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Based on record review and interview the facility failed to protect patient rights when they failed to ensure patients right to be free from restraints by failing to ensure the administrative staff appropriately enforce their policies and procedures for the application or release of restraints ordered by the physicians, using a comprehensive assessment, when determining the need for restraints in 2 of 2 patient's restrained in an enclosed bed restraint (Patient #1 and Patient # 6), failure failing to document the assessment of the patient's behavior that resulted in the use of an enclosure bed restraint in 2 of 2 patients restrained in enclosed bed restraints (Patient #1 and patient #6) and failing to document the assessment of the patient's behavior that resulted in the use of an enclosure bed restraint in 2 of 2 patients restrained in enclosed bed restraints (Patient #1 and patient #6).

Findings include:

The facility failed to ensure patients right to be free from restraints by failing to ensure the administrative staff appropriately enforce their policies and procedures for the application or release of restraints ordered by the physicians, using a comprehensive assessment, when determining the need for restraints. See Tag A-0154

The facility failed to document the use of less retrictive measures or the rationale for use of an enclosure bed restraint in 2 of 2 patients restrained in enclosed bed restraints. See Tag A-0165

The facility failed to document the assessment of the patient's behavior that resulted in the use of an enclosure bed restraint in 2 of 2 patients restrained in enclosed bed restraints. See Tag A-0188

The cumulative effect of these deficient practices have resulted in failing to protect the patients rights while the patient is in restraints.

Based on record review and interview the facility failed to ensure patients right to be free from restraints by failing to address, in their policy and procedures, who has the authority to discontinue the use of a restraints in 1 of 1 of their restraint policies ("Restraints and Seclusion" #R02-N) and failing to ensure the administrative staff appropriately enforce their policies and procedures for the application or release of restraints ordered by the physicians, using a comprehensive assessment, when determining the need for restraints in 2 of 2 patient's restrained in an enclosed bed restraint (Patient #1 and Patient # 6) in a total of 3 enclosure bed restraints used in the past 6 months.

Findings include:

Review of policy titled "Restraints and Seclusion" #R02-N last revised 10/2018 under purpose revealed "To ensure the patient's right to be free from restraints of any form that are not necessary...Restraint use is an exceptional event, not a routine response to a certain condition or behavior... determined by comprehensive assessment... used ONLY to meet the patient's individual clinical needs... and alternatives have failed. Restraint use must end as soon as possible... Page 5 in the box labeled "Interdisciplinary Team Roles & Responsibilities" revealed "Interdisciplinary Team" to be responsible for the application, monitoring and release of restraints and "Physician/LIP/RN" are responsible for the assessment, alternatives, and justification of the restraints... Purpose and Use: The patient has the right to be free from restraints, of any form, imposed as a means of ... convenience." There is no indication of who the "Interdisciplinary Team" consists of, with the authority to discontinue the use of a restraint.

Review of packet titled "HOSPITAL ORIENTATION PACKET" For the Medical Staff and Allied Health Professionals" #4 included "Key Policies and Procedures I. Restraints and Seclusion R02-N".

Review of form titled "Key policies and Procedures - Clinical" from the Medical Staff packet revealed "Policy R02-N: Restraints and Seclusion" under 1 Policy "The decision to use a restraint is determined by comprehensive assessment that concludes for this patient, at this time, the use of less intrusive measures poses a greater risk than the risk of using a restraint or seclusion... Restraint is used ONLY to meet the patiet's individual clinical needs... Restraint use must end as soon as possible.... 2. PROCEDURE... The physician's order indicates agreement with assessmet and the plan of care to use restraints... A written order, based on an examination of the patient by the MD/DO or LIP is entered into the patient's medical recordon a daily basis when restraint use is clinically appropriate."

Review of Patient #1's medical record revealed patient was an 82-year-old diagnosed with aortic valve endocarditis and chronic respiratory failure admitted 8/11/2020 for intravenous (IV) antibiotics and occupational therapy. Nursing notes on 8/25/20 at 7:40 AM revealed "Patient found on floor in corner of room without oxygen on, he reports he attempted to get out because "no one brought me a sandwich." He was frequently attempting to get out of bed and on 8/25/20 was moved from room 232 to 227, closer to the nursing station for more frequent monitoring. "24 Hour Patient Record & Plan of Care" nursing documentation on 8/25/20 revealed the bed was lowered, and mats were placed at the bedside for safety and on 8/25/20 at 6 PM the patient was placed in an enclosed bed for frequent attempts to get out of bed. On 8/26/20 at 2 AM nursing narrative note revealed "Pt (patient) pulling on lines and tubing on multiple occasion thru the night. Pt placed in bilateral mitts for pt safety" Rass score (Richmond Agitation Sedation Scale used to measure delirium) on 8/25/20 at 2 am was +1 indicating restlessness, movements not aggressive or vigorous. "Restraint Order/Assessment Sheet" dated 8/25/20 under Clinical Justification for Restraint Use" revealed "removing NC (nasal cannula) recent fall." The mitts were removed prior to 7 AM assessment and were not reapplied. "24 Hour Patient Record & Plan of Care" nursing documentation on 8/26/20 at 12 PM - revealed a RASS score of +3 (very agitated, pulls on or removes tubes or catheters or is aggressive) and at 7:45 PM +2 (agitated. Frequent nonpurposeful movement) and patient remained in the enclosure bed. "24 Hour Patient Record & Plan of Care" nursing documentation on 8/27/20 at 8:25 AM - revealed a RASS score of 0 (calm and alert) and at 8 PM -2 (light sedation, awakens briefly with eye contact to verbal command). "Restraint Order/Assessment Sheet" dated 8/26/20 under Clinical Justification for Restraint Use" revealed box marked poor judgement "pulling on lines." On 8/27/2020 patient refused his meals, was less responsive with altered mental status and, his code status was changed from a full code to DNR (do not resuscitate). "Restraint Order/Assessment Sheet" dated 8/27/20 under Clinical Justification for Restraint Use" revealed "pulls @ Bipap mask; poor impulse control to prevent patient from falling OOB (out-of-bed)." "24 Hour Patient Record & Plan of Care" nursing documentation on 8/28/20 at 8 AM and 8 PM revealed a RASS score of 0 (calm and alert). The patient weakened, and on 8/28/20 he refused placement of a nasogastric tube for feeding. There were no attempts to pull at lines, no attempts to get out of bed, or poor impulse control documented since 8/26/20. Patient #1 remained in the enclosure bed until he expired 8/31/20 at 1:40 AM.

Review of Patient #6's medical record revealed patient was a 37-year-old with a known long history of IV heroin abuse diagnosed multiple cystic lesions along the spine and a left forearm abscess admitted 8/11/2020 for intravenous (IV) antibiotics. Nursing narrative on 8/26/20 at 1:40 AM revealed "found on floor on knees after hearing bed alarm. Patient not able to explain what happened or when... able to follow commands." Nursing note dated 8/26/20 at 1:45 AM revealed "Enclosure bed ordered." No documentation of room change, mats placed on floor, or any increased confusion. In "24 Hour Patient Record & Plan of Care" documentation on 8/26/20 at 7:20 AM revealed "sitter present," at 7:20 AM and 9 PM revealed a RASS score (Richmond Agitation-Sedation Scale) of 0 (alert and calm). Restraint documentation revealed Patient #6 was in a "Posey Bed" (enclosure bed restraint) 8/26/20 from 2 PM through 8/27/20 at 5 AM. Nurses Progress/Narrative notes dated 9/04/20 at 9:15 AM revealed "late entry. 08/26/2020 1400 (2 PM) pt (patient) placed in vail bed for falls and attempts to leave floor." No documentation of attempts to leave floor, confusion, or altered mentation documented. "Restraint Order/Assessment Sheet" with telephone/verbal order dated 8/26/20 at 6:30 PM signed and date stamped "9/3/2020 1:53:06 PM" with box under Type of Restraint checked "Enclosure bed." Documentation of Patient #6's assessment on 8/26/20 did not demonstrate the need for restraints prior to initiating the enclosure bed, the response to the restraint, or behaviors consistent with the need for an enclosure bed restraint.

On 9/08/20 at 10:17 AM during interview with Physician E, Physician E stated the RN completes the daily comprehensive assessment and the "team" completes the Restraint Order/Assessment Sheet which he signs.

On 9/08/20 at 11:52 AM during interview with Registered Nurse (RN) D, RN D stated she was new to this facility and did not understand the paper charting. RN D stated she did not witness Patient #1 to be confused or have poor judgement but had received that information from previous charting. Her assessment was that he was "weak with no strength to move out of bed." RN D stated she had talked to the charge nurse and was told they "do not have sitters available."

On 9/08/20 at 5:20 PM during interview with DON B, DON B confirmed the restraint policy did not address who had the authority to discontinue restraints and stated the "multidisciplinary team" makes that decision. DON B stated the staff was "sometimes removing the restraints too early" and stated their sitters are not allowed to do any patient care, they can only watch the patient and alert the staff if the patient is in danger. DON B stated the enclosure bed was the least restrictive restraint stating "we don't use them very often."

Based on record review and interview the staff failed to follow their policies and procedures by failing to document the rationale for the use of an enclosure bed restraint in 1 of 2 patient's where an enclosure bed restraint was used (Patient #6) in a total of 9 medical records reviewed with patients in restraints.

Findings include:

Review of policy titled "Restraints and Seclusion" #R02-N last revised 10/2018 under purpose revealed "To ensure the patient's right to be free from restraints of any form that are not necessary...Restraint use is an exceptional event, not a routine response to a certain condition or behavior... determined by comprehensive assessment that concludes for this patient, at this time, the use of less intrusive measures poses a greater risk than the risk of using a restraint... used ONLY to meet the patient's individual clinical needs... and alternatives have failed... 2. Alternatives a. Attempt alternative interventions prior to every application of a restraint... b. Diversional activities. Prior to the use of a restraint, alternative interventions must be found to be ineffective to protect the patient or others from harm, provide frequent reality orientation/reorientation to surroundings... Consider environmental changes... Locate/relocate closer to nurses station... low beds Abdominal binder... Purpose and Use: The patient has the right to be free from restraints, of any form, imposed as a means of ... convenience."

Review of Patient #6's medical record revealed patient was a 37-year-old with a known long history of IV heroin abuse diagnosed multiple cystic lesions along the spine, and a left forearm abscess, admitted 8/11/2020 for intravenous (IV) antibiotics. Nursing narrative on 8/25/20 at 8:20 PM revealed "Patient noted to be trembling at times, seems weak." Rass score (Richmond Agitation-Sedation Scale) was 0 (calm and alert). Nursing narrative on 8/26/20 at 1:40 AM revealed "found on floor on knees after hearing bed alarm. Patient not able to explain what happened or when... able to follow commands." Nursing note dated 8/26/20 at 1:45 AM revealed "Enclosure bed ordered." No documentation of increased monitoring, mats placed on floor for safety, or bed lowered. No increased confusion documented. In "24 Hour Patient Record & Plan of Care" documentation on 8/26/20 at 7:20 AM revealed "sitter present," at 7:20 AM and 9 PM revealed a RASS score of 0 (alert and calm). Restraint documentation revealed Patient #6 was in a "Posey Bed" (enclosed bed restraint) 8/26/20 from 2 PM through 8/27/20 at 5 AM. Nurses Progress/Narrative notes dated 9/04/20 at 9:15 AM revealed "late entry. 08/26/2020 1400 (2 PM) pt (patient) placed in vail bed for falls and attempts to leave floor." No documentation of attempts to get out of bed, leave floor, falls, confusion, or altered mentation documented on 8/25/20 or 8/27/20. "Restraint Order/Assessment Sheet" with telephone/verbal order dated 8/26/20 at 6:30 PM signed and date stamped "9/3/2020 1:53:06 PM" with box under Type of Restraint checked "Enclosure bed." There was no documentation of Patient #6's behaviors or medical condition indicating need for enclosure bed restraint.

On 9/08/20 at 5:20 PM during interview with DON B, DON B stated clinical indications would have been reviewed with the interdisciplinary team, the enclosure bed was the least restrictive restraint stating "we do not use them very often." DON B confirmed the documentation in Patient #6's medical record "could have been better."

Based on record review and interview, the facility failed to ensure policies and procedures are followed by failing to document the assessment of the patient's behavior that resulted in the use of an enclosure bed restraint in 2 of 2 patients restrained in enclosed bed restraints (Patient #1 and patient #6).

Findings include:

Review of policy titled "Restraints and Seclusion" #R02-N last revised 10/2018 page 2 under Policy revealed ""Restraint use must end as soon as possible. This must be demonstrated by patient care staff through their documentation." Under Procedure revealed "If restraint is a consideration. Use concrete, objective observations to describe the patient's behavior." Page 3 "2. Alternatives a. Attempt alternative interventions prior to every application of a restraint... b. Diversional activities. Prior to the use of a restraint, alternative interventions must be found to be ineffective to protect the patient or others from harm, provide frequent reality orientation/reorientation to surroundings... Consider environmental changes... Locate/relocate closer to nurses station... low beds Abdominal binder... Purpose and Use: The patient has the right to be free from restraints, of any form, imposed as a means of ... convenience." Page 8 under Medical Record Documentation revealed "At a minimum documentation must include... The patient assessment that demonstrates the need for restraint as part of the patient's treatment... patient's response to restraint... State behavior/condition (justification) necessitating use of protective restraints (q (every) shift & prn)... State type of device applied and patient response (shift & prn)."

Review of Patient #1's medical record revealed patient was an 82-year-old diagnosed with aortic valve endocarditis and chronic respiratory failure admitted 8/11/2020 for intravenous (IV) antibiotics and occupational therapy. Patient #1 was placed in an enclosure bed restraint 8/25/20 at 6 PM due to "frequently attempting to get OOB (out-of-bed) without assist despite consistent re-orientation" documented in nursing narrative 8/25/20 at 6 PM. On 8/27/20 at 10:25 AM nursing narrative notes revealed "refusing meals... remains in posey bed d/t (due to) impulse control & prevent falling out of bed" and RASS scores were 0 (calm and alert) at 8:25 AM and -2 (light sedation, awakes briefly with eye contact to verbal command). 8 PM. Patient #1 was converted to a DNR (do not resuscitate) status 8/27/20 at 5:40 PM. There was no documentation of behaviors indicating need for enclosure bed restraint noted in Patient #1's medical record on 8/27/20, 8/28/20, 8/29/20, or 8/30/20 and Patient #1 expired 8/31/30 at 1:40 AM.

Review of Patient #6's medical record revealed patient was a 37-year-old with a known long history of IV heroin abuse diagnosed multiple cystic lesions along the spine and a left forearm abscess admitted 8/11/2020 for intravenous (IV) antibiotics. Nursing narrative on 8/25/20 at 8:20 PM revealed "Patient noted to be trembling at times, seems weak." Rass score (Richmond Agitation-Sedation Scale) was 0 (calm and alert). Nursing narrative on 8/26/20 at 1:40 AM revealed "found on floor on knees after hearing bed alarm. Patient not able to explain what happened or when... able to follow commands." Nursing note dated 8/26/20 at 1:45 AM revealed "Enclosure bed ordered." No documentation of increased monitoring, mats placed on floor for safety or bed lowered. No increased confusion documented. In "24 Hour Patient Record & Plan of Care" documentation on 8/26/20 at 7:20 AM revealed "sitter present," at 7:20 AM and 9 PM revealed a RASS score of 0 (alert and calm). Restraint documentation revealed Patient #6 was in a "Posey Bed"(enclosure bed) 8/26/20 from 2 PM through 8/27/20 at 5 AM. Nurses Progress/Narrative notes dated 9/04/20 at 9:15 AM revealed "late entry. 08/26/2020 1400 (2 PM) pt (patient) placed in vail bed for falls and attempts to leave floor." No documentation of attempts to leave floor, falls, confusion, or altered mentation documented on 8/26/20. "Restraint Order/Assessment Sheet" with telephone/verbal order dated 8/26/20 at 6:30 PM signed and date stamped "9/3/2020 1:53:06 PM" with box under Type of Restraint checked for "Enclosure bed." There was no documentation of Patient #6's behaviors indicating need for enclosure bed restraint.

On 9/08/20 at 5:20 PM during interview with DON B, DON B stated the enclosure bed was the least restrictive restraint and it was used for the patient's safety to prevent falls. DON B confirmed the documentation on Patient's #1 and #6 "could have been better."

Based on record review and interview, the facility failed to ensure the medical staff follow their policies and procedures for authentication of their history and physicals in 3 of 10 history and physicals reviewed (Patient #1, #4 and #10, 1 of 6 discharge summaries (Patient #1), and 4 of 7 consultations reviewed (Patient #4, #6, #9 and #10) in a total of 10 medical records reviewed.

Findings include:

Review of "Rules and Regulations of the Medical Staff" dated 3/05/2020 page 123 2. Medical History and Physical Examination revealed "At a minimum, each patient shall receive a history and physical examination... The history and physical must be placed in the patient's medical record within twenty-four (24) hours of admission... 6. All clinical entries in the patient's medical record shall be accurately dated, timed, and authenticated."

Review of Patient #1's medical record revealed Patient #1 was admitted 8/11/20 and expired 8/31/20. "History and Physical" (H&P) dated 8/12/20 revealed "Preliminary Until Signed." H&P was not signed, dated or timed. Discharge summary dated 8/31/20 was not signed, dated or timed.

Review of Patient #4's inpatient medical record revealed Patient #4 was admitted 8/25/20. H&P dated 8/26/20 was not signed, dated or timed. Consultation dated 9/03/20 was not signed, dated or timed.

Review of Patient # 5's inpatient medical record revealed Patient #5 was admitted 8/07/20. Consultation dated 8/15/20 revealed "Preliminary Until Signed" with 5 blanks that needed to be filled in by dictating physician not signed, dated or timed.

Review of Patient #9's medical record revealed Patient #9 was admitted 7/15/20 and discharged 8/18/20. Physician consult dated 8/04/20 was signed, not dated or timed.

Review of Patient #10's medical record revealed Patient #10 was admitted 6/08/20 and discharged 7/09/20. H&P dated 6/09/20 was signed 7/11/20. Pulmonary consultation dated 6/09/20 was not dated or timed.

On 9/08/20 at 3:40 PM during interview with Director of Quality A, A stated that the requirements for the physicians documentation are in the medical staff bylaws, not in the hospital policies, stating the physician documents should be either signed electronically or physically in the medical record. Director A confirmed some of the signatures, dates, and times were missing.

Based on record review and interview, the facility failed to ensure verbal orders are promptly signed, dated and authenticated in 8 of 9 medical records with restraint orders (Patient #1, #3, #4, #5, #6, #7, #8 and #9) and 6 of 10 medical records reviewed with verbal or telephone orders (Patient #1, #4, #6, #7, #8, and #9) in a total of 10 medical records reviewed.

Findings include:

Review of policy titled "Restraints and Seclusion" #R02-N last revision date of 1/15/07 under procedure revealed when a comprehensive assessment for restraint consideration is completed "if a physician or LIP is not available to issue such an order, a registered nurse initiates restraint use... the MD/DO or LIP is notified immediately... and a telephone order is obtained from that practitioner and entered into the patient's medical record."

Review of medical staff rules and regulations page 117 #3 revealed "All orders, including verbal orders, must be dated, timed and authenticated by the prescribing physician... who is responsible for the patient's care... page 124 #6 revealed "All clinical entries in the patient's medical record shall be accurately dated, timed, and authenticated."

Review of Patient #1's medical record forms titled "Restraint Order/Assessment Sheet" with verbal order dated 8/25/20 at 6 PM signed 9/3/20 at 10:25 AM, verbal order dated 8/27/20 at 7:30 AM not dated or timed, verbal order dated 8/30/20 at 8 AM dated 9/25/20 at 10:25 AM (2 restraint orders signed after 72 hours and 1 restraint order not dated or timed.). Medical record forms titled "Physician's Orders" with verbal order dated 8/22/20 at 10:37 AM signed 9/3/20 at 10:25 AM, verbal order dated 8/17/20 at 1:15 PM signed 9/03 at 10:25 AM, verbal order dated 8/18/20 at 12:20 PM not signed, dated or timed, verbal order dated 8/26/20 at 8 AM not signed, timed or dated, verbal order dated 8/26/20 at 4:30 PM not timed or dated, verbal order dated 8/26/20 at 4:15 PM signed 9/03/20 at 10:24 AM, verbal order dated 8/26/20 at 5 PM signed 9/03 at 10:24 AM, verbal order dated 8/26/20 signed 9/03/20 at 10:24 AM, telephone order dated 8/25/20 at 6:05 AM signed 9/09/20 at 11:25 AM, verbal order dated 8/28/20 at 1 PM signed 9/03/20 at 10:24 AM (total of 3 telephone/verbal orders not signed and 7 not signed within 72 hours).

Review of Patient #3's medical record forms titled "Restraint Order/Assessment Sheet" with verbal order dated 8/29/20 7:00 AM signed 9/01/20 at 11:30 am (1 restraint order signed after 72 hours).

Review of Patient #4's medical record forms titled "Restraint Order/Assessment Sheet" with verbal order dated 8/30/20 at 1:10 PM, signed 9/03/20 at 11:40 PM, verbal order dated 8/29/20 at 7 AM signed 9/3/2020 11:40 AM (2 restraint orders signed after 72 hours). Medical record forms titled "Physician's Orders" with verbal order dated 8/31/20 not timed (total of 1 telephone/verbal order not timed).

Review of Patient #5's medical record forms titled "Restraint Order/Assessment Sheet" with verbal order dated 8/11/20 at 1 PM not signed dated or timed, telephone order dated 8/13/20 at 12:45 PM not sign, dated or timed. (2 restraint orders not signed, dated, or timed).

Review of Patient #6's medical record forms titled "Restraint Order/Assessment Sheet" with verbal order dated 8/26/20 at 6:30 PM, signed with date stamped "9/3/2020 1:53:06 PM", verbal order dated 8/27/20 at 7:30 AM signed with date stamped "9/3/2020 1:53:06 PM" (2 restraint orders signed after 72 hours). Medical record forms titled "Physician's Orders" with verbal order dated 8/27/20 at 5:30 PM signed and date stamped "9/3/20 at 1:53:11 PM, telephone order 8/27/20 at 6:30 PM signed and date stamped "9/3/2020 1:53:12 PM", verbal order dated 8/24/20 at 7:15 PM not signed, timed or dated, verbal order 8/14/20 at 8 PM, signed with date stamped "9/3/2020 1:53:09 PM (total of 1 telephone/verbal order not signed, 3 not signed within 72 hours).

Review of Patient #7's medical record forms titled "Restraint Order/Assessment Sheet" with telephone order dated 6/18/20 at 7 AM signed 6/22/20 at 8 AM, order sheet dated 6/22/20 not timed signed with date stamped "7/9/2020 4:17:28 PM", (2 restraint orders signed after 72 hours). Medical record forms titled "Physician's Orders" with telephone order dated 6/22/20 at 7:19 PM signed with date stamp "7/9/2020 4:17:32 PM, telephone order dated 6/22/20 at 3 PM date stamped "7/9/2020 4:17:34 PM," telephone order dated 6/23/20 at 3:05 PM not signed, dated or timed, verbal order dated 6/24/20 at 1:10 PM signed with date stamp "7/9/2020 1:17.41 PM". (total of 1 verbal/telephone order not signed, 3 not signed within 72 hours).

Review of Patient #8's medical record forms titled "Restraint Order/Assessment Sheet" with verbal order dated 5/04/20 at 8:20 PM signed 5/19/20 at 5:44 PM (1 restraint order signed after 72 hours). Medical record forms titled "Physician's Orders" with telephone order dated 4/07/22 at 4:30 PM signed 4/13/20 at 9:50 AM, verbal order dated 4/07/20 (not timed) signed 4/13/20 at 9:50 AM, telephone order dated 4/20/20 at 11 AM signed 5/19/20 at 5:44 PM, verbal/telephone order dated 4/28/19 (not timed) not signed, timed or dated (total of 1 verbal/telephone order not signed, 3 not signed within 72 hours, 2 incomplete).

Review of Patient #9's medical record forms titled "Physician's Orders" with verbal order dated 8/28/20 at 3:15 PM not signed, dated or timed, telephone order dated 8/28/20 at 4:45 PM not signed, dated or timed, verbal order dated 4/07/20 (not timed) signed 4/13/20 at 9:50 AM, telephone order dated 4/20/20 at 11 AM signed 5/19/20 at 5:44 PM, verbal/telephone order dated 4/28/19 (not timed) not signed, timed or dated (total of 3 verbal/telephone orders ot signed, 2 not signed within 72 hours, 2 incomplete).

Review of Patient #10's medical record forms titled "Restraint Order/Assessment Sheet" with telephone order dated 7/06/20 4 PM for bilateral freedom splints, signed 7/19/20 at 3 PM, telephone order 7/06/20 at 8 AM for bilateral wrist restraints signed 7/19/20 at 3 PM.( 2 physician orders signed after 72 hours).

On 9/08/2020 at 11:08 AM during interview with Director of Nursing (DON) B, DON B stated restraint orders should be signed within 48 hours "with no flucuation."

On 9/08/20 at 10:17 AM during interview with Physician E, Physician E stated the RN completes the daily comprehensive assessment and the "team" completes the Restraint Order/Assessment Sheet, he signs it "the next day" and stated sometimes "I miss."

On 9/08/2020 at 2:50 PM during interview with Director of Nursing B, Director B stated physician orders, including verbal orders, would be signed within 48 hours stating "72 hours at the latest." Director B stated they were going to get an electronic medical record and confirmed there were too many physician entries that were not signed stating "the EMR will help with this."

Based on record review and interview the facility failed to ensure the medical staff followed their medical staff bylaws, rules and regulations to provide complete discharge summaries to assure continuity of care in 4 of 6 patients who were discharged (Patient #1, #7, #9 and #10) in a total of 10 medical records reviewed.

Findings include:

Record review of "Rules and Regulations of the Medical Staff" dated 3/05/2020 page 124, #8 revealed "A discharge summary (clinical resume) shall be written or dictated on all medical records of patients hospitalized. In all instances, the content of the medical record shall be sufficient to justify the diagnosis and warrant the treatment and end result. All summaries shall be authenticated by the responsible practitioner. 9. The discharge summary shall include: (a) The primary and secondary diagnoses... (d) A summary of pertinent history, physical findings, laboratory and x-ray results... (f) Progress during hospitalization, (g) Functional status at time of discharge... (i) List of medications, (j) Rehabilitation potential, and (k) Follow-up plan and physician for follow-up care."

Review of Patient #1's medical record revealed Patient #1 was admitted 8/11/20 and expired 8/31/20. Discharge summary dated 8/31/20 revealed under "Diagnoses" "No selection made." Under "PLAN" last entry was dated 8/29 "refuses enteral feeds." There are no primary or secondary diagnoses listed. There was no summary of pertinent history, physical findings, or x-ray results. There was no disposition of the patient (patient expired).

Review of Patient #7's medical record revealed Patient #7 was admitted 6/16/20 and discharged 7/03/20. Discharge summary dated 7/03/20 under "Hospital course" revealed "most of his antipsychotics have been weaned and discontinued. However he remains weak and deconditioned therefore the patient is being discharged to inpatient rehab." "Recent Labs" were listed. There was no summary of laboratory results, functional status at time of discharge, list of current medications or follow-up plan or physician for follow-up care.

Review of Patient #9's medical record revealed Patient #9 was admitted 7/15/20 and discharged 8/14/20. Discharge summary dated 8/14/20 under hospital course revealed "On this admission the patient has done very well... He continues to have significant anxiety issues for which he remains on appropriate antidepressants and anxiety medication. She please continue PT (physical therapy) OT (occupational therapy) and speech therapy... Please follow CBC (complete blood count) BMP (basic metabolic profile) closely... CNS (central nervous system) is unchanged he remains weak." "Recent Labs" were listed. There was no summary of laboratory results. There was no functional status at the time of discharge, list of discharge medications, rehabilitation potential or follow-up plan or physician for follow-up care. There was no disposition noted.

Review of Patient #10's medical record revealed Patient #10 was admitted 6/08/20 and discharge 7/09/20. Discharge summary dated 7/08/20 under "Diagnoses" revealed "No selection made." Under "Assessment and plan" revealed "Decannulated July 6, 2020. Aspergillus colonization of airway-continue to monitor for pulmonary symptomatology... Patient is status post debridement and continue with wound care and dressing changes... Hypertension-essential, chronic continue with amlodipine... underlying psychiatric disorder with would benefit from psychiatric evaluation as an outpatient." There was no follow-up plan for monitoring his pulmonary symptomatology, wound care, follow-up of hypertension medications, follow-up psychiatric evaluation, or physicians for follow-up care. There was no disposition noted.

On 9/08/20 at 3:40 PM during interview with Director of Quality A, A stated that the requirements for the physicians documentation are in the medical staff bylaws, not in the hospital policies. Director A confirmed the physicians discharge summaries "could be more complete."