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Based on medical record review, review of facility documentation, and interview, the facility failed to investigate incidents completely; failed to determine causes of incidents; and failed to implement interventions to prevent future recurrence of the incidents for one (#3) of five patients reviewed.

The findings included:

Patient #3 was admitted to the facility on October 15, 2013, after falling at home; sustaining a C2 (second cervical vertebra) fracture; undergoing surgical intervention; and also having diagnoses of Diabetes Mellitus, Hypertension, Cerebrovascular Accident, First Degree Atrioventricular Block (cardiac abnormal rhythm), Dysphagia (difficulty swallowing), and Dementia.

Medical record review of the History and Physical; dated October 15, 2013, revealed the patient had persistent encephalopathy (diminished mental status usually due to decreased oxygenation), high oxygen requirements, agitation, and inability to eat or drink. Continued review of the document revealed the patient had a Dobhoff tube (tube from nose into stomach for feedings) in place as well as a nasal trumpet (device placed in nose to facilitate suctioning secretions). Further review of the document revealed "...patient was quite agitated after arrival here, kept pulling oxygen off, and required physician restraints and Seroquel (medication used for sedation) to maintain medical appliances in place..."

Medical record review of the Wound Clarification form dated October 16, 2013, revealed the patient was admitted to the facility with right wrist abrasion, left leg blister, right arm raised knot, old trach (tracheostomy - opening in neck for breathing), left upper chest abrasion, left eyebrow laceration, and left arm abrasion

Medical record review of nursing notes dated October 15, 2013, at 9:12 p.m., revealed "...made unscheduled stop to look in on pt (patient). found...soiled and agitated with O2 (oxygen) cannula in fist instead of nose; pt. resisting my efforts to replace cannula and punched at me repeatedly with fists..." Continued review of nursing notes dated October 16, 2013, at 11:00 p.m., revealed "...while speaking with patient's nurse...divulged this patient had sustained bad skin tear to the rt. (right) dorsal (back) hand. went to patient's room large skin tear on right hand almost the entire dorsal part of the hand. patient was bleeding and was restrained with soft wrist restraints, nurse applied Vaseline gauze and wrapped hand with kerlix wrap after the wound was cleaned..."

Review of the QA investigation of the skin tear to the patient's right hand, revealed the potential contributing factors/causes included Patient/family non-compliance or lack of understanding. Continued review of the event notice revealed "...Nurse found patient agitated with O2 cannula out of nose, while trying to replace cannula in nostril, patient punched nurse repeatedly. Patient received skin tear to dorsum of left hand. Wound care nurse notified and will treat..." Further review of the event notice revealed no possible causes of the injury; no statement by the nurse caring for the patient; and no interventions to prevent this type of injury from occurring in the future.

Medical record review of respiratory therapy notes dated October 20, 2013, at 10:00 a.m., revealed "...second attempt to administer aerosol (breathing treatment). pt. combative, thrashing head with C-collar (rigid collar to keep neck immobile), beating restrained arms against bed rails, screaming help, spitting, ripping and clawing at isolation gown..." Continued medical record review of a respiratory therapy note dated October 21, 2013, at 11:40 a.m., revealed the patient's respiratory alarm was sounding; pt. was making odd noise from mouth; therapist "...began to try to clean pt's mouth out with mouth cleaning kit, pt. began hitting me and trying to bite me..."

Medical record review of nursing notes dated October 22, 2013, at 4:28 p.m., revealed the nurse noted a right upper extremity hematoma (blood filled blister). Continued review of nursing notes on the same day at 5:08 p.m., revealed "...rue (right upper extremity) purple raised warm to touch medial (toward middle) aspect hard firm lateral (toward side) aspect is soft mushy fluctuant (able to be moved)..." Further medical record review of nursing notes on the same day at 5:31 p.m., revealed "...son states this is site of old injury and it has been bruised there with some swelling and edema..." Continued review of nursing notes dated October 23, 2013, at 1:00 a.m., revealed the physician wanted the patient sent to the Emergency Room for "...right arm deformity..." Further review of nursing notes on that same day at 4:26 a.m., revealed "...ER nurse reports acute on chronic hematoma on right arm and to keep arm elevated for one to two weeks..."

Medical record review of nursing notes dated October 26, 2013, at 1:30 a.m., revealed "...found on floor, face first, with r (right) wrist restrained to the bed. C collar was off, ng (nasogastric - from nose to stomach for feeding) out. pt combative. Unable to reinsert ng tube due to agitation. Assisted back to bed after head to toe assessment, no s/s (signs/symptoms) of injury. Combative, C collar found on floor. Physician notified and said to transfer pt to hospital for CT scan. Wrist restraints very loose, patient able to move all over bed and reach for tubes..." Continued review of nursing notes on the same date at 9:47 a.m., revealed "...hospital is admitting patient with altered mental status and dehydration..."

Medical record review of Emergency Department (ED) notes dated October 26, 2013, revealed "...has skin tear to right wrist from restraints..." Continued review of the ED notes revealed "...upper extremity exam abnormal, abrasions present, contusions present, lacerations present. lower extremity exam abnormal, contusions present, abrasions present. Skin exam includes multiple bruises..." Continued review of ED notes revealed the patient was admitted for 23 hour observation for decreased oral intake, dehydration, uncontrolled accelerated hypertension, and dementia.

Review of the event notice dated October 26, 2013, revealed the patient fell from bed. Continued review of the event notice revealed the summary of the incident was "...Found on floor on face next to bed with R (right) wrist restrained and C-collar off, NG tube out. Patient combative. Notified physician - orders to transfer out for CT of neck since C collar was off..." Further review of the event notice revealed no documentation of possible causes; no documentation from the nurse caring for the patient at the time of the incident; and no interventions to prevent this incident from recurring in the future.

Medical record review of the Restraint Flow Sheet dated October 15, 2013, revealed bilateral soft wrist restraints were ordered because patient was pulling at lines/tubes/drains with attempts to harm self and others. Continued review of the flow sheet revealed patient assessment, medication review, reality orientation, education, and diversion were attempted before restraints but were unsuccessful. Further medical record review revealed there was a physician's signed order for restraints on October 15, 16, 17, 18, 19, 20, 21, 22, 23, 2013, but orders were unsigned by the physician on October 24 and 25, 2013. Continued medical record review revealed the Restraint Flow Sheet was not found for October 15, 2013, as well as for October 17, and 25, 2013.

Interview with the Director of Quality Assurance on November 18, 2013, at 3:30 p.m., in the conference room, revealed the facility does not do any investigations except what is documented on the Event form. Continued interview with the QA Director revealed nurses assessed patients after falls and entered the information into the computer. Further interview with the QA Director revealed the patient's restraints were on very loosely; the patient swung over in bed; and toppled off the edge. Continued interview revealed the patient's bed was in low position and there were mats on the floor.

Telephone interview with the Nursing Supervisor on November 18, 2013, at 3:45 p.m. revealed the supervisor was on duty the night of October 17, 2013, when the nurse reported the skin tear to the patient's left hand. Further interview with the supervisor revealed the back of the hand "...looked bad. The whole thing had the skin pulled back..." Continued interview with the supervisor revealed the supervisor did not know how the hand injury occurred but the patient had gotten out of restraints; pulled out the nasogastric tube; the nurse was trying to hold the patient's hand and reinsert the tube. Further interview with the supervisor revealed the supervisor was also on duty on October 26, 2013. Continued interview with the supervisor revealed the supervisor entered the room to find the patient on the floor and two staff members in the room. Further interview revealed the patient was lying on the face with the left arm out of restraints. Further interview with the supervisor revealed the restraints were loose because the patient had so many skin tears they did not want to injure the patient further. Continued interview with the supervisor revealed several staff members assisted the patient back to bed, and the supervisor notes there was bleeding from the right wrist.

Telephone interview on November 18, 2013, at 3:50 p.m., with the nurse who reported the skin tear, revealed the nurse stated "...I don't recall the patient or the incident. I would have to look at the chart to refresh my memory..."

Interview with the QA Director on November 18, 2013, at 4:00 p.m., confirmed there was no investigation for patient events other than the Event Notice.

Based on medical record review and interview, the facility failed to provide a complete medical record for one (#3) of five patients reviewed.

The findings included:

Patient #3 was admitted to the facility on October 15, 2013, after falling at home; sustaining a C2 (second cervical vertebra) fracture; undergoing surgical intervention; and also having diagnoses of Diabetes Mellitus, Hypertension, Cerebrovascular Accident, First Degree Atrioventricular Block (cardiac abnormal rhythm), Dysphagia (difficulty swallowing), and Dementia.

Medical record review of the History and Physical dated October 15, 2013, revealed the patient had persistent encephalopathy (diminished mental status usually due to decreased oxygenation), high oxygen requirements, agitation, and inability to eat or drink. Continued review of the document revealed the patient had a Dobhoff tube (tube from nose into stomach for feedings) in place as well as a nasal trumpet (device placed in nose to facilitate suctioning secretions). Further review of the document revealed "...patient was quite agitated after arrival here, kept pulling oxygen off, and required physician restraints and Seroquel (medication used for sedation) to maintain medical appliances in place..."

Medical record review of respiratory therapy notes dated October 20, 2013, at 10:00 a.m., revealed "...second attempt to administer aerosol (breathing treatment). pt. combative, thrashing head with C-collar (rigid collar to keep neck immobile), beating restrained arms against bed rails, screaming help, spitting, ripping and clawing at isolation gown..." Continued medical record review of a respiratory therapy note dated October 21, 2013, at 11:40 a.m., revealed the patient's respiratory alarm was sounding; pt. was making odd noise from mouth; therapist "...began to try to clean pt's mouth out with mouth cleaning kit, pt. began hitting me and trying to bite me..."

Medical record review of Emergency Department (ED) notes dated October 26, 2013, revealed "...has skin tear to right wrist from restraints..." Continued review of the ED notes revealed "...upper extremity exam abnormal, abrasions present, contusions present, lacerations present. lower extremity exam abnormal, contusions present, abrasions present. Skin exam includes multiple bruises..." Continued review of ED notes revealed the patient was admitted for 23 hour observation for decreased oral intake, dehydration, uncontrolled accelerated hypertension, and dementia.

Medical record review of the Restraint Flow Sheet dated October 15, 2013, revealed bilateral soft wrist restraints were ordered because patient was pulling at lines/tubes/drains with attempts to harm self and others. Continued review of the flow sheet revealed patient assessment, medication review, reality orientation, education, and diversion were attempted before restraints but were unsuccessful. Further medical record review revealed there was a physician's signed order for restraints on October 15, 16, 17, 18, 19, 20, 21, 22, 23, 2013, but orders were unsigned by the physician on October 24 and 25, 2013. Continued medical record review revealed the Restraint Flow Sheet was not found for October 15, 2013, as well as for October 17, and 25, 2013.

Review of the policy entitled "Use of Physical Restraint for Medical Non-violent, Non-self destructive behavior" revised in April 2013, revealed "...The physician must examine the patient as soon as possible when notified restraint use in indicated, but no later than 24 hours after the initiation of non-violent, non self-destructive restraint use. The need for restraints must be reevaluated and orders to renew the use of restraints must be entered at least once each calendar day..."

Interview with the QA Director on November 18, 2013, at 4:00 p.m., in the conference room, confirmed the physician orders for restraints were not signed on October 24 and 25, 2013, and the Restraint Flow Sheets were missing from the medical record for October 13, 17, and 25, 2013.