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Based on review of policies and procedures and personnel files, and staff interviews, it was determined the hospital failed to ensure there was a comprehensive system in place to protect patients from all forms and sources of abuse and neglect.

Findings:

1. The hospital's policies and procedures concerning allegations of abuse and/or neglect, Policies #35-PE-104 and #2500-RI-110, were provided to the surveyors on the morning of 07/08/2013. The policies did not specifically state what steps the hospital would take to protect the patient and the staff, against whom the allegation was made, and to continue while the allegation is investigated. This was verified with staff at the time of review.

2. The policies stated staff would be trained on abuse and neglect. Review of eight personnel files and other training documents, provided to the surveyors on the afternoon of 07/08/2013, did not contain evidence staff had been trained in the procedures to follow if they received a complaint that a staff member abused, harassed, or neglected a patient. This was confirmed with Staff J, K, P, and Q at the time of review.

Based on review of hospital documents, policies and procedures and medical records and interviews with hospital staff, the hospital failed to ensure restraints were used only to ensure the immediate safety of patients and staff and were discontinued at the earliest possible time. The hospital does not review and analyze restraint use, other than in the geriatric psychiatric unit, through the quality assessment and performance improvement (QAPI) program to ensure restraints are:
a. Used appropriately and according to hospital policy;
b. Discontinued as soon as possible; and
c. Are not used for staff convenience.

Findings:

1. The surveyors requested to review meeting minutes where restraint use was reviewed. The surveyors were provided minutes for the Restraint Committee, but only minutes for May 30, 2013 were provided, and the minutes did not contain evidence of a review and analysis of restraint use. Staff L and M stated the committee had met only once and confirmed that review and analysis of restraint use was not performed.

2. On the afternoon of 07/08/2013, Staff M stated that the Quality Medical Oversite Council would have contained any review of restraint use. The surveyors asked to review any meeting minutes for 2013 that contained a review of restraint use. Staff M stated she reviewed the meeting minutes, but they did not contain review of restraints.

3. This finding was reviewed during the exit conference with administrative staff on the afternoon of 07/08/2013. No additional information was provided.

Based on review of hospital policies and procedures and medical records, the hospital failed to ensure restraints orders were renewed according to hospital policy. This occurred in six (Records # 4, 6, 7, 8, 9, and 10) of ten medical records where restraints were utilized.

Findings:

1. The hospital's policy specified that restraint orders needed to be renewed every 24 hours.

2. Medical records #4, 6, 7, 8, 9, and 10 did not contain renewal orders for restraints as specified in the hospital's policy and procedures.

3. The findings for Record #10 were review with Staff J and P at the time of review on 07/08/2013.

4. The surveyors reviewed the findings from the additional medical records with administrative staff during the exit conference on the afternoon of 07/08/2013. No additional information was provided.

Based on review of patient medical records and hospital documents, the hospital failed to:

a. Develop a death reporting policy that addressed the requirements of reporting to CMS (Centers for Medicare and Medicaid Services) and the documentation required.

b. Ensure the clinical record contained documentation of the date and time CMS was notified of the death of a patient during the use of restraints. This occurred for three of four deaths relating to restraints that should have been reported to CMS (Record #2, 3 and 5 of Records #2, 3, 5 and 10) whose charts were reviewed.

Findings:

1. The restraint and seclusion policy did not provide guidance to staff regarding the requirements of reporting restraint deaths to CMS and charting the information with date and time in the patient's medical record. Staff J and K confirmed this finding.

2. On 07/08/2013, Staff H stated she checked to ensure the forms were sent to CMS, but any nurse could fill out the paperwork and send it to CMS.

3. On 07/08/2013 at 1223, Staff K stated that until their recent survey by their accrediting agency, they were unaware to the requirement to document the information in the medical record.