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Based on observation, interview, and record review, the hospital failed to ensure two of eight sampled patients (Patients 2 and 5) who were restrained, were monitored as evidenced by:

1. Documentation for medical restraint monitoring/assessment did not accurately reflect the nursing care for Patient 2.

2. There was no documented skin integrity and circulatory status every fifteen minutes for Patient 5 while the patient was on behavioral restraint as per the hospital's P&P.

These failures posed a risk of substandard outcomes for the patient.

Findings:

Review of the hospital's P&P titled Restraint & Seclusion revised dated March 2025, showed the following:

* Attachment B, Medical vs. Behavioral Restraint Comparison Table Inpatient Medical, ARU, and Emergency Department showed for medical (non-violent), the monitoring and assessment shall occur during intentional rounding: every one hours during the day and every two hours at night or more frequently based on needs; for behavioral (violent or self-destructive behavior), direct continuous observation (i.e., sitter) with every fifteen minutes documentation of skin integrity and circulatory status distal to restraint.

* Attachment D, Patients Restraint or Seclusion: Inpatient, ARU and Emergency Department showed for Medical (non-Violent) Restraints, the monitoring and assessments shall occur during intentional rounding and patient care activities. Intentional rounding is completed to address safety issues and ensure basic needs are met: hydration/nutrition, hygiene/elimination/comfort, turning/mobility/ROM, and safety/respiratory/circulatory status/skin/level or distress.

1. During a tour of the unit on 9/3/25 at 0910 hours, with the Assistant Director of Risk and Regulatory and Nurse Manager 1, Patient 2 was observed in two-point soft restraints to the upper extremities.

On 9/3/25 at 1013 hours, an interview and concurrent medical record for Patient 2 was conducted with the ED Educator. Patient 2's medical record showed Patient 2 was admitted to the hospital on 8/20/25.

Review of the Restraint dated 8/22/25 at 0200 hours, showed the non-violent medical restraint was initiated.

Random dates were selected to review the monitoring and assessment of the restraint. Review of the Restraint dated 8/22/25 at 0200, 0800, 1711, and 2000 hours; and 8/23/25 at 0730 and 2000 hours, showed the monitoring/assessment for restraint was performed.

On 9/4/25 at 0818 hours, the Clinical Nurse Specialist was interviewed in the presence of the Assistant Director of Risk and Regulatory. The Clinical Nurse Specialist stated the monitoring/assessment for restraint was to be performed during intentional rounding (every hour during day shift and every two hours during night shift). The Clinical Nurse Specialist also stated nursing staff attested that they performed the monitoring/assessment at the end of their shift but not required to document every time the monitoring/assessment was performed.

On 9/4/25 at 1445 hours, the Assistant Director of Risk and Regulatory verified the nursing documentation for medical restraint monitoring/assessment did not accurately reflect nursing care for Patient 2.

2. On 9/4/25 at 0910 hours, an interview and concurrent medical record for Patient 5 was conducted with the ED Educator. Patient 5's medical record showed Patient 5 arrived to the ED on 9/1/25.

Review of the ED Provider Notes under Workup Summary dated 9/1/25 at 1117 hours, showed Patient 5 was placed in four-point restraints due to violent/aggressive behavior towards self, imminent danger and violent/aggressive behavior towards others, imminent danger.

During an interview and concurrent medical record for Patient 5 with the ED Educator, the ED Educator stated Patient 5 was on behavioral restraint from 9/1/25 at 1120 hours to 9/2/25 at 1200 hours.

Review of the Restraint Assessment showed skin integrity and respiratory/circulatory status were performed every hour during Patient 5 was on behavioral restraint. Further medical record failed to show the skin integrity and circulatory status distal to restraint were performed every 15 minutes as per the hospital's P&P.

On 9/4/25 at 1400 hours, the Assistant Director of Risk and Regulatory verified the above findings.

Based on observation, interview, and record review, the hospital failed to ensure the nursing staff performed consistently NG tube feeding placement verification per the hospital's P&P for one of eight sampled patients (Patient 3). This failure had the potential for unsafe care to the patient.

Findings:

Review of the hospital's P&P titled Adult Core Nursing Standards of Care dated July 2025 showed if feeding tube present, placement of feeding tubes will be assessed every four hours for continuous feedings and as needed prior to intermittent feedings or medication administration.

During a tour of the unit on 9/3/25 at 0846 hours, with the Assistant Director of Risk and Regulatory and Nurse Manager 1, Patient 3 was observed receiving enteral tube feeding via NG tube.

On 9/3/25 at 1245 hours, an interview and concurrent medical record for Patient 3 was conducted with Clinical Nurse Educator 1 in the presence of the Regulatory Program Manager. Patient 3's medical record showed Patient 3 was admitted to the hospital on 8/15/25. Clinical Nurse Educator 1 stated the hospital followed Lippincott as the nursing guidelines for enteral tube.

Review of Lippincott's guideline titled Enteral Tube Feeding, Gastric dated 11/17/24, showed to verify enteral tube placement using at least two of the following methods:

* Observe for a change in the external tube length or the incremental marking on the enteral tube where it exits the patient's nose or mouth to detect tube migration.
* Observe for a change in the volume of aspirate from the enteral feeding tube because a persistent inability to withdraw fluid (or only a few drops of fluid) from the tube may signal the upward displacement of a gastric tube into the esophagus.
* Review routine chest and abdominal X-ray reports.
* Aspirate the enteral tube contents with an enteral syringe and inspect the visual characteristics of the tube aspirate. Fasting gastric secretions often appear grassy green, brown, or clear and colorless.
* Measure the pH of aspirate from the enteral tube. Fasting gastric pH usually is five or less, even in patients receiving gastric acid inhibitors.

Random dates were selected to review NG tube placement verification. Review of NG Tube- Nasogastric Right Nostril showed the following:

* On 9/2/25 at 1600 hours, air auscultation and gastric contents for placement verification.
* On 9/3/25 at 0800 hours, X-ray (per MD report) for placement verification. However, there was no documentation of another method to verify the placement.

Further review of Patient 3's medical record failed to show the enteral tube placement was consistently performed every four hours as per the hospital's P&P.

Clinical Nurse Educator 1 verified the above findings.

Based on observation, interview, and record review, the hospital failed to ensure the nursing staff administered medications as per the nursing guidelines that the hospital followed for one of eight sampled patients (Patient 3). This failure created the risk of medication errors and poor health outcomes to the patients.

Findings:

Review of Lippincott's guideline titled Enteral Tube Drug Instillation, Long-Term Care dated 11/17/24, showed not to mix different medications intended for administration together through the enteral tube because the risks of physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug responses.

During a tour of the unit on 9/3/25 at 0846 hours, with the Assistant Director of Risk and Regulatory and Nurse Manager 1, RN 1 was administering medication via NG tube to Patient 3. RN 3 was observed mixed crushed medications in the medication cup with the water and administered the mixed medication all together to Patient 3 via NG tube. During an interview with RN 1 stated the crushed medications were urea (medication for low level of sodium in the blood), amiodarone (antiarrhythmic medication), and potassium chloride (medication for low levels of potassium in the blood).

Review of the physician's order showed the following:

* On 8/28/25 at 1749 hours, the order was to administer urea packet 15 g via NG tube two times daily.
* On 8/28/25 at 1749 hours, the order was to administer amiodarone tablet 100 mg via NG tube daily.
* On 9/3/25 at 0724 hours, the order was to administer potassium chloride packet40 mEq via NG tube once.

On 9/3/25 at 1245 hours, an interview and concurrent medical record for Patient 3 was conducted with Clinical Nurse Educator 1 in the presence of the Regulatory Program Manager. Patient 3's medical record showed Patient 3 was admitted to the hospital on 8/15/25. Clinical Nurse Educator 1 stated the hospital followed Lippincott as the nursing guidelines for medication administration via enteral tube feeding.

During an interview and concurrent medical record review with Clinical Nurse Educator 1, Clinical Nurse Educator 1 stated RN 1 should have administered each medication separately via NG tube to Patient 3.