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Based on record review and interview the facility failed to ensure that contracted nursing staff had the restraint education as per facility policy in 1 of 1 units reviewed resulting in lack of assessment for patients in restraints in 6 of 7 (Patient #'s 1, 2, 3, 5, 10 & 11) restraint charts reviewed out of a total universe of 11 open medical records reviewed.
Findings include:

The facility document titled "Medical Restraint-Hospital" #14.260 last revised 1/21 was reviewed. This document revealed "Ongoing assessment of the patient's well-being while in restraints is made hourly by the nurse. The nurse will document in the EMR (electronic medical record) every two hours. Documentation will include: time, neurovascular check completed, skin integrity check, safety check, range of motion, re-assessment of restraint use, and alternative interventions. If there are any exceptions to the defined normal limits, the nurse must then also document in the comments section of the restraint flowsheet...Monitoring means that the patient will be seen to determine if the use of restraint continues to be safely applied, and if there appears to be a need for an assessment of the patient to occur. Ongoing assessment means that the patient will be evaluated to determine the patient's response to the restraint, and if the patient has any care needs. This assessment shall include checking the patient's hydration and circulation; the patient's level of distress and agitation; or skin integrity, and may provide for general care needs (e.g., eating, hydration, toileting, and range of motion exercises). This assessment shall also determine if the patient continues to require restraint."

Patient #1 had a physician order for a left mittens. Restraint flowsheet's dated 7/8/2022 - 8/15/2022 were reviewed. On the following dates there was either no documented checks every 2 hours on restraint flowsheet's or incomplete documentation (areas left blank): 8/11/2022 there were no documented checks from 2:00 PM until 8:00 PM; 8/10/2022 there were no documented checks from 6:00 PM until 8/11/2022 at 12:05 AM; 7/29/2022 there were no documented checks prior to 8:00 AM; 7/25/2022 there were no documented checks from 6:00 AM until 8:00 PM; 7/22/2022 there were no documented checks from 6:00 AM until 8:00 PM; 7/18/2022 there were no documented checks from 6:00 AM until 8:00 PM and on 7/8/2022 there were no documented checks from 12:00 AM until 8:00 PM.

Patient #2 had a physician order for a right wrist restraint. Restraint flowsheet's dated 7/8/2022 - 8/15/2022 were reviewed. On the following dates there was either no documented checks every 2 hours on restraint flowsheet's or incomplete documentation (areas left blank): 7/29/2022 there were no documented checks from 12:00 AM until 7:30 AM and 7/28/2022 there were no documented checks from 6:00 PM until 7/29/2022 at 12:00 AM.

Patient #3 had a physician order for bilateral wrist restraints and a lap belt on while up in wheel chair. Restraint flowsheet's dated 7/8/2022 - 8/15/2022 were reviewed. On the following dates there were either no documented checks every 2 hours on restraint flowsheet's or incomplete documentation (areas left blank): 8/13/2022 there were no documented checks from 6:00 AM until 8:00 PM; on 8/12/2022 there were no documented checks from 3:00 AM until 7:00 AM and from 5:00 PM until 8/13/2022 at 12:00 AM and on 8/11/2022 there was only 1 documented check completed at 6:30 PM.

Patient #5 had a physician order for bilateral hand mittens. Restraint flowsheet's dated 7/8/2022 - 8/15/2022 were reviewed. On the following dates there was either no documented checks every 2 hours on restraint flowsheet's or incomplete documentation (areas left blank); 8/15/2022 there were no documented checks from 6:00 AM until 8:00 PM and from 12:00 AM to 6:00 AM there were no documented (left blank) "Alternative Interventions;" 8/12/2022 there were no documented checks from 10:00 PM until 8/13/2022 at 8:00 AM; 8/11/2022 there were only 1 documented check completed at 6:30 PM for the 24 hour period; 8/8/2022 there were no documented from 12:00 PM until 8/9/2022 at 5:45 AM (9.75 hours later) and on 8/5/2022 there were no documented checks from 12:00 AM until to 9:00 AM.

Patient #10 had a physician order for side rails x 4 and a lap belt on while up in wheelchair. Restraint flowsheet's dated 7/8/2022 - 8/15/2022 were reviewed. On the following dates there was either no documented checks every 2 hours on restraint flowsheet's or incomplete documentation (areas left blank): 8/14/2022 there were no documented checks from 6:00 PM until 8/15/2022 at12:01 AM; 8/13/2022 there were no documented checks from 6:00 PM until 8/14/2022 at 12:05 AM; 8/6/2022 there were 2 documented checks at 8:00 PM and 10:00 PM for the entire day; 8/4/2022 there were no documented checks from 6:00 PM until 8/5/2022 at 12:00 AM; 8/3/2022 there were no documented checks from 4:00 PM until 8:00 PM; 8/1/2022 there were had no completed (blanks left) documented checks from 6:00 AM until 8:00 PM; 7/30/2022 there were no documented checks from 6:00 AM until 8:00 PM; 7/28/2022 there were no documented checks from 6:00 PM until 7/29/2022 at 12:00 AM; 7/24/2022 there were no documented checks from 6:00 AM until 8:00 PM; 7/23/2022 there were no documented checks from 12:00 AM until 7:00 AM and on 7/20/2022 there were only 2 document checks for the entire day completed at 8:00 PM and 10:00 PM.

Patient #11 had a physician order for siderails x 4, bilateral wrist restraints and a lap belt on while up in wheelchair. Restraint flowsheet's dated 7/8/2022 - 8/15/2022 were reviewed. On the following dates there was either no documented checks every 2 hours on restraint flowsheet's or incomplete documentation (areas left blank): 8/15/2022 there were no documented checks from 6:00 AM until 8/16/2022 at 12:00 AM; 8/14/2022 & 8/13/2022 there were no documented checks from 6:00 PM until 12:00 AM the next day; 8/11/2022 there were no documented checks from 7:00 PM until 8/12/2022 at 12:00 AM; 8/10/2022 there were no documented checks from 6:00 PM until 8/11/2022 at 12:00 AM); 8/6/2022 there were only 2 completed checks for the 24 hour period at 8:00 PM and 10:00 PM; 8/4/2022 there were no documented checks from 6:00 PM until 8/5/2022 at 12:00 AM; 8/3/2022 there were no document checks from 4:00 PM until 8:00 PM; 8/1/2022 from 6:00 AM until 2:00 PM there was no documented (left blank) "Skin integrity Check"; 7/30/2022 there were no documented checks from 6:00 AM until 8:00 PM; 7/29/2022 there were no documented checks from 6:00 PM until 7/30/2022 at 12:00 AM; 7/28/2022 there were no documented checks from 6:00 PM until 7/29/2022 at 12:00 AM; 7/14/2022 there were no documented checks from 7:00 PM until 7/15/2022 at 12:00 AM and incomplete documentation (left blank) from 4:00 PM until 7:00 PM under "Alternative interventions" and on 7/9/2022 there were no completed checks between 4:00 AM and 8:00 AM and no documentation from 6:00 PM until 7/10/2022 at 12:00 AM.

On review of medical records of patients with restraints (Patient #'s 1, 2, 3, 5, 10 & 11) multiple areas of incomplete or missing documentation were noted by Registered Nurses (RN) and Licensed Practical Nurses (LPN)'s. Quality Coordinator D stated "A lot of these seem to be the contracted staff."

An interview was conducted with Chief Nursing Officer (CNO) E on 8/16/2022 at 10:00 AM. When asked how often staff are educated on restraints CNO E stated "It is done on hire and then yearly. But we just did it with our staff because of an incident that happened in June. Otherwise it would be done this fall with our annual skills." When asked if the contract staff received the same education as facility staff as documented in plan of correction CNO E stated "No. We did it online for our staff but the contracted staff doesn't have access to that. So they haven't done it."

Based on observations, record review and interview the facility failed to ensure that all persons entering the facility had screening completed (as per facility policy) for COVID-19 in 1 of 1 hospital observed.

Findings include:

The facility policy titled "COVID-19 Testing" no number provided last revised 6/22 was reviewed. This document revealed "Core Principles of Infection Control: Screening for signs and symptoms of COVID-19 (e.g., temperature checks, questions about and observations of signs or symptoms) will be required for all who enter the facility...Screening Testing: It is recommended for Not Up-To-Date people to identify those who are asymptomatic and do not have known, suspected, or reported exposure to SARS-CoV-2. Screening helps to identify unknown cases so that measurers can be taken to prevent further transmission. Point of care serial screening can provide rapid results and be critical to identifying asymptomatic cases needed to interrupt SARS-CoV-2 transmission."

The facility email from Infectious Disease Physician O sent to all staff on 8/9/2022 was reviewed. This document revealed "Please continue observing the following Infection Control Recommendations: Screening: Everyone will be screened for COVID-19 to enter the facility. Employees who are not Up-To-Date may be asked for additional information."

An observation was conducted on 8/15/2022 and 8/16/2022 at main entrance to hospital of visitors, staff and vendors arriving to facility. The receptionist at the front desk informed everyone "If you are up to date on vaccinations you only have to check your temperature." There was a hand held infra red thermometer and a electronic screen that takes temperature when a person walks up to it. There was no documented screening questions to be completed by persons entering the facility.

An interview was conducted with Chief Nursing Officer E and Administrator P on 8/16/2022 at 11:15 AM. When asked the screening process that is expected to be completed by all persons entering the facility CNO E referred to the email from Infectious Disease Physician O in regards to testing for COVID-19. When asked the expectation of screening process for "all who enter the facility" as per facility policy CNO E stated "I see what you mean. We used to have a list of screening questions we asked everyone to complete but we aren't now."