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Based on record review and staff interview, the facility failed to ensure all allegations of abuse were reported (A0145). The facility failed to restraints were implemented in accordance with hospital policy (A0167).

Based on record review and staff interview, the facility failed to ensure that all allegations of abuse are reported for one of ten patients reviewed (Patient #1). The patient census was 568.

Findings include:

The medical record of Patient #1 revealed the patient presented to the Emergency Department on 07/22/18 at 11:11 PM intubated after cardiac arrest was noted. The patient remained inpatient in numerous hospital departments including Heart and Vascular Intensive Care Unit, Pulmonary Acute Care Unit, Cardiac Acute Care Unit, Neuroscience Intensive Care Unit, Gynecology Oncology Unit, and Renal Transplant Unit for several months after being placed on medical hold due to the assessment by the medical team stated the patient lacked the capacity to make decisions.

A progress note composed by a psychiatric resident on 10/10/18 at 4:47 PM and co-signed by his/her covering attending physician on 10/10/18 at 5:19 PM stated the following, "Patient states he/she is upset because he/she feels like no one is listening to him/her. He/she mumbles and is tangential but states belief that a respiratory therapist put his/her knee on his/her chest several days ago and that is why he/she has chest pain. He/she had his/her phone and cell phone taken away as he/she was calling 911 to report the alleged crime." Despite the patient reporting potential assault and both physicians stating the allegation was an alleged crime, the medical record lacked documentation the incident was investigated.

Review of new resident orientation dated 06/28/17 for Risk Management and Insurance revealed the that responsibilities as a resident included but were not limited to notification to risk management of any incident or event that causes harm to a patient, requires medical intervention, is an unexpected outcome or unanticipated deterioration in condition.

Review of the complaint/adverse event log from 01/01/18 to 01/03/19 revealed no evidence of any complaints regarding patient abuse.

Interview with Staff A on 01/04/19 at 12:30 PM revealed nursing was not made aware that Patient #1 had reported that a respiratory therapist had put their knee in his/her chest. Staff A revealed the resident physician should have reported this to someone.

Interview with Staff C on 01/04/19 at 1:00 PM revealed he/she was not aware of the allegation of abuse made by Patient #1 on 10/10/18. Staff C further revealed nothing was mentioned about this allegation of abuse until 01/03/19.

Based on record review and staff interview, the facility failed to ensure staff followed the current facility policy related to use of restraints for three of three patients reviewed who were restrained (Patient #1, #6, and #7). The sample size was ten patients. The patient census was 568.

Findings include:

The facility policy titled, Premier Nursing Services Nonviolent Restraint was reviewed on 01/03/19. Review of the policy revealed nonviolent restraint monitoring should occur every two hours or sooner based upon patient need. It was further noted an order by the physician or other licensed independent practitioner is required immediately (within a few minutes) after the restraint is applied. Authentication of a telephone order/verbal order based upon an examination of the patient by a qualified licensed independent practitioner must be in the computer system within 24 hours of initiation.

1. The medical record of Patient #1 revealed the patient presented to the Emergency Department on 07/22/18 at 11:11 PM intubated after cardiac arrest was noted. Nonviolent restraints were initiated on 07/22/18 at 11:40 PM as the patient was noted to be pulling at tubes and lines. The medical record revealed staff monitored the patient on 07/23/18 at 8:45 PM, however, the medical record lacked documentation the patient was monitored again until 8:00 AM on 07/24/18, more than 11 hours later.

Staff A was interviewed on 01/04/19 at 12:50 PM. It was confirmed that the medical record lacked documentation of monitoring as required be facility policy.

2. The medical record of Patient #6 was reviewed on 01/04/19. The patient, a resident of a local extended care facility, was found to be hypoxic and was transported to the facility Emergency Department on 12/05/18 at 9:07 AM. Further review of the patient's record revealed nonviolent restraints were initiated on 12/10/18 at 8:20 AM as the patient was noted to be pulling at tubes and lines. Documentation of the two hour monitoring was noted on 12/22/18 at 12:45 AM but not noted again until 4:45 AM. It was further noted that monitoring was completed on 12/22/18 at 5:45 AM but not completed again until 12:15 PM. Monitoring was completed on 12/23/18 at 4:15 AM but again, the medical record lacked documentation of monitoring until 8:15 AM.

Staff A was interviewed on 01/04/19 at 5:05 PM. It was confirmed that the medical record lacked documentation of monitoring as required by facility policy.

3. The medical record of Patient #7 was reviewed on 01/04/19. Patient #7 presented to the Emergency Department on 12/21/18 at 8:01 PM. The patient had a history of borderline personality disorder, factitious disorder with purposely swallowing non-food objects, and severe anorexia with malnutrition. The patient had a history of assaulting a nurse during a previous hospitalization. Bilateral locked wrist and ankle restraints, which were violent restraints, were initiated at on 12/23/18 at 10:55 AM. Although visual monitoring was noted every 15 minutes, the medical record lacked documentation violent restraint monitoring every two hours was performed until 6:15 PM on 12/23/18.

The facility policy for violent restraints was reviewed on 01/04/19. Review of the policy revealed violent restraint monitoring should be performed every two hours or sooner based upon patient need that includes: Clinical justification, current restraint device still appropriate; Circulation, range of motion, fluids, food/meals, and elimination as appropriate; Documented visual monitoring every 15 minutes.

Staff A was interviewed on 01/04/19 at 7:45 PM. It was confirmed the medical record lacked documentation the patient was monitored every two hours for clinical justification, circulation, range of motion, offering fluids and meals, and elimination.

Based on record review and staff interview, the facility failed to ensure staff followed the current facility policy related to the skin integrity maintenance program for one of one patient reviewed with presssure ulcers (Patient #2). The sample size was ten patients. The patient census was 568.

Findings include:

The Renal Transplant Unit was toured on 01/02/19 at 3:35 PM. During the tour, Patient #2 and his/her family were interviewed. Patient #2's family member reported that staff did not turn the patient and the patient was experiencing worsening of a pressure ulcer to the coccyx.

The medical record of Patient #2 revealed the patient presented to the Emergency Department on 12/25/18 at 6:15 PM via ambulance with complaints of shortness of breath that started the day before. The attending physician History and Physical (H&P) revealed the patient reported diarrhea and general "not feeling good" for one week. Although the patient showed no obvious signs of distress, he/she was noted to be pale. The H&P further noted the patient had chronic medical problems including congestive heart failure, chronic kidney disease, status post kidney transplant, sick sinus syndrome, status post pacemaker placement and morbid obesity.

The initial skin assessment on 12/25/18 at 10:30 PM noted the patient's general skin character was dry and flaky, the skin color was pale, and a "pressure injury" to the coccyx was noted next to skin integrity. The pressure injury to the coccyx was noted to be identified during a previous hospital admission on 10/15/18 but remained during this admission. The functional level of the patient was noted to be "total assist" at this time. The medical record also noted a space next to two person skin assessment. The space was blank.

Staff F, Staff Educator and computer guide, was interviewed on 01/03/19 at 10:00 AM. He/she was asked the meaning of the two person skin assessment and he/she replied that on admission, the admitting nurse was required to assess the skin of the patient with another staff member to assess for any areas of skin breakdown. The two staff members were required to place their initials in the space provided. It was confirmed that the designated area for the initials of the two staff members was blank. Staff C was interviewed at 12:00 PM. He/she corrected the staff educator informing this surveyor there was no requirement for a two person skin assessment, stating the assessment had been "done away with a while ago."

The facility policy titled Skin Integrity Maintenance Program and Pressure Ulcer Prevention Program Initiatives was reviewed on 01/03/19. Review of the policy revealed a comprehensive skin assessment, which included a pressure ulcer risk assessment or Braden Score would be completed upon admission, transfer, and day of discharge. A Braden score of less than 18 would generate an order for PUPPI (Pressure Ulcer Prevention Program Initiatives) guidelines. The policy further stated notification to the Wound Care Team was recommended for all patients having a pressure ulcer. The attending physician must be notified of all suspected pressure ulcers present on admission for evaluation, treatment, and documentation. The policy instructed staff that turn/position documentation was required at least every two hours.

The Braden score of Patient #2 was noted to be 15 on admission. The patient was noted to be turned and positioned to a supine position (lying horizontally with the face and torso facing up) on his/her back at 10:30 PM on 12/25/18. At 12:55 AM on 12/26/18 the patient was turned and repositioned to the right side. Five minutes later, at 1:00 AM the patient was turned and repositioned in a supine position on his/her back. The patient was noted to be turned and repositioned two hours later, at 3:00 AM, to a supine position on his/her back. At 3:59 AM the patient was turned and repositioned to the left side. The assessments at 4:35 AM, 5:00 AM, and 6:18 AM all revealed the patient was positioned on his/her back. Initiation of PUPPI guidelines (Pressure Ulcer Prevention Program Initiatives) was ordered on 12/26/18 at 6:26 AM. Despite an identified pressure injury to the coccyx, the medical record lacked documentation the attending physician was notified. On 12/26/18 the patient was noted to be turned and positioned at 8:17 AM, 8:38 AM, 3:08 PM, 5:38 PM, 6:45 PM, 7:00 PM, 8:46 PM, 9:00 PM, 10:51 PM, and 11:00 PM. Each of these turns and positioning were noted to be in the same supine position with the patient on his/her back. A nursing note at 5:49 PM on 12/31/18 stated a foam dressing was applied to the pressure injury on the coccyx of the patient; however, the medical record continued to lack documentation the attending physician was notified.

Staff A was interviewed on 01/03/19 at 2:45 PM. It was confirmed that although the patient was noted to have a pressure injury to his/her coccyx, the documentation revealed the patient remained primarily on his/her back instead of being turned to different positions to keep pressure off of the patient's coccyx. It was further confirmed that the medical record lacked documentation the attending physician was notified of the pressure injury as required by facility policy.

A nurse's note on 010/3/19 at 3:49 PM stated a two person skin assessment was completed prior to the patient being discharged home.