HospitalInspections.org

Based on interview and document review, it was determined the facility failed to ensure two (2) patients were informed of their patient's rights at the time of registration.

Findings:

The facility's policy titled, Patient Rights, was reviewed and reads, in part: "... POLICY: ...All Company-affiliated facilities must provide each patient with a written statement of patient rights at the time of registration and again at the time any patient or patient's representative has questions regarding their rights...". The policy was effective July 1, 2020.

During the review of medical record (MR) 20 and 22 on March 4, 2025 at approximately 12:30 PM, the state agency (SA) requested to see documentation of the patient's acknowledgement that they were informed of their patient rights. The documentation could not be located for either MR20 or MR22.

During the review, employee (EMP) 19 advised the SA the documentation "was likely" on the unit because both patients were still admitted. EMP19 notified EMP1 of the requested documentation.

At 3:00 PM, EMP1 provided the SA with a copy of MR20's "Condition of Admission and Consent for Inpatient and/or Surgical Care". The document is nine pages; on page 8, number 20 is a paragraph titled "Acknowledgement of Notice of Patient Rights and Responsibilities that partly reads, "I have been furnished with a Statement of Patient Rights and Responsibilities...". Page nine contained the patient's electronic signature that was captured on March 4, 2024, at 2:18 PM. MR20 was admitted to the facility on February 25, 2025.

At 3:25 PM, EMP1 provided the SA with a copy of MR22's "Condition of Admission and Consent for Inpatient and/or Surgical Care". Page nine contained the patient's electronic signature that was captured on March 4, 2024, at 2:43 PM. MR22 was admitted to the facility on February 18, 2025.

Based on medical record review, document review, and interview, it was determined the facility failed to conduct assessment and monitoring every two (2) hours for one (1) of four (4) patients placed in restraint.

Findings:

The facility's policy titled, Seclusion, Restraints and Restraint Alternatives, was reviewed and reads, in part: " PROCEDURE: ... 7. Monitoring the Patient in Restraints or Seclusion a. Patients are assessed by an RN immediately after restraints or seclusion are initiated to assure safe application/initiation of the restraint or seclusion. b. A RN will assess the patient at least every two hours...." The policy was last revised and effective May 2024.

A review was conducted of MR20 on March 4, 2025, at approximately 12:30 PM. The review revealed the physician entered a restraint order on February 26, 2025, at 9:46 PM for "combative" behavior and "OOB [Out of bed] is extreme inj [injury] risk". The level of restraint was "violent/self-destructive" with the restraint device documented as "soft LUE [left upper extremity] soft RUE [right upper extremity]". MR20 was placed in the restraints on February 26, 2025, at 10:00 PM. Nursing restraint documentation indicated MR20 was assessed on February 27, 2025, at 12:00 AM and again at 2:00 AM. There was no nursing restraint documentation indicating an assessment was performed at 4:00 AM or 6:00 AM. A nursing restraint documentation note on February 27, 2025, at 8:00 AM indicated the restraints were being discontinued.

EMP19 assisted the SA with the medical record review. EMP19 confirmed there was no documentation in the record indicating the patient was monitored/assessed, while in restraints, on February 27, 2025, at 4:00 AM and 6:00 AM.

Based on medical record review and document review, it was determined the facility failed to conduct a face-to-face evaluation within one (1) hour of applying a violent restraint for one (1) of four (4) patients sampled for restraint/seclusion review.

Findings:

The facility's policy titled, Seclusion, Restraints and Restraint Alternatives, was reviewed and reads, in part: " PROCEDURE: ... 9. Face-to-face assessment by a Physician or Licensed Practitioner a. A face-to-face assessment by a physician or licensed practitioner, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others...." The policy was last revised and effective May 2024.

A review was conducted of MR20 on March 4, 2025, at approximately 12:30 PM. The review revealed the physician entered a restraint order on February 26, 2025, at 9:46 PM for "combative" behavior and "OOB [Out of bed] is extreme inj [injury] risk". The level of restraint was "violent/self-destructive" with the restraint device documented as "soft LUE [left upper extremity] soft RUE [right upper extremity]". MR20 was placed in the restraints on February 26, 2025, at 10:00 PM. There was no documentation to indicate a face-to-face assessment was performed.

EMP19 assisted the SA with the medical record review. EMP19 conducted an additional review of the record and confirmed that there was no documentation indicating a face-to-face assessment was performed.