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Based on record review, interview, and facility document and policy review, the facility failed to ensure that restraints were implemented appropriately in accordance with hospital policy for 1 (Patient #4) of 1 sampled patient reviewed for restraints.

Findings included:

A review of a facility policy titled "Patient Rights and Responsibilities," dated 03/25/2022, revealed, "As a patient, guardian or other designated legal representative, you have the right:" to "Be free from restraints of any form that are not medically necessary."

A review of a facility policy titled "Restraints - Patient Care," dated 11/17/2021, revealed, "4: Orders:" included "c) An order for restraint use is not written as a standing for PRN [pro re nata; as needed] order." The policy revealed, "8) Assessment, monitoring, and documentation of the patient in restraints or seclusion: a) For all types of restraints or seclusion an RN [registered nurse] assesses the patient immediately after application and every two hours." The policy continued to reveal, "The assessment will include: i) Signs of injury associated with restraint ii) Respiratory and circulatory status iii) Psychological status including level of distress or agitation, mental status, and cognitive functioning [sic] iv) Need for range of motion, exercise of limbs, and systematic release of restrained limbs v) Hydration/nutritional needs vi) Hygiene, toileting/elimination needs are being met vii) Type of restraint used." Further review of the policy revealed, "9) Discontinuation:" "b) When an RN determines that the patient meets criteria for release in the restraint order, restraints are discontinued by staff with demonstrated competence. Once restraints are discontinued, a new order for restraint is required to reapply restraints."

A review of Patient #4's medical record revealed the patient was admitted to the facility on 09/03/2022 with a diagnosis of acute cerebellar stroke.

A review of Patient #4's medical record revealed an order for non-violent or non-self-destructive restraints dated 09/04/2022 at 5:26 PM with a discontinuation date of 09/05/2022 at 11:05 PM. A review of Patient #4's "Restraint Monitoring Every 2 Hours" flowsheet revealed that the last documented restraint monitoring for this order was on 09/05/2022 at 6:35 AM for right and left soft wrist restraints and revealed the restraints were "continued." Upon further review of Patient #4's medical record, there was no documentation of further assessments or an RN's determination that the patient met the criteria for restraint discontinuation for this order.

A review of Patient #4's medical record revealed an order for non-violent or non-self-destructive restraints dated 09/07/2022 at 12:55 AM with a discontinuation date of 09/07/2022 at 5:25 AM. Further review of the medical record revealed there was no documentation that the restraints were used during this time.

A review of Patient #4's medical record revealed an order for non-violent or non-self-destructive restraints dated 09/07/2022 at 10:18 AM with a renewal date of 09/08/2022 at 9:37 AM and a discontinuation date of 09/09/2022 at 9:33 AM. A review of Patient #4's "Restraint Monitoring Every 2 Hours" flowsheet revealed that on 09/07/2022, the use of right and left soft wrist restraints started at 11:03 PM. A review of the medical record revealed no documentation that the restraints were used prior to 09/07/2022 at 11:03 PM for this order.

During a review of Patient #4's medical record with RN #5 on 12/28/2023 from 9:15 AM to 10:50 AM, RN #5 confirmed there were missing assessments and there was an order dated 09/07/2022 at 12:55 AM that was placed and not used until being discontinued approximately five hours later on 09/07/2022 at 5:25 AM. RN #5 confirmed that an order was placed on 09/07/2022 at 10:18 AM and was not used until approximately 11 hours later on 09/07/2022 at 11:03 PM.

Based on record review, interviews, and facility document and policy review, the facility failed to ensure that restraints were used in accordance with the physician's order for 1 (Patient #4) of 1 sampled patient reviewed for restraints.

Findings included:

A review of a facility policy titled "Patient Rights and Responsibilities," dated 03/25/2022, revealed, "As a patient, guardian or other designated legal representative, you have the right:" to "Be free from restraints of any form that are not medically necessary."

A review of a facility policy titled "Restraints - Patient Care," dated 11/17/2021, revealed, "4: Orders:" included "c) An order for restraint use is not written as a standing for PRN [pro re nata; as needed] order."

A review of Patient #4's medical record revealed the patient was admitted to the facility on 09/03/2022 with a diagnosis of acute cerebellar stroke.

A review of Patient #4's medical record revealed an order for non-violent or non-self-destructive restraints dated 09/07/2022 at 12:55 AM with a discontinuation date of 09/07/2022 at 5:25 AM. A review of the medical record revealed no documentation that the restraints were used during this time.

A review of Patient #4's medical record revealed an order for non-violent or non-self-destructive restraints dated 09/07/2022 at 10:18 AM with a renewal date of 09/08/2022 at 9:37 AM and a discontinuation date of 09/09/2022 at 9:33 AM. A review of Patient #4's "Restraint Monitoring Every 2 Hours" flowsheet revealed that on 09/07/2022, the use of right and left soft wrist restraints started at 11:03 PM. A review of the medical record revealed no documentation that the restraints were used prior to 09/07/2022 at 11:03 PM for this order.

During a review of Patient #4's medical record with Registered Nurse (RN) #5 on 12/28/2023 from 9:15 AM to 10:50 AM, RN #5 confirmed that there was an order dated 09/07/2022 at 12:55 AM that was placed and not used until being discontinued approximately five hours later on 09/07/2022 at 5:25 AM. RN #5 confirmed that an order was placed on 09/07/2022 at 10:18 AM and was not used until approximately 11 hours later on 09/07/2022 at 11:03 PM.

During an interview on 12/29/2023 at 9:45 AM, RN #14 stated he has been in charge of restraint oversight since 2020. RN #14 stated there is an audit that is meant to be done each shift by the charge nurse of any patient in restraints. RN #14 stated looking at Patient #4 and the issues identified with the record that was reviewed during the survey, he reported that looking at the orders to see if any restraints were ordered and not being used was not part of the audit. RN #14 stated the challenge with non-violent restraints is the timing of orders versus how long patients are in the restraints.

Based on record review, interview, and facility document and policy review, the facility failed to ensure the condition of a restrained patient was monitored by an interval determined by hospital policy for 1 (Patient #4) of 1 sampled patient reviewed for restraints.

Findings included:

A review of a facility policy titled "Patient Rights and Responsibilities," dated 03/25/2022, revealed, "As a patient, guardian or other designated legal representative, you have the right:" to "Be free from restraints of any form that are not medically necessary."

A review of a facility policy titled "Restraints-Patient Care," 11/17/2021, revealed, "8) Assessment, monitoring, and documentation of the patient in restraints or seclusion: a) For all types of restraints or seclusion an RN [registered nurse] assess the patient immediately after application and every two hours." The policy continued to reveal, "The assessment will include: i) Signs of injury associated with restraint ii) Respiratory and circulatory status iii) Psychological status including level of distress or agitation, mental status, and cognitive functioning [sic] iv) Need for range of motion, exercise of limbs, and systematic release of restrained limbs v) Hydration/nutritional needs vi) Hygiene, toileting/elimination needs are being met vii) Type of restraint used."

A review of Patient #4's medical record revealed the patient was admitted to the facility on 09/03/2022 with a diagnosis of acute cerebellar stroke.

A review of Patient #4's medical record revealed an order for non-violent or non-self-destructive restraints dated 09/04/2022 at 5:26 PM with a discontinuation date of 09/05/2022 at 11:05 PM. A review of Patient #4's "Restraint Monitoring Every 2 Hours" flowsheet revealed that the last documented monitoring for this order was on 09/05/2022 at 6:35 AM for right and left soft wrist restraints and revealed the restraints were "continued."

During a review of Patient #4's medical record with RN #5 on 12/28/2023 from 9:15 AM to 10:50 AM, RN #5 confirmed there were missing restraint assessments/monitoring for Patient #4.

Based on record review, interviews, and facility document and policy review, the facility failed to assign nursing care in accordance with patient's needs for 1 (Patient #3) of 2 sampled patients reviewed for pressure ulcers.

Findings included:

A review of a facility policy titled "Pressure Injury Prevention and Management," dated 09/02/2020, revealed, "Patients assessed to be at a high risk (patients with a Braden [a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries] of <15) on admission or during shift assessments will require a WOC [wound, ostomy, and continence] nurse consult."

A review of a facility policy titled "Procedure: Pressure Injury Assessment and Management," dated 08/12/2020, revealed that for a "Total Braden Score less than or equal to 15," interventions directed staff to "Place timely consult to WOC nurse."

A review of Patient #3's medical record revealed the patient was admitted to the facility on 06/28/2022 with diagnoses that included anoxic brain injury, respiratory failure, and renal failure.

A review of Patient #3's wound documentation flowsheet dated 06/29/2022 revealed the patient had stage one pressure injuries to the patient's left inner thigh and lower sacrum that were present upon admission. A review of Patient #3's wound documentation flowsheet dated 07/01/2022 revealed that pressure injuries to the left inner thigh and lower sacrum had progressed to stage two.

A review of Patient #3's "Braden Scale Score" flowsheets revealed documentation of Braden scores less or equal to 14 on 06/28/2022, 06/29/2022, and 06/30/2022. Further review of the medical record revealed no documentation that a WOC consult was placed until 07/01/2022.

A review of Patient #3's "Initial WOC - Wound" note dated 07/06/2022 revealed an order for a WOC consult was placed on 07/01/2022 at 3:33 PM for a stage two pressure ulcer to the patient's sacrum. The note revealed Patient #3 had a stage two pressure ulcer to the gluteal cleft and coccyx. The note did not address the pressure injury to the patient's inner left thigh. The note revealed the gluteal cleft and coccyx pressure ulcer measured 5.5 centimeters (cm) length x (by) 2 cm width x 0.2 cm depth.

An interview was conducted on 12/28/2023 at 11:44 AM with Registered Nurse (RN) #9, a WOC nurse. RN #9 stated, when possible, they tried to see patients within 24 hours of a consult, not including weekends; sometimes, it was 48 hours. RN #9 stated staffing may play a role. RN #9 stated floor nurses were encouraged to use policies and procedures for prevention measures. RN #9 stated that Braden scale interventions could be implemented by any nurse; floor nurses did not need to wait for a WOC nurse to instruct them on what to do.

During a review of Patient #3's medical record with RN #5 on 12/28/2023 from 9:15 AM to 10:50 AM, RN #5 confirmed that the WOC nurse was not consulted according to the facility policy.

Based on record review, interviews, and facility document and policy review, the facility failed to adhere to policies and procedures for pressure injury prevention and wound consults for 2 (Patient #1 and Patient #3) of 2 sampled patients reviewed for pressure ulcers.

Findings included:

A review of a facility policy titled "Pressure Injury Prevention and Management," dated 09/02/2020, revealed, "3) Pressure reduction interventions based on the patients Braden assessment [a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries] will be implemented by nursing and documented in the EHR [electronic health record]." The policy revealed, "Skin care interventions will be implemented when appropriate and documented in the EHR." Further review revealed, "(v) Patients assessed to be at a high risk (patients with a Braden of <15) on admission or during shift assessments will require a WOC [wound, ostomy, and continence] nurse consult."

A review of a facility policy titled "Procedure: Pressure Injury Assessment and Management" dated 08/12/2020, revealed, "Total Braden Score less than or equal to 15" with interventions that directed staff to "Turn /reposition patient every 2 hours while in bed" "Order Low Air loss mattress for total Braden score less or equal to 14" "Keep head of bed at less than or equal to 30-degree angle." The policy further revealed that for a "Total Braden Score less than or equal to 15," interventions directed staff to "Place timely consult to WOC nurse."

A review of an undated facility policy titled "[Facility] Treatment Guide for Pressure Injuries" revealed for "Basic Care for all Pressure Injuries" "Reposition every 2 hours." Further review revealed, "All patients with pressure injuries stage 2 or greater should have WOC consult placed in [electronic medical record]."

1. A review of Patient #1's medical record revealed the facility admitted the patient on 01/12/2022 with diagnoses that included heart failure, end-stage renal disease (ESRD), a left closed femur fracture, and chronic anticoagulation.

A review of Patient #1's WOC note dated 01/25/2022 revealed that Patient #1's left buttock had a full thickness unstageable pressure injury measuring approximately 10 centimeters (cm) length x (by) 7 cm width x 0.3 cm depth. Further review revealed, there was a nonblanchable deep tissue pressure injury to the left buttock measuring 14 cm length x 8 cm width of light purple intact skin, and the coccyx had a partial thickness opening that measured 2 cm length x 2 cm width x 0.2 cm depth.

A review of Patient #1's "Position" flowsheets for the timeframe from 01/17/2022 to 01/27/2022 revealed documentation that the patient was observed lying in the Semi Fowler's position (a position in which the individual lies on their back on a bed with the head of the bed elevated at 30-45 degrees) on 01/17/2022, 01/18/2022, 01/23/2022, and 01/24/2022. Further review of the staff's flowsheet documentation revealed that the staff did not ensure that the patient was turned and repositioned every two hours.

During a review of Patient #1's medical record with Registered Nurse (RN) #5 on 12/27/2023 from 1:00 PM to 3:30 PM, RN #5 confirmed turning and repositioning was not documented every two hours.

2. A review of Patient #3's medical record revealed the facility admitted the patient on 06/28/2022 with diagnoses that included anoxic brain injury, acute respiratory failure with hypoxia, and hypercapnia.

A review of Patient #3's wound documentation flowsheet dated 06/29/2022 revealed the patient had stage one pressure injuries to the patient's left inner thigh and lower sacrum that were present upon admission. A review of Patient #3's wound documentation flowsheet dated 07/01/2022 revealed that pressure injuries to the left inner thigh and lower sacrum had progressed to stage two.

A review of Patient #3's "Braden Scale Score" flowsheets for the timeframe from 06/28/2022 through 07/06/2022 revealed documented Braden scores of less or equal to 14 for each day during that timeframe. A review of Patient #3's medical record revealed a WOC nurse consult was not placed until 07/01/2022. Further review revealed that a specialty mattress was not placed until 07/07/2022.

A review of Patient #3's "Position" flowsheet for the timeframe from 06/28/2022 through 07/06/2022 revealed documentation that the patient's head of bed (HOB) was 30 degrees or higher daily from 06/29/2022 through 07/02/2022, and on 07/04/2022. The flowsheets revealed documentation that the patient was observed lying in the Semi Fowler's position on 07/03/2022 and 07/06/2022. Further review of the staff's flowsheet documentation revealed that the staff did not ensure that the patient was turned and repositioned every two hours.

An interview was conducted on 12/28/2023 at 11:44 AM with RN #9, a WOC nurse. RN #9 stated, when possible, they tried to see patients within 24 hours of a consult, not including weekends; sometimes, it was 48 hours. RN #9 stated staffing may play a role. RN #9 stated floor nurses were encouraged to use policies and procedures for prevention measures. RN #9 stated that Braden scale interventions could be implemented by any nurse; floor nurses did not need to wait for a WOC nurse to instruct them on what to do.

During a review of Patient #3's medical record with RN #5 on 12/28/2023 from 9:15 AM to 10:50 AM, RN #5 confirmed that the WOC nurse was not consulted according to the facility policy. RN #5 confirmed that Patient #3's HOB was documented at 30 degrees or higher when the facility policy stated less than or equal to. RN #5 confirmed that the flowsheet documentation revealed that staff did not ensure Patient #3 was turned and repositioned every two hours. Additionally, RN #5 confirmed that a specialty mattress was not placed according to the facility's policy.