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Based on document review and interview, the hospital failed to ensure adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed between the dates of 12/14/20 to 12/20/20 (tag 392) and failed to ensure that nursing personnel followed established policies and standards for 5 processes: 1) notification of patient's family in the event of a fall for 1 of 10 patients (P3); 2) stating observations/interventions/findings from periodic observations during restraint for 2 of 10 patients (P2 and P3); 3) assessment and reassessment documentation descriptions of the patient's response/status relative to medical and/or nursing interventions and effectiveness of interventions for patients in restraints for 2 of 10 patients (P2 and P3); 4) Clinical Guidelines and Protocols for patient assessment with a condition change (fall) for 1 of 10 patients (P3) and hygiene for 5 of 10 patients (P2, P3, P4, P5 and P7) and 5) completion of a head-to-toe assessment and post fall monitoring for 1 of 10 patients (P3) (tag 398).

The cumulative effect of this resulted in the hospitals inability to ensure the provision of quality healthcare was provided by nursing.

Based on document review and interview, the hospital failed to ensure for adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed between the dates of 12/14/20 to 12/20/20.

Findings include:

1. Review of the hospital policy/procedure for Acuity Based Staffing Model, Revised 1/18, indicated that a nurse will have no more than a total of 12 acuity points.

2. Staffing documentation indicated that on 12/18/20, 12/19/20 and 12/20/20 at least 2 nurses carried a patient load with an acuity greater than 12 on each day.

3. On 5/10/21, beginning at approximately 3:30 PM, A2, Chief Nursing Officer, verified some nursing staff were over acuity during the dates in review.

Based on document review and interview, the nurse executive failed to ensure that nursing personnel followed established policies and standards for 5 processes: 1) notification of patient's family in the event of a fall for 1 of 10 patients (P3); 2) stating observations/interventions/findings from periodic observations during restraint for 2 of 10 patients (P2 and P3); 3) assessment and reassessment documentation descriptions of the patient's response/status relative to medical and/or nursing interventions and effectiveness of interventions for patients in restraints for 2 of 10 patients (P2 and P3); 4) Clinical Guidelines and Protocols for patient assessment with a condition change (fall) for 1 of 10 patients (P3) and hygiene for 5 of 10 patients (P2, P3, P4, P5 and P7) and 5) completion of a head-to-toe assessment and post fall monitoring for 1 of 10 patients (P3).

Findings include:

1. Policy/procedure review indicated the following:
A. Policy R03-A (2) for Significant Patient Injury/Unanticipated Outcomes, Revised 1/1/20, indicated that the nursing Clinical Supervisor was responsible for notifying the patient's family in the event of a fall.
B. Policy R02-N for Restraints and Seclusion, Revised 1/1/21, indicated Team Member documentation must: State observations/interventions/findings from periodic observations, to include: comfort, mobility, skin integrity, food/hydration and toileting - to include removal of restraints at least 10 minutes every 2 hours or more often.
C. Policy A03-G for Assessment and Reassessment of Patients, Revised 4/1/21, indicated Reassessment is a documented description of the patient's response/status relative medical and/or nursing interventions, effectiveness of interventions...
D. Policy S05-G for Guidelines and Protocols, Clinical; Revised 10/1/20, indicated the following for Minimum Frequency: Assessment: Every 12 hours and as condition changes. Hygiene: Gown changed: Daily. Oral Care: BID (2x/d) and PRN (as needed). Nutrition and Fluids: Intake and output (I&O) totaled: Every shift, 24 hour total by night shift. Oral Care for vent (ventilator) patients: Every 4 hours and PRN.
E. Policy C41-N for Change in Patient Condition, Revised 4/1/21, indicated that a complete head-to-toe assessment will be performed...for a change associated with a fall, also follow post fall monitoring...

2. Medical record (MR) review:
A. The MR of patient P2 indicated the following: On 12/17/21 at 1419 hours, soft bilateral wrist restraints were initiated. The MR lacked documentation of what the findings and/or activities were regarding restraint assessments/interventions. Due to lack of documentation relative to the findings and activities, the condition of the patient's skin under the restraints, their circulation and ROM could not be determined. Due to lack of documentation of activities provided for adequate hydration and nutrition, it could not be determined what (or if nutrition) and/or hydration was offered/provided as interventions. The MR lacked documentation of hygiene having been provided as follows: The MR lacked documentation of the patient's teeth being brushed and/or oral care provided from 12/7/20 at 1917 hour until 12/8/20 at 1930 hours; from 12/9/20 at 1100 hours until 12/10/20 at 1132 hours; from 12/10/20 at 1132 hour until 12/12/20 at 0832 hours.

B. The MR of patient P3 indicated the following: On 12/13/20 at 4:55 PM the patient had a fall. The note lacked documentation of the family having been notified of the patient's fall. The MR lacked documentation of a post-fall assessment. On 12/18/20 at 1:07 PM nursing documentation indicated the patient moved rooms again to be closer to the "desk". The MR lacked documentation of the family having been notified. On 12/18/20 bilateral soft wrist restraints were ordered/implemented. Restraint Flowsheet Data beginning 12/18/20 at 1811 hours indicated Restraint Type: Soft Restraint - Right Wrist/Left Wrist. "Continuing Observations/Interventions" included variances of information as follows: Assess skin integrity; Assessment of adequate hydration; Assessment of circulation; Offer fluids; Release restraint; ROM... The MR lacked documentation of the findings from skin assessments under the restraints/wrists every 2 hours; assessment findings related to adequate hydration; patient's consumption or refusal of hydration, length of the time the restraints were released and what type of ROM was performed every 2 hours. Due to lack of documentation of fluids having been provided or if the patient accepted or refused the offer for hydration, it could not be determined the interventions were implemented. Due to lack of documentation of length of time the restraints were released it could not be determined that the facility followed their policy. Shift Assessment Skin Integrity documentation on 12/20/20 indicated the following: Bruising; Tear - right wrist skin tear. Turgor non-tenting. Hourly rounding documentation lacked evidence of when/if the patient received fluids or used the toilet. Rounding documentation lacked evidence of the patient having been offered fluids and/or toileting as follows: From 12/16/20 at 0500 hours until 12/16/20 at 1600 hours the MR lacked documentation of the patient having been offered fluids or toileting. From 12/16/20 at 1654 hours until 12/16/20 at 2000 hours the MR lacked documentation of the patient having been offered fluids. From 12/16/20 at 1654 hours until 12/17/29 at 0700 hours the MR lacked documentation of the patient having been offered toileting. The MR lacked documentation of hygiene having been provided as follows: The MR lacked documentation of any patient hygiene or skin care having been provided from 12/11/20 (admission) until 12/14/20 at 1005 hours. The MR lacked documentation the patient's teeth being brushed and/or oral care provided from 12/11/20 (admission) until 12/15/20 at 1900 hours. The MR lacked documentation of the patient's gown having been changed from admission to 12/14/20 at 1005 hours; between 12/16/20 at 1143 hours and 12/19/20 at 1635 hours.

C. The MR of patient P4 indicated the patient was on mechanical ventilation. The MR lacked evidence of oral hygiene every 4 hours (per policy) as follows: Between 12/9/20 at 0815 hours and 12/9/20 at 1518 hours. Between 12/9/20 at 2035 hours and 12/10/20 at 0800 hours. Between 12/10/20 at 0837 hours and 12/10/20 at 2059 hours. Between 12/10/20 at 2059 hours and 12/11/20 at 0745 hours. The MR lacked documentation of the patient's gown having been changed between 12/10/20 at 0837 hours and 12/12/20 at 1020 hours.

D. The MR of patient P5 lacked evidence of BID (2x/d) oral care (per policy) on the following dates: 12/15/20 (no oral care documented); 12/16/20 and 12/17/20. The MR lacked documentation of the patient's gown having been changed from 12/16/20 at 1115 hours until 12/19/20 at 1134 hours.

E. The MR of patient P7 lacked evidence of BID (2x/d) oral (per policy) on the following dates: 12/17/20 (no oral care documented); 12/18/20 (no oral care documented); 12/19/20 at 1428 hours oral care indicated the mouth was swabbed, no other oral care was documented; 12/20/20 at 0943 hours denture care was documented, no other oral care was recorded. 12/21/20 lacked evidence of BID oral care. The MR lacked documentation of the patient's gown having been changed from admission 12/17/20 until 12/24/20 at 1141 hours. The MR indicated the patient moved rooms on 12/18/20. The MR lacked documentation of the family having been notified of the patient's change in rooms.

3. On 5/7/21, beginning at approximately 11:00 AM, A2, Chief Nursing Officer (CNO), verified the MR findings of P2. On 5/10/21, beginning at approximately 10:45 AM, A2, verified MR findings for patients P3, P4 and P5. Beginning at approximately 2:00 PM, A2 verified MR findings for patient P7.