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Based on document review and interview, the registered nurse failed to follow the facility policy and procedure related to an ongoing assessment and monitoring of a patient's wrist restraints and identifying the type of restraints used for one (1) of ten (10) medical record's (MR's) reviewed (Patient # 3).
Findings include:

1. Review of the hospital policy titled, "Restraints and Seclusion", policy number R02-N, indicated the MR documentation must include evidence of monitoring the patient's condition during restraint use and the type of restraint device used should be stated. This policy was last revised on 01/01/2021.

2. Review of the hospital policy titled, "Documentation Standards", policy number D05-G, indicated documentation will provide a current, complete and concise description of the patient's status. This policy was last revised on 07/01/2020.

3. Review of closed MR for patient # 3 indicated the patient was a 69 y/o (year/old) admitted to H # 2's (Long Term Acute Care Hospital) inpatient unit on 04/09/2021. The MR lacked the following:
A. The MR lacked documentation the patient's condition was assessed/monitored every two (2) hours while in wrist restraints on 04/18/2021 at 8:00 am, 10:00 am, 12:00 pm, 2:00 pm, 4:00 pm and 6:00 pm.
B. The MR lacked documentation indicating the type of restraint device that was applied to the patient on 04/21/2021 at 10:00 am, 12:00 pm, 2:00 pm, 4:00 pm and 6:00 pm.

4. In interview on 07/08/2021 at approximately 4:38 pm with administrative staff member A # 1 (Director Quality Management-DQM), confirmed the facility could not find any documentation that the restraints had been assessed/monitored by the nursing staff during the dates/times indicated, that the facility could not find any documentation supporting the patient was out of restraints on those dates/times and the type of patient restraints should have been identified/documented in the MR.

Based on document review and interview, the registered nurse failed to follow the facility policy and procedure related to hourly rounding and patient turning for one (1) of ten (10) medical record's (MR's) reviewed (Patient # 3) and failed to bath patient's daily for three (3) of ten (10) MR's reviewed (Patient # 3, Patient # 5 & Patient # 7).

Findings include:

1. Review of the hospital policy titled, "Documentation Standards", policy number D05-G, indicated documentation will provide a current, complete and concise description of the patient's status. This policy was last revised on 07/01/2020.

2. Review of the hospital policy titled, "Guidelines and Protocols, Clinical", policy number S05-G, indicated to ensure quality patient care, certain standards of care must be upheld. The table outlines basic tasks and designates the minimum frequency with which these tasks must be performed to maintain quality of care. The patient should be bathed daily and bedfast patients should be turned every two (2) hours and the position documented. This policy was last revised on 10/01/2020.

3. Review of the hospital policy titled, "Fall Reduction Program", policy number F02-G, indicated universal fall prevention strategies will be implemented for all patients which include hourly rounds. This policy was last reviewed on 10/01/2020.

4. The hospitals hourly rounding monitoring system "Amplion", was reviewed from 04/09/2021 through 06/29/3021. The system lacked hourly rounding for patient # 3 on 04/12 (10:00 pm), 04/14 (8:00 am, 1:00 pm, 4:00 am & 5:00 pm), 04/21 (12:00 pm & 9:00 pm), 04/22 (8:00 am & 3:00 pm), 04/24 (2:00 pm & 7:00 pm), 04/25 (4:00 pm), 04/26 (6:00 pm), 04/29 (1:00 pm), 05/04 (6:00 pm), 05/06 (8:00 pm), 05/07 (12:00 pm, 3:00 am & 6:00 am), 05/08 (12:00 am), 05/09 (5:00 pm), 05/10 (4:00 pm & 10:00 pm), 05/11 (2:00 pm, 8:00 pm & 5:00 am), 05/13 (12:00 pm), 05/14 (4:00 pm & 10:00 pm), 05/15 (8:00 am), 05/17 (9:00 pm & 3:00 am), 05/18 (7:00 am & 10:00 pm), 05/19 (4:00 am & 9:00 am), 05/21 (5:00 am, 11:00 am & 11:00 pm), 05/22 (2:00 pm), 05/23 (2:00 pm), 05/24 (3:00 pm), 05/25 (9:00 am, 4:00 pm & 8:00 pm), 05/26 (4:00 am, 8:00 am, 9:00 am, 12:00 pm, 2:00 pm & 5:00 pm), 05/27 (5:00 am & 5:00 pm), 05/28 (11:00 am), 06/06 (12:00 am, 8:00 am & 6:00 pm), 06/09 (4:00 am, 5:00 pm & 9:00 pm), 06/10 (12:00 am, 6:00 am & 4:00 pm), 06/11 (4:00 am, 10:00 am & 6:00 pm) and 06/28 (12:00 am, 2:00 pm, 3:00 pm and 5:00 pm) of 2021.

5. Review of closed MR for patient # 3 indicated the patient was a 69 y/o (year/old) admitted to H # 2's (Long Term Acute Care Hospital) inpatient unit on 04/09/2021. The MR lacked the following:
A. The MR lacked documentation the bedfast patient was being turned every two (2) hours on the following dates/times: 04/10 (1:30 am & 3:30 am), 04/11 (10:30 pm), 04/12 (1:30 am & 3:30 am), 04/14 (4:00 pm), 04/18 (4:00 pm), 04/20 (7:00 pm), 04/21 (2:00 pm), 04/24 (6:00 pm), 05/07 (6:00 pm) and 05/11 (10:00 am) of 2021.
B. The MR lacked documentation the patient was being bathed daily on 04/11, 04/14, 04/16, 04/19, 05/02, 05/07, 05/16, 06/01, 06/06, 06/08, 06/09, 06/11, 06/13, 06/14, 06/26, 06/28 of 2021.

6. Review of the open MR for patient # 5 indicated the patient was a 39 y/o admitted to H # 2's inpatient on 04/02/2021. The MR lacked documentation the patient was bathed on the following dates: 04/11, 04/12, 04/18, 04/20, 05/03, 05/07, 05/16, 05/31, 06/02, 06/09, 06/18, 06/24, 06/27, 06/28 and 07/02 of 2021.

7. Review of the open MR for patient # 7 indicated the patient was a 52 y/o admitted to H # 2's inpatient on 06/30/2021. The MR lacked documentation the patient was bathed on 07/02/2021.

8. In interview on 07/08/2021 at approximately 3:22 pm with administrative staff member A # 1 (Director Quality Management-DQM), confirmed that patient # 3 had not been turned per policy.

9. In interview on 07/09/2021 at approximately 12:20 pm with administrative staff member A # 3 (Chief Executive Officer-CEO), confirmed he/she "would agree the button was not pushed by a staff member" related to the non-compliant round times on the electronic monitoring system for patient # 3.

10. In interview on 07/09/2021 at approximately 1:25 pm with administrative staff member A # 1, confirmed all patients should have a bath everyday and it should be documented in their MR.