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Based on medical record (MR) review, document review and interview, facility staff did not ensure an incident of potential abuse was identified and investigated as a Complaint or Grievance.

This lack of investigation potentially resulted in the facility not identifying areas for improvement and implementing corrective actions.

Findings:

Review of Patient #1's MR identified a Physician Note written by Staff E (Psychiatrist), dated 9/3/2021 at 12:34PM, stated that Patient #1 "...struck staff with a closed fist...assaulted staff injuring one security member and in the tussle, [Patient #1] got a bloody nose that soon stopped."

Review of the facility's "Security Report," written by Staff G (Security Officer) and dated 9/3/2021 at 1:10PM, stated that Patient #1 was "Very combative" and "Scratched [Staff I / Security Officer] on his cheek and neck and punched him in the face." The Security Report stated that Staff I tried to defend himself from the patient's punche,s and the patient was "accidentally struck on the forehead."

Per interview of Staff G on 12/8/2021 at 2:12PM, Staff G stated he had received a call from the house manager of the patient's residential group home asking why the patient came back to the group home with "scratches" on her face. This phone call was not documented in the Security Report.

The facility policy and procedure titled, "Complaint/Grievance Policy/Process", last revised 9/5/2019, defined a complaint as "A verbal concern that is made regarding an issue raised by a patient or patient's representative." The same policy identified a Grievance as a "formal or informal ...verbal complaint ...regarding the patient's care, abuse or neglect..."

The policy stated, "Patient complaints that are considered grievances also include situations where a patient or a patient's representative telephones the Medical Center with a complaint regarding the patient's care or with an allegation of abuse.."

The facility policy and procedure titled, "Patient Abuse and Neglect: Prevention, Detection, Interventions and Reporting", last revised 4/19/2019, stated, "The Nursing Supervisor is notified immediately" and "All involved staff members will be requested to participate in an interview process ..."

Staff G did not document the phone call from the patient's group home nor escalate the patient concern to the Nursing Supervisor or another authority.

Per interview with Staff A (Director of Risk Management) on 12/7/2021 at 1:30PM, the facility security cameras save recorded video for 30 days. Video is only saved for a longer period in the event of an incident or complaint allegation. Since there was no complaint identified or reported, no video of the patient altercation was saved, and no investigation into the patient concern / injury was conducted by the facility.

These findings were confirmed by Staff A at the time of interview.

Based on medical record (MR) review, document review and interview, the facility staff did not ensure a patient was re-evaluated by a physician after a physical altercation.

This failure placed all patients at increased risk of not having medical needs met.

Findings:

Review of the Patient #1's MR identified a Physician Note by Staff E (Psychiatrist) dated 9/3/2021 at 12:34PM, which stated that during discharge, Patient #1 "Assaulted staff injuring one security member and in the tussle, [Patient #1] got a bloody nose that soon stopped."

Review of the facility's "Security Report" dated 9/3/2021 at 1:10PM, stated that Patient #1 was "very combative" and "scratched a security officer on his cheek and neck and punched him in the face. While trying to defend himself from the patient punches, [Patient #1] was accidentally struck on the forehead."

Staff E's Physician Note further stated that because of Patient #1's "Continued violent behavior, police were called." The police offered the patient transport to another hospital, but the patient refused.

As per the Security Report, Patient #1 was returned to her group home residence in a taxi.

Per interview of Staff G (Security Officer) on 12/8/2021 at 2:12PM, Staff G stated that he received a call from Patient #1's residential group home's House Manager asking why the patient returned to the group home with "scratches" on her face?

There is no documented evidence Patient #1 was medically re-evaluated for injuries by a physician after the incident, and before Patient #1 was returned home from the hospital premises.

This finding was confirmed on 12/8/2021 at 1:15PM by Staff E (Psychiatrist), who was present during the incident.

Based on medical record (MR) review, document review and interview, in three (3) of five (5) MRs, the facility did not ensure Physician Orders were in place or renewed for patients in four-point Behavioral restraints.

This failure placed all patients at increased risk of harm.

Findings:

The facility policy and procedure (P&P) titled "Restraints," last dated 5/9/2019 stated, "The physician ...must write an order for restraints..." and "...Each order must include: date and time of order, reason for restraint, type of restraint, start time of restraint and duration ...as indicated by age: 4 hours for Adults."

Patient #4's MR identified that on 11/15/2021, Patient #4 presented to the Emergency Department (ED) for evaluation after running into a door at the psychiatric facility where he was receiving care. The patient was agitated and having auditory hallucinations on initial presentation to the ED.

The physician ordered Patient #4 placed in four-point Behavioral restraints for four (4) hours for severe agitation and aggression, starting at 4:53PM. At 8:24PM, Patient #4 was admitted with a diagnosis of Rhabdomyolysis. The patient remained in restraints until 3:30AM on 11/16/2021. The patient was restrained for a total of 7 hours and 6 minutes, with no documented evidence that the restraint order was renewed four (4) hours after the initial restraint order.

The facility policy and procedure (P&P) titled, "Restraints," last dated 5/9/2019, lacked guidance directing staff to obtain new physician orders for Behavioral restraints required beyond the initial 4-hour period.

During interview of Staff F (Director of ED) on 12/8/2021 at 10:15AM, Staff F confirmed this finding.

Patient #2's MR identified this patient presented to the ED on 9/10/2021 at 7:22PM for evaluation after a suicide attempt. The patient was treated and placed on 1:1 constant observation.

On 9/11/2021 at 5:54AM, Patient #2 became agitated. The patient was medicated and placed in 4-point restraints. A face-to-face evaluation was completed at 5:58AM; however the physician ordered 2-point restraints, and the order was not placed until 8:57AM, three (3) hours after the initiation of the restraints. No order for the 4-point Behavioral restraint was found, and the type of restraint applied by staff was inconsistent with the physician's order.

Patient #3's MR identified this patient was admitted to the ED on 10/14/2021 at 4:56PM for evaluation after a suicide attempt with a self-inflicted laceration to her left forearm. Patient #3 became aggressive towards staff and was placed in 4-point behavioral restraints. The physician completed a face-to-face assessment at 5:00PM, but no order for the 4-point behavioral restraint was found.

Per interview with Staff D (Nurse Manager of ED) on 12/8/2021 at 9:30AM, Staff D confirmed these findings.

Based on medical record (MR) review, document review and interview, in one (1) of four (4) MRs, the facility did not ensure a physician face-to-face evaluation was completed within one-hour of behavioral restraint initiation.

The lack of a face-to-face evaluation placed restrained patients at increased safety risk.

Findings:

The facility policy and procedure (P&P) titled, "Restraints," last dated 5/9/2019 stated, "If violent restraints are indicated, a [facility]-employed Physician...must perform a face-to-face assessment within one hour of initiation. Each order must include: ...start time of restraint and duration, as indicated by age: 4 hours for Adults...Each renewal needs a face-to-face re-evaluation by a Physician."

Patient #4's MR identified that on 11/15/2021, Patient #4 presented to the Emergency Department (ED) for evaluation after running into a door at the psychiatric facility where he was receiving care. The patient was agitated and having auditory hallucinations on initial presentation to the ED.

The physician ordered 4-point behavioral restraints for four (4) hours on 11/15/2021 at 12:20PM. There is no documented evidence a physician face-to-face evaluation was performed within 1-hour of the initiation of the behavioral restraint.

The physician then ordered Patient #4 placed in 4-point behavioral restraints for four (4) hours at 4:53PM. There is no documented evidence a physician face-to-face evaluation was conducted within 1-hour.

Patient #4 remained in 4-point behavioral restraints until 3:30AM on 11/16/2021. No documented evidence of a physician face-to-face evaluation for Patient #4's behavioral restraints were found.

Per interview with Staff F (Director of ED) on 12/8/2021 at 10:15AM, Staff F confirmed these findings.