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Based on medical record review, staff interview, and review of the restraint log and policies and procedures, the facility failed to ensure the patient was seen face-to-face within one hour of the initiation of a restraint by a licensed practitioner or registered nurse for 1 of 6 sample patients reviewed for restraints or seclusion (#3). The findings were:

1. Review of the restraint and seclusion log showed patient #3 was restrained on 5/27/22, 6/1/22 and 6/3/22. The type of restraint listed was "soft ties."

2. Review of the medical record showed physician orders dated 5/27/22, 6/1/22 and 6/3/22 for "2 pt [point] soft rest [restraint]" to be used during transportation to medical appointments due to verbalizing suicidal ideation with plan to elope. The following concerns were identified:
a. Review of the "Special Observation" sheet dated 5/27/22 showed the patient was restrained at 4 AM and released from the restraint at 8:45 AM. Review of the nursing assessment dated 5/27/22 indicated it was a "one hour face to face" assessment; however it was not completed until 9:21 AM. Further review of the medical record showed no evidence of a face-to-face assessment within one hour of the restraints being applied.
b. Review of the "Special Observation" sheet dated 6/1/22 showed the patient was restrained at 4:30 AM, and released from restraints at 9:27 AM. Review of the nursing assessment dated 6/1/22 at 9:35 AM showed it was a "post release/discontinuation" nursing assessment. Further review of the medical record showed no evidence of a face-to-face assessment within one hour of the restraints being applied.
c. Review of the "Special Observation" sheet dated 6/3/22 showed the patient was restrained at 4:19 AM and was out of restraints at 9:02 AM. Review of nursing documentation showed a 6/3/22 at 11 AM "post release/discontinuation" assessment. Further review of the medical record showed no evidence a face-to-face assessment within one hour was completed.

3. During an interview on 8/18/22 at 9:35 AM the assistant director of nursing (ADON) stated the patient was restrained with soft wrist restraints while being transported to medical appointments. On 8/18/22 at 10:05 AM the ADON stated he was not able to locate documentation to show a face-to-face evaluation was completed within one hour of restraint application on 5/27/22, 6/1/22 or 6/3/22 for the patient.

4. Review of the facility's policy "Restraint or Seclusion Use- CMS regulations" (reviewed/revised June 2018) showed "When restraint and/or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff or others, the patient must be seen face-to-face with one (1) hour after the initiation of the intervention by either a physician or other LIP [licensed independent practitioner], or a registered nurse or physician assistant who has received the appropriate training."

Based on medical record review, staff interview, and review of the restraint log and policies and procedures, the facility failed to ensure the patient was seen face-to-face within one hour of the initiation of a restraint to evaluate the patient's immediate situation, reaction to the intervention, the medical and behavior condition, and the need to continue the restraint or seclusion for 1 of 6 sample patients reviewed for restraints (#3). The findings were:

1. Review of the restraint and seclusion log showed patient #3 was restrained on 5/27/22, 6/1/22 and 6/3/22. The type of restraint listed was "soft ties."

2. Review of the medical record showed physician orders dated 5/27/22, 6/1/22 and 6/3/22 for "2 pt [point] soft rest [restraint]" to be used during transportation to medical appointments due to verbalizing suicidal ideation with plan to elope. The following concerns were identified:
a. Review of the "Special Observation" sheet dated 5/27/22 showed the patient was restrained at 4 AM and released from the restraint at 8:45 AM. Review of the nursing assessment dated 5/27/22 indicated it was a "one hour face to face" assessment; however it was not completed until 9:21 AM. Further review of the medical record showed no evidence of a face-to-face assessment within one hour of the restraints being applied.
b. Review of the "Special Observation" sheet dated 6/1/22 showed the patient was restrained at 4:30 AM, and released from restraints at 9:27 AM. Review of the nursing assessment dated 6/1/22 at 9:35 AM showed it was a "post release/discontinuation" nursing assessment. Further review of the medical record showed no evidence of a face-to-face assessment within one hour of the restraints being applied.
c. Review of the "Special Observation" sheet dated 6/3/22 showed the patient was restrained at 4:19 AM and was out of restraints at 9:02 AM. Review of nursing documentation showed a 6/3/22 at 11 AM "post release/discontinuation" assessment. Further review of the medical record showed no evidence a face-to-face assessment within one hour was completed.

3. During an interview on 8/18/22 at 9:35 AM the assistant director of nursing (ADON) stated the patient was restrained with soft wrist restraints while being transported to medical appointments. On 8/18/22 at 10:05 AM the ADON stated he was not able to locate documentation to show a face-to-face evaluation was completed within one hour of restraint application on 5/27/22, 6/1/22 or 6/3/22 for the patient.

4. Review of the facility's policy "Restraint or Seclusion Use- CMS regulations" (reviewed/revised June 2018) showed "When restraint and/or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff or others, the patient must be seen face-to-face with one (1) hour after the initiation of the intervention by either a physician or other LIP [licensed independent practitioner], or a registered nurse or physician assistant who has received the appropriate training. The evaluation shall include a physical and health assessment which includes evaluation of: 1) The patient's immediate situation. Review patient's physical and psychological status 2) The patient's reaction to the intervention 3) The patient's medical and behavioral condition 4) The need to continue or terminate the restraint or seclusion."

Based on review of policies, staff interview, and review of quality assurance (QA) documentation, the facility failed to complete an ongoing review of its discharge planning process, including a review of a sample of discharge plans. The findings were:

1. During an interview on 8/18/22 at 8:15 AM the social services director (SSD) stated the facility did not formally review its discharge planning process. She further stated there was no documentation to show the facility reviewed a sample of discharge plans, including those patients who were re-admitted. In addition, she stated the facility did not have a policy to address reviewing the discharge planning process.

2. Review of a photocopy provided by the SSD on 8/15/22 at 5:31 PM revealed it included "Steps to Discharge." The SSD stated at that time that the facility did not have a discharge planning policy, but the photocopy came from a manual for the social workers. Review of the photocopy showed it did not address reviewing the discharge planning process.

3. Review of QA documentation revealed there was no data pertaining to discharge planning.

Based on review of policies and procedures and staff interview, the facility failed to develop COVID-19 policies and procedures which addressed contingency plans for staff who were not fully vaccinated. The findings were:

1. Review of the facility's "COVID-19 Vaccination" policy (effective 2/4/22) showed it did not address contingency plans for staff who have not completed the primary vaccination series for COVID-19. For instance, it did not address deadlines for new hires to get their second vaccination (for multi shot vaccines) or procedures to follow if new hires did not get their second shot. Further, it did not address procedures to follow if an employee's exemption request was denied.

2. During an interview on 8/18/22 at 8:33 AM the director of nursing (DON) stated new hires needed to have a first COVID-19 vaccination or apply for an exemption. He stated if new hires did not get their second shot, the facility would follow the State's personnel rules for progressive discipline. However, he stated the facility's policy did not address the contingency plan (following the personnel rules on discipline).