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Based on interview and record review, the hospital staff failed to ensure a physician's orders (PO) was obtained for restraints for one of one sampled patient (Patient 1). This failure resulted in a violation of Patient 1's right to be free from unnecessary restraints.

Findings:

During a concurrent interview and record review on 7/22/25 at 8:40 a.m. with Registered Nurse Licensing and Accreditation (RNLA), Patient 1's PO was reviewed. Patient 1's PO for "Restraints for Non-Violent Behavior (RNVB)" dated 7/19/25-7/20/25 was reviewed. The RNVB indicated,order started on 7/19/25 at 8:57 a.m., "Restraint Type: Bilateral Soft Wrist," and ended on 7/20/25 at 8:57 a.m. Next order dated 7/20/25 was started at 11:05 p.m. "Restraint Monitoring (RM)" dated 7/20/25 was reviewed and the RM indicated "Soft Wrist" applied from 10:28 a.m. to 8:14 p.m. RNLA stated there was no PO and there should've been a PO for the time while Patient 1 was on restraints.

During a review of the facility's policy and procedure (P&P) titled, "Restraints: Management of Non-Violent, Non-Self-Destructive Patient Behavior/Situations," dated 9/2024, the P&P indicated, "V. Procedure: B. Implementation of Restraints for Non-Violent, Non-Self-Destructive Behavior/Situations 2. Obtain a Physicians Order for Restraint a) Obtain an order from a qualified attending, resident and/or authorized designee. . .d) In an emergency situation, when the attending or designee is not immediately available to give the order, a qualified RN [Registered Nurse] may initiate the restraint. The RN will notify the attending or designee as soon as possible to obtain the order."

Based on interview and record review, the hospital failed to develop a care plan for one of one sampled patient (Patient 2) when the care plan was not developed according to patient needs. This failure resulted in care plans not being developed and implemented for admitted patients and had the potential for unmet care needs.

Findings:

During a review of Patient 2's "Behavioral Health Notes (BHN)," dated 6/12/25, the BHN indicated "Patient [Patient 2] reports that she is still breast-feeding her 3-year-old."

During a concurrent interview and record review on 7/21/25 at 1 p.m. with Registered Nurse Licensing and Accreditation (RNLA), Patient 2's BHN, dated 6/14/25 was reviewed. The BHN indicated "Spoke to pt's [Patient 2] fiancé ROI [Release of Information] on file. Called Fiancé to ask if pt is breastfeeding. Fiancé reports pt does breastfeed one child."

During a review of Patient 2's "BHN," dated 6/15/25, at 6:58 p.m. indicated, "Pt [Patient 2] endorses breast pain/tenderness. Pt received breast pump and is able to pump in private room with female staff for safety without any issues."

During a concurrent interview and record review on 7/21/25 at 1:30 p.m. with RNLA, Patient 2's BHN, dated 6/15/25 was reviewed. The BHN indicated Patient used the breast pump. RNLA stated Patient 2 received the breast pump on 6/15/25 (three days later).

During a concurrent interview and record review on 7/21/25 at 1:40 p.m. with RNLA, a document in Patient 2's record "Document in Plan," dated 6/12/25 was reviewed. RNLA stated the Document in Plan is an Interdisciplinary Plan of Care (IPOC). IPOC indicated there was no care plan for breast pump or breast feeding. RNLA stated there was no care plan for breast pump or breast feeding, and there should be a care plan developed.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Plan of Care (IPOC) Non-Psychiatric Patients)," dated 2/2024, the P&P indicated, "III. Policy Statement: It is the policy of [Hospital] that all inpatients will have an interdisciplinary plan of care (IPOC) to assist in setting priorities of care that promote health, wellbeing and healing, and to provide for continuity of care between all disciplines."

Based on interview and record review, the hospital failed to follow their policy and procedure (P&P) titled "Infant Feeding," when a breast pump was not provided to one of one sampled patient (Patient 2). This failure resulted in discomfort for Patient 2.

Findings:

During a review of Patient 2's "Behavioral Health Notes (BHN)," dated 6/12/25, the BHN indicated, "Patient [Patient 2] reports that she is still breast-feeding her 3-year-old."

During a review of Patient 2's "Progress Note (PN)," dated 6/13/25, the PN indicated, patient [Patient 2] said that she should be released because she's breastfeeding 2 kids."

During a review of Patient 2's "BHN," dated 6/13/25, at 7:48 p.m. indicated, "I [Patient 2] haven't breastfed my baby for four days."

During a review of Patient 2's "BHN," dated 6/14/25, at 8:52 a.m. indicated, "I'm [Patient 2] breastfeeding both of my kids. I feel bad; I breastfeed them eight times a day. . .I [nurse] explained to the pt [patient] that I would talk with doctor regarding her breastfeeding concerns."

During a review of Patient 2's "BHN," dated 6/15/25, at 6:58 p.m. indicated, "Pt [Patient 2] endorses breast pain/tenderness."

During a concurrent interview and record review on 7/21/25 at 1 p.m. with Registered Nurse Licensing and Accreditation (RNLA), Patient 2's BHN, dated 6/14/25 was reviewed. The BHN indicated "Spoke to pt's [Patient 2] fiancé ROI [Release of Information] on file. Called Fiancé to ask if pt is breastfeeding. Fiancé reports pt does breastfeed one child." RNLA stated nurses knew about it on 6/14/25 and Patient 2 still didn't receive breast pump.

During a concurrent interview and record review on 7/21/25 at 1:30 p.m. with RNLA, Patient 2's BHN, dated 6/15/25 was reviewed. The BHN indicated Patient used the breast pump and she feels better. RNLA stated Patient 2 received breast pump on 6/15/25.

During a review of Patient 2's "Grievance," dated 6/19/25, the Grievance indicated, "I [Patient 2] arrived Wednesday night around 10 or 11 pm (June 11, 2025) and requested a breast pump as I am breast-feeding mom. I continued to ask, and was told to let my milk dry up. Even with the continued requests, I did not receive a pump until Day 5."

During a review of the facility's P&P titled, "Infant Feeding," dated 1/2028, the P&P indicated, "V. Procedure: E. Step V - Show parents how to breastfeed and how to maintain lactation, even if they are separated from their infants. . . 6. If the parent is separated from infant, the parent will be shown how to hand express milk within two (2) hours of separation. The parent will be given a hospital-grade double electric pump and kit, and instructed on use. Parent will be educated to hand express or pump at least ten (10) times in 24-hours."