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Based on observation, interview, and record review, the facility failed to ensure an order was created and and that a patient was safely monitored when placed in four-point locking restraints for 1 (P-1) of 2 patients reviewed with restraint orders resulting in the increased likelihood of adverse consequences for the patient. Findings include:

See tags:

0168 Failure to have a physician order for restraints.
0175 Failure to monitor a patient in restraints.

Based on interview and record review, the facility failed to provide nursing services in accordance with orders and care plans for 1 (P-1) of 10 patients reviewed, resulting in less than optimal patient care. Findings include:

See tags:

0392 - Failure to follow physician orders.
0396 - Failure to implement care plan and monitor patient's weight.
0405 - Failure to administer medications per orders.

Based on interview and record review, the facility failed to renew a restraint order according to the facility's policy for 1 (P-1) of 2 patients reviewed for restraints resulting in the loss of patient rights and increased likelihood for adverse outcomes for the patient. Findings include:

On 2/3/2025 at 1340, P-1's medical record was reviewed with Clinical Informatics Nurse Staff F and revealed the following.

On 1/4/2025 at 0012, P-1 had an order for four-point locking restraints on the left and right wrists and left and right ankles and the restraints were discontinued on 1/6/2025 at 0022.

On 1/4/2025 at 0733, P-1's nurses note revealed that P-1 "remains in 4-point restraints."

On 1/5/2025 at 0748, P-1's nurses note revealed that P-1 "remains in 4-point restraints at this time."

When queried on 2/3/2025 at 1352, Staff F confirmed that P-1 was in restraints and there was no order to renew P-1's four-point locking restraints on 1/5/2025.

According to the facility's policy, "Restraint Management for Acute Care Hospital and Ambulatory Setting," dated 2/23/2022, for "Restraint Renewal Orders Specific to Non-Violent Non-Self-Destructive (NVNSD) Behavior: 1. Orders are valid for one (1) calendar day. 2. These orders can be renewed following a face-to-face evaluation each calendar day. 3. The provider evaluates the patient and documents in the electronic health record (EHR) a face-to-face assessment within twenty-four (24) hours of the original restraint order and each calendar day, if the restraint order is renewed."

Based on interview and record review, the facility failed to monitor a patient in restraints according to policy for 1 (P-1) of 2 patients reviewed resulting in an increased likelihood for negative consequences for the patient. Findings include:

On 2/3/2025 at 1340, P-1's medical record was reviewed with Clinical Informatics Nurse Staff F.

On 1/4/2025 at 0012, P-1 had an order for four-point locking restraints on the left and right wrists and left and right ankles and the restraints were discontinued on 1/6/2025 at 0022. On 1/5/2025, there was no renewal order for P-1's restraints and there was no complete face to face evaluation documented as performed.

On 1/5/2025 at 2330, P-1's Internal Medicine note revealed that P-1 was "in restraints." There was no other documentation on 1/5/2025 in P-1's medical record to support the need to continue or to remove the four point locking restraint.

On 2/3/2025 at 1352, during interview, Staff F confirmed that P-1 was in restraints on 1/15/2025 and there was no order and no face to face evaluation documented.

According to the facility's policy "Restraint Management for Acute Care Hospital and Ambulatory Setting," dated 2/23/2022, "The provider evaluates the patient and documents in the electronic health record (EHR) a face to face assessment within twenty-four (24) hours of the original restraint order and each calendar day, if the restraint order is renewed. The policy also revealed that "Provider documentation of the face to face evaluation must include:

a. The patient's immediate situation
b. The patient's reaction to the intervention
c. The patient's medical and behavioral condition
d. The need to continue or remove the restraint.

Based on interview and record review, the facility failed to ensure that oral care was documented as being performed per physician order for 1 (P-1) of 10 patients reviewed, resulting in less-than-optimal outcomes for the patient. Findings include:

On 1/2/2025, P-1 had an order for oral care to be performed 2 times daily at 0800 and 2000.

On 1/9/2025 at 1350, the Speech Language Pathologist (SLP) plan note revealed "Frequent oral care to reduce bacterial load in oral cavity and for comfort."

On 1/9/2025, P-1's care plan for Daily Care revealed that the intervention to provide oral care was "every 2 hours as needed to start 1/9/2025."

On 2/4/2025, Speech Language Pathologist Staff GG was asked to be interviewed, and she was not available.

On 2/4/2025, Accreditation Specialist Staff D was asked for any policy that refers to oral care activities and documentation, and no policy was provided. Staff D provided an education handout on Personal Care, dated 9/6/2024.

According to the medical record documentation, P-1's oral care was only performed once per day on 1/3/2025 (0800), 1/11/2025 (2000), 1/15/2025 (0800), and 1/18/2025 (0800) and there was no documentation that any oral care was performed on 1/12/2025.

On 2/4/2025 at 1430, CNO Staff B was interviewed and was queried if they expected staff to follow all policies and procedures and they said "of course." When queried if they expected staff to follow all orders and protocols and they said "yes."

Based on interview and record review, the facility to ensure a patient's weight was recorded in the medical record as directed in the plan of care and by physician order for 1 (P-1) of 10 patients resulting in unrecognized weight loss of P-1.

P-1 was admitted to the facility to the facility's Emergency Department on 1/1/2025 and P-1's recorded weight on 1/1/2025 was 111.6 kg or 245 pounds.

On 1/3/2025 at 1124, P-1 had an order to be weighed, and the comments included "and as per physician order or as recommended by Nutrition." On 1/3/2025 at 1125, P-1's recorded weight was 111.5 kg (245 pounds and 12.8 ounces).

On 1/6/2025 at 1234, the Registered Dietician Staff T note revealed " Monitor Nothing by Mouth/Diet status, tube feeding rate and tolerance - if/when started, weights, BM (bowel movement) skin integrity and nutrition-related lab values."

On 1/9/2025, P-1's care plan revealed to monitor patient weight to start on 1/9/2025.

On 1/21/2025 at 0638, P-1 had an order to be weighed once with comments "And as per physician's order or as recommended by Nutrition." According to P-1's flowsheets, there was no weight recorded on that date by the staff nurse taking the order for P-1 to be weighed.

On 1/21/2025 at 1046, P-1's Physical and Rehabilitation History and Physical note revealed "there is no weight on file to calculate BMI (body mass index)" and the height and weight fields were blank.

On 1/28/2025 at 1142, according to P-1's flowsheet in the medical record, P-1's recorded weight was 105.9 kg or 233 pounds and 7.5 ounces.. From admission to discharge, P-1 experienced a 13 pound weight loss. P-1's medical record revealed that there was no weight recorded for P-1 from 1/4/2025 to 1/27/2025.

According to the facility's policy "IPD (Inpatient Department) Nursing Document: Nursing Process," dated 2/18/2022, "The Registered Nurse will document all phases of the nursing process in the Electronic Health Record (EHR)" and "Ongoing assessment data will be obtained and documented on the area specific EHR or other appropriate approved forms. Findings will be incorporated in the plan of care.

On 2/4/2025 at 1430, CNO Staff B was interviewed and was queried if they expected staff to follow all policies and procedures and they said "of course." When queried if they expected staff to follow all orders and protocols and they said "yes."

Based on interview and record review, the facility failed to follow safe medication administration practices by administering medication that was not warranted for 1 (P-1) of 10 patients resulting in less-than-optimal outcomes for the patient. Findings include:

On 1/2/2025 at 0708, P-1 was ordered "Initiate Alcohol Withdrawal Treatment Protocol" and the "clinical institute withdrawal assessment (CIWA) q 4 hours scheduled until specified and within approximately one hour after every dose of lorazepam."

On 1/2/2025 at 0708, P-1 was ordered lorazepam 2 to 4 mg intravenously every 1 hour as needed with administration instructions Give 2 mg for CIWA-AR score of 8 to 15, give 4 mg for CIWA-AR score of 16 to 20 and give 4 mg for a CIWA-AR score of 21 or greater and call provider or rapid response per local hospital practice to consider transfer to higher level or care."

On 1/2/2025 at 2355, P-1 received a dose of lorazepam 4 mg intravenously by Nurse Staff HH. On 1/2/2025 at 2000, Staff HH documented a CIWA-AR score of 4 and on 1/2/2025 at 2010 a CIWA-AR score of 4. According to the medication order for a CIWA score of less than 8, lorazepam was not to be administered. According to the medical record, there were no other medication orders for lorazepam to be administered at that date and time. Clinical Informatics Nurse Staff F confirmed the finding at the time of discovery.

On 2/4/2025 at 1430, CNO Staff B was interviewed and was queried if they expected staff to follow all policies and procedures and they said "of course." When queried if they expected staff to follow all orders and protocols and they said "yes."