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Based on record review, staff interview and review of policy and procedures the facility failed to ensure the staff provided 3 (Patient 3, Patient 10 and Patient 12) of 7 sampled patients requiring physical restraints to protect staff and the patients were ordered appropriately per the hospital policy. This had the potential to affect all patients in the facility requiring physical restraints. The facility identified 224 patients with restraint orders in the last 60 days.

Findings are:

A. Review of the policy titled Restraint/Seclusion Guidelines (effective date 5/31/23) under Procedures/Requirements stated the following:
-"Non-Violent/Non-Self Destructive Restraint- Restraint application (wrists or ankles) for the physical safety of the patient to support medical healing (pulling lines, tubes, removal of dressings or equipment). The documentation of Non-Violent/Non-Self Destructive Restraint is every 2 hours. The order can continue with a daily review by the practitioner."
-"Violent/Self Destructive Restraint-Restraint application (soft wrist and ankle, leather wrist and ankle restraint,chest or thoracic strap) for the protection of the patient against injury to self or others because of an emotional or behavioral disorder. The physician order for Violent/Self Destructive Restraints application time limits for the protection of the patient or others against injury due to an emotional or behavioral disorder requires; if the patient is; Under 9 years -1 hour; Age 9-17 -2 hours; Adult 18 & up -4 hours, the patient must be reassessed by a RN prior to time limit and if continuation is necessary a renewal order must be obtained from the practitioner.; A face to face assessment by a practitioner or specially trained RN must see the patient within 1 hour of initiation of the restraint/seclusion; The practitioner responsible for the patient's care will perform an in person evaluation within 24 hours of initiation of restraint/seclusion ands will document in the record. Continuous 1:1 is required for patients being physically restrained or secluded for violent/self-destructive behaviors."

B. Review of the medical record for 56 year old, Patient 3 (Pt 3) identified that the patient was brought to the hospital on 7/25/24 for acute alcohol withdrawal and a history of schizophrenia which was not being treated. Patient 3 was discharged home on 8/14/24. On admission the patient was experiencing tremors, was alert and oriented. The patient developed anxiety, restlessness, combativeness and delirium on 7/27/24. The patient was admitted and started on IV medication to assist the patient with acute alcohol withdrawal symptoms, and to continually assess the progress of withdrawal. The tool Clinical Institute Withdrawal Assessment Alcohol Scale Revised (CIWA) measures the level of withdrawal. A score of 8-10 indicates minimal to mild withdrawal; scores of 8-15 indicate Moderated withdrawal (marked autonomic arousal); and scores of 15 or more indicate severe withdrawal (impending delirium tremens). The tool assists the physician and nursing to provide medications related to the severity of withdrawal. The total score can range from 0 (no symptoms) to a maximum of 67.

Review of the Pt 3's medical record flowsheets identified:
-CIWA flowsheet indicated on 7/25/24 at 3:42 upon admission had a CIWA score of 16, indicating severe withdrawal. The CIWA scores during the inpatient stay fluctuated with the scores ranging from 16 on admission to 19 on 7/26/24; 27 on 7/27/24; 20 on 7/28/24; intubated on 7/29/24; extubated on 7/30/24- CIWA 19 on 7/30/24; 15 on 7/31/24; 12 on 8/1/24; 11 on 8/2/24; 13 on 8/3/24; 10 on 8/4/24; 36 on 8/5/24; intubated on 8/6/24 and extubated on 8/7/24; 22 on 8/8/24; 17 on 8/9/24; and 10 on 8/10/24.
-Restraint flowsheet indicated on 7/25/24 at 6:20 PM bilateral soft wrist restraints (non-violent) were started for interference with medical treatment/restless. The bilateral soft wrist restraints were continued daily with every 2 hour charting. On 7/30/24 at 10:45 AM the restraints were discontinued. On 7/31/24 at 11:55 PM bilateral soft wrist restraints (non-violent) were started for interference with medical treatment/restless, with every 2 hour charting through 8/3/24 at 5:21 PM when discontinued. On 8/4 at 1:06 PM bilateral soft wrists and bilateral soft ankles (non-violent) initiated. (Note documented due to interference with medical treatment/agitated/restless, additional documentation at 12:45 PM identified patient was aggressive, hitting, kicking and having assaultive behavior.) The every 2 hour documentation on 8/5 and 8/6 continues to show the patient as agitated, restless, aggressive, hallucinating, screaming foul language at staff and trying to swing at staff even in restraints. On 8/7/24 the (non-violent)bilateral ankle soft restraints were discontinued at 6:00 AM, the patient continued to have (non-violent) bilateral wrist restraints due to interference with medical treatment, restless and agitated through 8/8/24 at 11:10 PM. On 8/8/24 at 11:30 PM the patient was documented as agitated and restless and due to interference with medical treatment, bilateral (non-violent) soft wrist restraints were restarted. The every 2 hour documentation on 8/9 identified the bilateral soft wrist restraints continued until 8/9/24 at 7:00 PM. The bilateral (non-violent) soft wrist restraints were restarted on 8/9/24 at 11:02 PM due to interference with medical treatment, restless and agitated and discontinued 8/10/24 at 8:00 AM.

C. Interview with MD-M (9/3/24 at 12:40 PM) revealed when reviewed Pt 3's charting on 8/4/23 at 12:45 PM related to behaviors including interference with medical treatment/agitated/restless/aggressive, hitting, kicking and having assaultive behavior; then reviewed MD-M's order on 8/4/24 at 1:04 PM ordered "Restraints Non-violent or non-self destructive soft wrist restraints" and 8/4/24 at 1:06 PM "Restraints Non-violent or non-self destructive soft ankle restraints". MD-M stated, "The patient kicked a nurse so ordered the ankle restraints. That should have been ordered as a violent restraint."

D. Review of the medical record for 50 year old, Patient 10 (Pt 10) identified that the patient was brought to the hospital on 6/28/24 for acute alcohol withdrawal, alcohol encephalopathy and a history of paranoid schizophrenia with suicidal ideation's. Patient 10 was discharged home with a friend on 7/8/24. The patient developed anxiety, restlessness, combativeness, cursing, threatening, verbally abusive and yelling on 6/30/24 at 1:20 PM. The physician ordered bilateral soft wrist and bilateral soft ankle (Violent) Restraints due to a danger to self and others. combativeness, cursing, threatening, verbally abusive and yelling.

Review of the Pt 10's medical record restraint flowsheets identified:
-On 6/30/24 at 1:20 PM bilateral (Violent) soft wrist and bilateral soft ankle restraints were applied due to a danger to self and others. The documentation of the Violent Restraints showed every 15 minute charting.
-On 6/30/24 at 3:51 PM an order to discontinue all 4 violent restraints. The physician than ordered bilateral (non-violent) soft wrist restraints on 6/30/24 at 3:51 PM. An order was obtained for bilateral (non-violent) soft ankle restraints on 6/30/24 at 4:23 PM. The documentation to justify the need for the restraints ordered at 3:51 PM and 4:23 PM was interference with medical treatment, with behaviors identified as agitated and restlessness. The every 2 hour documentation identified the 4 restraints remained on until the ankle restraints were discontinued on 7/1/24 at 3:37 AM.
-On 7/1/24 at 9:08 AM the soft wrist restraints were discontinued and Non-Violent bilateral 2 point leather wrist restraints were applied. The leather ankle restraints and soft wrist restraints were discontinued on 7/2/24 at 5:44 AM.
-On 7/4/24 at 10:11 AM an order for bilateral (non-violent) soft wrist and ankle restraints for interference with medical treatment, with behaviors identified as agitated and restlessness. The every 2 hour documentation identified the 4 restraints remained on until the ankle restraints were discontinued on 7/5/24 at 12:00 AM, the wrist restraints continued.
-On 7/5/24 at 10:00 AM an order for bilateral (non-violent) soft ankle restraints for agitated and restlessness were added, the bilateral soft wrist restraint continued.
-On 7/6/24 at 9:40 AM an order for the bilateral wrist and ankle restraints were discontinued.

E. Review of the medical record for 51 year old, Patient 12 (Pt 12) identified that the patient was brought to the hospital on 8/10/24 for acute alcohol withdrawal, alcohol encephalopathy. The patient developed agitation and restlessness on 8/16/24 at 12:41 PM, an order for (non-violent) bilateral wrist and ankle restraints was obtained with the justification of interference with medical treatment.

Review of the Pt 12's medical record restraint flowsheets identified:
-On 8/16/24 at 12:41 PM, an order for (non-violent) bilateral soft wrist and ankle restraints was obtained with the justification of interference with medical treatment, with behaviors identified as agitated and restlessness. The every 2 hour documentation identified the 4 restraints remained on until the ankle restraints were discontinued on 8/17/24 at 3:20 AM. The bilateral soft (non-violent) wrist restraints continued.
-On 8/19/24 at 10:57 AM, an order to discontinue the bilateral wrist restraints was received.

F. Interview with Behavioral Health Manager RN-C (9/4/24 at 3:10 PM) revealed when reviewing ankle restraint documentation for Pt 3, Pt 10, and Pt 12, verified that the use of ankle restraints for agitation/restlessness would be a Violent Restraint and not a Non-Violent Restraint.

Based on record review, staff interview, review of policy and procedures, and administrative record review, the facility failed to maintain a safe environment by ensuring staff were educated on the facility expectation following an allegation of staff to patient abuse in 1 (Patient 3) of 19 sampled patients. The facility failed to ensure the nursing staff provided adequate supervision of care related to the allegation of abuse until an facility investigation could occur. This failure had the potential to affect all patients receiving nursing care in the facility. The census at the time of the survey was 466.

Findings are:

A. Review of the policy titled Abuse, Neglect and Exploitation: Identification and Reporting (effective date 10/1/2023) under Identification and Screening stated the following:
-"Situations of abuse/neglect suspected of having occurred within the hospital will result in immediate action to eliminate the possibility of further occurrences in collaboration with house supervisor.
-The staff person who suspects abuse or received the report of abuse is mandated by law to report to the proper authorities.
-For support staff, reporting will be completed under the supervision of a Social Worker, Therapist, or Registered Nurse."

B. Review of the policy titled Corrective Action and Termination (effective date 2/17/23) under Violations which may result in immediate suspension or termination stated the following:.
-"Depending on the nature and severity of the performance issue, the organization reserves the right to skip any of the aforementioned steps and move directly to suspension or termination. The list below includes some of the violation that may be cause for immediate suspension and/or termination. This is not intended to be an exhaustive list.
-Abuse, harassment, discrimination or inconsiderate treatment of patients, visitors, volunteers, or other employees."

C. Review of the Administration Liaisons follow up on a grievance reported to the facility of an alleged staff to patient abuse from 8/4/24 revealed the report was shared with the facility on 8/4/24 when a family member was told by the patient (Pt 3) that a staff member hit them. The family member also had other concerns regarding nursing and patient rights.

D. Interview (9/3/24 at 11:05 PM) with Pt Liaison stated, "When a concern is received by us, the leaders (Nurse Managers, Physicians, or their designee) of each area of the concern looks into the concern and investigates the issues and it is brought back to the group and we send a letter to the complaintant when the investigation is completed within the appropriate time frames." "The concern's that (Pt 3) family called in on 8/5/24 have been sent to the specific manager, physician or designee's to follow up and investigate. Many of the area's are still being reviewed and in process."

E. Interviews completed regarding the allegation of staff to patient abuse included:
-An interview with the House Supervisor (HS RN F) on 9/3/24 at 2:30 PM, identified that he was working at the time of the allegation of abuse and other nursing issues that the family of Pt 3 had questions about. When asked if the bedside nurse or charge nurse had notified him that the patient family alleged the patient had told the family that a nurse hit (gender). The HS RN F stated, "No, we were involved with a conversation about hospital policy related to the family using their phone for photos and taping of the pt and staff. The family also had a concern of (Pt 3's) position in bed, the patient was in bilateral wrist and ankle restraints, had a tube feeding running and asleep at the time. The family member was escorted out of the hospital due to the filming, and disruptive loud behaviors."
-An interview on 9/4/24 at 1 PM with the Nurse Manager RN E (NM RN E) for the unit that Pt 3 was a patient on 8/4/24), when asked when did RN H notified her of the incident, "RN H called me that night after the shift, the nurse told me that the patient had outbursts punched 2 nurses. When family got there was upset and became loud and aggressive, was video taping and taking pictures, refused to stop so the HS RN F and security was contacted. The family told RN H that (Pt 3) wasn't being treated correctly and was calling LPD." "I don't think anything was said about the allegation of the patient being hit in that call." "I talked to RN H the next day (8/5/24), that day I was informed that the family said we weren't feeding (the pt) and claimed the nurse hit him." "I found out also that LPD came on 8/4 and the HS RN F accompanied them to the patient room. LPD said that a family member reported that the patient was punched by a nurse, LPD then asked the bedside nurse (RN H) if (gender) hit the patient and about the feeding. RN H responded "NO." When asked the Nurse Manager RN E, if once the facility staff was notified of an alleged allegation of staff to patient abuse, was the staff member removed from patient care, or how did they protect this and other patients until the Administrative staff can investigate the allegation. NM RN E stated, "no the staff member wasn't removed."
-An interview with the Director of Safety and Security (DSS) on 9/3/24 at 1:18 PM. When asked if as part of the job gets involved in allegations of abuse by staff. The DSS responded, "yes, I am involved with employee misconduct." When asked if was aware of the 8/4/24 allegation of staff to nurse. DSS stated, "yes, I received a report placed by the Charge Nurse (CN G) on 8/4/24." "Its my understanding that the family member told staff that they were reporting to the Lincoln Police Department (LPD) and Adult Protective Services (APS) on 8/4/24." "Approximately 2 hours after the family was escorted out of the hospital, LPD came to the unit, the Officer informed staff that the family had called LPD with reports that (hospital) staff is abusing the patient. The Bedside RN (RN H), CN G and HS RN F all gave their statements, and the Officer informed staff that the family was planning on contacting APS." When asked after an allegation of a particular staff to patient alleged abuse was received, how does the facility ensures all patients are safe while the facility looks into the allegation, do you reassign the staff person immediately to non patient area's, or have them go home while the facility looks into the allegation? "No not necessarily." When asked if there is guidance for how floor staff (ie.charge nurse, house supervisor) handles the incident in the policy? "Not specifically, but staff does make a report and gets up the chain of command."

F. Review of the Pt 3's medical record flowsheets identified:
-CIWA flowsheet indicated on 7/25/24 at 3:42 upon admission had a CIWA score of 16, indicating severe withdrawal. The CIWA scores during the inpatient stay fluctuated with the scores ranging from 16 on admission to 19 on 7/26/24; 27 on 7/27/24; 20 on 7/28/24; intubated on 7/29/24; extubated on 7/30/24- CIWA 19 on 7/30/24; 15 on 7/31/24; 12 on 8/1/24; 11 on 8/2/24; 13 on 8/3/24; 10 on 8/4/24; 36 on 8/5/24; intubated on 8/6/24 and extubated on 8/7/24; 22 on 8/8/24; 17 on 8/9/24; and 10 on 8/10/24.
-Restraint flowsheet indicated on 7/25/24 at 6:20 PM bilateral soft wrist restraints (non-violent) were started for interference with medical treatment/restless. The bilateral soft wrist restraints were continued daily with every 2 hour charting. On 7/30/24 at 10:45 AM the restraints were discontinued. On 7/31/24 at 11:55 PM bilateral soft wrist restraints (non-violent) were started for interference with medical treatment/restless, with every 2 hour charting through 8/3/24 at 5:21 PM when discontinued. On 8/4 at 1:06 PM bilateral soft wrists and bilateral soft ankles (non-violent) initiated. (Note documented due to interference with medical treatment/agitated/restless, additional documentation at 12:45 PM identified patient was aggressive, hitting, kicking and having assaultive behavior.) The every 2 hour documentation on 8/5 and 8/6 continues to show the patient as agitated, restless, aggressive, hallucinating, screaming foul language at staff and trying to swing at staff even in restraints. On 8/7/24 the (non-violent)bilateral ankle soft restraints were discontinued at 6:00 AM, the patient continued to have (non-violent) bilateral wrist restraints due to interference with medical treatment, restless and agitated through 8/8/24 at 11:10 PM. On 8/8/24 at 11:30 PM the patient was documented as agitated and restless and due to interference with medical treatment, bilateral (non-violent) soft wrist restraints were restarted. The every 2 hour documentation on 8/9 identified the bilateral soft wrist restraints continued until 8/9/24 at 7:00 PM. The bilateral (non-violent) soft wrist restraints were restarted on 8/9/24 at 11:02 PM due to interference with medical treatment, restless and agitated and discontinued 8/10/24 at 8:00 AM.

G. Interview with MD-M (9/3/24 at 12:40 PM) revealed when reviewed Pt 3's charting on 8/4/23 at 12:45 PM related to behaviors including interference with medical treatment/agitated/restless/aggressive, hitting, kicking and having assaultive behavior; then reviewed MD-M's order on 8/4/24 at 1:04 PM ordered "Restraints Non-violent or non-self destructive soft wrist restraints" and 8/4/24 at 1:06 PM "Restraints Non-violent or non-self destructive soft ankle restraints". MD-M stated, "That should have been ordered as a violent restraint."

H. Review of Pt 3's medical record revealed an entry on 8/4/24 at 3:14 PM from Case Management (CM B) stated, "Of note, (Family member) did visit today and was verbally aggressive toward staff, including the primary RN (RN H), CRN (CN G) and house supervisor (HS RN F) and was escorted out by security."