staff involved [EMP24 and EMP25]. Review of the MR6 revealed no documented evidence that EMP18, EMP24 or EMP25 notified nursing or called a rapid response after the patient’s fall to ensure that the patient was immediately assessed to rule out injuries related to the “fall” on March 5, 2024. In addition, the on-call provider was not contacted until several hours later when the patient was observed by nursing with difficulty bearing weight on their right leg. There was no documented evidence that EMP24 and EMP25, reported or completed an incident report, and at the time of the survey, two of three employees involved in the incident were still on the schedule whereas one employee had been suspended pending the investigation.”