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Based on document review and interview, it was determined that for 3 of 7 (Pt. #4, Pt. #5, and Pt. #12) clinical records reviewed for death within 24 hours of restraint use, the Facility failed to ensure the completion of a report for each death that occurred within 24 hours after the patient has been removed from restraint or seclusion.

Findings include:

1. On 5/16/2022, the Facility's policy titled, "Restraint Use" reviewed by the Facility 3/2022, was reviewed. The policy required, "2. Physical restraint: physical restraints include: ... arm restraints ... side rails - the use of side rail to restrict the patient's freedom to voluntarily exit the bed is a restraint....G. Reporting of Restraint-Related Deaths 1. Nursing staff shall notify the Clinical Nursing Supervisor. The Clinical Nursing Supervisor documents in Meditech and notifies the director of Quality and Patient safety and Risk Management, whenever...b. Any patient dies within 24 hours of restraint use...2. Quality and Patient Safety shall notify the regional office of the Centers for Medicare and Medicaid Services of such deaths within one business day of the knowledge of the death..."

2. On 5/16/2022, Pt. #4's clinical record was reviewed. Pt. #4 was admitted on 4/15/2021 with the diagnoses of respiratory failure, chronic kidney failure, and COVID-19. Pt. #4 expired at the Facility on 9/22/2021 at 5:45 AM. Pt. #4's clinical record included physician orders, dated 9/21/2021 and 9/22/2021, for soft limb restraints (bilateral upper extremities) and 4 siderails. Pt. #4's restraint assessments, dated 9/21/2021 and 9/22/2021, showed that Pt. #4 had 4 soft limb restraints and 4 siderails (within 24 hours of death). The report of a hospital death associated with the use of restraint or seclusion form, dated and submitted 9/22/2021, was incomplete and lacked documentation of the hospital's information, patient diagnosis, date of admission, condition of patient leading to death, reason(s) for restraints/seclusion use, circumstances surroundind death, and restraint application and monitoring information.

3. On 5/16/2022, Pt. #5's clinical record was reviewed. Pt. #5 was admitted on 1/11/2021 with the diagnoses of respiratory failure, chronic kidney failure, chronic obstructive pulmonary disease, and COVID-19. Pt. #5 expired at the Facility on 2/16/2022 at 12:05 AM. Pt. #5's clinical record included physician orders, dated 2/15/2022, for soft limb restraints (bilateral upper extremities) and 4 siderails. Pt. #5's restraint assessments, dated 2/15/2022, showed that Pt. #5 had soft limb restraints and 4 siderails (within 24 hours of death). The report of a hospital death associated with the use of restraint or seclusion form, dated and submitted 2/16/2022, was incomplete and showed only the use of siderails and lacked documentation of the use of soft limb restraints within 24 hours of Pt. #5's death.

4. On 5/17/2022, Pt. #12's clinical record was reviewed. Pt. #12 was admitted on 2/1/2021, with the diagnoses of respiratory failure, Encephalopathy, and COVID-19. Pt. #12 expired at the Facility on 8/25/2021. Pt. #12's clinical record included physician orders, dated 8/24/2021 and 8/25/2021, for soft limb restraints (bilateral upper extremities) and 4 siderails. Pt. #12's restraint assessments, dated 8/24/2021 and 8/25/2021, showed that Pt. #12 had soft limb restraints and 4 siderails (within 24 hours of death). The Facility failed to report Pt. #12's death associated with the use of restraints to CMS.

5. On 5/17/2022 at approximately 8:45 AM, an interview was conducted with the Manager of Quality and Patient Safety (E #9). E #9 stated that the Facility does not report deaths of patients in soft restraints because it is not a requirement by CMS. During another interview at approximately 1:35 PM, E #9 stated that there is not any documentation of a completed death report related to Pt. #4 and Pt. #12.

Based on document review and interview it was determined that for 3 of 7 staff (1 Respiratory Therapist/E #4, 1 Registered Nurse/E #5, and 1 Environmental Services Worker/E #6) reviewed for COVID-19 testing, the Facility failed to follow the process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19.

Findings include:

1. On 5/16/2022, the Facility's policy titled, "COVID-19 Vaccinations" dated 8/2021, was reviewed. The policy required, "...2. If [Hospital] approves an exemption...the employee will be required to provide documentation of weekly COVID-19 testing results to the [Hospital] Employee Health department."

2. On 5/17/2022, the weekly COVID-19 testing was reviewed for the COVID-19 vaccination exempt employees and included the following;
-E #4 had a medical exemption and worked 18 shifts as a Respiratory Therapist from April 3, 2022 - May 14, 2022, without COVID-19 testing for these weeks, as required per policy.
-E #5 had a medical exemption and worked 3 shifts as a Registered Nurse the week of 4/17/2022, without COVID-19 testing for that week, as required per policy.
-E #6 had a religious exemption and worked 5 shifts as an environmental Services Worker the week of 4/17/2022, without COVID-19 testing for that week, as required per policy.

3. On 5/17/2022 at 10:03 AM, an interview was conducted with the Executive Director of Human Resources (E #8). E #8 stated that all employees that are exempt from the COVID-19 vaccination must have weekly COVID-19 testing and provide the test results to the Employee Health department.

4. On 5/17/2022 at 11:29 AM, an interview was conducted with the Director of Respiratory Therapy (E #7). E #7 stated that he is aware of the COVID-19 weekly testing policy for employees with COVID-19 vaccination exemption. E #7 stated that it is the responsibility of the employee to have weekly COVID-19 testing and to report it to employee health. E #7 stated that the Respiratory Managers should have followed up on E #4's lack of weekly COVID-19 testing. E #7 stated that he was not aware of E #4's non-compliance with weekly testing.