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Based on interview and record review, the facility failed to ensure a face-to-face evaluation was performed after a patient was placed in violent restraints for 1 (P-2) of 3 patients reviewed for restraint monitoring resulting in the increased likelihood of negative outcomes and loss of patient rights for the patient. Findings include:

On 11/7/2025 at 1320, P-2's medical record was reviewed with Nursing Director Staff E. On 9/6/2025 at 1845, P-2 had an order for violent, four point soft restraints for danger to self. There was no documentation that a face-to face evaluation was performed following the initiation of the restraints. Staff E confirmed the findings at the time of discovery.

According to the facility's policy, "Restraint," dated 7/8/2025, "A face-to-face evaluation includes both a physical and behavioral assessment of the patient that must be conducted by a qualified practitioner within the scope of their practice; Documentation must include, The patient's immediate situation, The patient's reaction to the intervention, The patient's medical and behavioral condition, The need to continue or terminate restraint."

The policy also revealed that for "Violent/Self-Destructive Behavior Restraint, A face-to-face assessment by the Attending Physician or the LP must be obtained within 1 hour after the patient is restrained; A telephone call or telemedicine methodology is not permitted.

(a) If the patient's violent or self-destructive behavior resolves and the restraint intervention is discontinued before the practitioner arrives to perform the 1-hour face-to-face evaluation, the practitioner is still required to see the patient face-to face and conduct the evaluation within 1 hour after the initiation of this intervention.

(b) If the Attending Physician or the LP of record is unavailable, responsibility for the patient must be delegated to another LP, who would then be considered the LP of record."

Based on interview and record review, the facility failed to assess a patient following the administration of a pain medication for 1 (P-7) of 3 patients reviewed for pain reassessment resulting in the increased likelihood of negative outcomes for the patient. Findings include:

On 11/17/2025 at 1330, P-7's medical record was reviewed with Nursing Director Staff E.

On 11/16/2025 at 0722 and at 0900, P-7 had a documented pain score of 9.

On 11/16/2025 at 0844, P-7 had a one-time only order for hydrocodone 7.5 mg with acetaminophen 325 mg oral tablet to be given once.

On 11/16/2025 at 0901 P-7 medication administration record revealed P-7 received a dose of hydrocodone 7.5 mg with acetaminophen 325 mg oral tablet by Nurse Staff X. After administering the dose, P-7's medical record revealed there was no pain score documented to determine whether the pain medication had an impact on P-7's pain.

On 11/16/2025 at 1416, P-7 had an order for hydrocodone 7.5 mg with acetaminophen 325 mg oral tablet, every 6 hours as needed for anticipated pain.

On 11/16/2025 at 2331, P-7 had a documented pain score of 9.

On 11/16/2025 at 2331, P-7 received one dose of hydrocodone 7.5 mg with acetaminophen 325 mg oral tablet. There was no documented pain score following the administration of the pain medication to determine whether the pain medication had any impact on P-7's pain. The next documented pain score for P-7 was on 11/17/2025 at 0748 and P-7 had a documented pain score of 9.

On 11/17/2025 at 0810, P-7 received one dose hydrocodone 7.5 mg with acetaminophen 325 mg oral tablet. There was no documented pain score following the administration of the pain medication to determine whether the pain medication had any impact on P-7's pain and P-7's next documented pain score was on 11/17/2025 at 1623 with a pain score of 9.

Nursing Director Staff E confirmed the findings at the time of discovery.

According to the facility's policy, "Pain Management," dated 8/25/2025, "Pain will be reassessed following PRN and one-time (i.e. ONCE) dose pain medication administration and as needed. 1. Reassess pain once sufficient time has elapsed to evaluate the effectiveness of intervention(s) 2. A pain reassessment includes, at minimum, the use of an appropriate pain assessment tool (the same tool used previously, unless patient's condition now warrants use of a different tool) a. If the intervention was the administration of an opioid, include a sedation assessment at time of reassessment 3. Compare reassessment findings to previous assessment and patient's pain management goal(s) to evaluate effectiveness of intervention."

Based on observation, interview and record review, the facility failed to follow national standards and policy in safely preparing medication for 1 (P-6) of 2 patients reviewed resulting in the increased likelihood of negative outcomes for the patient. Findings include:

On 11/18/2025 at 1010, during observation of Nurse Staff O preparing a medication for administration to P-6, Staff O obtained a vial of hydromorphone 2 mg /milliliter for injection. Staff O removed the flip cap and proceeded to withdraw the medication into a syringe. After administering the dose, Staff O was queried whether they should have wiped the vial top with an alcohol pad prior to removing the medication into a syringe, Staff O revealed they did not have to wipe with alcohol since the vial has a "cap."

On 11/18/2025 at 1340, CNO Staff B confirmed that Nurse Staff O should have used an alcohol swab to wipe the vial prior to removing the medication contents.

According to the facility's policy, "Safe Injection Practices," dated 6/5/2025, for "Injections: Septum on all medication vials, whether unopened or previously accessed, is disinfected with alcohol prior to piercing."