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Based on observation, interview and document review, the hospital failed to thoroughly investigate allegations of sexual abuse for 1 of 3 (P1) patients reviewed for abuse.

Findings include:

P1's Face Sheet printed 1/12/22, indicated P1 was admitted for altered mental state and an infrarenal aortic thrombus (blood clot inside kidney vessel).

P1's History and Physical (H&P) dated 12/9/21, indicated P1 was admitted for altered mental state and an infrarenal aortic thrombus, and was diagnosed with acute encephalopathy (brain dysfunction), acute kidney injury, and hypoxic respiratory failure from COVID-19 pneumonia. The H&P indicated P1 was "profoundly confused," picking at air, unable to following directions, and was non-verbal. The note identified P1 lived with FM-A.

On 1/12/22, at 3:06 p.m. nursing assistant (NA)-C was interviewed and stated on 12/31/21, during the evening shift, she observed P1's family member (FM)-A lean over the side of the bed and kiss P1 in a manner making her feel very uncomfortable. NA-C stated she had only seen the type of sexual kiss on television and not in real life. NA-C stated she was assigned to be a 1:1 attendant to P1 to keep him from pulling on lines or trying to get out of bed. NA-C when FM-A arrived to visit, he asked her to leave the room so they could have privacy. NA-C stated she stepped out of the room but then looked back and saw FM kissing P1 on the mouth for a "long period of time, almost a minute." NA-C stated she promptly reported this to the charge nurse, registered nurse (RN)-H. NA-C stated she reported it to NA-B the next day, because she was concerned for P1's safety and wanted NA-B to be alert and watch when FM-A was visiting P1.

P1's Nursing Shift Care Plan Summary Note (NSPCPSN) dated 12/31/21, at 10:47 p.m. indicated P1 was calm in the morning and agitated in the afternoon. The note lacked documentation of the FM-A's visit, concerns about the FM-A's visit, the nursing assistant (NA) observation of the FM-A's behavior, or any changes in the plan to keep P1 safe.

P1's NSPCPSN dated 1/7/22, at 10:30 p.m. indicated FM-A visited P1 for half of the shift; the note lacked indication of any concerns with FM-A's visit.

On 1/12/22, at 2:21 p.m. RN-C stated she worked on 1/1/22, the day after FM-A allegedly kissed P1 on the mouth. RN-C stated she did not learn about the incident until 1/4/22, when RN-D told her a NA reported FM-A asked her to leave the room for privacy and when she looked back, she FM-A kissing P1 on the mouth. RN-C stated she informed her manager RN-G, and social worker (SW)-A on 1/5/22. RN-C stated she "didn't think to report to someone" because she thought it was "hearsay." RN-C stated P1's care plan was not changed because he already had a 1:1 attendant to prevent falls, but believed the attendants were told not to leave the room unless they check with the charge nurse first.

On 1/12/22, at 2:38 p.m. SW-A stated he learned about the sexual abuse allegation during rounds on 1/5/22, and once he heard about it, he informed RN-G this needed to be reported to the state agency (SA), which he did. SW-A stated the Adult Protective Services Case Worker (APSCW) called him on 1/6/22, and informed him the facility might need to interview FM-A, but SW-A had no further part in the abuse allegation investigation. SW-A stated RN-G took on the role as the primary contact for APSCW.

On 1/12/22, at 4:06 p.m. RN-G stated during rounds on 1/3/22, RN-D informed RN-C, SW-A, RN-G, and the care coordinator (CC) that NA-C had witnessed inappropriate contact between P1 and FM-A. RN-G stated SW-A reported to the SA and she reported to risk management (RM), whom RN-G stated would take the lead in the internal investigation. RN-G stated staff were informed not to allow the 1:1 to leave the room when FM-A was present and when 1:1 discontinued, P1 was observed using a remote observation camera. RN-G stated there were no visitors now because of COVID-19, but they did move P1 closer to the nurses' station so they could observe who went in and out of the room. RN-G verified FM-A could still visit, but staff needed to monitor him.

On 1/14/22, at 11:11 a.m. FM-A was interviewed and stated on 12/31/21, he asked the NA to leave so he could have privacy with P1, but only because he really loved and missed him. FM-A stated he showed P1 affection by hugging and "maybe and occasional peck on the forehead" but denied ever kissing P1 on the lips or in a sexual manner.

The facility's Attendant Use Policy dated December 2019, directed the attendant (1:1)'s primary responsibility was to observe the patient and keep the patient safe.

Based on interview and document review, the hospital failed to report a death of a patient within 24 hours of being restrained for 3 of 3 patients (P2, P3, P4) reviewed for deaths related to restraint use.

Findings include:

The facility's Patient Death Associated with Restraint or Seclusion document printed 1/12/22, indicated P2, P3, and P4's deaths occurred within 24 hours after restraints were removed, were not reported to the Centers for Medicare and Medicaid Services (CMS).

P2's History and Physical (H&P) dated 12/3/21, indicated P2 had diagnoses of bacteremia (blood infection), diabetes, heart disease, and kidney disease, and was admitted for confusion and delirium without a history of any neurocognitive disorders.

P2's Physician Orders dated 12/14/21, at 10:50 p.m. indicated soft limb restraints were ordered for a maximum time of 1 calendar day. The order lacked specificity of how many soft limb restraints and which limbs were to be restrained.

P2's Restraint Flowsheet reviewed 1/14/22, indicated
Soft left ankle and right ankle restraints were applied on 12/14/21, at 10:07 p.m.; they were discontinued on 12/15/21, at 6:17 a.m.
Soft left wrist and right wrist restraints were applied on 12/15/21 at 12:34 a.m.; they were discontinued on 12/15/21, at 6:17 a.m.

On 12/15/21, a progress note indicated P2 died at 8:59 p.m., less than 24 hours after ankle and wrist restraints were removed.

P3's H&P dated 12/22/21, indicated P3 had diagnoses of heart disease, diabetes, and kidney disease, and was admitted with heart failure.

P3's Physician's Orders dated 12/25/21, at 11:33 p.m. indicated soft limb restraints were ordered for a maximum time of one calendar day. The order lacked specificity of how many soft limb restraints and which limbs were to be restrained.

P3's Restraint Flowsheet reviewed 1/14/22, indicated:
Soft right ankle, right wrist, and left wrist restraints were applied on 12/26/21, at 12:38 a.m.; they were discontinued on 12/26/21, at 8:14 a.m.
Soft left ankle restraint was applied on 12/26/21, at 4:14 a.m.; they were discontinued on 12/26/21, at 8:14 a.m.

P3's progress note dated 12/27/21, indicated P3 died at 1:29 a.m., less than 24 hours after ankle and wrist restraints were removed.

P4's H&P dated 8/6/21, indicated P4 had diagnoses of heart disease and was admitted to the hospital after a cardiac arrest (heart attack) requiring advanced cardiac life support prior to hospitalization.

P4's Physician's Orders dated 8/14/21, at 4:22 p.m. indicated soft limb and secured mitts restraints were ordered for a maximum time of one calendar day. The order lacked specificity of how many soft limb restraints and which limbs were to be restrained.

P4's Restraint Flowsheet reviewed 1/14/22, indicated:
Soft and left wrist restraints were applied on 8/12/21, at 11:34 a.m.; they were discontinued on 8/14/21, at 6:35 p.m.
Secured left and right mitt restraints were applied on 8/14/21, at 6:35 p.m.; they were discontinued on 8/14/21, at 10:15 p.m.

P4's progress note dated 8/14/21, indicated P4 died at 11:50 p.m., less than 24 hours after wrist restraints and left and right secured mitt restraints were removed.

On 1/14/22, at approximately 2:00 p.m. the safety specialist (SS)-A, director of system accreditation (DSA)-A, and registered nurse (RN)-G confirmed P2, P3, and P4's medical records indicated they were in more than 2-point soft wrist restraints, and died in less than 24 hours after they were removed. DSA-A verified the deaths were not reported to CMS.

The facility's Restraints - Nonviolent Behavior policy dated August 2018, lacked information about reporting deaths within 24 hours of being restrained.