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Based on interview and record review, the hospital failed to ensure the hospital's P&P was implemented for one of two sampled patients (Patient 1) related to the investigation not being thoroughly completed prior to having NA 1 return to provide the patient care after an allegation of physical assault was reported to the hospital involving Patient 1 and NA 1. This failure increased the risk of substandard care to the patients.

Findings:

Review of the hospital's P&P titled Patient Complaints and Grievances dated December 2022 showed the purpose is to describe the process for receiving, investigating, and responding to complaints or grievance. A complaint is defined as a verbal complaint of concern or dissatisfaction made by a patient or the patient's legally authorized representative that can be resolved at the time of the complaint by staff present. A grievance is defined as a written or verbal complaint that is made by a patient or the patient's authorized representative regarding patient care, abuse or neglect. Any verbal complaint that can not be resolved time of complaint, is postponed for later resolution, is referred to other staff for later solution, or required investigation, is considered a grievance.

Review of the hospital's P&P titled Guidelines for Addressing Allegations of Inappropriate Behavior Toward a Patient dated October 2022 showed the facility will evaluate all allegations, observations, and suspected cases of abuse that occurs in the facility and report such incidents in accordance with the provisions of the policy and guidance.

Further review of the P&P showed any workforce member who is informed by a patient or visitor of reasonable suspicion of abuse of any kind will report it to the supervisor or manager. An interview will take place as soon as possible after the complaint by a manager, administrator, or risk management to determine the details of the complaint. Any reasonable suspicion of inappropriate conduct will be referred to the Sheriff's department. During an investigation, the workforce member or other person will be removed from providing patient care, treatment, or services to the patient as appropriate.

On 8/30/24 at 1052 hours, an interview was conducted with the Director of Regulatory Affairs, Clinical Nursing Director II, House Supervisor 1, and NA 1.

The Director of Regulatory Affairs stated on 8/17/24 at approximately 1100 hours, Patient 1's family member stated the patient alleged a staff member had hit her during the night shift. When asked, the Director of Regulatory Affairs stated the patient pointed and identified NA 1 as the staff member who had hit her. House Supervisor 1 stated NA 1 worked on the dayshifts. House Supervisor 1 was notified and spoke to the patient's family member. The patient's family member shared the patient alleged she was shoved into the bed's side rail by a staff member. House Supervisor 1 stated NA 1 was removed from the patient care at that time.

House Supervisor 1 stated House Supervisor 1 was in communication with the Risk Manager who was Clinical Nursing Director II, CNO, and COO via email and text messages regarding this case. House Supervisor 1 stated House Supervisor 1 was instructed by the CNO and COO to complete an investigation. House Supervisor 1 stated House Supervisor 1 was told to have NA 1 come back to provide patient care if the allegation of assault was not substantiated. When asked, House Supervisor 1 stated he spoke with Patient 1 when the sheriff arrived. According to Patient 1, the staff member was "rough with me". House Supervisor 1 stated House Supervisor 1 spoke to the sheriff and determined no allegation of abuse or assault had occurred for Patient 1 by NA 1.

Review of the investigation data showed affidavits were gathered by House Supervisor 1 for NA 1 on 8/17/24.

The Director of Regulatory Affairs stated NA 1 was returned to provide the patient care on 8/17/24 at 1830 hours.

However, further interview and record review showed NA 2, who was with Patient 1 on the night shift on 8/16 to 8/17/24, was not interviewed as part of the investigation findings prior to making a determination of assault on Patient 1.

When asked, the Director of Regulatory Affairs stated House Supervisor 1 was communicating with the risk management staff all the findings of the investigation. The Director of Regulatory Affairs stated House Supervisor 1 notified the risk management staff of returning NA 1 to provide the patient care and the risk management staff agreed with the determination.

The above concern for not conducting a thorough investigation was shared with the Director of Regulatory Affairs, Clinical Nursing Director II, and House Supervisor 1. The Director of Regulatory Affairs stated the hospital deviated from their normal practice and after the joint decision that no assault had happened, there still was an opportunity to get more information and investigate further.

Based on observation, interview, and record review, the hospital failed to ensure the nursing services were provided to two of two sampled patients (Patients 1 and 2) as evidenced by:

1. Patient 1's RASS and restraint assessments were inconsistent, and the nursing staff did not provide the accurate clinical status to justify the use of non-violent restraints for Patient 1.

2. RN 1 failed to accurately document Patient 2's restraint assessments after providing care for the patient.

These failures increased the risk of substandard outcome for the patients in the hospital.

Findings:

Review of the hospital's P&P titled The Use of Restraints Including Seclusion dated December 2019 showed a restraint is any manual method or physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move the arms, legs, body, or head freely. Restraints will be implemented in the least restrictive manner possible and used only when least restrictive measures have been found to be ineffective to protect the patient and others from harm. Restraints may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others, and must be discontinued at the earliest possible time.

1. Review of the Richmond Agitation Sedation Scale (RASS) showed the scoring system on a RASS assessment is as follows:

- A score of +4 means the patient is combative and described as overtly combative, violent, and an immediate danger to staff.

- A score of +3 means the patient is very agitated, pulling or removing tubes or catheters, and aggressive.

- A score of +2 means the patient is agitated, has frequent non-purposeful movement, and is fighting the ventilator.

- A score of +1 means the patient is restless and anxious, but the movements are not aggressive or vigorous.

- A score of 0 means the patient is alert and calm.

- A score of -1 means the patient is drowsy and not fully alert but has sustained awakening.

- A score of -2 means the patient is lightly sedated and briefly awakens with eye contact to voice for less than ten seconds.

- A score of -3 means the patient is moderately sedated and has movement or eye opening to voice, but no eye contact.

- A score of -4 means the patient is deeply sedated and has no response to voice, but movement or eye opening to physical stimulation.

- A score of -5 means the patient is unarousable with no response to voice or physical stimulation.

On 8/29/24, review of Patient 1's open medical record was initiated.

Patient 1's medical record showed the patient was admitted to the hospital on 7/13/24. Patient 1 was intubated and on a ventilator.

Review of the physician's order dated 7/15/24 at 1208 hours, showed to place Patient 1 on the non-violent restraints on the left and right wrists as the patient was "unable to follow directions, unsafe."

Review of the Restraint Episode showed Patient 1 was restrained on the left and right wrists at the following times on 7/15/24:

- At 1254 hours, Patient 1's BUE soft wrist restraints were initiated due to the patient's behaviors of "interfering with medical care, devices, tubes/drains". The goal criteria for releasing restraints were "Medical devices, tubes, and dressing removed".

- At 1400 and 1600 hours, Patient 1's BUE soft wrist restraints were continued for the same reason.

- At 2000 hours, the reason for requiring the BUE soft wrist restraints was "Behavior interfering with medical care, devices, tubes/drains. Unable to follow instruction; unsafe".

However, review of Patient 1's RASS assessments showed Patient 1's RASS score were -4, or deeply sedated, continuously on 7/15/24 from 1100 to 1700 hours. At 1900 and 2000 hours, Patient 1's RASS score was -5 or unarousable.

2. On 8/29/24 at 1003 hours an observation in the ICU was conducted. RN 1 was observed providing care to Patient 2 in Room A. Patient 2 was observed lying in bed with two padded siderails. Patient 2's eyes were closed. RN 1 approached Patient 2 and communicated she would be providing oral care to the patient. Patient 2 opened and closed his eyes intermittently while receiving oral care. Patient 2 appeared calm and followed simple directions to open or close his mouth. Patient 2 was not observed with restraints and his limbs were free.

Review of Patient 2's open medical record was initiated on 8/30/24 at 0900 hours with the Director of Nursing Quality and RN 3. Patient 2's medical record showed the patient was admitted to the hospital on 8/23/24, for symptoms of alcohol withdrawal and trauma.

Review of the Restraint Episode dated 8/29/24 at 1000 hours, showed Patient 2 was in four-point soft restraints for the behaviors interfering with medical care, devices, tubes/drains, being unable to follow the instructions, and being unsafe. The restraint behavior description showed Patient 2 was attempting to pull the lines and tubes, and get out of bed.

The above concerns were shared and acknowledged by the Patient Safety Officer, Director of Nursing Quality, and RN 3.

Based on interview and record review, the hospital failed to ensure the hospital's P&P related to education and training was implemented when NA 1 did not complete the annual abuse training as per the hospital's P&P. This failure increased the risk of substandard care to the patients.

Findings:

Review of the hospital's P&P titled Department Policy and Procedure Manuals dated July 2022 showed under the Education, Training and Competency Determination section, the Re-Orientation would be performed annually.

On 8/30/24 at 1131 hours, an interview and concurrent review of NA 1's training records was conducted with the Senior Staff Analyst.

Review of the Re-Orientation Handbook, including "Abuse Prevention, Sexual Abuse, Sexual Coercion (Inappropriate Behavior Toward a Patient)" was not completed annually for NA 1. NA 1 had the abuse training from the Re-Orientation Handbook on 8/21/22 and 8/30/24.

The Senior Staff Analyst was informed of and acknowledged the above findings.