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Based on record review and interview, the facility failed to ensure patients had the right to refuse treatment (A0129); failed to protect a patient after an allegation of abuse (A0145); and failed to obtain physician orders prior to restraining a patient (A0168). The cumulative effect of these systemic practices resulted in the facility's inability to ensure patient's safety needs would be met.

Based on record review and interview, the facility failed to ensure interventions were implemented consistently to prevent avoidable skin breakdown and failed to ensure wounds were treated and assessed immediately upon identification (A0392). The cumulative effect of these systemic practices resulted in the facility's inability to ensure patients' nursing needs would be met.

Based on record review and interview, the facility ensure patients could exercise their right to refuse treatment. This affected one (Patient #1) of ten patients reviewed. The census was 47.

Findings include:

Review of Patient #1's medical record revealed an admission date of 06/21/18 with diagnoses including respiratory failure and quadriplegia with quadriparesis and had a tracheostomy. The patient was discharged to the hospital on 09/24/18. Patient #1's consent and patient rights forms were signed on 6/21/18 at 12:00 PM by the parent as the patient was a minor. The patient was alert and oriented.

Review of the facility's undated abuse allegation statement from Staff D revealed he/she was asked by a registered nurse to check on Patient #1 because his/her oxygen saturations were dropping. Staff D documented that he/she needed to remove the speaking valve from Patient #1's tracheostomy for the night. Upon entering Patient #1's room he/she noticed the pulse oximeter probe was on the knuckle of the patient's toe. Staff D documented that he/she informed Patient #1, who the protested removal of the probe. The patient began to curse "loudly" so Staff D stated he/she could remove the speaking valve. Staff D documented, "when I went to reach for it (valve), he/she swung his/her right arm at me." Staff D stated he/she "backed off" and informed the patient that he/she needed to remove the valve for the night. Staff D stated Patient #1 relaxed his/her right arm but when he/she moved close to remove the valve, Patient #1 swung his/her arm with "somewhat of a fist" and hit him/her on the left cheek bone. Staff D stated Pt #1 drew his/her arm back again so he/she brought up his/her right arm to try to block Pt #1's swing, "and in doing so, I came close to his/her face and his/her swing contacted my arm." The speaking valve was taken off and Staff D documented it was given to the registered nurse to put back on, "as I knew he/she would want to talk more."

Review of Staff E's hospital statement dated 09/23/18 revealed he/she was in with Patient #1 assessing his/her vital signs and Staff D entered. Staff D stated he/she was in to fix the pulse oximetry sensor but the patient said, "No!" Staff D continued to remove the sensor so Patient #1 said, "hurry up." Staff D "aggressively" told Staff E, "I'll take as long as I need to." Patient #1 then said, "Bro you're just being extra." Staff D then moved up to Patient #1's chest area and it "appeared that he/she was going to remove the speaking valve." Patient #1 was saying, "No stop!" Patient #1 tried to push Staff D's arm away with his/her right arm twice. Staff D pushed Patient #1's arm away both times and the last he/she moved "very close" to Patient #1's face and said, "Do that again and I'll have security up here." Patient #1 brought his/her arm up again and Staff D then made contact with his fist onto Patient #1's chin. Staff D stated he/she then "quickly" exited the room and notified the nurse.

Review of Staff F's hospital statement dated 09/24/18 at 1:00 A.M. revealed at 12:15 AM Staff E informed him/her that Staff D hit Patient #1 in the face. Staff E then spoke with Patient #1 to obtain his/her statement. Patient #1 stated Staff D was fixing the pulse ox sensor on his/her toe and the patient was "bothered." Staff D then began to remove Patient #1's speaking valve and SP #1 stated he/she did not want it removed and put his hand up to stop Staff D. Patient #1 said Staff D then punched him/her in the jaw with a closed fist.

Interview on 10/16/18 at 4:00 PM with Staff A revealed speaking valves are removed at night for safety issues. Staff A verified that Patient #1 refused having his/her speaking valve removed on 09/24/18 but Staff D removed the valve anyway without receiving consent from Patient #1 or his/her power of attorney.

This deficiency substantiates Substantial Allegation OH00100627.

Based on record review and interview, the facility failed to ensure a patient was protected after an allegation of physical abuse. This affected one (Patient #1) of ten patients reviewed. This had the potential to affect all 47 patients.

Findings:

1. Review of Patient #1's medical record revealed an admission date of 06/21/18 with diagnoses including respiratory failure, quadriplegia with quadriparesis and a tracheostomy. The patient was discharged to the hospital on 09/24/18. The patient was alert and oriented.

Review of the facility grievance log revealed on 07/27/18, Patient #1's mother informed staff that Patient #1 told her that a nursing assistant slapped him/her the evening of 07/26/18. The corrective action was listed as: the physician examined the patient and found no injury and the Chief Nursing Officer (CNO) spoke with Staff I. The findings were as follows: statements were obtained from relevant employees, physician notification and assessment of the patient was completed. The conclusion was listed as Staff I was removed from Patient #1's unit for the duration of his/her stay and the CNO provided education regarding treating all patients with respect, dignity and kindness. In addition, staff was to ensure two staff members were present for all patient interaction.

Review of Staff E's hospital statement dated 09/23/18 revealed he/she was in with Patient #1 assessing his/her vital signs when Staff D entered. Staff D stated he/she was in to fix the pulse oximetry sensor but the patient said, "No!" Staff D continued to remove the sensor so Patient #1 said, "hurry up." Staff D "aggressively" told Staff E, "I'll take as long as I need to." Patient #1 then said, "Bro you're just being extra." Staff D then moved up to Patient #1's chest area. Staff E documented, "it appeared that he/she was going to remove the speaking valve." Patient #1 was saying, "No stop." Patient #1 tried to push Staff D's arm away twice. Staff D pushed Patient #1's arm away both times and moved "very close" to Patient #1's face and said, "Do that again and I'll have security up here." Patient #1 brought his/her arm up again and Staff D then made contact with his fist onto Patient #1's chin. Staff D stated he/she then "quickly" exited the room and notified the nurse.

Review of Staff G's statement dated 09/24/18 revealed he/she was approached by Staff E and Staff F to report an incident that happened between Patient #1 and Staff D. Staff E informed Staff G that he/she witnessed Staff D strike the patient on the chin with his/her fist. Staff G stated he/she immediately went to Patient #1's room. Patient #1 stated Staff D came into his/her room earlier to fix the oxygen sensor on his/her foot. Patient #1 stated he told Staff D to stop. The patient stated Staff D got upset and started cussing at him/her and attempted to remove the speaking valve from the tracheostomy tube. The patient began to scream over the tracheostomy telling Staff D to stop. The patient raised his/her right arm to stop Staff D and Staff D made a fist and struck Patient #1 on the left side of the chin. The patient stated Staff D left the room and came back a few minutes later and apologized. Staff G then found Staff D in room 308 providing care and instructed Staff D not to go into Patient #1's room. Staff G then contacted the Administrator who informed him/her to send Staff D home and to notify the police. Staff G asked Staff D to write a statement and was informed that he/she would be suspended with pay.

Interview on 10/16/18 at 11:40 A.M. with Staff A, B and C revealed they have not received the finalized police report so they have not terminated Staff D from employment. All staff verified that Staff E left Patient #1 in the room after witnessing Staff D punch him/her in the face and Staff D removed Patient #1's speaking valve after the patient refused. In addition, Staff A verified that the incident happened on 09/23/18 at 12:15 A.M. and Staff D remained in the building until 09/24/18 at 2:00 A.M.

Interview with Staff E on 10/16/18 at 2:00 P.M. via telephone revealed after he/she witnessed Staff D punch Patient #1 in the face and he/she left the patient with the abuser to go get the nurse.

Interview with Staff A on 10/17/18 at 1:12 PM revealed he/she cannot find any evidence that education was provided to staff concerning treating patients with respect and dignity. The education was planned to be completed as a result of the unsubstantiated allegation of abuse on 07/27/18 by Patient #1. As of 10/17/18 at 6:30 P.M., no evidence of the education was provided.

Review of the facility policy titled "Abuse, Neglect Policy", dated 07/01/17, revealed an allegation of abuse by a patient will result in removal of the patient from any potential for harm or injury. There will be no delay in removing patients from potential of danger pending notifications and investigation. All investigations will be prompt and thorough. If an allegation of abuse is substantiated, the involved employees will be terminated and reported to the appropriate licensing agency.

This deficiency substantiates Substantial Allegation OH00100627.

Based on record review and interview, the facility failed to ensure physician's orders were obtained for the use of physical restraints. This affected one (Patient #7) of ten medical records reviewed. The census was 47.

Findings include:

Review of the medical record for Patient #7 revealed the patient was admitted to the facility on 08/22/18 for ventilator weaning and continuation of care.

Review of the nursing flow sheets revealed the patient was placed in bilateral soft wrist restraints due to interference with medical treatment. Review of the the nursing flow sheets indicated the patient was in restraints on 10/10/18 as the nurses were monitoring as per policy. The medical record lacked evidence of a physicians order for bilateral soft wrist restraints on 10/10/18.

During interview on 10/17/18 at 4:30 P.M., this finding was confirmed with Staff B.

Review of the facility policy titled "Clinical Services Policy and Procedure for Restraints and Seclusion", revised October 2018, stated "a written order, based on an examination of the patient by the MD/DO [medical doctor or doctor of osteopathy] or LIP [licensed independent practitioner] is entered into the patient's medical record on a daily basis when restraint is clinically appropriate."

Based on record review and interview, the facility failed to ensure interventions were implemented consistently to prevent avoidable skin breakdown and failed to ensure wounds were treated and assessed immediately upon identification. This affected one (Patient #1) of ten patients reviewed. The census was 47.

Findings include:

Review of Patient #1's revealed an admission date of 06/21/18 with diagnoses including respiratory failure and quadriplegia with quadriparesis. The patient was discharged to the hospital on 09/24/18.

Review of the daily mobility flow sheets from admission on 06/21/18 until discharge on 09/24/18 the patient was assessed as a "1" indicating the patient was dependent for mobility of rolling left to right.

Review of the repositioning flow sheets from 06/21/18 through 09/24/18 revealed staff was intermittently documenting that Patient #1 turned him/her self and the patient was not being repositioned every two hours for skin breakdown prevention.

On 06/22/18 at 12:00 A.M. the patient was repositioned to his right side and the patient was not repositioned again until 05:31 A.M. No refusal was documented. On 06/22/18 at 5:31 A.M.. the patient was repositioned and not asked again until 06/22/18 at 10:00 A.M. No refusal was documented.

On 06/23/18 at 11:00 A.M. the patient was repositioned and not repositioned again until 4:00 P.M. No refusal was documented.

On 06/30/18 at 1:00 P.M. the patient was repositioned and not again until 06/30/18 at 7:43 P.M. No refusals were documented.

On 07/10/18 at 2:00 P.M. the patient was repositioned and not again until 7:00 P.M. No refusals were noted.

On 07/27/18 at 12:00 A.M. the patient was repositioned and not again until 10:00 P.M. No refusals were documented.

On 07/28/18 at 8:00 A.M. the patient was repositioned and not again until 12:00 P.M. No refusals were documented. Again on 07/28/18 at 4:00 P.M. the patient was repositioned and not again until 8:00 P.M. No refusals were documented.

On 07/29/18 at 8:00 A.M. the patient was repositioned and not again until 12:00 P.M. No refusals were documented.

On 08/09/18 at 5:56 A.M. the patient was repositioned and not again until 10:00 A.M. No refusals were documented.

On 08/10/18 at 6:00 A.M. the patient was repositioned and not again until 10:00 A.M. No refusals were documented. On 08/10/18 at 4:00 PM the patient was repositioned and not again until 8:00 P.M. No refusals were documented.

On 08/11/18, a stage III pressure ulcer to the left heel and a deep tissue injury to the right was discovered by the registered nurse, Staff S.

Review of the skilled nursing note dated 08/11/18 at 4:38 P.M. revealed Staff S notified the physician of Patient #1's new left and right heel concerns. The nurse documented no new orders were received from the physician.

Initial measurements were obtained on 08/13/18. On 08/13/18 at 8:57 AM, orders to elevate the patient's heels with pillows under the calves and to turn and reposition the patient were received. On 08/13/18, the physician ordered daily monitoring of the patient's heel and leave open to air. For the left heel ulcer, an order was received to cleanse with normal saline, apply skin prep, let dry, apply alginate to base and cover with foam.

On 08/19/18 at 2:00 P.M. the patient was repositioned and not again until 8:00 P.M. No refusals were documented.

On 08/27/18 at 4:00 P.M. and 08/30/18 at 10:00 A.M. staff documented, "patient turns self."

On 09/02/18 at 3:00 P.M. the patient was repositioned and not asked again until 8:00 P.M. when he/she refused.

On 09/17/18 at 4:00 P.M. staff documented that the patient turns himself/herself.

On 09/21/18 at 12:00 P.M., 2:00 P.M. and 4:00 P.M. staff documented that the patient turns himself/herself. On 09/21/18 from 4:34 P.M. through 9:00 P.M. the patient was not repositioned. No refusals were documented. On 09/21/18 a skilled nurse documented during care that the patient stated that the nurse tech had not been in to check on him/her in two hours.

On 09/24/18 at 5:00 A.M. and again at 6:36 A.M. staff documented that the patient turns himself/herself.

These findings were verified with Staff B on 10/17/18 at 4:10 P.M., who verified Patient #1 was assessed as dependent for repositioning throughout his/her stay and staff intermittently documented the patient was able to reposition himself/herself. In addition, Staff B verified staff was not turning the patient every two hours consistently.

Interview on 10/17/18 at 4:20 PM with Staff A and C revealed Patient #1's heel wounds were not assessed on 08/11/18 when identified because a new nurse was working who was unfamiliar with the hospital's procedure. Staff A states wounds should be assessed, measured and treatment should be initiated at the time they are found. The patient's nurse should notify the charge nurse who will then come and assess the wound. Staff A verified that Patient #1's wounds were not assessed or treated until 08/13/18.

Interview on 10/17/18 at 5:50 PM with Staff C revealed he/she could not find a policy specific to patients who develop wounds during the hospital stay.

Review of the facility policy titled "Wound Assessment", last revised on 10/2018, revealed all patients will have a skin assessment every shift. A comprehensive assessment of the wound will be completed on admission and every seven days after. The wound will be photographed and assessed for location, size, tunneling, undermining, drainage, odor, color and surrounding tissue. Pressure injuries will be staged by the wound nurse. The policy was specific to patients admitted for wound care.

Review of the facility policy titled "Guidelines and Protocols", revised on 07/01/18, revealed bedfast patients will be turned every two hours.

This deficiency substantiates Substantial Allegation OH00100627.