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Based on document review and interview, the facility failed to follow their policy and procedure to ensure staff promptly notified and documented a patient's representative of seclusion in two (2) instances. (Patient # 6 & Patient # 9)

Findings include:

1. The facility policy titled, "Restraint or Seclusion Use", PolicyStat ID 10577449, indicated the patient's Power of Attorney (POA) or appropriate representative shall be notified of the reason for the restraint/seclusion, the process used and the expected outcome. All notifications will be documented in the patient record including the time, date, person notified. This policy was last revised in 11/2021.

2. Review of patient # 6's open medical record (MR), indicated the patient was a 71 y/o (year/old) admitted to the hospital on 01/20/2023 with a diagnosis of schizophrenia and vascular dementia. Notification of Seclusion and/or Restraint Episode form, signed and dated 01/21/2023 at 11:45 am, indicated in the event that seclusion would be required as part of the patient's treatment intervention the patient would like his/her family member notified. The Daily Nursing Narrative, dated 01/21/2023 at 12:10 am, indicated the patient was placed in seclusion as ordered. The Patient Safety Observation Rounds, dated 01/21/2023, indicated the patient was placed in seclusion at 12:30 am until 2:15 am. The MR lacked any documentation the patient's representative was notified.

3. Review of patient # 9's MR, indicated the patient was a 67 y/o admitted to the hospital on 11/14/2022 with a diagnosis of schizoaffective bipolar type. Notification of Seclusion and/or Restraint Episode form, signed and dated 11/15/2022 at 10:15 am, indicated in the event that seclusion would be required as part of the patient's treatment intervention the patient would like his/her family member notified. The family member was also the patient's Power of Attorney (POA) and documented in the MR. The Daily Nursing Narrative, no date, at 7:00 am to 7:00 pm, indicated the physician was contacted for an order for seclusion. The patient was escorted to seclusion. The Patient Safety Observation Rounds, dated 11/28/2022, indicated the patient was placed in seclusion at 8:30 am until 8:45 am. The MR lacked any documentation the patient's representative/POA was notified.

4. In interview on 02/16/2023 at approximately 4:30 pm with administrative staff member A # 2 (Vice President of Quality & Compliance), confirmed family representation/POA notification of seclusion should be documented in
the patient's MR.

Based on document review and interview, the facility failed to electronically document an incident report in one (1) instance (patient # 10).

Findings include:

1. The facility policy titled, "Incident Reports", PolicyStat ID 12386386, indicated an incident report should be completed in the system by the end of the shift in which the incident occurred but no later than twenty-four (24) hours from the time of the event occurred. This policy was last revised in 09/2022.

2. Review of the facilities incident report list dated November 2022 to January 2023 documentation related to a patient to patient encounter from 12/2022.

3. Review of patient # 10's MR, indicated the patient was a 84 y/o admitted to the hospital on 12/25/2022 with a diagnosis of major neurocognitive disorder, Alzheimer type with behaviors severe. Review of the patient medical record (MR) Daily Nursing Narrative, dated 12/26/2022, indicated patient # 10 struck another patient (unknown) and the patient struck back at patient # 10. The Daily Nursing Narrative dated 12/31/2022, indicated faded bruising noted to right forehead.

4. In interview dated 02/21/2023 at approximately 4:20 pm with administrative staff member A # 2 (Vice President of Quality & Compliance), confirmed the administrative staff were unaware of the situation. Staff members S # 11 (Registered Nurse-RN) and S # 12 (Licensed Practical Nurse-LPN) could not recall the (unknown) patient's name from the incident on 12/26/2022. At 4:30 pm, A # 2 confirmed S # 12 should have completed an incident report per the facilities policy and procedure.

Based on document review and interview, the registered nurse failed to ensure weekly skin assessments were completed for three (3) of ten (10) patients. (Patient # 6, Patient # 9 and Patient # 10)

Findings include:

1. The facility policy titled, "Skin Assessment", PolicyStat ID 12385990, indicated a head-to-toe assessment should be done upon admission and skin assessments should be completed one time per week or as ordered by provider. The assessment should include identification of any wounds, injuries, bruises and skin conditions. This policy was last revised in 09/2022.

2. Review of patient # 6's open medical record (MR), indicated the patient was a 71 y/o (year/old) admitted to the hospital on 01/20/2023 with a diagnosis of schizophrenia and vascular dementia. The Weekly Skin Assessment form had documentation indicating an assessment was completed on 01/20/2023. The MR lacked the weekly skin assessments for the following dates: 01/27/2023, 02/03/2023, and 02/10/2023.

3. Review of patient # 9's MR, indicated the patient was a 67 y/o admitted to the hospital on 11/14/2022 with a diagnosis of schizoaffective bipolar type. The Weekly Skin Assessment form had documentation indicating an assessment was completed on 01/10/2023 (date of discharge). The MR lacked the weekly skin assessments for the following dates: 11/21/2022, 11/28/2022, 12/05/2022, 12/12/2022, 12/19/2022, 12/26/2022, and 01/02/2022.

4. Review of patient # 10's MR, indicated the patient was a 84 y/o admitted to the hospital on 12/25/2022 with a diagnosis of major neurocognitive disorder, Alzheimer type with behaviors severe. The Weekly Skin Assessment indicated an assessment was completed on 12/25/2022. The MR lacked 01/02/2023 weekly skin assessment. The patient was discharged on 01/03/2023.

5. In interview on 02/16/2023 at approximately 4:30 pm with administrative staff member A # 2 (Vice President of Quality & Compliance), confirmed per the facilities policy/procedure the patient's should have had weekly skin assessments.