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Based on observation, interview, and record review it was determined the hospital failed to ensure a nursing care plan was developed that reflected the nursing care provided related to a lapbelt restraint for 1 of 16 sampled patients. (Patient #5)

Findings include:

A tour of unit 32 was conducted on 3/10/25 at approximately 1:20 PM. During that tour, patient #5 was observed seated in a highback wheelchair in the main living area with a blue lapbelt across her waist and appeared to be sleeping. Hospital staff were observed coming in and out of the area. At 1:55 PM, patient #5 was observed yelling out and appeared agitated. No staff responded to the patient or assessed her in anyway. At 2:40 PM, patient #5 was observed in the same position.

An interview with staff member D, a certified nursing assistant (CNA) was conducted at this time and asked about the process for the monitoring of patient #5. Staff member D indicated the patient was to be released from the lapbelt every 2 hours when toileted. Staff member D stated, "if she does not have a lapbelt then she will slide out and fall."

Staff member D was noted to be making entries on a flow record titled Critical Pathway which reflected 30 minute increments of time for staff to document when the patient was offered fluids, received range of motion, lapbelt to be checked if it was in the correct position, patient's skin was warm and dry, position changed every 2 hours, and if patient had voided or had a bowel movement. The Critical Pathway was noted be signed by both registered nurses (RN) and CNAs. The Critical Pathway indicated the patient had received offering of fluids, range of motion, and had her skin assessed, however during the observation period from 1:20 PM till 2:40 PM, staff did not offer fluids, assess the patient, change her position or assess if the restraint was applied correctly. The Critical Pathway did reflect patient #5 had been toileted twice from 7:00 AM till 2:00 PM, at 7:00 AM and again at 12:00 PM, but not every 2 hours as described by staff member D as the process. (copy obtained)

A continuous observation of patient #5 was conducted on 3/11/25 from 8:45 AM till 11:20 AM. Patient #5 was observed in a highback wheelchair in the main living area with a blue lapbelt across her waist and she appeared to be sleeping. A review of the Critical Pathway dated 3/11/25 revealed staff had documented patient #5 had been offered fluids, had her skin assessed as warm and dry, had been assessed that the restraint was correctly applied, been provided range of motion and position changes every 30 minutes during the continuous observation period, however those nursing interventions did not occur. (copy obtained)

A review of the hospital's Restraint policy and procedure dated January 2025 (OP16-01-02) revealed that direct care staff were to monitor the patient and document the safety checks every 30 minutes on the Critical Pathway for medical restraints for the offered activities of:
skin integrity, circulation and general condition
nutritional status and intake
toileting or changing every 2 hours
repositioning at least every 2 hours
(copy obtained)

A review of patient #5's nursing care plan, last updated 9/17/24, revealed nursing diagnosis of fall risk/unsteady gate and muscle weakness. The care plan goal was listed as the patient would be free from falls and request assistance for support if needed. The nurse interventions were for nursing/staff will assist with transfers and activities of daily living (ADLs). The nursing care plan lacked any notations of the lapbelt restraint or justification for the restraint. (copy obtained)

An interview was conducted with staff member B, unit 32 nursing supervisor, on 3/11/25 at approximately 10:45 AM. She was asked about the lack of a nursing care plan for the lapbelt restraint and the documentation concerns on the Critical Pathway. She stated, "we have been told we do not need a care plan for a medical restraint." She had no explanation for the documentation concerns and observations related to the Critical Pathway.

On 3/11/25 at approximately 3:30 PM, an interview was conducted with the interim Chief Nursing Officer, (CNO). He indicated the hospital did not have a specific policy and procedure for nursing care plans.