HospitalInspections.org

Based on observation, interview, and record review, the facility to ensure that the Condition of Participation for Patient Rights was met as evidence by:

1. The facility failed to ensure for six (6) of six sampled patients (Patients 17, 18, 19, 20, 21, and 22), admission forms (Important Message from Medicare [IM - a notice given to the patient with Medicare benefits indicating the patient's rights to a hospital discharge appeal] and or Condition of Admission (COA - a document that include provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risks and benefits] for treatment and may also require the patient's confirmation of understanding on various arrangements related to the treatment the patient will receive in the facility) according to facility's policy and procedure (P&P) for admission were completed and provide. (Refer to A - 0117).

2. The facility failed to ensure for one of 15 sampled patients (Patient 13) that an Advance Directives (legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes) information was provided upon admission according to facility's policy and procedure for Advance Directive. (Refer to A - 0132).

3. The facility failed to ensure patient's call light device were soft-touch call light (a flat pad call button that can be activated by slight pressure from the hand, arm, or body) for two of 10 sampled patients (Patients 18 and 19) while their hands were covered with hand mittens (mittens were applied to keep the patient's hands and/or fingers immobilized). (Refer to A - 0144).

4. The facility failed to ensure the use of restraint (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) was in accordance with the physician order for two (2) of eight (8) sampled patients (Patients 22 and 26). (Refer to A - 0168).

5. The facility failed to ensure that two of eight sampled patients (Patients 22 and 26) were assessed every 2 hours while on non-violent restraint and every 15 minutes while on violent restraint according to facility's policy and procedure. (Refer to A - 0175).

6. The facility failed to ensure for one (1) of two (2) sampled patients (Patients 26) has a face-to-face assessment within one hour, after the initiation of a restraint to manage violent or self-destructive behavior according to facility policy and procedure for restraints. (Refer to A0179).

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality care and ensure the patient's rights.

Based on observation, interview, and record review, the facility failed to ensure for six (6) of six sampled patients (Patients 17, 18, 19, 20, 21, and 22), admission forms (Important Message from Medicare [IM - a notice given to the patient with Medicare benefits indicating the patient's rights to a hospital discharge appeal] and or Condition of Admission [COA - a document that include provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risks and benefits] for treatment and may also require the patient's confirmation of understanding on various arrangements related to the treatment the patient will receive in the facility]) according to facility's policy and procedure (P&P) for admission were completed and provide as evidence by:

1. For Patient 17, the IM was not provided to Patient 17 and/or the patient's next of kin (NOK - a designated person who would receive medical information for the patient).

2. For Patient 18, the COA and the IM information were not provided to Patient 18 and/or the patient's NOK.

3. For Patients 19, the COA was not provided to Patient 19 and/or the patient's NOK.

4. For Patient 20, the IM was not provided to Patient 20, and/or the patient's NOK.

5. For Patient 21, the COA was not provided to Patient 21 and/or the patient's NOK.

6. For Patient 22's NOK, the COA was not provided in a language Patient 22's NOK understand.

These deficient practices resulted in Patient17, 18, 19, 20, 21, and 22 and the patients' NOK to not be informed of patient rights, and the potential for the patients' and or the NOKs' inability to effectively make decisions regarding the patient's care or treatment.

Findings:

1. During an observation on 9/26/2023, at 3:15 p.m., with Clinical Director 1 (CD 1), Patient 17 was observed lying in bed, unresponsive, with Patient 17's NOK was at bedside. Patient 17's NOK stated he (Patient 17's NOK) was always at bedside during visiting hours, and he was involved in Patient 17's care.

During a review of Patient 17's medical records, on 9/26/2023, with CD 2, the "ED (Emergency Department) Note," dated 9/22/2023, indicated Patient 17 was admitted to the facility with a chief complaint of altered level of consciousness. CD 2 verified there was no documented evidence Patient 17 or Patient 17's NOK was provided an IM.

During an interview on 9/27/2023, at 12:14 p.m., with the Senior Manager for Patient Access (SMPA), the SMPA stated when a patient was admitted to the facility, the Admitting Staff (AS) would provide the IM information to the patient. The SMPA stated when a patient was unable to receive and sign the IM, the AS should provide the IM to the patient's NOK. The SMPA stated a daily follow-up should be done to provide the IM information to the patient or the patient's NOK. The daily follow-up should be documented on what was the result of the follow-up.

During an interview with SMPA and concurrent record review of Patient 17's medical records, on 9/27/2023, at 12:14 p.m., the SMPA verified Patient 17's "Account Notes Update," indicated:

a. On 9/22/2023, the IM was for pending signature and needed follow up.

b. On 9/23/2023, follow-up attempt was conducted, Patient 17 was unable to sign the IM and there was no family at bedside.

c. Patient 17's medical records had no documentation of additional follow-up was attempted until 9/27/2023 (four days after the last attempt on 9/23/2023).

During an interview with SMPA, on 9/27/2023, at 12:14 p.m., the SMPA stated the AS should have called Patient 17's NOK when there was no family at bedside to provide the IM information. The SMPA stated a daily follow-up should have been done after 9/23/2023, to provide the IM information to Patient 17's NOK.

2. During a review of Patient 18's medical records on 9/26/2023, with CD 1, the "Face sheet Report," indicated Patient 18 was admitted to the facility, on 9/21/2023, and Patient 18's NOK was Patient 18's son.

During a review of Patient 18's medical records, on 9/26/23, with CD 1, the COA form indicated, on 9/21/2023 at 10:28 a.m., "...Patient (Patient 18) unable to sign due to medical condition..." Patient 18's medical records indicated had no documented evidence the IM was provided to Patient 18 or Patient 18's NOK.

During an interview, on 9/27/2023, at 10:20 a.m., the SMPA stated when a patient was admitted to the facility the AS would provide the COA and IM information to the patient. The SMPA stated when a patient unable to receive and sign the COA and IM, the AS should provide the documents to the patient's NOK. The SMPA stated a daily follow-up should be done to provide the COA and IM information to the patient or the patient's NOK. The daily follow-up should be documented on what was the result of the follow-up.

During an interview with SMPA and concurrent record review, on 9/27/2023, at 10:20 a.m., the SMPA verified Patient 18's "Account Notes Update," indicated, on 9/22/2023, Patient 18 was unable to sign due to medical condition and no family at bedside. Patient 18's medical records had no documentation of additional follow-up was attempted until 9/26/2023 (four days after the last attempt on 9/22/2023) .

During an interview, on 9/27/2023, at 10:20 a.m., the SMPA stated the AS should have called Patient 18's NOK when there was no family at bedside to provide the COA and IM information. The SMPA stated a daily follow-up should have been done, after 9/22/2023, to provide the COA and IM information to Patient 18's NOK.

3. During a review of Patient 19's medical records, on 9/26/2023, with CD 1, Patient 19's "Face sheet Report," indicated Patient 19 was admitted to the facility, on 9/19/2023, and Patient 19's NOK was Patient 19's daughter.

During a review of Patient 19's medical records, on 9/26/23, with CD 1, the COA form indicated, on 9/19/2023 at 8:34 p.m., "...Patient (Patient 19) unable to sign due to medical condition..."

During an interview on 9/27/2023, at 10:20 a.m., the SMPA stated when a patient was admitted to the facility the AS would provide the COA to the patient. The SMPA stated when a patient was unable to receive and sign the COA, the AS should provide the documents to the patient's NOK. The SMPA stated a daily follow-up should be done to provide the COA to the patient or the patient's NOK. The daily follow-up should be documented on what was the result of the follow-up.

During an interview and concurrent record review of Patient 19's medical records, on 9/27/2023 at 10:20 a.m., the SMPA verified Patient 19's "Account Notes Update," indicated on 9/19/2023, a follow-up was needed for COA, because Patient 19 was unable to sign due to medical condition. Patient 19's medical records had no documentation of additional follow-up was attempted until 9/27/2023 (eight days after the last attempt on 9/19/2023).

During an interview, on 9/27/2023, at 10:20 a.m., the SMPA stated a daily follow-up should have been done after 9/19/2023, to provide the COA to Patient 18 and/or Patient 18's NOK.

4. During a review of Patient 20's medical records, on 9/27/2023, with CD 1, Patient 20's "ED (Emergency Department) Note," dated 9/22/2023, indicated Patient 20 was alert, oriented and was admitted to the facility with a chief complaint of weakness. Patient 20's medical records indicated no documented evidence the IM was provided to Patient 20.

During an interview, on 9/27/2023, at 1010 a.m., the SMPA stated when a patient was admitted to the facility the AS would provide the IM information to the patient. The SMPA stated a daily follow-up should be done to provide the IM information to the patient. The follow-up should be documented on what was the result of the follow-up.

During an interview with SMPA and concurrent record review of Patient 20's medical records, on 9/27/2023, at 1010 a.m., the SMPA verified Patient 20's "Account Notes Update," indicated on 9/22/2023, the IM was for pending signature because Patient 20 was asleep. Patient 20's medical record indicated no documentation of additional follow-up was attempted until 9/27/2023 (five days after the last attempt, on 9/22/2023).

During an interview, on 9/27/2023, at 10:10 a.m., the SMPA stated the AS should have made a daily follow-up to provide the IM information to Patient 20.

5. During a review of Patient 21's medical records, on 9/27/2023, with the Accreditation and Licensing Coordinator (ALC), the "Face sheet Report" indicated Patient 21 was admitted to the facility, on 9/25/2023 and Patient 21's NOK was Patient 21's mother. Patient 21's medical records had no documented evidence the COA was provided to Patient 21 or the patient's NOK.

During an interview on 9/27/2023, at 10:12 a.m., , the SMPA stated when a patient was admitted to the facility the AS would provide the COA to the patient.

During a record review of Patient 21's medical records, on 9/27/2023, with SMPA, Patient 21's "Account Notes Update," indicated, on 9/25/2023, a follow-up was needed for COA, because Patient 21 was unable to sign due to medical condition. Patient 21's medical records had no documentation of additional follow-up was attempted until 9/27/2023 (two days after the last attempt, on 9/25/2023) .

During an interview, on 9/27/2023, at 10:12 a.m., , the SMPA stated a daily follow-up should have been done to provide the COA to Patient 21's NOK.

A review of the facility P&P titled, "Signature on Admission/Registration Forms," revised on 1/6/2023, indicated the following:

a. Signatures on COA and other forms, as appropriate, will be obtained for each patient admitted at the facility.

b. If the patient's condition does not permit signature of the forms, it is the staff responsibility to notify coworker and the patient's nurse that a signature is needed.

c. If patient's spouse or family member is willing to sign, obtain this signature.

d. Important Message from Medicare About Your Rights: Required notice given within 48 hours of admission to inpatients with Medicare Insurance.

A review of the facility's P&P titled, "Important Message from Medicare," revised on 1/6/2023, the P&P indicated the facility will issue IM within 2 calendar days of the day of admission and obtain the signature of the beneficiary or his or her representative to indicate that he or she received and understood the notice.

6. During an observation on 9/27/2023, at 9:25 a.m., with the Accreditation and Licensing Coordinator (ALC), Patient 22 was observed lying in bed, awake and alert. Patient 22's NOK was at bedside and requested to converse in Spanish. The ALC interpreted the questions asked to Patient 22's NOK.

During a review of Patient 22's record on 9/27/2023, with the ALC, the "Critical Care Consult," dated 9/12/2023, indicated Patient 22 was a transfer from another acute care facility and was admitted for altered mental status.

During a review of Patient 22's COA on 9/27/2023, with the ALC, the COA was written in English and was signed by Patient 22's NOK on 9/22/2023.

During an interview, on 9/27/2023 at 10:22 a.m., the ALC stated Patient 22's NOK was Spanish speaking and should have been given a Spanish version of the COA. The ALC stated medical information provided to the patient or patient's NOK should be in a language the patient or patient's NOK understand.

During a review of the facility's P&P titled, "Patient Rights and Responsibilities," revised on 8/1/2019, the P&P indicated the following:

a. The purpose of the policy was to assure that a patient is informed of his or her rights and responsibilities upon receiving care and service from the facility.

b. The list of patient rights included: Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcome of care in terms you can understand.

Based on interview and record review the facility failed to ensure for one of 15 sampled patients (Patient 13), an Advance Directives (legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes) information was provided upon admission according to facility's policy and procedure for Advance Directive.

The deficient practice had the potential to prohibits decision making regarding the patient's care or treatment in the best interest of the patient.

Findings:

A review of Patient 13'sAuthorizatin For and Consent to Surgery or Special Diagnostic or Therapeutic Procedure, dated on 9/25/2023, indicated Patient 13 was admitted to the facility on 9/25/2023, for a left total hip arthroplasty (a surgical procedure to restore the function of a bone joint on the hip).

A review of Patient 13's Advance Directive Information for document indicated that Advanced Directive was provided but the date the information was provided was 12/1/2020.

During an interview on 9/28/2023 at 1 PM, the Vice President of Regulatory Affairs (VPRA) stated that information regarding advance directives should be given upon admission and the date of 12/1/2020 was not the correct date. VPRA stated that a couple glitch allowed the faulty information to appear on the "Advance Directive Info."

A review of facility's policy and procedure policy titled, "Advance Directives for Healthcare Information - E.83600.628," last revised 8/13/2022, indicated for facility provide patient information regarding Advanced Directives. The policy and procedure indicated all inpatient and outpatients who are in the emergency department, in an observation status, undergoing same day surgery or invasive procedure upon admission will be provided information outlining patient rights under the Patient Self Determination Act (PSDA, Medicare and Medicaid programs to notify patients about their rights to engage in health care decision making).

Based on observation, interview, and record review, the facility failed to ensure patient's call light device were soft-touch call light (a flat pad call button that can be activated by slight pressure from the hand, arm, or body) for two of 10 sampled patients (Patients 18 and 19) while their hands were covers with hand mittens (mittens were applied to keep the patient's hands and/or fingers immobilized) as evidence by:

1. Patient 18 was not provided soft-touch call light to use while Patient 2 was wearing bilateral (both, left and right) hand mittens.

2. Patient 19's call light was not within the Patient 19's reached and ws not provided soft-touch call light for use while Patient 19 had bilateral hand mitten restraint.

These deficient practices resulted in Patient 18 and 19 not be able to call for assistance for care.

Findings:

1. During an observation, on 9/26/2023 at 3:18 p.m., with Clinical Director 1 (CD 1), Patient 18 was observed in bed awake, alert, and verbalized in Spanish, "I need to go bathroom." Patient 18 had a nasogastric tube (NGT - special tube that carries food and medicine to the stomach through the nose). Patient 18 had bilateral soft wrist restraints (a type of physical restraint used to limit a patient's movement), and Patient 18 also had wearing bilateral hand mittens. Patient 18 had to press the call light button to call for help.

During an interview, on 9/26/2023 at 3:18 p.m., CD 1 stated Patient 18 had bilateral soft wrist restraint and was wearing hand mittens to prevent Patient 18 from pulling out her NGT. CD 1 stated Patient 18 would not be able to press the call light button, because of the bilateral hand mittens Patient 18 was wearing. CD 1 stated the facility has the soft-touch call light that should be provided to patient with limited hand and/or finger movement. CD 1 stated Patient 18 should have been given a soft-touch call light.

2. During an observation on 9/26/2023 at 3:19 p.m., with CD 1, Patient 19 was observed in bed and asleep. Patient 18 was on bilateral soft wrist restraints, bilateral hand mitten restraint, and a soft posey jacket restraint (a type of physical restraint). Patient 19's call light was hanging on Patient 19's IV (intravenous, inside the vein) pole and not within reach.

During an interview, on 9/26/2023 at 3:19 p.m., CD 1 stated Patient 19 was on physical restraints to prevent Patient 19 from pulling her IV and getting out of bed. CD 1 stated Patient 19 was able to verbalize her needs and has on and off outburst of behavior (pulling her IV and getting out of bed). CD 1 stated Patient 19's call light should be within her reached. CD 1 stated Patient 19 would not be able to press the call light button because of the bilateral hand mitten restraints. CD 1 stated the facility has the soft-touch call light that should be provided to patient with limited hand and/or finger movement. CD 1 stated Patient 19 should have been given a soft-touch call light.

During a review on 9/27/2023 at 12:10 p.m., with the Vice President of Regulatory Affairs (VPRA), the facility's policy and procedure (P&P) titled, "Medical-Surgical Standards of Care," revised on 7/11/2023, indicated every bedside will have a call system which is immediately available and within reach of the patient.

During an interview, on 9/27/2023 at 12:10 p.m., the VPRA stated there was no specific P&P written for the use of alternative call light however, the facility used the soft-touch call light to accommodate the needs of the patients who are not able to use the call light button. The VPRA stated the patients on hand mitten restraints or wearing diversion hand mittens should have been provided with a soft-touch call light.

Based on observation, interview, and record review, the facility failed to ensure the use of restraint (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) was in accordance with the physician order for two (2) of eight (8) sampled patients (Patients 22 and 26) as evidence by:

1. For Patient 22, there was no physician ordered for the use of 4 bed siderails as a restraint.

2. For Patient 26, the physician ordered was not for violent and/or self-destructive restraint (a restraint used to manage behavior that jeopardizes the immediate safety of the patient, staff member, or others) when Patient 26 was put on restraint to control the patient's violent behavior (hitting staff) according to facility's policy and procedure.

These deficient practices had result to use of restraint without a physician order and had the potential to result in an inappropriate, unnecessary, and prolonged use of restraints.

Findings:

1. During an observation on 9/27/2023 at 9:25 a.m., with Registered Nurse 1 (RN 1), Patient 22 was observed in bed, awake, and alert. Patient 22 was on bilateral soft wrist restraint and the four bed siderails were up.

During an interview, on 9/27/2023 at 9:25 a.m., RN 1 stated Patient 22 was on bilateral soft wrist restraint because Patient 22 was trying to pull out his indwelling catheter(a soft rubber tube that is inserted into the bladder to drain the urine). RN 1 stated Patient 22's four bed siderails were up. RN 1 put down Patient 22's left upper bed siderails and stated, "I don't know who put his up." RN 1 stated all four bed siderails should not be up. RN 1 stated Patient 22 has an order only for soft wrist restraint.

During a review of Patient 22's medical records, on 9/28/2023, with the Patient Safety Coordinator (PSC), the "Critical Care Consult," dated 9/12/2023, indicated Patient 22 was a transfer from another acute care facility and was admitted for altered mental status (confusion and not acting right).

During a review of Patient 22's medical records, on 9/28/2023, with the PSC, the physician's order for Patient 22's restraint indicated the following:

a. From 9/18/2023 at 4:51 p.m., through 9/26/2023 at 12:13 p.m., Patient 22's non-violent restraint was bilateral soft wrist restraint.

b. From 9/26/2023 at 4:14 p.m., through 9/27/2023 at 11:18 a.m., Patient 22's non-violent restraint was bilateral soft wrist restraint.

During a review of Patient 22's medical records, on 9/28/2023, with the PSC, Patient 22's "Adult Assessment" indicated the following:

a. From 9/19/2023 at 8 p.m., through 9/20/2023 at 4 a.m., Patient 22's restraints were bilateral soft wrist restraint and the four side rails were up.

b. From 9/21/2023 at 8 p.m., through 9/22/2023 at 4 a.m., Patient 22's restraints were bilateral soft wrist restraint and the four side rails were up.

During an interview on 9/28/2023, at 8:50 a.m., the PSC stated Patient 22 did not have a physician order to use four side rails up as a restraint. PSC stated Patient 22's restraints on the dates observed and reviewed mentioned were not in accordance with the physician's order for restraint.

2. During a review of Patient 26's record on 9/28/2023, with the PSC, the "History and Physical," dated 4/20/2023, indicated Patient 26's chief complaint was diarrhea and vomiting. Patient 22 had a medical history of dementia (term used for loss of memory, language, problem-solving and thinking abilities that interfere with daily life).

During a review of Patient 26's medical records, on 9/28/2023, with the PSC, the "RN MD Notification," dated 5/8/2023, at 1:05 p.m., authored by Registered Nurse (RN) 2, indicated, "...Let MD (physician) know that I assessed (RN 2) to potentially remove restraints and he clenched his arms like he was trying to hit staff. MD said ok to leave restraints on..."

During a review of Patient 26's medical records, on 9/28/2023, with the PSC, the physician's order for Patient 26's on 5/8/2023 at 1:17 a.m., indicated a non-violent restraint used of bilateral soft wrist restraint, posey jacket, and siderails up x (times) 4 (to put 4 side rails up). Patient 26 had no documented evidence a violent restraint was ordered on 5/8/2023 at 1:05 p.m.

During a concurrent interview on 9/28/2023, at 8:50 a.m., with PSC, the PSC stated based on RN 2's notification on 5/8/2023 at 1:05 p.m., Patient 22 was put on restraint for behavioral reason. The PSC stated RN 2 should have asked the physician for a violent restraint order when Patient 22 was put on restraint for behavioral reason.

During a review of the facility's policy and procedure titled, "Restraints, Non-Violent/Non-Self-Destructive and Violent, Self-Destructive," revised on 7/3/2023, the P&P indicated the following:

a. This policy requires that a physician or other licensed independent practitioner responsible for the care of the patient order restraint prior to application of restraint.

b. In some situation, however, the need for a restraint intervention may occur so quickly that an order cannot be obtained prior to application. The order must be obtained either during the emergency application of the restraint or immediately (within a few minutes) after the restraint had been applied.

c. Definition: Violent/Self Destructive, a restraint used to manage behavior that jeopardizes the immediate safety of the patient, staff member or others. The purpose was to prevent injury to self or others.

Based on interview and record review, the facility failed to ensure for two of eight sampled patients (Patients 22 and 26), were assessed every 2 hours while on non-violent restraint and every 15 minutes while on violent restraint (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) according to facility's policy and procedure.

These deficient practices had the potential to result in an inappropriate, unnecessary, and prolonged use of restraints.

Findings:

1. During a review of Patient 22's record, on 9/28/2023, with the Patient Safety Coordinator (PSC), the "Critical Care Consult," dated 9/12/2023, indicated Patient 22 was a transfer from another acute care facility and was admitted for altered mental status (confusion and not acting right).

During a review of Patient 22's record on 9/28/2023, with the PSC, the physician's order for Patient 22's restraint indicated the following:

a. From 9/14/2023 at 12:18 a.m., through 9/18/2023 at 10 a.m., Patient 22's non-violent restraint was bilateral (both, left and right) soft wrist restraint and siderails up x (times) 4 (to put 4 side rails up).

b. From 9/18/2023 at 4:51 p.m., through 9/26/2023 at 12:13 p.m., Patient 22's non-violent restraint was bilateral soft wrist restraint.

During a review of Patient 22's record on 9/28/2023, with the PSC, Patient 22's "RN Restraint Assessment every 2 hours" indicated the following:

a. Patient 22 had a restraint assessment on 9/16/2023 at 10 p.m., the next restraint assessment was on 9/17/2023 at 8 a.m. (a total of 10 hours after the last assessment).

b. Patient 22 had a restraint assessment on 9/18/2023 at 6:40 p.m., the next restraint assessment was on 9/18/2023 at 8 a.m. (a total of 13 hours after the last assessment).

c. Patient 22 had a restraint assessment on 9/20/2023 at 4 a.m., the next restraint assessment was at 8:45 a.m. (a total of 4 hours after the last assessment).

During an interview on 9/28/2023, at 8:50 a.m., the PSC stated based on Patient 22's record for restraint assessment, it (Patient 22's restraint assessment) indicated assessment gaps. The PSC stated Patient 22 was not assessed every 2 hours while on restraint.

2. During a review of Patient 26's record on 9/28/2023, with the PSC, the "History and Physical," dated 4/20/2023, indicated Patient 26's chief complaint was diarrhea and vomiting. Patient 22 had a medical history of dementia (term used for loss of memory, language, problem-solving and thinking abilities that interfere with daily life).

During a review of Patient 26's record on 9/28/2023, with the PSC, the physician's order for Patient 26's on 5/8/2023 at 1:17 a.m. through 5/9/2023 at 4:20 p.m., indicated a non-violent restraint used of bilateral soft wrist restraint, posey jacket, and siderails up x (times) 4.

During a review of Patient 26's record on 9/28/2023, with the PSC, Patient 26's "RN Restraint Assessment every 2 hours" indicated the following:

a. Patient 26 had a restraint assessment on 5/8/2023 at 4:12 a.m., the next restraint assessment was at 10:18 a.m. (a total of 6 hours after the last assessment).

b. Patient 26 had a restraint assessment on 5/8/2023 at 10:18 a.m., the next restraint assessment was at 8 p.m. (a total of 10 hours after the last assessment).

During a review of Patient 26's record on 9/28/2023, with the PSC, the physician's order for Patient 26's on 5/11/2023 at 10:26 p.m. through 5/12/2023 at 2:30 a.m., indicated a violent restraint used of soft wrist restraint x 4 limb, posey jacket, bilateral mittens, and siderails up x 4.

During a review of Patient 26's record on 9/28/2023, with the PSC, Patient 26's "Restraint Monitoring every 15 minutes" indicated Patient 26 had a restraint assessment on 5/12/2023 at 1:15 a.m., the next restraint assessment was at 1:45 a.m. (a total of 30 minutes after the last assessment).

During an interview on 9/28/2023, at 9:20 a.m., the PSC stated based on Patient 26's record for restraint assessment, it (Patient 26's restraint assessment indicated the restraint assessment had gaps. The PSC stated Patient 26 was not assessed every 2 hours while on non-violent restraint and every 15 minutes while on violent restraint.

During a review of the facility's policy and procedure titled, "Restraints, Non-Violent/Non-Self-Destructive and Violent, Self-Destructive," revised on 7/3/2023, the P&P indicated the following:

a. Depending on the patient's needs and situational factors, the use of restraint may require either every 15 minutes or every 2 hours monitoring and assessment.

b. For violent or self-destructive behavior monitored at least every 15 minutes.

c. For non-violent and non-destructive behavior monitored at least every 2 hours.

Based on interview and record review, the facility failed to ensure for one (1) of two (2) sampled patients (Patients 26) has a face-to-face assessment within one hour, after the initiation of a restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) to manage violent or self-destructive behavior according to facility policy and procedure for restraints.

This deficient practice resulted for Patient 26 to not have an in-person evaluation and assessment for any changes or deterioration of the patients' physical and psychological condition after restraints were applied.

Findings:

During a review of Patient 26's record on 9/28/2023, with the Patient Safety Coordinator (PSC), the "History and Physical," dated 4/20/2023, indicated Patient 26's chief complaint was diarrhea and vomiting. Patient 22 had a medical history of dementia (term used for loss of memory, language, problem-solving and thinking abilities that interfere with daily life).

During a review of Patient 26's record on 9/28/2023, with the PSC, the physician's order for Patient 26's violent restraint indicated the following:

a. On 5/11/2023 at 10:26 p.m., through 5/12/2023 at 2:30 a.m., indicated a violent restraint used of soft wrist restraint x (times) four (4) limb, posey jacket (restraint jacket use to prevent a patient from getting up), bilateral hand mittens (restraint used to immobilize use of fingers), and siderails up x (times) 4 (to put 4 side rails up).

b. On 5/12/2023 at 2:26 a.m., through 5/12/2023 at 6:50 a.m., indicated a violent restraint used of soft wrist restraint x 4 limb, posey jacket, bilateral mittens, and siderails up x 4.

c. Patient 26's medical records had no documented evidence a face-to-face assessment was conducted within 1 hour after restraints were applied to manage violent or self-destructive behavior.

During an interview, on 9/28/2023, at 9:20 a.m., the PSC stated she could not find documentation from physician regarding Patient 22's face-to-face assessment. The PSC stated the result of the evaluation from face-to-face assessment should have been documented.

During a review of the facility's policy and procedure titled, "Restraints, Non-Violent/Non Self-Destructive and Violent, Self Destructive," revised on 7/3/2023, the P&P indicated the following:

a. When restraint is used to manage violent or self-destructive behavior, a physician, other LIP (Licensed Independent Practitioner), specially trained RN or physician assistant trained in accordance with this policy must see the patient face-to-face within one hour after the initiation of the intervention.

b. The one hour face-to-face evaluation should include both a physical and behavioral assessment of the patient.

c. An evaluation of the patient"s medical condition would include a complete review of systems assessment, behavioral assessment, as well as review and assessment of patient's history, drugs and medications, most recent lab results, etc., as well as to evaluate the patient's reaction to the intervention, the patient's medical and behavioral condition; and the need to continue or terminate the restraint.