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Based on record review and staff interviews, the facility failed to ensure patients were free from abuse (A145) and failed to ensure the use of restraint or seclusion was implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy (A167). The cumulative effect of these practices resulted in a risk to the health and safety of all facility patients.

Based on record review and staff interviews the facility failed to ensure patients were free from abuse including conducting a thorough investigation into allegations of abuse or implementing interventions to prevent further potential abuse from occurring. This finding affected two patients (Patient #3 and Patient #7) and had the potential to affect all patients receiving care in the facility. The census was 15.

Findings include:

Review of the facility's policy and procedure titled "Complaint and Grievances" with a most recent revision date of 08/03/2020 directed that immediate attention must be given to situations that place the patient or visitor in immediate danger. All complaints and grievances will be monitored, and appropriate action taken when trends identified. A review of the facility's policy and procedure titled "Event Notification/Occurrence Protocol" with a most recent revision date of 02/21/2020 directed the occurrence process protocol for incidences involving a patient, directed staff to immediately after the event occurred or was discovered to do the following: initiate appropriate intervention; Notify the charge nurse and physician of the event and others as appropriate; obtain information from all persons knowledgeable of the event and complete an event report.

Review of the facility complaint and grievance log revealed two allegations of abuse. The first allegation of abuse was reported on 06/22/2020 at 12:30 PM by Patient #3 and the second on 06/23/2020 at 11:30 AM by Patient #7 regarding a male staff member.

Review of the medical record for Patient #3 revealed the patient was admitted to the facility on 06/11/2020 with respiratory failure requiring a tracheostomy and mechanical ventilation to breathe. Review of the medical record revealed the facility had received a daily order for bilateral wrist restraints due to behaviors which included pulling tubes and attempting to get out of bed without assistance starting on 06/20/2020 and continuing through 06/22/2020. Review of the nursing narrative notes prepared by Staff C and dated 06/22/2020 at 12:30 PM documented the patient and sister requested to see the Chief Executive Officer (CEO) and that the message was given to Staff A. Review of the Pulmonology Integrative Progress notes prepared by the physician extender dated 06/22/2020 at 12:45 documented Patient #3 was seen and examined and was anxious, restless, crying patient wanted to go home and a sister was at the bedside. The patient alleged a male employee punched her in the face and that management was aware of the patient and family concerns and will address.

Review of the facility's complaint investigative notes for Patient #3 documented the facility reviewed a list of male staff on duty from 06/20/2020 to 06/21/2020. Pictures of male staff were shown to the patient who was not able to identify male staff member from the pictures. Patient #3 is scared, upset, but not physically hurt. No visual evidence of physical harm. Emotional support was provided. The patient agreed to a video monitor placement in room and curtains and door to remain open to allow visual observation from nurse's station. No males permitted in room per Patient #3's request. Male employees working over weekend have walked by patient's room and although we asked patient to use call bell if male employee is seen, patient has not rung the call bell; continuing to investigate.

On 06/23/2020 at 11:30 AM the facility received a second allegation of abuse regarding a male staff member. Review of the facility's complaint form documented Patient #7 complained of being hit by a male employee during the night shift. Patient #7 said the man hit him in the neck and his trach (tracheostomy) really hurts now. Patient #7 was asked if anyone else had hit or hurt Patient #7 and replied no; Patient #7 said that the man that hit his neck had hit him in the face before. Patient #7 was shown pictures of four male employees and indicated he thought it was one of the male employees, but that it was a bad picture of him (Staff F). Patient #7 agreed to facility taking pictures of his neck and then notifying the local police. The facility complaint form documented the local police met with Patient's #3 and #7 who both verified reports of being hit by a male, that Patient #7 believed to be Staff F based on the photos Patient #7 reviewed. Patient #7 said his neck hurt but not his face. Pictures of Patient #7's neck and physical assessment did not reveal any injury. Human resources and the Ohio Board of Nursing was notified.

Review of the medical record for Patient #7 revealed the patient was admitted to the facility on 05/01/2020 with generalized debility and ventilator weaning and tracheostomy.

Following the second allegation of abuse the facility re-approached Patient #3 on 06/23/2020 at 12:23 PM. Patient #3's statement was read back to her and she confirmed it was accurate except that she was hit on the chin three times (not documented in previous statement but what patient had demonstrated during the 06/22/2020 statement with administrative staff). Patient #3 interrupted the interview to inform staff that the person who allegedly hit her was walking the halls last night (6/22/2020 until 06/23/2020). Patient #3 agreed to look at the same four pictures previously viewed and in so doing, Patient #3 identified Staff F as the person who hit her three times on the chin, punched her stomach, and felt her breast inappropriately. Patient #3 approved the facility to notify the local police on her behalf.

Review of the local police report documented the police interviewed both Patient #3 and Patient #7 on 06/23/2020 at 1:00 PM and took statements. The facility reported the local police had taken no further action.

Interview with Nursing Staff C on 09/08/2020 at 12:47 PM revealed Staff C worked 6/22/2020 from 7:00 AM to 7:00 PM shift. Staff C verbalized that she took shift report from the night shift nurse, Staff F. Staff C verbalized, when she went to assess Patient #3 the patient was upset and tearful and informed her the male nurse had abused her, and the patient alleged he had hit her. In hindsight, I should have reported this as an allegation of abuse when I first heard it, "I just couldn't believe it." Staff C was asked if she was requested by the facility to prepare a statement or provide information regarding the alleged allegation of abuse. She verbalized no, no one ever asked me anything about it. Staff C verbalized the facility provided training modules on abuse, neglect and misappropriation at hire and on the facility's computer-based learning program which all staff complete annually.

Interview with Staff E on 09/09/2020 at 11:53 AM revealed she and three other staff members had provided morning care to Patient #7 the morning of 06/23/2020. Staff E verbalized she had a very good working relationship with Patient #7. She verbalized Patient #7 had been at the facility quite a while and she had taken care of him for a long time, so she knew him very well. Staff E verbalized that Patient #7 had a tracheostomy, but he was able to talk over it and was easily understood. I remember on 06/23/2020 Patient #7 was just so upset; he was so mad stating Staff F hit me in the face, and he's done it before too. Staff E verbalized she immediately went to get administration after hearing this.

Interview with Staff G on 09/09/2020 at 1:31 PM revealed she was assigned to provide care for Patient #7 frequently and that she had a very good relationship with the patient. Staff G verbalized, she remembers the morning of 06/23/2020, I knew something was very wrong when I first when into the room. Patient #7 didn't want to make eye contact with me or talk and joke with me like he usually did. During his morning care I asked him, what's wrong? Patient #7 began punching the bed and was very very angry. The patient replied, that "expletive" hit me in the face. This isn't the first time he has hit me either. I'm sick and tired of it. Patient #7 proceeded to say a male night shift staff member had hit him. I asked what color scrubs? Staff G explained that aides wear black scrubs and that nurses wear blue scrubs. Patient #7 replied blue. Patient #7 was visibly upset and began saying I'm not taking this anymore; he's always being rough with me. Patient #7 was very out of character and very very upset and distraught, this was not like him at all. Patient #7 verbalized that it happened only on nights and again stated, its not the first time either and I'm not taking it anymore. Staff G was asked if she was interviewed by administrative staff or asked to prepare a written statement regarding this alleged abuse to which she replied, no.

Interview with Nursing Staff D on 09/09/2020 at 2:01 PM revealed she remembered taking care of Patient #7 on 06/23/20202. It was Staff E, Staff G and me who provided his morning care that day, we were all in the patient's room. I observed that Patient #7 was very, upset. Patient #7 was able to talk over his trach (tracheostomy) and was very easy to understand. He was visibly distraught and upset and alleged that the night male nurse had been hitting him and he was tired of it. Patient #7 verbalzized it was not the first time this staff member had hit him either, and that he was sick and tired of it. Patient #7 was very alert and oriented and knew full well what he was saying. The three of us went and immediately got Staff A. Staff D was asked if she was questioned about the allegation of abuse or asked to prepare a written statement to which she replied, no.

After receiving the second allegation of abuse on 06/23/2020 at 11:30 AM, Human resources and the Ohio Board of Nursing was notified per the facility's complaint form. The police interviewed both Patient #3 and Patient #7 on 06/23/2020 at 1:00 PM and took statements. The facility reported the local police had taken no further action. The facility reported it has received no written documentation from the Ohio board of Nursing as of this time 09/01/20.

Interview with Administrative Staff A and Staff B on 09/09/2020 at 12:12 PM confirmed that Staff F was a current facility employee and was scheduled to work three twelve hour shifts weekly since 06/26/2020.

Review of the personnel file of Staff F lacked evidence of suspension, discipline, education, or monitoring by the facility since the allegations of abuse on 06/22/20 and 6/23/2020.

There was no evidence the facility conducted any further investigation into allegations of abuse or implemented interventions to prevent further potential abuse from occurring. Staff A confirmed the facility was unable to provide documentation that other staff who cared for Patient #3 and Patient #7 were interviewed or requested to make statements regarding the allegations of abuse.

Based on record review and staff interview the facility failed to ensure restraints were applied per facility policy and procedures. This finding affected one patient (Patient #9). The facility census was 13.

Findings include:

Review of the facility's policy and procedure titled "Restraints/Protective Devices" with a most recent revision date of 10/31/19 directed that a physical restraint was any manual method, physical or mechanical device, material or equipment that immobilized or reduced the ability of the patient to move his or her arms, legs, body or head freely. The policy directed that a LIP (Licensed Independent Practitioner) order was required prior or immediately following the application of all restraints. The restraint order must include the following the date and time the order was received and the type of restraint utilized. The policy directed that the restraint must be applied according to manufacturer's instructions. The policy further directed that documentation for a patient in a restraint device will include but is not limited to the current LIP order, the type restraint used and evidence that the least restrictive restraint was chosen.

Review of the medical record revealed Patient #9 was admitted to the facility on 07/16/2020 with diagnoses which included history of a motor vehicle accident, and injuries that included a subarachnoid hemorrhage (medical emergency involving bleeding in the brain) and the need for mechanical ventilation (breathing tube).

Patient #9 had physician's orders on 08/21/2020, 08/22/2020 and 08/23/2020 for bilateral soft wrist restraints.

Review of the facility's Event Notification and Occurrence Report dated 8/23/2020 at 8:00 PM revealed the nurse found the patient with the top sheet across the patient, all four corners were tied to the side rails of the bed. The patient was unable to sit up or move in the bed. The sheet was immediately untied revealing the bilateral wrist restraints to be intact. The charge nurse was notified, the improper restraint was released and no injuries were noted. Staff will need education as they are unavailable at this time.

Review of the Daily Nursing Flow Sheet dated 8/23/2020 7:00 AM until 7:00 PM under the Restraint Documentation Section noted that every two hours Patient #9 was maintained in bilateral wrist restraints. The nursing narrative notes dated 08/23/2020 at 12:00 PM documented the patient's restraints were secured. The entry timed 4:30 PM documented the patient managed to pull off the condom catheter while in restraints. The notes failed to document the presence of a top sheet tied to the bed rails across the patient.

Interview with Staff A on 09/09/2020 at 1:17 PM confirmed staff members had placed an unapproved and improper restraint on Patient #9. A request was made to review the documentation that staff were retrained or re-educated on approved restraint types and proper application. Staff A was unable to provide evidence staff had received retraining or education.

Based on record review and staff interview the facility failed to ensure the medical record contained documentation of a nurse's finding of an improper restraint. This finding affected one patient (Patient # 9). The facility census was 13.

Findings include:

Review of the facility's policy and procedure titled "Patient Record Content" with an effective date of 05/01/2008 directed that to assure that all information documented by the hospital staff pertaining to a patient's stay at the facility was retained in the medical record. The medical record shall contain significant findings.

Patient #9 had physician's orders on 08/21/2020, 08/22/2020 and 08/23/2020 for bilateral soft wrist restraints.

Review of the facility's Event Notification and Occurrence Report dated 8/23/2020 at 8:00 PM documented the nurse found the patient with the top sheet across the patient, all four corners were tied to the side rails of the bed. The patient was unable to sit up or move in the bed. The sheet was immediately untied revealing the bilateral wrist restraints to be intact. The charge nurse was notified and the improper restraint was released and no injuries were noted. Staff will need education as they are unavailable at this time.

Review of the Daily Nursing Flow Sheet dated 8/23/20202 for 7:00 AM until 7:00 PM lacked evidence of a top sheet tied to bed rails over the patient.

Interview with Staff A on 09/09/2020 at 1:17 PM confirmed the medical record failed to record this significant finding.