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Based on document review and interview, the facility failed to follow their policy and procedure to ensure staff promptly notified a patient's representative of an incident/occurrence in one (1) instance. (Patient # 1)

Findings include:

1. Review of the hospital policy titled, "Patient Rights and Responsibilities", policy number I-A.9, issued date 12/2011, indicated that "every patient who enters the hospital for care has rights, and he/she may exercise these rights while hospitalized". The patient has the right to have their "family and/or agent, when appropriate, be informed" of their care, "including unanticipated outcomes". This policy was last revised on 06/2017.

2. Review of the hospital policy titled, "Incident Reports", policy number III-B.11, issued date 05/2015, indicated the incident report should be completed by the "end of the shift that the incident occurred", and include documentation of the "family/legal guardian of the patient" being "notified of incident/injury". This policy was last revised 01/2017.

3. Review of the incident/occurrence report dated 6/21/2018 at 2:00 am by NS # 1 (Licensed Practical Nurse-LPN), indicated the POA (Power of Attorney) was notified on 06/23/2018 at approximately 8:00 am.

4. In interview with administrative staff member A # 4 (Chief Executive Officer-CEO) on 08/23/2018 at approximately 4:15 pm, confirmed "I don't know why the nurse didn't call the family".

5. In interview with administrative staff member A # 4 on 08/24/2018 at approximately 11:40 am, confirmed that NS # 1 "should have notified the family".

6. In interview with administrative staff member A # 3 (Director of Nursing-DON) on 08/24/2018 at approximately 11:50 am, confirmed NS # 1 "had been trained" related to the proper way to complete incident reports.

Based on document review and interview, the facility failed to ensure a patient's rights were maintained in a safe setting during one (1) inpatient admission. (Patient # 1)

Findings include;

1. Review of the hospital policy titled, "Patient Rights and Responsibilities", policy number I-A.9, issued date 12/2011, indicated that "every patient who enters the hospital for care has rights, and he/she may exercise these rights while hospitalized". The patient has the right to "be made comfortable and be treated with dignity". The patient has the right to "receive care in a safe setting" and "refuse treatment". This policy was last revised on 06/2017.

2. Review of the hospital policy titled, "Safe Patient Transfers", policy number II-A.17, issued date 12/2011, indicated the purpose was to "make lifting and transferring patients' easier and safer for the patient and patient care provider". The key assessment criteria was the "ability of the patient to cooperate and follow instructions". This policy was last revised on 10/2017.

3. Review of the hospital patient's handbook titled, "Patient Handbook", copyright 06/2016, indicated the patient has the right to the following: (page 4 of 14) "receive considerate ethical behavior and respectful care, (page 5 of 14) "refuse treatment" and (page 6 of 14) "receive care in a safe setting".

4. Review of the competency training for PS # 2 (Nursing Assistant-NA) indicated the following:
A. Patient Rights & Responsibilities was completed 07/13/2017.
B. Nonviolent Crisis Intervention Training Program-Safety maintaining an environment that is physically and emotionally safe was completed on 07/13/2018.

5. Review of the closed MR for patient # 1 indicated the following:
A. The patient was a 90 y/o (year/old) who was admitted on 06/20/2018 to H # 1 (Psychiatric Hospital) from H # 2 (Skilled Nursing Facility-SNF) on a voluntary basis. The patient's diagnoses included, but were not limited, to major neurocognitive disorder, vascular type, with behavioral disturbances-severe, unspecified depressive disorder, and unspecified anxiety disorder.
B. Review of the nursing note dated 06/21/2018 at approximately 2:00 am by NS # 1 (Licensed Practical Nurse-LPN), indicated the following:
1. NS # 1 was "unable to draw admission labs" because the patient was "very aggressive and defending".
2. The patient was "hard to redirect want to fight and bite".
3. The patient was being helped to go to bed and was "very un-cooperative aggressive hitting and kicking".
4. The patient "hit" his/her "head on the bed rail and got a small laceration on the left eye".
5. "Steri strips" were applied and "patient stabilized".
C. The Psychiatric Evaluation completed on 06/21/2018 at approximately 8:49 am by MS # 2 (Nurse Practitioner), indicated the patient was "uncooperative with episodes of physical aggression". Since arrival to H # 1 the patient was noted to have "anxious behavior". When the "patient was being assisted" to bed on 06/21/2018 at approximately 2:00 am the patient sustained a "small laceration" near the left eye from "hitting" his/her "head on the bed-rail".

6. In interview on 08/23/2018 at approximately 4:40 pm with PS # 2, confirmed the patient was "complaining all the way" to the room he/she "didn't want to lay down". The patient "would not let go of the wheelchair arms" while attempting to transfer him/her. The patient was "holding on and kind of standing" when he/she tried to "bite me" so I just "let go" of him/her "during transfer". The patient fell on the bed rail.

7. In interview on 08/24/2018 at approximately 12:15 pm with A # 3 (Director of Nursing-DON), confirmed "no" the staff members are "not supposed to make the patients go to bed".

8. In interview on 08/24/2018 at approximately 11:40 am with administrative staff member A # 4 (Chief Executive Officer-CEO), confirmed the staff member "should not of let go of the patient during transfer". The staff member "had been trained in proper transfers". The staff member "should have" asked for "help" from another staff member because the patient had been combative earlier.

Based on document review, and interview the registered nurse failed to follow the policy and procedure related to accurately and thoroughly completing an incident/occurrence report, failed to ensure the patient's family member was notified promptly of an incident/occurrence which involved an injury, and to ensure the plan of care/treatment plan was updated in one instance. (Patient # 1)

Findings include:

1. Review of the hospital policy titled, "Patient Rights and Responsibilities", policy number I-A.9, issued date 12/2011, indicated that "every patient who enters the hospital for care has rights, and he/she may exercise these rights while hospitalized". The patient has the right to have their "family and/or agent, when appropriate, be informed" of their care, "including unanticipated outcomes". This policy was last revised on 06/2017.

2. Review of the hospital policy titled, "Incident Reports", policy number III-B.11, issued date 05/2015, indicated the incident reports should include documentation of the following elements: "Attending provider notified within one (1) hour of incident/injury involving their patient", and the "Family/legal guardian of the patient notified of incident/injury". This policy was last revised 01/2017.

3. Review of the hospital policy titled, "Change of Condition", policy number II-C.100, issued date 02/2014, indicated the RN (registered nurse) "will evaluate the patient and notify the physician via telephone with assessments". The assessments, "physician notification", and any interventions and/or orders received will be documented in the nursing notes of the patient's medical record (MR). The RN "will also update/amend the patient's care plan" regarding the change of condition. The "patient's family/designee will be notified of the change of condition". This policy lacked a revision date.

4. Review of the incident/occurrence report dated 6/21/2018 at approximately 2:00 am by NS # 1 (Licensed Practical Nurse-LPN), indicated the report lacked the documented time MS # 1 (Physician) was notified and the written statements by NS # 1 and PS # 2 (Nursing Assistant-NA), lacked the documented date the report was reviewed by the administrative staff members A # 3 (Director of Nursing) and administrative staff member A # 4 (Chief Executive Officer).

5. Review of the MR for patient # 1 indicated the following:
A. The patient was a 90 y/o (year/old) who was admitted on 06/20/2018 to H # 1 (Psychiatric Hospital) from H # 2 (Skilled Nursing Facility-SNF) on a voluntary basis. The patient was "becoming aggressive with staff and other residents", and trying to "hit" at H # 2. The patient's diagnoses included, but were not limited, to major neurocognitive disorder, vascular type, with behavioral disturbances-severe, unspecified depressive disorder, and unspecified anxiety disorder.
B. The Psychiatric Evaluation completed on 06/21/2018 at approximately 8:49 am by MS # 2 (Nurse Practitioner), indicated the patient was "uncooperative with episodes of physical aggression". Since arrival to H # 1 the patient was noted to have "anxious behavior". When the "patient was being assisted" to bed on 06/21/2018 at approximately 2:00 am the patient sustained a "small laceration" near the left eye from "hitting" his/her "head on the bed-rail" during a transfer.
C. Review of the Care Plan/Treatment Plan for 06/21/2018 and 06/25/2018, indicated the plan lacked any documentation update for interventions related to the laceration the patient sustained during his/her fall.
D. Review of nurses notes dated 06/21/2018 by NS # 1, indicated the MR lacked documentation related to notification of MS # 1, and notification of the patient's family member, which was listed on the patient's registration as contact one (1), after the incident/occurrence in which the patient sustained an injury.

6. In interview on 08/23/2018 at approximately 4:15 pm with administrative staff member A # 4, confirmed that the incident/occurrence report for patient # 1 should have been "completed correctly and thoroughly".

7. In interview on 08/24/2018 at approximately 11:40 am with administrative staff member A # 4, confirmed that NS # 1 "should have notified the family" promptly.

8. In interview on 08/24/2018 at approximately 11:50 am with administrative staff member A # 3, confirmed that "there was no follow up related to the laceration". NS # 1 "can update the plan of care" and then the RN would have to "sign off".

9. In interview on 08/24/2018 at approximately 1:55 pm with administrative staff member A # 4, confirmed that the "patient's plan of care and/or treatment plan wasn't updated" by the nurse or the treatment team after the patient had a change of condition.

Based on document review and interview, the facility failed to ensure the nursing staff followed the policy and procedure related to developing and updating the patients plan of care/treatment plan for one (1) of ten (10) patient's medical records (MR's) reviewed. (Patient # 1)

Findings include:

1. Review of the hospital policy titled, "PLAN FOR THE PROVISIONS OF NURSING CARE", policy number I-C.1, issued date 12/2011, indicated "to identify nursing care needs of the patient using the nursing process", registered nurses (RN's) shall use the assessment skills initially, on an "ongoing basis" to determine the level of care and/or "necessary interventions". A competent RN "is expected" to apply the nursing process and "evaluate the effectiveness of the plan of care and modify the plan as needed". This policy was last revised 10/2017.

2. Review of the hospital policy titled, "CHANGE OF CONDITION", policy number II-C.100, issued date 02/2014, indicated the RN will also "update/amend the patient's care plan as needed, regarding the change of condition". This policy lacked a revision date.

3. Review of the hospital policy titled, "STAFFING PLAN", policy number II-C.107, issued date 12/2011 indicated, the "Registered Nurse maintains responsibility for coordinating the plan of care for each patient". This policy was last revised on 05/2017.

4. Review of the hospital policy titled, "PLAN OF CARE-PROTOCOL FOR THE USE OF THE MULTIDISCIPLINARY FORMAT", policy number I-C.34, issued date 04/2011, indicated the purpose was to "provide a structure that assists the treatment team in care planning, coordination of interventions, and evaluation of patient progress toward goals for discharge". The "Multidisciplinary Team will review" the patient progress and "revise the plan" on a "weekly basis as is necessary". This policy was last revised on 04/2018.

5. Review of the MR for patient # 1 indicated the following:
A. The patient was a 90 y/o (year/old) who was admitted on 06/20/2018 to H # 1 (Psychiatric Hospital) from H # 2 (Skilled Nursing Facility-SNF) on a voluntary basis. The patient was "becoming aggressive with staff and other residents", and trying to "hit" at H # 2. The patient's diagnoses included, but were not limited, to major neurocognitive disorder, vascular type, with behavioral disturbances-severe, unspecified depressive disorder, and unspecified anxiety disorder.
B. The History & Physical (H&P) dated 06/20/2018 at approximately 11:48 pm by MS # 1 (Physician), indicated the patient was admitting with a right anterior shin laceration. "Orders written for daily assessments, to keep clean and dry."
C. Review of MS # 1's orders on 06/20/2018 at approximately 11:20 pm, indicated an order was written for "right anterior shin laceration-daily assessment to keep clean and dry". The MR lacked any further documentation related to wounds.
D. The Psychiatric Evaluation completed on 06/21/2018 at approximately 8:49 am by MS # 2 (Nurse Practitioner), indicated the patient was "uncooperative with episodes of physical aggression". Since arrival to H # 1 the patient was noted to have "anxious behavior". When the "patient was being assisted" to bed on 06/21/2018 at approximately 2:00 am the patient sustained a "small laceration" near the left eye from "hitting" his/her "head on the bed-rail".
E. Review of the Care Plan/Treatment Plan for 06/21/2018 and 06/25/2018, indicated the plan lacked any documentation for interventions related to the laceration the patient sustained during his/her fall on 06/21/2018.

6. In interview on 08/24/2018 at approximately 11:50 am with administrative staff member A # 3, confirmed that "there was no follow up related to the laceration". NS # 1 (Licensed Practical Nurse-LPN) "can update the plan of care" and then the RN would have to "sign off".

7. In interview on 08/24/2018 at approximately 1:55 pm with administrative staff member A # 4 (Chief Executive Officer-CEO), confirmed that the "patient's plan of care and/or treatment plan wasn't updated" by the nurse or the treatment team after the patient had a change of condition.