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Based on document review and interview, the facility failed to analyze the causes of a critical patient safety event and implement a corrective action plan with monitoring for sustained effectiveness to prevent future occurrences for 1 patient abuse event (Patient #11).

Findings include:

1. Review of the policy/procedure Sentinel Events (approved 6-18) indicated the following: "The hospital will take the following steps... Immediate investigation [and] completion of a root cause analysis for identifying the causal and contributory factors... An action plan will be developed based on the root cause analysis... the action plan will be implemented and then evaluated for effectiveness. An action plan will be considered acceptable if it does the following... Identifies, in situations where improvement actions are planned, who is responsible for implementation, when the action will be implemented, and how the effectiveness of the actions will be evaluated."

2. On 8-14-19 at 1420 hours, the President and Chief Executive Officer A1 was requested to provide documentation identifying the action plan to be implemented and the quality indicators for measuring the effectiveness of the improvement actions to prevent future occurrences of the critical patient safety event.

3. Review of the 8-9-19 Operations/Clinical Operations Meeting minutes provided for review indicated the actions for implementation including staff education and training, CPI refreshers, Town Hall meetings, corporate team coverage, security coverage and video spot checks and lacked documentation indicating how the effectiveness of the actions would be evaluated.

4. On 8-14-19 at 1720 hours, A1 confirmed the facility lacked documentation identifying the quality indicators for evaluating the effectiveness of corrective actions to prevent a patient abuse event from occurring in the future.

Based upon document review and interview, the facility failed to ensure adequate numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nurse Aides (CNAs) and Nurse Assistants (NAs) were available to provide care to all patients for 4 of 10 medical records (MR) reviewed (Patient's #2, 4, 6 & 12).

Findings include:

1. Review of the policy/procedure Nursing Staffing Plan (revised 5-19) indicated the following: "DON [Director of Nursing] has the final responsibility and accountability of approving usage of supplemental nursing staff ...Specific staffing for the facility will be commensurate with the care requirements ...Acuity that deviates from the projected needs is assessed and accommodated in the shift-to-shift allocation of staff..." and indicated the following for Unit 300: "For 1-7 Patients, (1) RN and (2) Nursing Aides and for 8-15 Patients, (1) RN/LPN and (2) Nursing Aides..." and lacked a provision to address orders for 1:1 patient observations by staff.

2. Review of the policy/procedure Patient Observation Policy (revised 6-19) indicated the following: "Providers will order specific observations for any patient(s) who requires a level of monitoring other than routine, including but not limited to... Level II - 1:1 Observation... At least one health care provider will be present with the patient at all times, be within arm's length..."

3. Review of the policy/procedure Suicide Precautions (revised 5-19) indicated the following: "1-to-1 observation at all times Level II: This is the most restrictive toward the patient and involves continuous monitoring and physical proximity to the patient at all times. Staff must be within arm's reach at all times, including toileting and showering..."

4. Review of the One Week Staffing Pattern Worksheet for Unit 300 indicated on Saturday, 7-27-19 there were 14 patients (and 3 patients (Pt#1, Pt#5 & Pt#12) had orders for 1:1 observation) and one Registered Nurse, one Licensed Practical Nurse and three Nursing Aides were scheduled for 0700 hours to 1900 hours and one Registered Nurse and three Nursing Aides were scheduled for 1900 hours to 0700 hours. Review of the One Week Staffing Pattern Worksheet for Unit 300 indicated on Sunday, 7-28-19 there were 14 patients (and 3 patients (Pt#1, Pt#5 & Pt#12) had orders for 1:1 observation) and one Registered Nurse, one Licensed Practical Nurse and two Nursing Aides were scheduled for 1900 hours.

5. Review of the MR for Patient #2 (Pt#2) indicated orders on 6-13-19 for 1:1 observation and Review of the 6-28-19 Patient Observation Monitoring records indicated the Certified Nurse Aide N18 documented 1:1 monitoring when Pt#2 was resting in bed in room 207 from 1015 hours to 1045 hours and documented q 15 min checks when Pt#4 was resting in bed in room 205B from 1015 hours to 1045 hours.

6. Review of the 6-29-19 Patient Observation Monitoring records indicated the Certified Nurse Aide N14 documented 1:1 monitoring when Pt#2 was resting in bed in room 207 from 1030 hours to 1145 hours and documented q 15 min checks when Pt#4 was resting in bed in room 205B from 1030 hours to 1145 hours.

7. Review of the 7-1-19 Patient Observation Monitoring records indicated the Certified Nurse Aide N16 documented 1:1 monitoring when Pt#2 was resting in bed in room 207 from 1000 hours to 1145 hours and documented q 15 min checks when Pt#4 was resting in bed in room 205B from 1000 hours to 1145 hours.

8. Review of the MR for Patient #4 (Pt#4) indicated admission orders on 6-23-19 for 1:1 suicide precautions and the narrative entry on 6-23-19 by Registered Nurse N39 indicated the RN called the former Administrator A11 and voiced their concerns about the "...ability to implement 1:1 precautions due to staffing needs/shortage ...[and]... was notified that [the] pm supervisor would address/resolve [the] issue..." and review of the 6-23-19 Patient Observation Monitoring records indicated the Certified Nurse Aide N19 documented 1:1 monitoring when Pt#4 was resting in bed in room 205A from 2030 hours to 0645 hours and documented 1:1 monitoring for Pt#2 when the patient was in room 207 from 2030 hours to 2245 hours, in the milieu/common area from 2300 hours to 0230 hours, in room 207 from 0245 hours to 0545 hours and in the milieu/common area from 0600 hours to 0645 hours.

9. Review of the 6-24-19 Patient Observation Monitoring records indicated the Nurse Assistant N21 documented 1:1 monitoring when Pt#4 was resting in bed in room 205A from 1900 hours to 2230 hours and documented 1:1 monitoring for Pt#2 when the patient was in room 207 from 1900 hours to 2230 hours.

10. Review of the 6-25-19 Patient Observation Monitoring records indicated the Certified Nurse Aide N14 documented 1:1 monitoring when Pt#4 was resting in bed in room 205A from 0700 hours to 1200 hours and documented 1:1 monitoring for Pt#2 when the patient was in the bathroom of room 207 from 0700 hours to 0730 hours, in the dining room from 0745 hours to 0845 hours, in the milieu/common area from 0900 hours to 1100 hours and in the dining area from 1115 hours to 1200 hours. Staff N14 documented 1:1 monitoring for Pt#4 in room 205A from 1330 hours to 1515 hours and from 1645 hours to 1900 hours and documented 1:1 monitoring for Pt#2 in room 207A from 1330 hours to 1515 hours, in the milieu/common area from 1645 hours to 1745 hours and in room 207 from 1800 hours to 1900 hours.

11. On 8-14-19 at 1020 hours, the Director of Clinical Operations A2 confirmed the above.

12. Review of the 6-27-19 Patient Observation Monitoring records indicated the Certified Nurse Aide N17 documented 1:1 monitoring when Pt#4 was resting in bed in room 205A from 1000 hours to 1200 hours and from 1245 hours to 1445 hours and documented 1:1 monitoring for Pt#2 in the hallway/milieu/common area from 1000 hours to 1200 hours, in room 207 from 1245 hours to 1330 hours, in the milieu/common area from 1345 hours to 1415 hours, and in room 207 from 1430 hours to 1445 hours.

13. Review of the 2nd admission for Pt#4 indicated admission orders on 7-23-19 for 1:1 suicide precautions and review of the 7-28-19 Patient Observation Monitoring records indicated the Certified Nurse Aide N23 documented 1:1 monitoring when Pt#4 was resting in bed in room 113 from 1415 hours to 1730 hours and documented q15 min (every 15 minutes) monitoring for Pt#6 in the hallway/milieu/common area from 1415 hours to 1730 hours.

14. Review of the 7-30-19 Patient Observation Monitoring records indicated the Certified Nurse Aide N24 documented 1:1 monitoring when Pt#4 was resting in bed in room 113 from 1915 hours to 2000 hours and documented q15 min monitoring for Pt#8 in the milieu/common area from 1915 hours to 2000 hours. The Certified Nurse Aide N25 documented 1:1 monitoring for Pt#4 in room 113 from 2000 hours to 2200 hours and on 7-31-19 from 0015 hours to 0230 hours and documented q15 min monitoring for Pt#8 in the milieu/common area from 2000 hours to 2200 hours and on 7-31-19 in room 103 from 0015 hours to 0230 hours. The Nurse Assistant N26 documented 1:1 monitoring on 7-31-19 when Pt#4 was resting in bed in room 113 from 0245 hours to 0500 hours and documented q15 min monitoring when Pt#8 was resting in bed in room 103 from 0245 hours to 0500 hours.

15. Review of the MR for Patient #6 (Pt#6) indicated orders on 8-1-19 for 1:1 fall precautions and indicated on 8-5-19 at 1215 hours the patient experienced a fall with injury and review of the Patient Observation Monitoring records for Pt#6 lacked documentation indicating on 8-3-19 from 0445 to 0700 hours that staff N24 or other staff maintained 1:1 monitoring for the patient.

16. Review of the 8-3-19 Patient Observation Monitoring records indicated the Nurse Assistant N28 documented 1:1 monitoring when Pt#6 was resting in bed in room 114A from 1115 hours to 1300 hours and documented q15 min checks for Pt#8 in room 103 from 1115 hours to 1300 hours. The Certified Nurse Aide N29 documented 1:1 monitoring when Pt#6 was resting in bed in room 114A from 1315 hours to 1845 hours and documented q15 min checks for Pt#8 in room 103 from 1315 hours to 1600 hours, in the day room from 1615 hours to 1800 hours and in room 103 from 1815 hours to 1845 hours.

17. Review of the 8-4-19 Patient Observation Monitoring records indicated the Certified Nurse Aide N31 documented 1:1 monitoring when Pt#6 was resting in bed in room 114B from 1315 hours to 1645 hours and documented q15 min checks for Pt#8 in room 103 from 1315 hours to 1400 hours and in the milieu/common area from 1415 hours to 1645 hours.

18. Review of the 8-7-19 Patient Observation Monitoring records indicated staff N23 documented 1:1 monitoring when Pt#6 was resting in bed in room 114B from 0700 hours to 1000 hours and documented q15 min checks for Pt#8 in the bathroom of room 103 from 0700 hours to 0715 hours, in the dining area from 0715 hours to 0815 hours, in the milieu/common area from 0815 hours to 0930 hours and in room 103A from 0930 hours to 1000 hours. The Patient Observation Monitoring record indicated the Certified Nurse Aide N31 documented 1:1 monitoring when Pt#6 was resting in bed in room 114B from 1000 hours to 1200 hours and 1400 hours to 1600 hours and documented q15 min checks for Pt#8 in room 103A from 1000 hours to 1200 hours and from 1400 hours to 1600 hours. The Patient Observation Monitoring record indicated staff N32 documented 1:1 monitoring when Pt#6 was resting in bed in room 114B from 2330 hours to 8-8-19 at 0130 hours and documented q15 min checks for Pt#8 in room 103A from 2330 hours to 8-8-19 at 0130 hours.

19. Review of the 8-8-19 Patient Observation Monitoring records indicated the Nurse Assistant N37 documented 1:1 monitoring when Pt#6 was resting in bed in room 114B from 2130 hours to 2345 hours and on 8-9-19 from 0300 hours to 0500 hours and documented q15 min checks for Pt#8 in room 103A from 2130 hours to 2345 hours and on 8-9-19 from 0300 hours to 0500 hours.

20. Review of the 8-9-19 Patient Observation Monitoring records indicated staff N24 documented 1:1 monitoring when Pt#6 was resting in bed in room 114B from 2130 hours to 8-10-19 at 0245 hours and documented q15 min checks for Pt#8 in room 103A from 2130 hours to 8-10-19 at 0245 hours.

21. Review of the MR for Patient #12 (Pt#12) indicated admission orders on 7-18-19 for 1:1 observation and review of the 7-23-19 Patient Observation Monitoring records indicated the Nurse Assistant N22 documented 1:1 monitoring for Pt#12 in the hallway/milieu/common area and dining area from 1015 hours to 1445 hours and documented 1:1 monitoring when Pt#4 was resting in bed in room 113 from 1015 hours to 1445 hours.

22. On 8-14-19 at 1350 hours, the Director of Clinical Operations A2 confirmed that 1:1 observation means that a staff member is within arm's reach of a patient and paying attention to the patient.

23. On 8-14-19 at 1620 hours, the President and Chief Executive Officer A1 was requested to provide documentation indicating any additional direct care staff were present on the nursing units 100, 200 and/or 300 for the time period from 6-1-19 to the present day and none was received prior to exit.

24. On 8-14-19 at 1720 hours, staff A1 confirmed the above and confirmed no other documentation was available.

Based on document review and interview, the facility failed to ensure nursing supervision related to fall prevention for 1 of 10 medical records reviewed (Patient #6), wound treatments as ordered for 1 of 10 medical records reviewed (Patient #8), and assistance of activities of daily living related to showers/bathing for 2 of 10 medical records reviewed, (Patient #6 and 8) and failed to ensure documntation of assessments were completed by the person responsible for evaluating or providing the care for 1 of 10 MR reviewed (Patient #11).

Findings include:

1. Facility policy titled "PATIENT OBSERVATION POLICY" last reviewed/revised 6/2019 indicated the following: "...PROCEDURE...2. Observation levels can be increased or decreased by a provider's order. A. Provider Orders: Providers will order specific observations for any patient(s) who requires level of monitoring other than routine, including but not limited to: ...4. Fall...B. Observation Levels: A frequency or intensity of observation assigned to a patient during which a healthcare professional, or their designee, will observe a patient. The approved observation levels assigned are...2. Level II - 1:1 Observation...b. At least one health care provider will be present with the patient at all times, be within arm's length..."

2. Facility policy titled "STANDARDS OF PATIENT CARE" issued 6/2018 indicated the following: "...POLICY... Patients admitted...can expect patient care management that is compliant with quality care standards...PROCEDURE...MAINTENANCE OF SKIN INTEGRITY/WOUND MANAGEMENT...Standard of Care II: Treatments prescribed for wound management will be performed..."

3. Facility policy titled "PERSONAL HYGIENE" issued 6/2018 indicated the following: "...II. POLICY...a. All patients admitted to the hospital will be supported...in activities of daily living (ADLs), focusing on personal hygiene and grooming...III. PROCEDURE...i. CMS [Centers for Medicare and Medicaid Services] defines ADLs as activities related to personal care, which includes the following: 1. Bathing/showering..."

4. The policy/procedure Timeliness of Nursing Medical Record Completion (revised 6-19) indicated the following: "A complete head to toe shift assessment will be completed every shift by the RN... Progress notes will be completed every shift to document patient behaviors and activity during the shift."

5. Review of patient #6's medical record indicated the following:
(A) The patient was admitted on 7/27/19 and a current patient.
(B) A review of "DAILY NURSING NARRATIVE" dated 8/5/19 at 12:15 p.m. indicated the following: "...Noted on the floor next to table side lying [with] blood to back of head [and] on floor..."
(C) A review of an "INCIDENT/OCCURENCE REPORT" indicated the patient had a fall on 8/5/19 at 12:15 p.m. and indicated the following: "...Fall [check in box indicated] Unwitnessed...[Patient] Sitting up in w/c [wheelchair] at the table outside the glass door...Tab alarming alert sounding look to the left and [Patient #6] is lying on the floor. Left side lying. Blood noted to floor under [Patient #6's] head...Area to back of head...approx. [approximately] 1 cm [centimeters] opening [with] initial signs of bruising noted..."
(D) A review of a physician order dated 8/1/19 at 0336 hours indicated the following: "...Patient 1:1 due to recent fall. A review of a physician order dated 8/1/19 at 1435 hours indicated the following: "...Continue 1:1 for patient safety at this time..." The medical record lacked documentation for patient #6's 1:1 observation status ordered on 8/1/19 at 0336 hours.
A review of a physician order dated 8/5/19 at 1226 hours indicated the following: "Continue 1:1 status..."
(E) The patient had a bed bath on 8/7/19 and lacked documentation of showers/baths and/or refusals on the following dates: 7/28/19, 7/29/19, 7/30/19, 7/31/19, 8/1/19, 8/2/19, 8/3/19, 8/4/19, 8/5/19, 8/6/19, 8/8/19, 8/10/19, 8/11/19 and 8/12/19.

6. Review of patient #8's medical record indicated the following:
(A) The patient was admitted on 7/15/19 at 2249 hours and was a current patient.
(B) The patient had a shower on 7/23/19, 7/27/19, 7/31/19, a refusal on 7/30/19 and lacked documentation of showers/baths and/or refusals on the following dates: 7/16/19, 7/17/19, 7/18/19, 7/19/19, 7/20/19, 7/28/19, 7/29/19, 8/1/19, 8/2/19, 8/3/19, 8/4/19, 8/5/19, 8/6/19, 8/7/19, 8/8/19, 8/9/19, 8/10/19 and 8/11/19.
(C) The patient had a physician order for the following:
a. On 7/17/19 at 1700 hours, "...Cleanse stasis ulcer to Lt [Left] lower shin [with] N.S. [normal saline]. Apply Anasept wound gel to wound bed et [and] cover [with] dry dressing every other day et prn [as needed] if soiled or dislodged..."
b. On 8/2/19 at 0909 hours, "...4) Diligent wound care to (L) [Left] shin wound as ordered by wound care on 7/17 [2019]..."
(D) The patient had wound treatments to his/her left shin on 7/17/19, 7/24/19, 7/28/19, 7/31/19, 8/2/19, 8/3/19, 8/5/19 and lacked documentation of wound treatments and/or refusals on 7/19/19, 7/21/19, 7/23/19, 7/26/19 and 7/30/19.

7. Review of the MR for Patient #11 lacked documentation on 7-27-19 from 1900 hours to 7-28-19 at 0700 hours of a complete head to toe shift assessment or a progress note entry by the Registered Nurse N3 or N7 around the day and time of a critical patient safety event.

8. During an interview on 8/14/19 at 1:50 p.m. with A2 (Director of Clinical Operations), he/she verified that Patient #6 was on 1:1 observation at the time of his/her fall on 8/5/19. A2 verified that 1:1 observation means that a staff member is within arm's reach of a patient and paying attention to the patient. A2 verified the medical record for Patient #6.

9. During an interview on 8/14/19 at 3:00 p.m. with A2, he/she verified that patients are scheduled two times a week and on patient preference related to assistance with bathing.

10. During an interview on 8/14/19 at 5:10 p.m. with A2, he/she verified the medical record for Patient #8. A2 verified that Patient #8's wound treatment related to his/her left shin would be documented on the treatment administration record and/or the Wound Nurse's notes. A2 verified if any documentation of bathing for Patients #6 and #8, it would be on the patients' observation monitoring or shower sheets. A2 verified he/she had provided all the additional bathing documentation he/she had for Patients #6 and #8 prior to exit of the facility on 8/14/19.

11. During an interview on 8-14-19 at 1114 hours, the Director of Clinical Operations A2 confirmed the MR for patient #11 lacked the indicated entries and no other documentation was available.