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Based on interview, record review, and policy review, the hospital failed to ensure that physical restraints/seclusion were applied in accordance with physician's orders for 1 of 4 applicable patients (Patient #1).

Findings include:

Per review of nursing notes for Patient #1, on 7/19/21 at 1600, "LNA alerted this charge RN, [proper name omitted], and this RN that patient had made suicidal remarks to LNA while LNA was in room. LNA stated that pt showed her a video on her phone that discussed suicide. This RN and LNA alerted charge nurse of patient's remarks. Charge nurse contacted NCSS crisis line to obtain crisis eval. This RN and LNA remained outside of patient's door to watch patient in room. Charge nurse notified shift supervisor. At approximately 1630 this RN, LNA, and shift supervisor entered patient's room to strip room of all potentially dangerous objects per NMC protocol. When this RN entered room patient shouted at RN "Get out of my room!", "I'm leaving!", "I'm going to beat you if you touch my phone charger! and "You're a liar!". Patient continued to yell at this RN. This RN attempted to explain protocol to patient. Patient further escalated and continued yelling and swearing at this RN and shift administrator, Chris. Patient then got into wheelchair at bedside and gathered personal belongings. Shift administrator attempted to explain rationale for protocol to patient. Patient continued to yell at staff stating "get out!", "I'm leaving!", "You're a liar!" Patient shouted multiple more profanities at staff and began to wheel wheelchair toward the door of bedroom. Shift administrator explained to patient that she had to stay in room until NCSS crisis counselor arrived. Pt then shouted "get your foot off my wheelchair!" and attempted to run wheelchair through staff in doorway. Patient began to use upper body to swing at staff behind wheelchair. Pt ran wheelchair into door. Pt. stated "I'm going to hit you!". Pt provider [proper name omitted] notified and came to see patient on unit. Patient continued to yell at staff and not agreeable to speak with provider. Two additional nurses on scene and attempted to approach patient for assistance with behavior. Patient continued to yell and became increasingly violent and belligerent toward nursing staff. This RN asked RN at nurses station to call code green. Code green was called in the hospital. Hospital security came to unit and assisted shift administrator in keeping patient in room. Pt continued to yell profanities in hallway. Patient yelled, "I'm leaving!:, "You can't stop me!", "You are all liars!". Patient continued to threaten staff. Patient continued to use upper body to swing at security guards while seated in wheelchair. Security guards assisted patient back into room with door open. Three security guards and shift admin watched patient in room from door way. Patient continued to yell and swear in room. Pt. ripped out peripheral IV. Patient repeatedly attempted to slam door on security guards. At approximately 1815, NCSS crisis counselor arrived and assessed patient. Following crisis assessment pt agreeable to remain in hospital. Per shift administrator, patient states she is agreeable to change behavior. Pt cleared by NCSS crisis. Charge nurse and shift administrator assisted patient back to bed from wheelchair. Room stripped of all belongings and objects that could be potentially harmful to patient. New IV placed in pt's right AC. IV MsO4 administered per patient request. Initialized on 07/19/21 18:31 - END OF NOTE". There was no evidence in the patients medical record that an order had been obtained to restrain the patient from leaving the hospital.

Per review of the hospital policy and procedure titled, "NMC Use of Force", effective date of 12/15/2018, revealed the following under "Policy Statement": "It is the policy of Northwestern Medical Center (NMC) that qualified NMC staff use only the force that reasonable appears necessary to effectively bring an incident under control, while protecting the lives and safety of the patients, visitors, employees, and others as is reasonably possible. Security personnel should attempt to de-escalate any situation before using any level of force upon a person. Should the use of physical force be deemed required, security personnel are to use only the amount of force necessary to overcome the opposing resistance. The use of force must be objectively reasonable. The security personnel must only use that force which a reasonably prudent person would use under similar circumstances."

Per review of the hospital policy and procedure titled, "NMC Restraint Use", effective date of 6/04, last revision date 12/18, revealed the following under "Purpose": "To assure safe and effective care is provided when restraints are used for the support of medical healing or behavioral emergencies. To describe NMC's commitment to progressively minimizing the use of restraints by offering interventions and alternatives. To assure restraints are used only when medically necessary and are used for patient benefit and safety." Under "Definitions", "Physical Restraint: Any manual method, physical or mechanical device, material or equipment attached or adjacent to the patient's body that he/she cannot easily remove or that restricts freedom of movement or normal access to one's body. Types of physical restraints include: safety belt, soft limb restraint, neoprene limb restraint, and possibly geriatric/cardiac chair and bed rails. Seclusion: The involuntary confinement of a person in a room or an area where the person is physically prevented from leaving. Seclusion is a type of physical restraint."

Per interview on 9/1/21 at 8:45 AM with the Shift Administrator, s/he stated that there was no "hands on" the resident, with the exception of when the patient grabbed and twisted this staff members arm - the staff did use her/his free hand to remove the patients grip on her/his arm. S/he stated that at the time of this incident the patient had been on the PCU unit for a couple of days for medical issues. S/he explained that on this particular day the patient had played a video for an LNA that discussed suicide. The LNA notified the charge nurse and the shift administrator. Per policy and procedure of the hospital, initiates were started to keep the patient safe. These initiatives were to remove any and all items from the patients room that were potentially dangerous. The patient became angry and started yelling profanities, threatening staff, threatening to harm staff when she see's them on the streets and that she knows where they live. She was verbally abusive and then became physically abusive. NCSS Crisis was called for the need of a psychiatric evaluation, the physician was notified, a code green was called, security officers responded to assist and ensure the safety of everyone. The nursing staff and security officers did not put their hands on the patient, they did grab the back of the patients wheelchair and pulled her/him back into her/his room and then security stood in the doorway to prevent her/him from leaving her/his room/hospital, pending the outcome of the psychiatric evaluation. The police were also called due to the patient threatening to harm staff.

Per interview on 9/1/21 at 11:45 AM with one of the security officers involved in the restraint/seclusion, s/he received a call from the PCU staff as well as an overhead page for a code green. When s/he arrived to the unit, the patient was in her/his room and was threatening and yelling at staff. The patient was in her/his wheelchair so staff positioned themselves to prevent her/him from leaving. This officer stated that s/he went behind the patients wheelchair and s/he and another officer each grabbed a handle on her/his wheelchair and pulled her/him back into her/his room. S/he threatened another member of the code green team with a bag of urine and elbowed another member in the side. This officer confirmed that no hands were placed on the patient while s/he was assisting with the code green. Once s/he was pulled back into her/his room the officers just stood outside the door and watched her/him to maintain safety of staff, other patients and visitors. Crisis came and spoke with the patient, a plan of action was developed with crisis and the patient, and the all clear was called by the hospital at approximately 1900 hours. stated that the patient had made comments about wanting to die and that s/he would take her/his own life.

There was no evidence in the record that physician's orders were written for a restraint or seclusion of Patient #1. Per interview on 8/31/21 at 4:10 PM with the Manager of Regulatory Affairs & Health Information Integrity, s/he confirmed that there were no physician orders for restraint/seclusion of Patient #1.

Based on record review, and interview, it was determined that the facility failed to administer medications timely and in accordance with accepted standards of practice for 3 of 10 patients reviewed.

Findings include:

Per review of Resident #1's medical record, revealed the following medications were administered more than 1 hour after the scheduled medication time:

Tylenol 650 mg (milligram) PO (by mouth) Q6H (every 6 hours) scheduled for 04:00, 10:00, 16:00 and 22:00. The 04:00 dose was administered at 05:25.
MSIR 15 mg PO Q6H scheduled for 04:00, 10:00, 16:00, and 22:00. The 04:00 dose on 7/18/21 was administered at 05:24.
MSIR 15 mg PO Q6H scheduled for 04:00, 10:00, 16:00, and 22:00. The 04:00 dose on 7/20/21 was administered at 06:02.
Tylenol 975 mg PO Q6H scheduled for 04:00, 10:00, 16:00, and 22:00. The 04:00 dose on 7/20/21 was administered at 06:02.

Per review of Resident #3's medical record, revealed the following medications were administered more than 1 hour after the scheduled medication time:
Coreg 3.125 mg PO BID (twice a day) scheduled for 10:00 and 21:00. The 10:00 dose on 7/27/21 was administered at 11:31 and the 21:00 dose was administered at 22:46.
Heparin 5,000 units SC (Subcutaneous) BID scheduled for 10:00 and 21:00. The 10:00 dose on 7/28/21 was administered at 11:31 and the 21:00 dose was administered at 22:46.

Per review of Resident 4's medical record, revealed the following medications were administered more than 1 hour before or 1 hour after the scheduled medication times:

Lamictal 100 mg PO BID scheduled for 10:00 and 21:00. The 10:00 dose on 7/22/21 was administered at 08:43.
Lamictal 100 mg PO BID scheduled for 10:00 and 21:00. The 10:00 dose on 7/24/21 was administered at 11:21.

Per interview on 8/31/21 at 4:10 PM with the manager of Regulatory Affairs & Health Information Integrity, s/he confirmed the expectation of administration of medications is that nurses are compliant with the standard of practice. The standard of practice is that medications are administered to the patient within the time frame of 1 hour before to 1 hour after the medication is scheduled.

Per interview on 9/1/21 at approximately 8:47 AM with the Shift Administrator, s/he confirmed that her/his expectation of nursing staff is that scheduled medications are administered no earlier than 1 hour before the medication is ordered/scheduled and no later than 1 hour after the medication is ordered/scheduled.

Per interview on 9/1/21 at 10:15 AM with the Manager of Clinical Education, s/he confirmed that nurses are taught they have a 2 hour window for getting medications to the patient. Medications are to be administered no sooner than 1 hour before the medication is scheduled and no later than 1 hour after the medication is scheduled.