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Based on record review interview and policy review, the hospital facility failed to ensure when non-violent restraints were used, the condition of the patient who was restrained was monitored by a physician, other licensed practitioner or trained staff at an interval determined by hospital policy. This affected four (Patients #1, #9, #13, and #4) of seven patients reviewed with non-violent restraints. The hospital's census was 768.

Findings include:

1. Review of the medical record for Patient #9 revealed orders for restraints from 07/02/24 through 07/09/24. The medical record lacked documentation every two hours of patient and restraint assessments on 07/05/24 from 4:00 PM through 8:00 PM. The last patient and restraint assessment documented was on 07/09/24 at 8:00 AM. The last restraint order was dated 07/09/24 at 7:48 AM. The medical record lacked documentation of when the restraint was discontinued.

During an interview on 04/22/25 at 1:45 PM, Staff D verified the lack of documentation.

2. Review of the medical record for Patient #1 revealed orders for restraints from 11/25/24 through 12/10/24. The medical record lacked documentation every two hours of patient and restraint assessments on 11/26/24 from 12:00 AM to 8:00 AM and on 12/07/24 from 12:00 AM to 4:00 AM.

During an interview on 04/22/25 at 2:13 PM, Staff D verified the lack of documentation.

3. Review of the medical record for Patient #13 revealed an order for mitten restraints to both hands on 12/04/24 at 12:51 AM. The medical record documented the restraints were applied on 12/03/24 at 10:30 PM. The medical record lacked documentation every two hours of patient and restraint assessments from 10:30 PM on 12/03/24 to 6:41 AM on 12/04/24, and from 6:41 AM to 8:00 PM on 12/04/24 when the restraints were discontinued.

During an interview on 04/22/25 at 2:48 PM, Staff D verified the lack of documentation.


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4. Review of Patient #10's medical record revealed the patient arrived via emergency medical services on 02/05/25 at 11:50 PM.

On 02/05/25 at 11:56 PM the nurse charted the patient was pulling at her medical lines and was disoriented and agitated. Redirection, personal alarms, and decreased stimuli were not effective so soft wrist and ankle restraints were ordered. These restraints stayed on through 02/11/25 at 10:23 AM. On 02/11/25 at 3:40 PM the patient was put back in ankle and wrist restraints for agitation, pulling at lines, and disorientation.

On 02/11/25 at 6:43 PM the restraint order was changed to non-violent bilateral soft wrist restraints.

On 02/14/25 at 3:29 AM the provider ordered bilateral soft wrist restraints and the order was good for 30 hours or until discontinued. However, the every two hour restraint checks were not completed on 02/14/25 from 6:00 AM until at 6:00 PM. On 02/16/25 at 4:30 PM the staff stopped the restraint charting.

On 02/22/25 at 2:51 AM non-violent soft wrist restraints were applied due to the patient pulling lines, pulling out her trach, and agitation with Behavioral Health was consulted. On 02/22/25 at 10:32 AM the wrist restraints were discontinued and then reordered at 4:40 PM for hallucinations. On 02/24/25 at 4:00 PM the restraints were discontinued.

During an interview on 04/17/25, Staff C verified the findings.

Review of the policy titled "Use of Restraints" policy, effective 03/10/22, revealed the patient should be evaluated every two hours by the nurse. The documentation every two hours of this evaluation should include a visual check, behavior in restraints, alternatives and effectiveness, circulation, skin check, range of motion, fluids, food/meals, elimination, and vital signs if medically appropriate. When the restraints are discontinued, the nurse should document the time the restraints were removed, the criteria for discontinuation, and the plan of care should be updated.

Based on record review, interview and policy review, the facility failed to patients restrained for violent or self-destructive behavior was seen face-to-face by a physician or other licensed practitioner within one hour after the initiation of the restraints. This affected one (Patient #20) of two patients reviewed with violent or self-destructive behavior restraints. The facility's census was 768.

Findings include:

Review of the medical record for Patient #20 revealed orders for violent or self-destructive behavior restraints (four point locked restraints) on 04/23/25 from 2:30 AM to 1:15 PM at the time of record review. The medical record lacked documentation of a face-to-face evaluation by the provider or other licensed practitioner on 04/23/25.

During an interview on 04/23/25 at 1:15 PM, Staff C verified the findings.

Review of the policy titled "Use of Restraints", effective 03/10/22, revealed when restraints for violent or self-destructive behavior are applied, the Licensed Independent Practitioner should evaluate the patient face-to-face within one hour of the application of the restraints. The evaluation must include the evaluation of the patient's immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the restraint. If the restraints are removed the episode is completed. If restraints are needed again, another episode starts and a new order is needed.

Based on record review, interview, and policy review, the hospital failed to ensure appropriate interventions were in place to prevent falls, failed to notify the responsible party when a patient fell and had a change in condition and failed to ensure it was documented when a patient was placed in isolation for an infection. This affected two (Patients #4 and #5) of two patients reviewed for falls and isolation. The census was 768.

Findings include:

1. Record review revealed Patient #4 was transferred to the hospital via emergency medical transportation on 11/25/24 at 9:37 PM for palliative radiation after falling at a skilled nursing facility. The patient was to receive physical and occupational therapy up to five days each week.

Review of the Radiology Oncology Inpatient Consult note dated 11/25/24 revealed Patient #4 had a history of high grade invasive urothelial carcinoma of the bladder as well as stage IV high grade neuroendocrine carcinoma with brain metastasis. He noted magnetic resonance imaging (MRI) of the brain without contrast showed multifocal progression in brain including brainstem lesions and stated the patient would be receiving palliative radiation therapy.

Patient #4 was assessed for falls on 11/25/24 and was at high risk. The e-companion (camera in room with a virtual assistant that notes movements on the camera that alerts or reminds the patients for safety reasons) intervention was implemented on 11/25/24 at 9:40 PM. On 12/05/24 at 7:21 AM the nurse documented she removed the e-companion at 5:00 AM as the patient had improved balance when going to the bathroom. Patient #4 was expected to be discharged after radiation the following day. The patient fell on 12/06/25 at 6:53 PM. Review of the fall risk interventions revealed appropriate interventions were documented as implemented prior to the fall, to include a bed alarm.

Review of nursing note dated 12/06/24 at 6:43 PM revealed the patient had an unwitnessed fall, did not hit head, his blood pressure was low, the patient was reporting no pain. Rapid Response was called. Skin tears were assessed. There was no documentation stating Patient #4's responsible party was notified of the fall.

Review of the Post fall Assessment (SWARM Card) dated 12/06/24 for Patient #4 revealed the patient had an unobserved fall at 6:30 PM and obtained a skin tear. Pre-fall interventions were listed as yellow socks, fall risk armband, and gait belt. Keep the e-companion for patient safety was listed for post fall interventions implemented. The provider was notified.

During an interview on 04/22/24 at 12:25 PM, Staff C verified the above findings.


2. Review of Patient #5's medical record revealed the patient arrived on 11/29/24 at 5:08 PM via emergency medical services (EMS) as a transfer from another hospital.

On 11/29/24 at 5:17 PM, Patient #5 was assessed for falls and scored 2, indicating no risk. On 11/30/24 at 12:03 AM the patient was assessed for falls and scored a 3. The intervention implemented was to assist the patient with ambulation. On 11/30/24 at 8:00 AM the fall risk score was 1. On 11/30/24 at 8:09 PM the fall risk score was 4, and the intervention was to ambulate with assistive devices and keep the call light in reach. On 12/01/24 at 12:00 AM the patient scored a 4 and a bed alarm was added. On 12/01/24 at 7:12 AM the fall risk score was 5 due to the patient having a fall during this stay. The interventions implemented were bed alarm, call light in reach and the fall risk bundle.

Review of nursing notes dated 12/01/24 at 7:12 AM revealed the patient had an unwitnessed fall. She stated she was uncomfortable in bed and wanted to change positions and fell to the ground on her buttock. The nurse noted the patient was very weak. Patient #5 was assessed, the nurse notified provider, there were no injuries noted. Her interventions that were implemented after the fall were a bed alarm and yellow socks.

Review of the SWARM Card: Post fall form for Patient #5 dated 12/01/24 at 7:12 AM completed by the charge nurse revealed the patient had an unwitnessed fall and no injury was observed. The physician was notified. The intervention noted as in place prior to the fall was a fall risk sign on the door. The nurse noted the bed alarm was turned off. Post-fall interventions were bed exit alarm, fall risk wristband, yellow socks and keeping the call light in reach.

Review of the provider notes dated 12/14/24 at 9:10 AM revealed the physician suspected the patient had clostridium difficile colitis (C-diff) and a polymerase chain reaction (PCR) test was sent to the lab for testing. The lab resulted on 12/14/24 at 3:56 PM and the lab called the patient's nurse to inform of the positive C-Diff results. On 12/19/24 at 1:32 PM the provider noted C-diff was caused by prolonged antibiotics and an extended hospital stay. There was no documentation in the medical record indicating the patient was in contact isolation and contact precautions were implemented until 12/15/24 at 8:10 AM.

During an interview on 04/22/24 at 12:25 PM, Staff C verified the findings.

Review of the hospital's policy titled "Fall Prevention", dated 10/13/22, revealed all patients should be assessed for risk of falling with the initial AM or PM assessment and as needed using the fall risk assessment tool. Any patient that receives a score of three or higher on the fall risk assessment tool is considered to be high risk. Fall care interventions for all patients include orienting the patient to the room, adequate lighting, bed in the lowest position, locked equipment, assess pain, repositioning, and anticipating toileting needs. Fall interventions for patients at an elevated fall risk were for staff to apply a yellow fall risk wristband, encourage patients to wear yellow non-skid footwear, place a visual identifier to communicate the elevated risk for falls and any individualized interventions based on the reason the patient is at risk for falls. For patients with altered mental status consider applying bed/chair alarms or providing a patient observer or e-companion. In the event a patient experiences a fall, staff should secure the physical environment and a safe position for the patient to decrease the risk of injury. The registered nurse (RN) should complete a post fall assessment to include a full set of vitals. The SWARM (post-fall huddle with staff caring for the patient to discuss the fall) should be completed by the patient care team, a physician should be notified. If the patient is not competent, the nurse should notify the patient's next of kin as soon as appropriate before the end of the shift. The documentation in the medical record should include a post fall assessment, nursing interventions implemented, notification of the physician. Prior to a fall, documentation in the medical record should include the fall risk assessment tool. interventions/outcomes and patient education should be documented in the medical record.