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Based on interview, documentation in 2 of 2 medical records reviewed of patients on the geriatric psychiatric unit who were involved in patient to patient altercations or sustained injuries (Patient #s 2 and 5), and review of policies and procedures, it was determined that the hospital failed to fully develop and implement policies and procedures related to the identification, investigation, and response to patient incidents and injuries to ensure patient protection from abuse, neglect, or mistreatment. There was no evidence of incident identification and investigation secondary to patient to patient altercations for both patients involved; or for patient injuries.

Findings include:

1. The geriatric psychiatric unit policy and procedure titled "Patient Rights", dated as last revised "3/13", was reviewed. It reflected that "The following patient rights are adhered to at all times on the unit...The patient has the right to be free from mental, physical, sexual, and verbal abuse, neglect, and/or exploitation...Receive humane services, be protected from harm..."

The hospital policy and procedure titled "Confidential Occurrence Reporting System", dated as last revised August 2013, was reviewed. It reflected that "A Confidential Occurrence Report (COR) is used to document/report an occurrence or incident that is not consistent with the routine operations of the facility or the routine care of a particular patient...To ensure...that immediate attention and response can be given to individual occurrences...All CORs are to be initiated by the employee(s) or physician directly involved in, witnesses of, or first responders to the occurrence...Forms should be completed by the end of the individual's shift, or as soon as possible after the event...the form is electronically routed to the Department Director/Manager who begins an initial investigation for each occurrence...

The hospital policy and procedure titled "Abuse: Identifying and Reporting, Child, Adult & Elder Adults", dated as last revised May 2009, was reviewed. That policy reflected it "provides guidelines...for staff to identify, assess, and notify the proper authorities of those persons who might be, or are victims of physical abuse, neglect...". It directed "hospital staff who witness, or suspect abuse, or neglect, should notify his/her supervisor of the incident for follow-up." It defined physical abuse in part as "any physical injury, which has been caused by other than accidental means..." Neglect was defined as "negligent treatment, or maltreatment, which causes actual harm, or substantial risk of harm..." The policy and procedure proceeded to provide direction for reporting and investigating suspected or actual physical abuse and neglect, and includes the completion of a Confidential Occurrence Report.

The policy and procedure titled "Secure Training", dated as last revised "3/13" was reviewed. It reflected it was "To provide staff with specific guidelines and best practice for the prevention and de-escalation of patient anger and aggression." It reflected "Staff involved in a crisis will be participate in a de-briefing as soon as possible following crisis..."

2. The record of Patient 2 reflected an admission date of 01/14/2014. The Interdisciplinary Master Treatment Plan identified diagnoses which included "Bipolar...current episode manic, severe, [with] psychotic features."

A Nurse Progress Note was recorded at 2309 on 01/19/2014 by an RN. The documentation reflected "Staff report that [patient] went into a peer's room and sat on the peer's bed. When asked to come out of the peer's bed, [patient] refused...hostile, kicking at staff...was held by [his/her] hands and wrists...assisted to stand...About 45 minutes later...Staff observed bruising and swelling on bilateral wrists...right wrist...skin tear...Doctor was called..."

There was no documentation by other staff who were present, interacted, observed, or provided care to the patient at the time of the incident on 01/19/2014, nor did the record reflect which "staff" reported the incident to the RN. In addition, the documentation is not clear whether the "staff report" to the RN was made after the actual incident, or only after the injuries were observed.

The note reflects the patient was seen in the ED at 2120, that X-rays were taken which revealed no fracture, that the skin tear and swelling was treated, and the patient returned to the geriatric psychiatric unit at 2225.

3. The record of Patient 5 reflected an admission date of 03/19/2014. The Interdisciplinary Master Treatment Plan identified diagnoses which included "Dementia [with] behavioral disturbance."

A Nurse Progress Note was recorded at 0018 on 03/24/2014 by an RN. The documentation reflected that "...increased agitation as evening progressed. irritable with...[another patient] and needing to be separated...came up behind [another patient] and kicked [patient] in the legs...punched [a staff person]...escorted with 3+ persons to the seclusion at 2300..."

A Nurse Progress Note was recorded at 0247 on 03/26/2014 by an RN. The documentation reflected that "At 2340 [patient] entered into [another patient's] room and became combative with redirection; swinging out at staff and closed fisted hitting of [another patient] in the torso and chest...escorted to quiet room at 2344 by 3+ staff."

The documentation did not clearly reflect if these events were observed by the author of the notes or if they were reported events. There was no documentation to reflect which staff were present, interacted, observed, or provided care to the patient at the times of the incidents.

4. Review of incident and occurrence documentation for Patient 2 revealed that another situation which occurred on 01/22/2014, not related to patient behaviors or injuries, was investigated. The Risk Management Worksheet reflected that the disposition was identified as "Complete" on 02/04/2014. There was no other incident and occurrence documentation related to Patient 2.

There was no incident and occurrence documentation provided which involved Patient 5 or the patients whom Patient 5 physically assaulted.

5. During interview on 04/23/2014 at 1430 the hospital Risk Manager stated that staff should initiate incident reporting for any patient injury. He/she also stated that there was no other report or documentation related to Patient 2's injuries.

During interview on 04/23/2014 at 1445 the unit Nurse Manager stated that there was no incident report for the 01/19/2014 event involving Patient 2 and that he/she had no other record or memories of it.

During interview on 04/23/2014 at 1630 with the Risk Manager and the unit Program Director, it was confirmed that there was no incident or investigation documentation for the incidents involving Patients 2 and 5, or for any patients whom Patient 5 hit or kicked. It was further confirmed that they did not know how to identify the patients who Patient 5 hit and kicked and were unable to identify if those patients had been injured.

During interview on 04/23/2014 at 1645 the unit Acting Clinical Assessment Coordinator stated that in order to discover which staff were involved in the 01/19/2014 incident with Patient 2, on 04/23/2014 he/she contacted the RN charge nurse and a CNA who were on duty at the time of the incident and those staff identified the involved staff.

During interview on 05/06/2014 at 1000 a CNA who provided care to Patient 2 on 01/19/2014 stated that he/she talked to the charge nurse on duty at the time of the incident after the patient injuries were observed, but that no one else at the hospital had spoken with him/her about the event.

Based on interview, documentation in 5 of 5 personnel records reviewed of direct care staff who regularly worked on the geriatric psychiatric unit (Employee #s 1, 2, 3, 4, and 5), and review of policies and procedures it was determined that the hospital failed to maintain complete and accurate training records related to restraint and seclusion. Documentation of training and competency related to techniques for management of aggressive patient behaviors, including restraint and seclusion, did not reflect successful completion.

Findings include:

1. The unit policy and procedure titled "Secure Training", dated as last revised "3/13", was reviewed. It reflected it was "To provide staff with specific guidelines and best practice for the prevention and de-escalation of patient anger and aggression." It reflected "Clinical staff will successfully complete a training program designed to teach staff to assess, prevent, intervene, and evaluate patient aggression...Staff may not provide direct patient care until successful completion of SECURE training." The policy and procedure proceeded to outline requirements for the training course instructor, the elements of the training, and the competency demonstration items. "Documentation of competency will be evidenced by completion of a post test and competency assessment of physical intervention techniques...Staff will demonstrate competence in all three SECURE modules...Staff will be retrained/re-certified on an annual basis..."

Secure training records reflected that "Module One" of the training was titled "Assessment, Prevention, Intervention, and Evaluation of Aggressive Behavior"; "Module Two" was titled "Physical Intervention and Containment"; and "Module Three" was titled Seclusion, Restraint, and Documentation".

2. Personnel records for Employee 1 reflected a hire date of 07/19/2002. The most current records for SECURE annual training was documented as conducted on 09/04/2013 and reflected the following:
* There was no documentation of post-tests for all three required modules;
* The "Module One Competency Verification Checklist" lacked the name of the employee, and lacked the initials of the certified instructor who observed the demonstration of each of the 6 listed skills as required on the form;
* The "Module Two Competency Verification Checklist" lacked the initials of the certified instructor who observed the demonstration of each of the 15 listed skills as required on the form, and lacked explanation for the reason skills #8 and #9 on the list were crossed out while there was a date observed recorded for each;
* The "Module Three Competency Verification Checklist" lacked the initials of the certified instructor who observed the demonstration of each of the 11 listed skills as required on the form, and lacked explanation for the entry next to skill #2 that was "[not applicable]" while there was a date observed recorded next to it.

3. Personnel records for Employee 2 reflected a hire date of 03/27/2008. The most current records for SECURE annual training was documented as conducted on 03/13/2013 and reflected the following:
* The "Module One Competency Verification Checklist" lacked the name of the employee, lacked the initials of the certified instructor who observed the demonstration of each of the 6 listed skills as required on the form, and lacked the signature of the instructor and date of "certification" as required on the form;
* The "Module Two Post-Test" had not been scored. The "Score" section was blank.
* The "Module Two Competency Verification Checklist" lacked the name of the employee, lacked the initials of the certified instructor who observed the demonstration of each of the 15 listed skill as required on the form, and lacked the signature of the instructor and date of "certification" as required on the form;
* The "Module Three Post-Test" had not been scored. The "Score" section was blank.
* The "Module Three Competency Verification Checklist" lacked the name of the employee, lacked the initials of the certified instructor who observed the demonstration of each of the 10 listed skills as required on the form, and lacked the signature of the instructor and date of "certification" as required on the form.

4. Personnel records for Employee 3 reflected a hire date of 08/08/2003. The most current records for SECURE annual training was documented as conducted on 03/13/2013 and reflected the following:
* There was no evidence of the "Module One Competency Verification Checklist".
* The "Module Two Post-Test" had not been scored. The "Score" section was blank.
* The "Module Two Competency Verification Checklist" lacked the initials of the certified instructor who observed the demonstration of each of the 15 listed skills as required on the form, and lacked the signature of the instructor and date of "certification" as required on the form;
* The "Module Three Post-Test" had not been scored. The "Score" section was blank.
* The "Module Three Competency Verification Checklist" lacked the initials of the certified instructor who observed the demonstration of each of the 10 listed skills as required on the form, lacked explanation for the entry next to skill #2 that was "[not applicable]" while the date observed was recorded next to it, and lacked the signature of the instructor and date of "certification" as required on the form.

5. Personnel records for Employee 4 reflected a hire date of 10/06/2005. The most current records for SECURE annual training was documented as conducted on 06/28/2013 and reflected the following:
* The "Module One Post-Test" had not been scored. The "Score" section was blank.
* The "Module One Competency Verification Checklist" lacked the initials of the certified instructor who observed the demonstration of each of the 6 listed skills as required on the form, and lacked the signature of the instructor and date of "certification" as required on the form;
* The "Module Two Post-Test" had not been scored. The "Score" section was blank.
* The "Module Two Competency Verification Checklist" lacked the initials of the certified instructor who observed the demonstration of each of the 15 listed skills as required on the form, and lacked the signature of the instructor and date of "certification" as required on the form;
* The "Module Three Post-Test" had not been scored. The "Score" section was blank.
* The "Module Three Competency Verification Checklist" lacked the initials of the certified instructor who observed the demonstration of each of the 11 listed skills as required on the form, lacked explanation for the entry next to skill #2 that was "[not applicable]" while the date observed was recorded next to it, and lacked the signature of the instructor and date of "certification" as required on the form.

6. Personnel records for Employee 5 reflected a hire date of 09/08/2009. The most current records for SECURE annual training was documented as conducted on 06/28/2013 and reflected the following:
* The "Module One Post-Test" had not been scored. The "Score" section was blank.
* The "Module One Competency Verification Checklist" lacked the initials of the certified instructor who observed the demonstration of each of the 6 listed skills as required on the form, and lacked the signature of the instructor and date of "certification" as required on the form;
* The "Module Two Post-Test" had not been scored. The "Score" section was blank.
* The "Module Two Competency Verification Checklist" lacked the initials of the certified instructor who observed the demonstration of each of the 15 listed skills as required on the form, and lacked the signature of the instructor and date of "certification" as required on the form;
* The "Module Three Post-Test" had not been scored. The "Score" section was blank.
* The "Module Three Competency Verification Checklist" lacked the initials of the certified instructor who observed the demonstration of each of the 11 listed skills as required on the form, lacked explanation for the entry next to skill #2 that was "[not applicable]" while the date observed was recorded next to it, and lacked the signature of the instructor and date of "certification" as required on the form.

7. During interview on 04/23/2014 in the late p.m. the Program Director, Risk Manager, and the Chief Human Resources Officer stated that it was unknown why some of the skills on the competency lists for some employees, as identified in the findings above, were crossed out or not applicable.

The lack of documentation identified in these records was shared with the Program Director, the Risk Manager, and the Chief Human Resources Officer on 04/23/2014 and no additional information was provided.

Based on interview and documentation in 6 of 6 medical records reviewed of patients on the geriatric psychiatric unit (Patient #s 1, 2, 3, 4, 5, and 6), it was determined that the hospital failed to ensure that all entries on patient observation records, nursing assessment documents, treatment plan documents, admission and discharge documents were legible, complete, timed, or authenticated.

Findings include:

1. The medical record for Patient 1 reflected the patient was admitted to the unit on 01/14/2014. Examples of entries that were not legible, complete, dated, timed, or authenticated in this record include, but are not limited to:
* Entries on the "24 Hr Nursing Assessment" forms for 01/14/2014 through 01/24/2014 were not timed.
* Entries on the "Treatment Plans" were not timed.
* An entry on the Close Observation records dated 01/15/2014 at 0945 had been altered as the original entry had been written over.
* Entries on the Close Observation records dated 01/20/2014 at 1430, 1445, 1500, 1515, 1530, 1545, 1600, 1615, 1630, and 1645; and on 01/23/2014 at 1445, 1500, 1515, and 1530 identified the patient location at those times as "G". However, "G" was not a code reflected on the "Location Key" on the form and did not accurately or clearly reflect the patient's location in accordance with the requirements of the form.
* 15-minute observation entries on the Close Observation form dated 01/21/2014 from 1615 through 1930 did not clearly reflect the author of those entries. The author's initials were not identified to a signature on the initials/signature key on the form. The Close Observation form dated 01/21/2014 and 01/22/2014 reflected the initials of nine different authors. However, the "Initials and Signatures" key on the form reflected only three sets of initials and signatures. Those forms dated from 01/14/2014 through 01/25/2014 which reflected the initials of multiple authors, contained between zero and three initial and signature sets only.
* Spaces on the Close Observation forms dated 01/14/2014 through 01/24/2014 for the "Day Shift...Charge Nurse Initials" and "Charge Nurse Signature @ 1930" were blank. Spaces on those forms for the "Night Shift...Charge Nurse Initials" and "Charge Nurse Signature @ 0730" were blank.
* Entries on the "Discharge and Aftercare Summary" dated 01/24/2014 were not timed.

2. The medical record for Patient 2 reflected the patient was admitted to the unit on 01/14/2014. Examples of entries that were not legible, complete, dated, timed, or authenticated in this record include, but are not limited to:
* The patient's and witness's signatures dated 01/14/2014 on the Patient Safety form were not timed.
* Shift entries on the "24 Hr Nursing Assessment" forms for 01/14/2014 through 02/01/2014 were not timed.
* Entries on the "Treatment Plans" were not timed.
* Entries on the Close Observation records dated 01/15/2014 at 2115 and 2130; on 01/22/2014 at 1945; on 01/24/2014 at 0900; and on 01/25/2014 at 2100 and 2115 had been altered as the original entries had been written over.
* Entries on the Close Observation records dated 01/15/2014 at 1030, 1045, 1100, 1115, 1130 and 1545, 1600, 1615, 1630, 1645, and 1700 identified the patient location at those times as "G". However, "G" was not a code reflected on the "Location Key" on the form and did not accurately or clearly reflect the patient's location in accordance with the requirements of the form.
* The Close Observation form dated 01/29/2014 and 01/30/2014 did not reflect the authors of all entries as required by the form. Documentation reflected the initials of nine different authors. However, the "Initials and Signatures" key on the form contained no initials and signatures. Those forms dated from 01/14/2014 through 02/02/2014 which reflected the initials of multiple authors, contained between zero and three initial and signature sets only.
* Spaces on the Close Observation forms dated from 01/14/2014 through 02/02/2014 for the "Day Shift...Charge Nurse Initials" and "Charge Nurse Signature @ 1930" were blank. Spaces on those forms for the "Night Shift...Charge Nurse Initials" and "Charge Nurse Signature @ 0730" were blank.
* Entries on the "Discharge and Aftercare Summary" dated 01/31/2014 were not timed.

3. The medical record for Patient 5 reflected the patient was admitted to the unit on 03/19/2014. Examples of entries that were not legible, complete, dated, timed, or authenticated in this record include, but are not limited to:
* The patient's and witness's signatures dated 03/19/2014 on the Patient Safety form were not timed.
* Shift entries on the "24 Hr Nursing Assessment" forms for 03/19/2014 through 04/09/2014 were not timed.
* The "24 Hr Nursing Assessment" forms for 03/19/2014, 03/20/2014, 03/24/2014, 03/28/2014, 03/29/2014, and 04/01/2014 contained entries that had been altered as the original entries had been written over.
* Entries on the "Treatment Plans" were not timed.
* Entries on the Close Observation records dated 04/05/2014 at 0845, 0900, and 1730; and on 03/29/2014 at 0730, 0745, 0800, and 0815 had been altered as the original entries had been written over.
* Entries on the Close Observation records dated 03/24/2014, 03/26/2014, 04/03/2014, 04/04/2014, 04/05/2014, and 04/08/2014 identified the patient's "Clinical Status" or "Location" with codes such as "W", "AR", "G", "PB", "OR", "OPR", "PR", "OPB", "QR", "W/C", "W/R", and "CT". Those codes were not reflected on the "Location Key" on the form and did not accurately or clearly reflect the patient's location in accordance with the requirements of the form.
* The Close Observation form dated 01/29/2014 and 01/30/2014 did not reflect the authors of all entries as required by the form. Documentation reflected the initials of nine different authors. However, the "Initials and Signatures" key on the form contained no initials and signatures. Those forms dated from 01/14/2014 through 02/02/2014 which reflected the initials of multiple authors, contained between zero and three initial and signature sets only.
* Close Observation forms for the patient's stay, dated from 03/20/2014 through 04/09/2014 contained spaces for the "Day Shift...Charge Nurse Initials" and "Charge Nurse Signature @ 1930". Only the forms dated 03/27/2014, 03/28/2014, 04/03/2014, 04/04/2014, and 04/05/2014 were signed by the charge nurse.
* Close Observation forms for the patient's stay, dated from 03/20/2014 through 04/09/2014 contained spaces for the "Night Shift...Charge Nurse Initials" and "Charge Nurse Signature @ 0730". Only the forms dated 03/21/2014, 03/23/2014, 03/24/2014, 03/25/2014, 03/26/2014, 03/27/2014, 03/30/2014, 04/02/2014, 04/04/2014, 04/05/2014, and 04/10/2014 were signed by the charge nurse.
* Entries on the "Discharge and Aftercare Summary" dated 01/31/2014 were not timed.

4. Similar findings were identified in the records of Patients 3, 4, and 6.

5. During interview on 04/23/2014 in the p.m. the RN Nurse Manager confirmed that codes were used that were not identified in the location key on the Close Observation form and further stated he/she did not know what those codes meant. He/she stated that if codes other than the codes in the location key are used on the form, staff should identify the code in the space for "Other".