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Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of three (3) sampled patients (Patient #1) was free from restraints, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Patient #1 had a physician's order for Patient #1 to be provided with a sitter (1:1 observation). However, the facility failed to provide the sitter as required (on 03/24/2020 and on 03/26/2020) and staff restrained Patient #1 with soft wrist restraints instead.

The findings include:

A review of the facility policy titled Patient Rights and Responsibilities, not dated, revealed patients have the right to be free from the use of seclusion and restraints as means of coercion, convenience, or retaliation by staff. The policy also stated if restraints were used, they would only be used if clinically required, and in accordance with the patient's care plan. According to the policy, restraints should only be used as a last resort and in the least restrictive manner possible to protect the patient and others from harm.

Review of the facility policy titled Restraint and Seclusion, dated August 2019, revealed a physical restraint is any method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely. Prior to considering utilization of restraints or seclusions, the patient should be assessed for possible physiological causes of behavior and alternative interventions should be reviewed and exhausted. The policy stated alternative interventions should be documented and the interventions included but were not limited to reorientation and redirection, diversional activities, and constant observation/sitter.

An interview was attempted with Patient #1 on 04/07/2020 at approximately 10:45 AM; however, due to the patient's cognitive impairments he/she was unable to recall any recent events which involved his/her care/treatment in the facility. No restraints were in use when he/she was observed.

Review of Patient #1's medical record revealed he/she was admitted to the facility on 03/12/2020 with diagnoses that included Acute Encephalopathy and Peripheral Vascular Disease. Further review revealed on 03/14/2020 Patient #1's physician ordered staff to provide the patient with a sitter.

Review of Patient #1's nurse's notes revealed on 03/24/2020 at 12:09 AM, Patient #1 attempted to "pull at" his/her central line (catheter placed into a large vein) where medication was being administered that helped the patient's blood pressure "stay up." The notes also revealed staff notified the patient's provider (an Advanced Practice Registered Nurse) and "new orders to apply restraints" were obtained.

Interview with Registered Nurse (RN) #1 on 04/08/2020 at 4:35 PM revealed she cared for Patient #1 during the night shift on 03/24/2020. RN #1 stated the patient had already "pulled so many IVs out and was wild." The RN stated the patient had a physician's order to provide a sitter; however, no sitter was with the patient as required. RN #1 stated she notified the house supervisor (unable to recall whom) of the patient's behaviors and requested a sitter be sent to ensure the patient's safety but was informed by the house supervisor that there were no sitters available to sit with the patient. The RN stated she applied soft wrist restraints to Patient #1, to prevent the patient from pulling out his/her intravenous access, because a sitter was not available. The RN stated there have been concerns with having physician ordered sitters provided with patients for months.

Interview with RN #2 on 04/09/2020 at 9:15 AM revealed she cared for Patient #1 on 03/26/2020. The patient was confused and staff were unable to redirect his/her behaviors. The RN stated the patient's upper extremities were restrained with soft wrist restraints, and he/she had dislodged his/her urinary catheter, even though he/she was restrained. RN #2 stated she notified House Supervisor #1 of the need for a sitter, related to the patient's behaviors but was informed that no sitters were available to help ensure Patient #1's safety. RN #2 also stated there had been concerns with patients being provided physician ordered sitters for a while.

Interview with RN #3 on 04/09/2020 at 9:25 AM and RN #4 on 04/09/2020 at 9:40 AM revealed there had been concerns in the facility with patients being provided with a physician ordered sitter for a while. The RNs also stated there had been occasions where soft wrist restraints were applied to patients because a sitter was not provided as ordered.

Interview with House Supervisor (HS) #1 on 04/09/2020 at 3:30 PM revealed patients that had an order for a sitter to be provided should be provided with a sitter as required. The HS stated there were no concerns with patients being provided a sitter in the facility, and he did not recall staff requesting a sitter for a patient that was not provided.

Interview with Risk Manager #1 on 04/09/2020 at 4:30 PM revealed she was notified on 04/09/2020 that there had been concerns with sitters being provided to patients as ordered by the physician. She also stated patients should not have been restrained because a sitter was not provided, and the least restrictive measures should be implemented and documented before patients were restrained in the facility.

Based on interview and record review, it was determined that the facility failed to ensure that a registered nurse supervised nursing care for one (1) of three (3) sampled patients (Patient #1). Patient #1 was assessed to be high risk for falls and interventions had been put in place to prevent the patient from falling. However, on 03/14/2020 nursing staff failed to ensure his/her fall alarm was working properly, and Patient #1 experienced a non-injury fall. Further interview revealed that nursing staff also failed to ensure the patient's fall alarm was working properly again on 03/29/2020, and Patient #1 experienced a fall that resulted in a fractured hip. In addition, a sitter who was assigned to supervise Patient #1 on 03/29/2020, failed to remain within arm's length of the patient as required.

The findings include:

Review of the "Tip Sheet for Psych Patients Admitted to the Medical Center," provided by the facility, dated 01/24/2020, revealed a sitter must always sit between the patient and the door and the patient must be within arm's length at all times. The sheet also indicated these patients should have a 1:1 sitter at all times.

Review of the facility policy titled "Falls," last revised May 2017, revealed staff were required to assess all patients admitted to the facility utilizing the standardized fall risk assessment tool to determine the patient's risk for falls and were required to implement fall prevention/injury reduction interventions as appropriate. The policy also stated staff were required to identify patients with fall risks each shift and were required to perform fall safety checks when assessing the patient to ensure all required fall and injury interventions are in place on patients that are at risk for injury.

Review of Patient #1's medical record revealed the facility admitted the patient on 03/12/2020 with diagnoses that included Acute Encephalopathy and Peripheral Vascular Disease.

Review of Patient #1's Fall Risk Assessment dated 03/12/2020 revealed staff assessed him/her to be at high risk for falls and implemented a bed/chair alarm to prevent falls for Patient #1.

Review of Patient #1's fall reports revealed he/she experienced a fall from the bed on 03/14/2020 at approximately 12:45 PM. Further review of the report revealed the patient sustained no injury from the fall.

Further review of Patient #1's medical record revealed on 03/14/2020 Patient #1's physician ordered staff to provide the patient with a sitter.

Interview with Registered Nurse (RN) #4 on 04/09/2020 at 9:40 AM revealed she was assigned to supervise care provided to Patient #1 on 03/14/2020 when he/she fell. The RN stated the patient was confused and impulsive that shift, and she identified at the beginning of her shift that the patient's bed alarm was not working properly. However, the RN stated she failed to get a new bed alarm for the patient because she felt that she could prevent the patient from falling. At approximately 12:45 PM on 03/14/2020, RN #4 observed Patient #1 on the floor beside his/her bed, and the bed alarm was not sounding. The RN stated the patient sustained no injury from the fall, and stated she should have retrieved a new alarm at the beginning of her shift, which could have prevented the patient's fall.

Further review of Patient #1's fall reports revealed he/she experienced a fall on 03/29/2020 (no time on the report) and sustained major injury as a result.

Interview with RN #5 on 04/08/2020 at 9:50 AM revealed she was assigned to supervise care provided to Patient #1 on 03/29/2020. The RN stated Patient #1 was confused/agitated and had a bed alarm as well as a sitter on 03/29/2020. However, the RN stated she failed to ensure the bed alarm was working at the beginning of her shift as required. RN #5 stated she heard someone yelling from the hallway at approximately 8:00 AM. Per the RN, when she entered the patient's room, she observed Patient #1 lying on the floor; however, the bed alarm was not sounding. The RN stated Patient #1 complained of pain to his/her right leg, and an x-ray was later performed which indicated a fractured right hip.

An interview was attempted with the sitter on multiple occasions on 04/07/2020 and 04/08/2020; however, she was unable to be reached. The facility also had not been able to reach her since she was suspended pending the investigation on 03/29/2020.

Review of Patient #1's diagnostic test dated 03/29/2020 after he/she fell revealed he/she sustained a "Mild to Moderately displaced sub capital fracture right hip."

Interview with Risk Manager (RM) #1 on 04/09/2020 at 4:30 PM revealed nurses had been trained and were required to ensure patients' fall alarms were working properly, and stated sitters were required to remain within arm's length of patients to ensure their safety. The RM also stated RN #4 and RN #5 should have ensured Patient #1's fall alarms were working properly, and if concerns were identified a new alarm should have been obtained for him/her. The RM also stated the sitter should have remained within arm's length of Patient #1 as required.

Based on interview and record review, it was determined that the facility failed to ensure that nursing staff developed and kept current a nursing care plan that addressed the risk for falls for one (1) of three (3) sampled patients (Patient #1). Patient #1 was assessed to be high risk for falls and interventions had been put in place to prevent the patient from falling. However, interviews and record reviews revealed no evidence a care plan was developed that addressed the patient's fall risk.

The findings include:

Review of the facility policy titled "Interdisciplinary Plan of Care," updated 03/03/2019, revealed a patient's care, treatment, and services should be planned to ensure they are appropriate to the patient's needs. The facility policy also indicated care planning would be implemented through the integration of assessment findings, consideration of the prescribed treatment plan, and the development of goals for the patient would be reasonable and measurable. The policy also stated care plans would be continually evaluated based on the patient's clinical condition, and should be revised as needed to meet the needs of the patient's changing condition.

Review of Patient #1's medical record revealed the facility admitted the patient on 03/12/2020 with diagnoses that included Acute Encephalopathy and Peripheral Vascular Disease.

Review of Patient #1's Fall Risk Assessment dated 03/12/2020 revealed staff assessed him/her to be at high risk for falls and implemented a bed/chair alarm on the Assessment to prevent falls for Patient #1.

However, review of Patient #1's care plan revealed no evidence staff developed a care plan that addressed his/her fall risk.

Review of Patient #1's fall reports revealed he/she experienced a fall from the bed on 03/14/2020 at approximately 12:45 PM. Further review of the report revealed the patient sustained no injury from the fall.

Interview with Registered Nurse (RN) #4 on 04/09/2020 at 9:40 AM revealed she was assigned to supervise care provided to Patient #1 on 03/14/2020 and at approximately 12:45 PM on 03/14/2020, she observed Patient #1 on the floor beside his/her bed and stated the patient sustained no injury from the fall. The RN stated a 1:1 sitter was implemented after the fall; however, she did not recall seeing a care plan that addressed his/her fall risk and stated she did not develop a care plan for the patient's fall risk but stated she should have.

Further review of Patient #1's fall reports revealed he/she experienced a fall on 03/29/2020 (no time on the report) and sustained major injury as a result.

Interview with RN #5 on 04/08/2020 at 9:50 AM revealed she was assigned to supervise care provided to Patient #1 on 03/29/2020 and stated the patient was confused/agitated and she observed him/her lying on the floor beside his/her bed at approximately 8:00 AM. The RN stated Patient #1 complained of pain to his/her right leg, and an x-ray was later performed which indicated a fractured right hip. RN #5 stated she had not ensured the patient had a nursing care plan that addressed his/her fall risk.

Review of Patient #1's diagnostic test dated 03/29/2020 after he/she fell revealed he/she sustained a "Mild to Moderately displaced subcapital fracture right hip."

Interview with Risk Manager (RM) #1 on 04/09/2020 at 4:30 PM revealed the facility system had "glitches" which sometimes affects care plans showing up as they should in the patient's medical record. The RM also stated nurses had been trained to develop care plans that addressed the patient's care needs, which included identified risks of falls. She also stated staff should have developed a care plan for Patient #1's fall risk on admission and care plans should have been reviewed by staff, and new interventions added on the patient's plan of care, when falls or other changes in the patient's condition occurred in the facility.