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Based on document reviews and interviews, the hospital failed to ensure that one (1) of ten (10) patients were free from abuse and/or neglect (Patient #1).

Findings:

The hospital's "Suspected Patient Abuse or Neglect by a Team Member" policy, last revised 7/21/2023, states in part, defines abuse as "The infliction of injury, unreasonable confinement, intimidation or cruel punishment that causes or is likely to cause physical harm or pain or mental anguish; sexual abuse or sexual exploitation; financial exploitation; or the intentional, knowing or reckless deprivation of essential needs. "Abuse" includes acts and omissions;

An employee suspected of, or whom an allegation of abuse is made, will be immediately removed from patient care and placed on suspension, or leave of absence as appropriate, pending further investigation; and

If any Mandated Reporter of the CMH Healthcare System knows or has reasonable cause to suspect that an incapacitated or dependent adult has been or is at substantial risk of abuse, neglect or exploitation, s/he shall immediately report the same, via telephone, to the Maine Department of Health and Human Services".

On 11/20/2023 at approximately 1:00 PM, Patient #1's medical record was reviewed. This revealed the following:
- On 11/3/2023 at 5:30 PM, Patient #1 arrived via ambulance to the Emergency Department ("ED") with a chief complaint of throat and abdominal pain after swallowing batteries;
- On 11/3/2023 at 7:35 PM, Registered Nurse ("RN") #1 documented that, "[Patient #1] had become violent and was kicking, hitting, biting, and spitting on staff members. [Patient #1] attempted to bite and scratch this RN multiple times. With numerous security staff and nursing staff, [Patient #1] was moved to a bed and placed into 4 point restraints";
- On 11/3/2023 at 7:38 PM, a provider documented that Patient #1 was violent toward self and staff and was not able to be verbally redirected. Patient #1 was administered a chemical restraint and was then placed in four (4) point restraints; and
- On 11/4/2023 at 9:42 AM, Patient #1 was discharged from the ED.

On 11/20/2023 at 3:30 PM, an interview was conducted with the ED Nurse Director. She stated the following:
- [Security Officer #1] sent an email to me on Friday 11/3/2023 at 11:30 PM to let me know that he witnessed a nurse slap [Patient #1] in the face after the patient spit on the nurse while performing a restraint;
- I did not read the email until the evening of 11/5/2023, and I then informed the RN covering for me that week, as I was going on vacation;
- On 11/6/2023, security entered an incident report;
- During the week of 11/6/2023, the hospital had meetings to discuss this incident, and RN #1 was terminated;
- On 11/13/2023, I submitted a report to Adult Protective Services; and
- The hospital policy is "not clear for front line staff".

On 11/21/2023 at 1:12 PM, an interview was conducted with Security Officer #1. He recalled that he was a part of the security team that assisted the RN staff in the ED with Patient #1. He stated the following:
- I watched [RN #1] assault [Patient #1]. He slapped him/her across the face. I told him he can't be doing that;
- Two (2) of my officers saw it and said something, but no one else in the room made comments;
- I should have notified the nursing supervisor or my supervisor. I just notified the ED Nurse Director that night at 11:30 PM by email; and
- When asked if he would consider it abuse, he stated, "Yes, absolutely 100%."

On 11/21/2023 at 9:24 AM, an interview was conducted with the Director of Risk Management and the Clinical Risk Manager. When asked what is expected of staff when witnessing or suspecting abuse or neglect, the Director of Risk Management responded, "Make sure the patient is safe" and "Take the employee out of the mix."

On 11/21/2023 at 10:30 AM, RN #1's time card was reviewed and revealed the following:
- On 11/3/2023, RN #1 continued to work, after being witnessed to slap Patient #1, until the end of the shift, until 10:08 PM;
- On 11/4/2023, RN #1 worked a full shift from 9:38 AM to 10:11 PM;
- On 11/5/2023, RN #1 worked a full shift from 9:38 AM to 10:08 PM; and
- On 11/7/2023, the hospital terminated the employment contract with RN #1.

On 11/21/2023 at 9:24 AM, The Clinical Risk Manager confirmed that when leadership reviewed the incident on 11/6/2023, the ED Nurse Director did not have information related to RN #1 in the report. However, as they started to investigate, security shared the information related to RN #1 slapping Patient #1. The allegation of abuse was not reported to the Department of Health and Human Services until 11/13/2023, a duration of ten (10) days after the incident.

The Clinical Risk Manager further stated, "We have had some delay in the immediate reporting, and I am doing education on the mandated reporter. Typically, the ones [reports] that I have seen, it has not been immediate."

Based on document reviews and interviews, the hospital failed to ensure a physician's order was obtained for two (2) of six (6) patients that were restrained (Patient 2R and 6R).

Findings:

Central Maine Medical Center's "Restraint and Seclusion" policy, last approved 05/26/2023 states, in part, "Initiation: Each episode of restraint or seclusion shall be initiated: a. Upon the order of a provider who is responsible for the patient. At CMH [Central Maine Health] Providers who may write orders for a restraint include Physician, Nurse Practitioner, Physician Assistants and Midwife. b. By a trained RN when he or she determines it is necessary to protect the patient, staff member or others. An order from a provider who is responsible for the patient shall be obtained as soon as possible after such initiation ... ".

On 11/20/2023 at 1:01 PM, six (6) records were reviewed with the Clinical Quality Review Coordinator. This review revealed the following:

1. Documentation in Patient 2R's record indicated the following:
- On 11/03/2023 at 7:37 PM, Patient 2R required four (4) point restraints;
- The restraint was discontinued at 8:35 PM; and
- There was no evidence in the medical record of a Provider order for four (4) point restraints.

2. Documentation in Patient 6R's record indicated the following:
- On 11/20/2023 at 6:05 PM, Patient 6R required four (4) point restraints;
- The restraint was discontinued at 6:25 PM; and
- There was no evidence in the medical record of a Provider order for four (4) point restraints.

On 11/20/2023, the Clinical Quality Review Coordinator confirmed the above findings at the time of the review.

Based on document reviews and interviews, the hospital failed to ensure a restraint was discontinued at the earliest time possible for one (1) of six (6) patients (Patient 5R).

Findings:

Central Maine Medical Center's "Restraint and Seclusion" policy, last approved 05/26/2023 states, in part, "Documentation of Assessment/Monitoring: a. Episodes of restraint or seclusion shall be documented as indicated on currently approved assessments, monitoring and ordering forms ... Discontinuation: a. Restraint or seclusion shall be discontinued by the RN as soon as is safely possible once the behaviors or situations that prompted the use of restraint or seclusion are no longer evident b. Restraint shall be discontinued by the RN as soon as is safely possible when it is determined that less restrictive means will be effective in protecting the patient/others".

On 11/20/2023 at 1:01 PM, six (6) records were reviewed with the Clinical Quality Review Coordinator. This review revealed the following:

1. Documentation in Patient 5R's record indicated the following:
- Nursing staff documented that on 11/06/2023 at 5:55 PM, Patient 5R had soft bilateral mitt restraints applied; and
- There was no nursing documentation regarding the removal of the soft bilateral mitt restraints; and therefore,
- It could not be determined if the restraint was discontinued at the earliest possible time.

On 11/20/2023, the Clinical Quality Review Coordinator confirmed the above finding at the time of the review.

Based on document reviews and interviews, the hospital failed to ensure the condition of a patient, who was in restraints, was monitored in accordance with hospital policy for one (1) of six (6) patients reviewed (Patient 5R).

Findings:

Central Maine Medical Center's "Restraint and Seclusion" policy, last approved 05/26/2023 states, in part, " ... Assessments by a RN shall occur as often as indicated by the patient's condition/ behavior and at least every two (2) hours ... ".

On 11/20/2023 at 1:01 PM, six (6) records were reviewed with the Clinical Quality Review Coordinator. This review revealed the following:

1. Documentation in Patient 5R's record indicated the following:
- Nursing staff documented that on 11/06/2023 at 5:55 PM, Patient 5R had soft bilateral mitts applied;
- On 11/6/2023 at 5:55, the doctor wrote an order for Patient 5R to have, in part, "Restraint monitoring will occur [every] 2 [hours] while in restraint"; and
- There was no documented evidence of the required monitoring while in restraints.

On 11/20/2023, the Clinical Quality Review Coordinator confirmed the above finding at the time of the review.

Based on document reviews and interviews, the hospital failed to ensure the patient received a face-to-face evaluation by the provider within one (1) hour of initiating a restraint for three (3) of six (6) patients that were restrained (Patient 1R, 2R and 6R).

Findings:

Central Maine Medical Center's "Restraint and Seclusion" policy, last approved 05/26/2023 states, in part, "A responsible physician, trained NP [Nurse Practitioner], PA [Physician Assistant] or Midwife shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of restraint....".

On 11/20/2023 at 1:01 PM, six (6) records were reviewed with the Clinical Quality Review Coordinator. This review revealed the following:

1. Documentation in Patient 1R's record indicated the following:
- On 08/13/2023 at 3:30 PM, Patient 1R required a physical hold for a chemical restraint;
- On 08/13/2023 at 4:30 PM, Patient 1R required four (4) point restraints; and
- There was no documented evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation.

2. Documentation in Patient 2R's record indicated the following:
- On 11/03/2023 from 7:10 PM to 8:35 PM, Patient 2R required four (4) point restraints; and
- There was no documented evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation.

3. Documentation in Patient 6R's record indicated the following:
- On 11/03/2023 at 5:45 PM, Patient 6R required a physical hold for a chemical restraint;
- On 11/03/2023 at 6:05 PM, Patient 6R required four (4) point restraints; and
- There was no documented evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation.

On 11/20/2023, the Clinical Quality Review Coordinator confirmed the above findings at the time of the review.

Based on document reviews and interviews, the hospital failed to ensure that restrained patients received an evaluation within one (1) hour of restraint initiation that documented the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint for three (3) of six (6) patients that were restrained (Patient 1R, 2R and 6R).

Findings:
Central Maine Medical Center's "Restraint and Seclusion" policy, last approved 5/26/2023 states, in part, Documentation of Assessment/Monitoring: a. Episodes of restraint or seclusion shall be documented as indicated on currently approved assessments, monitoring and ordering forms ... ".

On 11/20/2023 at 1:01 PM, six (6) records were reviewed with the Clinical Quality Review Coordinator. This review revealed the following:

1. Documentation in Patient 1R's record indicated the following:
- On 08/13/2023 at 3:30 PM, Patient 1R required a physical hold for a chemical restraint;
- On 08/13/2023 at 4:30 PM, Patient 1R required four (4) point restraints; and
- There was no evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation that documented the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint.

2. Documentation in Patient 2R's record indicated the following:
- On 11/03/2023 from 7:10 PM to 8:35 PM, Patient 2R required four (4) point restraints; and
- There was no evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation that documented the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint.

3. Documentation in Patient 6R's record indicated the following:
- On 11/03/2023 at 5:45 PM, Patient 6R required a physical hold for a chemical restraint;
- On 11/03/2023 at 6:05 PM, Patient 6R required four (4) point restraints; and
- There was no evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation that documented the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint.

On 11/20/2023, the Clinical Quality Review Coordinator confirmed the above finding at the time of the review.

Based on document reviews and interviews, the hospital failed to ensure staff completed restraint training according to hospital policy and the documentation of the training was contained in the staff member's personnel record for four (4) of 10 (ten) staff who had been involved in a patient restraint (Registered Nurse #2, Medical Doctor #1, #2, and #3).

Findings:

Central Maine Medical Center's "Restraint and Seclusion" policy, last approved 05/26/2023 states, in part, "Training Plan: Hospital and Medical staff members shall receive training in the following subjects as it related to assigned duties performed under this policy regarding the use of restraints during the orientation process. Such training shall take place before the new staff member is asked to implement the provisions of this policy and shall be repeated periodically, based on the results of quality monitoring activities. Medical staff members will receive additional education every two years as part of their re-credentialing process and hospital staff will receive additional education annually. a. Providers who order restrain shall be trained in the requirements of this policy. b. Hospital staff members who assess patients for restraint or who apply restraint shall receive the training in the following: i. Techniques to identify staff and patient behaviors, events and environmental factors that may trigger circumstances that require the use of restraint. ii. The use of non-physical intervention skills. iii. Choosing the least restrictive intervention based on individualized assessment of the patient's medical or behavioral status or condition. iv. The safe application and use of all types of restraints by the staff member, including training in how to recognize and respond to physical and psychological distress (for example; positional asphyxia). v. Clinical identification of specific behavior changes that indicate that a restraint is no longer necessary. vi. Monitoring the physical and psychological well-being of the patient who is restrained including but not limited to; respiratory and circulatory status, skin integrity and vital signs. vii. The use of first aid techniques & cardiopulmonary resuscitation".

1. Documentation in Patient #5R's record indicated the patient was placed in restraints on 11/06/2023 and Registered Nurse ("RN") #1 was involved with the patient and the restraint.

There was no evidence provided by the hospital to indicate RN #1 had completed training on restraints since 12/26/2021.

2. Documentation in Patient #6R's record indicated the patient was placed in restraints on 11/03/2023 and Medical Doctor ("MD") #1 was involved in the care of the following patient who was restrained.

There was no evidence provided by the hospital to indicate MD #1 had completed training on restraints.

3. Documentation in Patient #5R's record indicated the patient was placed in restraints on 11/06/2023 and MD #2 was involved in the care of the following patient who was restrained.

There was no evidence provided by the hospital to indicate MD #2 had completed training on restraints.

4. Documentation in Patient #1R's record indicated the patient was placed in restraints on 08/13/2023 and MD #3 was involved in the care of the following patient who was restrained.

There was no evidence provided by the hospital to indicate MD #3 had completed training on restraints.

On 11/21/2023 at 2:36 PM, the Quality Accreditation Program Manager confirmed no evidence could be provided that indicated RN #1 and MD #1, MD #2, and MD #3 had completed the required hospital policy training on restraints.