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Based on surveyor observation, record review and staff interview, it was determined that the hospital failed to provide the patient/family with written notice of the results of the grievance process for one of one patients, ID# 1.

Findings are as follows:

Patient ID# 1, who lacks mobility, sustained injuries to his/her feet on 9/13/2016. On 9/17/2016, family members approached the supervising nurse (staff A) and requested that a formal grievance be filed. Interview with the risk manager (staff B) on 10/11/2016 at approximately 1:30 PM revealed that the hospital did not provide the patient's family with written notice of the steps taken to investigate the grievance, the results of the grievance investigation or the date of the completion of the investigation.

Based on surveyor observations, record review and staff interview, it has been determined that the hospital failed to obtain an order for a restraint from a physician or other licensed practitioner acting within his/her scope of practice for 4 of 4 sample patients (ID #16, 41, 42, & 43) who are in restraints.

Findings are as follows:

1. Patient ID# 16 has diagnoses to include: severe developmental disabilities (MR) with autism, seizure disorder, and impulse control disorder with agitated/assualtive behavior.

Record review revealed physician's orders dated 10/13/2016, under the fall reduction protocol, for a Craigs bed (a bed with 4 foot padded sides to prevent egress and with a door that opens from the outside) and posey lap belt with crotch strap when in chair for fall prevention. Additionally, there is an order for a 1 piece suit to be worn to prevent disrobing.

The patient was observed on 10/7/2016 at 8:42 AM, 10/20/2016 at 11:45 AM, and on 10/21/2016 at 12:45 PM reclined in a geriatric chair wearing a 1 piece suit, with a zipper in the back. The patient was also secured to the chair with a pelvic posey surrounding the patient's hips, which is secured from the back of the chair. The patient cannot remove either the 1 piece suit or the posey.

Additionally, on 10/20/2016 at 9:40 AM, the patient was observed sleeping in the Craigs bed.

The patient's physician was interviewed on 10/20/2016 at 1:30 PM relative to the above orders. She stated that the patient frequently has hallucinations/psychotic events with self injurious behaviors such as head banging and thrashing of the limbs. The Craigs bed keeps the patient safe during these events. Additionally, the patient enjoys the bed and becomes combative when placed into a regular bed. The pelvic posey is utilized to keep the patient safe as he/she tends to thrash when in the chair. The 1 piece suit is utilized as, in the past, the patient has removed his brief and smeared the contents.

2. Patient ID# 41 has diagnoses to include: history of muscular dystrophy with secondary incomplete quadriplegia, lower leg contractures, severe cognitive & language deficits.

Record review revealed physician's orders dated 10/11/2016, under the fall reduction protocol for a Craigs bed.

The patient's room was observed on 10/20/2016 at 11:00 AM and revealed a Craigs bed.

The patient's physician was interviewed on 10/20/2016 at 10:40 AM relative to the Craigs bed. She stated that the patient lived with the mother and basically lived on floor mats where he/she was able to crawl around the house. They attempted to put the patient in a regular bed, but he/she just crawled out and was found crawling down the hall. They feared for the patient's safety. The padded walls of the bed are necessary to prevent injury during head banging behaviors.

3. Patient ID# 42 has diagnoses to include: frontal lobe dementia, anxiety/behavior disorder.

Record review revealed physician's orders dated 10/4/2016, for hand mitts when the patient is observed to punch hard objects (TV, window, chair, table, etc) and a one piece suit for infection control purposes (pt smearing feces on his/her head).

Observations of the patient on 10/21/2016 at 9:10 AM, 11:35 AM, and 1:30 PM revealed the patient walking up and down the halls in a one piece suit.

The patient's physician was interviewed on 10/20/2016 at 10:40 AM relative to the hand mitts. She stated that the patient walks up and down the halls banging hard objects. To prevent him/her from injury, hand mitts are applied to his/her hands and removed when the behavior stops. The one piece suit is for infection control.

4. Patient ID# 43 has diagnoses to include: dementia of the Alzheimer's type and behavior disorder.

Record review revealed physician's orders dated 10/12/2016, for roll belt when in bed and a padded posey lap belt when in chair for fall prevention.

Observation of the patient on 10/21/2016 at 1:30 PM revealed the patient sitting in a geriatric with a padded posey lap belt in place.

The nurse (staff C) was interviewed at this time and stated that the posey is utilized for this patient because he/she cannot understand his/her physical limitations. The roll belt is also utilized so that he/she cannot roll out of bed.

Although the above interventions are appropriate for these patient's, there is no evidence that they are ordered as restraints or continually assessed, monitored, and reevaluated.

Based on record review and staff interview, it was determined that the hospital failed to implement the patient care plan, based on assessment of patient needs, for 1 of 5 patients (ID # 1) relative to safe patient handling and for 1 of 5 patients (ID# 16) relative to constant observation.

Findings are as follows:

1. Patient ID # 1 lacks mobility. The patient care plan dated, 8/19/2016 to current, specifies, "2 CNA's provide total care w/ADL's (activities of daily living) per hospital P&P (policies and procedures)". On 9/13/2016 this resident sustained injuries to both feet in the form of abrasions to several toes. The resident was being showered by only one CNA at the time the injury occurred.

The nurse (staff C) was interviewed by the surveyor on 10/5/2016 at 11:15 AM. Although the schedule showed that two CNA's were assigned to the patient on 8/13/2016, staff C told the surveyor that the usual routine is for one CNA to provide the shower to a patient while the second CNA changes the bed and cleans up in the patient's room. The staff member reported that this is the situation that existed at the time of the injury on 9/13/2016.

On 10/20/2016, between 11:00 AM and noon, three additional nursing staff were interviewed regarding showering procedures for totally dependent patients. Staff A told the surveyor that this patient, "should have been a two person assist. I don't know why the second aid was not in there." Staff D told the surveyor, "Anyone who is non-verbal should be a two-person assist at all times." Staff E told the surveyor that, "the number of staff assisting with the shower depends on the safe handling assessment".

On 10/21/2016, the policy & procedure for showering dependent patients was requested by a surveyor. The Nurse Manager (staff F) told the surveyor that there is no written procedure, but that the hospital policy is to have two staff members present for bathing/personal care.



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2) Patient ID# 16 has diagnoses to include: severe developmental disabilities (MR) with autism, seizure disorder, and impulse control disorder with agitated/assualtive behavior.

There is a physician's order, which is renewed daily, for 1:1 supervision in constant view and at arm's length when patient is seated for patient safety. There is a care plan for falls dated 8/25/2016 to current with an approach which requires a 1:1 supervision in constant view and at arm's length.

The patient was observed on 10/7/2016 at 8:42 and 9:26 AM seated in a geriatric chair. A Nursing Assistant (staff G) was seated approximately 4 feet from the patient with an over the bed table in front of her.

When interviewed on 10/7/2016 at 12:15 PM, staff G was unable to explain why she did not follow the plan of care.