HospitalInspections.org

Based on staff [EMP] interview and facility document review, it was determined the hospital failed to develop comprehensive policies and procedures related to investigation of allegations of abuse and neglect to include methods to protect patients from abuse during the investigation.

Findings:

Review of facility document, "Care of Victims and Perpetrators of Abuse, Neglect, or Exploitation" last revised August 19, 2022, revealed, "...Reports abuse/neglect/exploitation occurred on the premise of a BSR facility. Required Action. Obtain information specific to the reported events. ..Who is alleging that abuse, neglect, or exploitation occurred (patient, visitor, staff member, etc.)? What type of abuse, neglect or exploitation occurred and by whom? When did the abuse/neglect/exploitation occur? Where did the abuse/neglect/exploitation occur (in what jurisdiction)? Implement steps to preserve or avoid the destruction of potential evidence...Mandated Reporting Requirements. If the reported abuse, neglect, or exploitation is a mandated reporting requirement, notify either Adult Protective Services or Child Protective Services as appropriate...Document agencies and individuals contacted in patient's medical record on-duty..."

The above noted policy did not include information related to how the hospital would investigate allegations of abuse or how the hospital would protect patients from abuse during the investigation.

Review of facility document, "Corrective Action" last revised October 31, 2019, was reviewed and reads in part,"...An associate may be placed on administrative leave pending an investigation into an event, behavior, or performance..."

The policy does not describe what events, behavior, or performance may indicate the need for administrative leave or that employees under investigation for patient abuse and neglect would be placed on such leave to protect patients from abuse during such an investigation.

An interview was conducted with EMP12 on July 01, 2025 at 10:30 AM who indicated hospital leadership was working on a new policy to address investigation of abuse and neglect, but this policy was still in development. The hospital currently had no written policy and/or procedure related to conducting investigations of patient abuse and neglect.

On June 30, 2025, the hospital became aware of an allegation of abuse between an employee and Patient alleged to have occurred June 12, 2025.

An interview was conducted with EMP5 on June 30, 2025 at 2:30 PM. EMP5 was unclear on what procedures should be followed if a patient alleged abuse or neglect by a staff member.

Interview with EMP10 at 9:30 AM on July 01, 2025 indicated the hospital did not have a written policy related to actions that would be taken if a staff member was alleged or suspected to be a perpetrator of abuse and/or neglect to include protecting patients from further abuse while the facility conducted an investigation.

Based on staff interview [EMP] and document review, it was determined the facility failed to ensure each episode of restraint was conducted in accordance with the physician's order for two (2) of five (5) records reviewed of patients in restraints (Medical records (MR) 8 and 10).

Findings:

Review of facility document, "Restraints for Nonviolent, non-self destructive patient situations. Medical use of Restraints" last revised February 10, 2025, revealed, "...An order from a physician or authorized practitioner is required for all instances of restraint...type of restraint to use must be designated....Removal. The decision to discontinue the intervention should be based on the determination that the medical need for restraint is no longer present of the patient's needs can be met with less restrictive methods...Absence of the behavior that required restraints allows for the removal or termination of the restraint....The plan of care and/or treatment plan must be modified to include end address the use of restraints..."

Review of facility document, "Restraints or seclusion for violent, self-destructive patient situations" revealed, "...Any type of violent restraint including, but not limited to 4-point restraints, chemical restraints, physical hold, or use of force in order to medicate a patient, seclusion, etc. requires a provider order...The plan of care and/or treatment plan must be modified to include and address the use of restraints or seclusion for violent or self-destructive behavior..."

Review of MR8 revealed on June 27, 2025, the physician documented the patient was attempting to bite staff and bilateral wrist restraints were ordered for "patient and staff safety."

On June 27, 2025, the nurse added problems and interventions for both violent and non-violent restraints to the patient's care plan, despite the patient not being in non-violent restraints and having no physician order for non-violent restraints. The violent restraints were discontinued at 10:29 PM on June 27, 2025. On June 28, 2025, at 10:43 AM, the nurse documented problems and interventions for both violent and non-violent restraints in the patient's record, despite the patient's restraints being discontinued approximately twelve (12) hours prior to the documentation and the patient not being in any restraints on June 28, 2025.

Review of MR10 revealed the physician ordered hard two-point opposing wrist and ankle restraints on June 12, 2205 at 6:30 PM. Nursing flowsheet documentation indicated that the patient was in two-point opposing wrist and ankle restraints from 6:30 PM to 10:30 PM on June 12, 2025. The flow sheet did not contain documentation related to which limb was restrained (i.e. right or left) or the rationale for determining what side limb to restrain. Nursing and physician documentation reviewed for June 12, 2025 indicated the patient had a new dialysis fistula and pitting edema to the right arm. Nursing note documentation was reviewed and indicated the patient was placed in soft bilateral wrist restraints at 6:30 PM on June 12, 2025 and not opposing wrist and ankle restraints as ordered by the physician and documented in the nursing flowsheet during the same time period.

The patient was again placed in bilateral wrist restraints for interfering with medical treatment on June 16, 2025 and remained in restraints on June 17, 2025, June 18, 2025, and June 19, 2025 for pulling at lines and tubes. On June 17-18, 2025, nursing documented that the patient was "sedated" every two (2) hours for the fourteen (14) hour time period from 4:00 PM - 8:00 AM. The medical record contain no documentation that the patient continued to meet the criteria for restraints (pulling at lines and tubes) during this time period. There was no documentation in the record that nursing staff attempted to discontinue the restraints or utilize a less restrictive alternative to restraints while the patient was "sedated."

Interview with EMP15 at 1:15 PM on July 01, 2025, revealed that the physician erroneously entered the order for MR10 to have hard restraints to opposing wrist and ankle. EMP15 indicated that the facility does not have hard restraints. EMP15 indicated the physician meant to order bilateral soft upper extremity restraints. EMP15 indicated that during a chart audit they noticed the discrepancy in the restraint documentation and had nursing staff enter a narrative note indicating the patient was actually put into soft wrist restraints and not opposing hard restraints as documented on the flowsheet and ordered by the physician. EMP15 indicated it was inappropriate for MR10 to be left in restraints for 14 hours while sleeping/sedated and a less restrictive alternative should have been implemented by nursing staff.