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Based on policy review and staff interview, the facility failed to appropriately document and record the existence of one of four patients reviewed regarding allegations of abuse received from a source other than the patient or family member. (Patient #1)

Findings include:

On 11/06/17 at 1:35 PM, Staff A provided the Abuse, Neglect (A02-A) Policy and Procedure for review. The policy was last reviewed 07/01/17. Per the policy, the facility has a "zero tolerance" for abuse, neglect and harassment. Any employee suspecting a "patient or visitor has been abused, neglected, and/or harassed will immediately report the situation to Chief Executive Officer, Chief Nursing Officer or administrator on-call immediately." The policy specified that "an allegation of abuse of a patient by staff, visitors or other patients will result in the removal of the patient (and others, as indicated) from any potential for harm or injury." Per policy "all investigations will be prompt and thorough. All allegations will be logged in the Lotus Notes Grievance Log and reported to the Governing Board. If a complaint of abuse, neglect or harassment is substantiated, the involved employees will be terminated and reported to the appropriate licensing agency."

At 1:57 PM Staff B was asked how and when the facility first became aware of the allegation of abuse involving Patient #1 but stated she didn't know.

Staff B confirmed the allegation of abuse involving Patient #1 was not logged in the Lotus Notes Grievance Log as per policy. Staff B stated this was because the allegation came from a staff member and not a patient. Staff B was then asked where in the policy it stated reports of abuse from staff members were excluded from inclusion on the Lotus Notes Grievance Log. Staff B was unable to locate this.

Based on review of hospital policy, medical record review and staff interview the hospital failed to ensure an assessment of the need for restraint was documented prior to restraint order per hospital policy for Patient #2.

Findings include:

Review of hospital policy titled "Restraints and Seclusion" revised 07/2017, revealed the decision to use a restraint is determined by comprehensive assessment that concludes for this patient, at this time, the need for restraints. Perform a comprehensive assessment, if restraint is a consideration. Use objective observations to describe the patient's behavior. Perform a physical assessment to identify medical problems. An initial assessment performed by the RN shall be reviewed by the physician. The physician's order indicates agreement with assessment. "A written order, based on an examination of the patient by the MD/DO is entered into the patient ' s medical record on a daily basis when restraint use is appropriate." The patient assessment that demonstrates the need for restraint is to be documented in the medical record.

On 11/02/17 at 2:01 AM a verbal order for restraints for Patient #2 was obtained by an RN.

Review of the medical record lacked documented evidence of the patient's behavior or assessment of the need for restraints by the nurse or physician.

Review of the physician's order, dated 11/02/17, revealed the physician had signed the verbal order at 6:33 AM (four and a half hours after the order for restraints).

As of 11/07/17 at 4:16 PM, Staff C was unable to provide documented evidence of the patient's behavior or assessment of the need for the restraints.

Based on review of hospital policy, medical record review and staff interview the hospital failed to ensure one (Patient #3) of two patients reviewed with orders for restraints was monitored every two hours per hospital policy.

Findings include:

Review of hospital policy titled "Restraints and Seclusion", last revised 07/2017, revealed on page 8 observations (safety, comfort, skin integrity, hydration and toileting) are done every two hours for medical restraints.

1. Review of the medical record for Patient #3 revealed soft wrist restraints and four bed rails were ordered on 11/04/17 at 9:43 PM for 24 hours. Review of the restraint monitoring form revealed Patient #3 was monitored at 2:00 AM and not again till 6:00 AM (four hours between monitoring of patient with restraints on.)

On 11/08/17 at 12:10 PM Staff B and C both confirmed these findings did not follow hospital policy.