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Based on interview and record review, the facility failed to assess and monitor 3 restrained patients (P-1, 2 and 13) of 13 patients reviewed, resulting in potential risk for adverse outcomes for all restrained patients. Findings include:

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A-175 Failure to assess and monitor patients in restraints.

Based on interview and record review, the facility failed to assess and monitor 3 restrained patients (P-1, 2 and 13) of 13 patients reviewed, resulting in the potential for adverse outcomes for all patients in restraints. Findings include:

P-1
P-1 was a 90-year-old male who was brought to Emergency department of the facility on 7/15/23 at 1120 with chief complaint of confusion and right-sided facial pain. P-1 had a past medical history of 2-vessel coronary artery disease, anemia, ankle fracture, arthritis, BPH (benign prostatic hyperplasia), cardiomyopathy (an acquired or inherited disease of the heart muscle which makes it difficult for the heart to pump blood to other parts of the body), carotid arterial disease, cataract, chronic obstructive pulmonary disease, chronic renal insufficiency, glaucoma, hyperlipidemia, hypertension, Inflammatory bowel disease, and LBBB (left bundle branch block).

Emergency medicine provider note dated 7/15/23 1355 indicated: This is a 90-year-old male who presents with altered mental status and right ear pain. Brought in by family for worsening confusion according to his partner at home. Three days ago, patient was seen for a right ear infection and given Amoxicillin for 10 days. He just started his third day today but has been complaining of worsening ear pain that now radiates to his right face/jaw. It is painful for him to chew as well. Family member also reports he had an episode of slurred/garbled speech yesterday AM and today AM for a brief period of time. They thought it was because he was sleepy but then today, when patient was unsteady on his feet, family brought him to the ED (emergency department). Patient has a hx (history) of dementia, A&Ox1 (alert and oriented to himself) at baseline and so most of history is provided by family. Further in the note, Mental Status: He is alert. Gait abnormal. Comments: Patient is very unsteady on his feet. No other neurologic deficits.

Record review revealed ED registered nurse (RN) Admission note dated 07/15/23 1910 had the following documentation: The following information is reflective of patient's condition within 1 hour of transferring to an observation or inpatient unit. Is assistance required to ambulate? Yes. If assistance is required 1 or 2 person? One. Diet: No diet orders on file.

P-1 was admitted to the observation unit on 7/15/23 at 2117.
There was a nursing admission (to the observation unit) assessment dated 07/15/23 2157: Diet/Nutrition Received- regular.
Diet order was identified as: Diet- Regular; thin liquids, soft and bite sized. Ordering user: Staff W, RN 07/16/23 1435. Electronically signed by: (physician's name), MD on 07/18/23 1234.

There was a documented order for restraints, non-violent or non-self-destructive. Ordering user: (provider's name) on 07/16/23 0833. Restraint reason: Interference with medical treatment. Alternatives found ineffective: Comfort, Therapeutic, Environmental, Diversionary. Select a Restraint Device (s): Soft R Wrist (NV), Soft L Wrist (NV), Soft R Ankle (NV), Soft L Ankle (NV) (4-points restraints). Restraints were initiated at 0836 and discontinued at 1646 on 07/16/23 by Staff W, RN.

Nursing restraint Q2H (every 2 hours) monitoring documentation reflected that P-2 was NPO (nothing by mouth) at 0838. At 1000, 1047, 1200 and 1407 documentation was as following: food- "offered, snack", fluids- "offered". No documentation regarding patient accepting food or drink was noted. At 1446 the following was documented: food- "offered", fluids- "offered". No documentation regarding patient accepting food or drink was noted. No documentation was evident regarding P-1 food or fluids intake on 7/16/23. No record of consuming/declining breakfast or lunch while in 4-point restraints from 0836 till 1446.

Review of the P-1 record revealed pain assessment performed on 7/16/23 at 1100 and documented on 7/16/23 at 1126 by Staff W, nurse in care. Painad (pain behavior tool that is used to assess pain in older adults who have dementia or other cognitive impairment and are unable to reliably communicate their pain) score was documented as 4 (on the 1-10 scale) which indicated mild to moderate pain.

Further review indicated that patient's pain was not addressed by the nurse after the pain assessment with prescribed/available medication (Tylenol) while patient was in 4-point restraints. Next pain assessment documented by Staff W at 1450 had a score of 4. Tylenol was given to P-1 on 07/16/23 at 1420 (3 hours later after first pain score of 4).

There was Acetaminophen (TYLENOL) order: tablet 325-650 mg, oral, as needed for mild pain (1-3 on a scale 1-10). Ordered on 07/15/23 2112, discontinued on 07/18/23 1836.

Nursing note signed 07/16/23 1434 revealed: Patient daughter expressing frustration with plan of care. Patient had no diet order in upon start of shift, nurse has been attempting to contact attending and teaching team since am (morning)- phones will not connect to any of teams' phones (IT was notified). Direct page to a physician was never read. In afternoon physician was changed to (a different name), situation was forwarded to that physician. Patient has been in restraints throughout day due to previous notes [sic] behavior. Daughter has been administering oral medications under supervision of nurse due to patient refusing medications from staff.

On 04/24/24 at 1403 Staff W, registered nurse in care on 07/16/23, was interviewed. She was asked if she remembered when patient's family arrived to the facility on 07/16/23. Staff W stated it was in afternoon, approximately around 1 or 2 pm. She was asked why Tylenol was not given to P-1 after his pain assessment of score 4 at 1100. Staff W said that it was possible that patient refused to take it. When asked about food order for the patient, nurse stated that when she found out about the situation with the diet, she initiated communication with providers. However, providers did not respond to her inquiries timely. Staff W was asked about her restraint documentation on 7/16/23 with "offered" snack and fluids to the P-1 while there was no diet order in place. She said she was offering it anyway. When queried if patient consumed any fluids or food offered by her, she could not recall.

On 07/16/23 1032 Staff W documented following drug administration: Carbamide peroxide (DEBROX) 6.5 % otic [sic] solution 5 drops. Given 5 drops to right ear. Performed by: [Staff W], RN. Comments: patient family administered. (Suggesting that family member was with the patient on 07/16/23 at 1032 and was available to give pain medications and food).

No food or fluid intake documentation was identified in P-1's record during his time in 4-point restraints, resulting in incomplete assessment/monitoring of restrained patient regarding his nutritional/ nourishment needs.

P-2
P-2 was a 78-year-old female who was brought to Emergency Department (ED) by family member on 10/23/23 at 1800. ED physician note dated 10/23/23 1829 revealed: Patient presents to emergency department due to aggressive behavior. Patient this time is a poor historian due to her dementia. Psychiatric recommendations reviewed. They recommended inpatient psychiatric placement. Given patient's need for dialysis, rapid placement to a psychiatric facility will be difficult. We will place patient in the hospital for further management and evaluation by Internal Medicine as well as Psychiatry. I discussed the case with Internal Medicine Service (IM), and they have accepted patient. A consult to Nephrology has been placed as well. Patient is currently hemodynamically stable.

Admitting diagnoses for P-2 were listed as Acute psychosis, Paranoid delusion, ESRD (end stage renal disease). Patient had a past medical history of AKI (acute kidney injury), carpal tunnel syndrome, cervical spondylosis, congestive heart failure, hyperlipidemia, hypertension, kidney stone, dementia and venous insufficiency. P-2 was admitted to observation unit on 10/25/23 at 1230 and was transferred to a regular medical telemetry unit on 10/25/23 at 2127.

Review of P-2 medical record revealed the following documentation.
There was an ED (emergency department) RN Admit (admission) note dated 10/25/23 1216: Diet-Thin Liquids, Regular.

P-2 had a scheduled CT (computed tomography) guided kidney biopsy on 10/30/23 for which she was made NPO (nothing by mouth) starting midnight 10/30/23. This order had not been changed after P-2's attempted procedure and patient continued with the order for nothing by mouth till her discharge on 11/01/23.

There was a nursing note dated 11/01/23 1804: Patient (P-2) cleaned and dressed for discharge. Patient's daughter given discharge instructions. Questions answered. Patient given by mouth meds with pudding. No swallowing deficit noted. Patient's daughter upset that patient has not had anything to eat since Sunday (10/29/23). Writer received in report that patient was on a regular diet. Upon checking the orders, patient was nothing by mouth. Writer investigated why patient was nothing by mouth. Patient was made nothing by mouth 10/30/2023 12:01 am for renal biopsy that was performed on Monday. Diet was never resumed. Writer informed unit 3100 manager [name] of situation. Writer notified Dr. [name] that patient is being discharged home.

Registered Dietitian note was found in the record dated 11/01/23 1426: Patient (P-2) interview in room with sitter, not able to provide nutrition history, no family present. Spoke with nursing related to nothing by mouth diet order. Nursing aware, reported potential discharge today on 11/1/23. Further in the note under Nutrition Diagnosis was the following documented: Problem: Inadequate oral intake with increased energy/protein needs; Signs/Symptoms: charted meal acceptance on 10/26- zero acceptance. 10/30-NPO. Medical history of dementia with charted aggravation (wrist restraints present). Hemodialysis, charted anasarca (general swelling of the whole body). Intervention: 1. Continue with nothing by mouth as prescribed, oral diet advance at discretion of medical (provider).
1. Discussed with nursing-nothing by mouth status. 2. With nothing by mouth status consider alternate nutrition support. 5. With oral diet advance, please provide total meal assistance. 6. With oral diet advance recommend oral nutrition supplement. 7. Nephro supplement at lunch. 8. High protein gelatin at breakfast.

During interview with Staff O, registered dietitian who wrote the above-mentioned note, on 4/24/24 at 1220, she stated that she did not remember what exactly she discussed with nursing staff regarding P-2's diet. When asked if Staff O could place patient on a specific diet or change the current diet order, she said "no". She explained that physicians or midlevel providers only can prescribe diet orders; dietitians can only recommend the diet or prescribe supplements. When asked if she was able to contact providers with concerns or recommendation, Staff O answered "yes". When clarified if she did contact a provider after assessing P-2, she could not recall.

On 04/24/24 at approximately 1000 Staff GG, registered nurse in care of P-2 on 10/30/23, 10/31/23 and 11/1/23, was interviewed over the phone. Staff GG was asked if he remembered P-2 and details of care. He stated that he did not remember the patient. When asked if diet status would be given in nursing reports between shifts. Staff GG stated that usually it is a part of the report along with the other pertinent information.

Further review of P-2 record revealed no documentation of intake of breakfast, lunch or dinner from 10/30/23 till 11/1/23. No documentation of patient's fluid intake was noted in the record for the period from 10/30/23 till 11/1/23. No IV (intravenous) fluids were administered, except during dialysis treatments.

Nephrology consulting physician' note dated 10/30/23 1053 indicated: No intake/output data recorded (in patient's record).

P-2 Care plans were reviewed. Interventions (for skin integrity) dated 10/27/23 had the following: Perform a nutrition assessment that includes a nutrition-focused physical exam; identify malnutrition risk. Assess for adequate oral intake; if inadequate, offer oral supplemental food or drinks to enhance calorie and protein intake. Assess for vitamin and mineral deficiencies, supplement if depleted. Assess need and assist with meal set-up and feeding. Adjust diet or meal schedule based on preferences and tolerance. Minimize unnecessary dietary restrictions to increase oral intake. Establish bowel elimination program to increase comfort and appetite. Provide and encourage oral hygiene to enhance desire to eat. Consider enteral nutrition support if oral intake remains inadequate; provide parenteral nutrition if enteral is contraindicated.

Nursing assessment every shift documentation had the following:
10/30/23 1347- diet regular (P-2 was NPO for procedure on 10/30/23 midnight)
10/30/23 2135- diet regular (P-2 still had NPO order active and not changed)
10/31/23 1251- diet regular (P-2 still had NPO order active and not changed)
On 10/31/23 at 1922 nursing documentation indicated: under Diet/Feeding assistance- "tray set up", "refused".
On 11/01/23 0955- diet regular, "tray set up", "refused".

P-2 had nothing by mouth (NPO) order since 10/30/23 midnight and was in 4-point restraints on:
10/30/23 from 0536- till 10/31/23 0548
10/31/23 from 0548 till 0540
11/1/23 from 0541 till 1031.

Nursing restraint monitoring Q2H (every 2 hours) had this documentation:
On 10/30/23 at 0000- fluids, food/meal offered (P-2 was NPO for the procedure); at 0200- fluids, food/meal offered (P-2 was NPO for the procedure); at 0400- NPO; at 0600- NPO; at 0800, 1000 and 1200- patient declined food and fluids.
No restraint assessment was recorded on 10/30/23 at 1400. P-2 was in dialysis treatment from 1529 till 1730.
The rest of the restraint assessments for 10/30/23 indicated fluids, food/meal offered to P-2 at 1800, 2000, 2135 and 2335 with no record of acceptance/decline by patient.

On 10/31/23 restraint assessment had documentation of fluids, food/meal as "offered" at 1000, 1200, 1600, 1738, 2000 and 2200. No documentation of patient acceptance or decline of food was noted (except at 1922 it was documented that patient refused food).

On 11/1/23 restraint assessment had documentation of fluids, food/meal as "offered" at 0000, 0200, 0400 and 0554. No record of acceptance or decline form the patient.
On 11/1/23 at 0554 a 4-point restraint order was renewed and discontinued later at 1031. No nursing Q2h assessment were found for this period of over 4 hours in patient's record.

Palliative Medicine physician's consult note dated 10/31/23 1355 revealed: Patient (P-2) seen and examined this pm (afternoon). Notes reviewed. Still in restraints. Under Assessment and Plan: Acute confusional state. Delirium, superimposed on dementia. Patient without own decision-making capacity. Agree with Zyprexa/Depakote. Attempt to discontinue restraints as able. To avoid worsening delirium: Redirect patient as first line treatment for any behavior issues, use medications as second line treatment only when patient's behavior is negatively impacting care. Encourage family visits to help with orientation. Keep the patient hydrated, and correct electrolyte abnormalities. Optimize nutrition. Have patient sit up in chair for several times during the day. Recommend early mobilization with PT (physical therapy). Avoid restraints.

P-3
Patient was a 92-year-old female who was brought to Emergency department of the facility on 4/15/24 at 1255 with a chief complaint of the unwitnessed fall at home with 4 cm (centimeters) laceration to her left eyebrow.
Patient was placed in observation for fall after syncopal episode.

There was a 2-point non-violent restraint order dated 4/16/24 at 2024. Restraints were applied on 4/16/24 at 2147.
Restraints order (non-violent 2-point) was renewed on 4/17/24 at 0547. Full every 2 hours (Q2h) nursing assessment was completed and documented at 0400 before renewal. At 0548 there was documentation of renewal justification and less restrictive alternatives with no full nursing assessment documented till 0800. Last full Q2h restraints assessment was completed at 1400. Restraints were discontinued by nurse on 04/17/24 at 1843. No restraints nursing assessments were found for 1600 and 1800.

On 04/24/24 at 1107 during interview with clinical nurse specialist and facility's restraint specialist, Staff BB, she was asked if the expectation for staff nurses to know and follow facility's policy for restraints. She stated yes. Staff BB was asked how often nursing assessments need to be performed for non-violent restrained patients. Nurse said the assessments had to be done every 2 hours with specific documentation outlined in facility's policy.

Facility's Restraint Management for Acute Care Hospital and Ambulatory Setting policy was requested and reviewed on 04/24/24.

Policy dated 2/23/22 indicated:
"This policy is a combined effort on the parts of all system hospitals represented with adherence to the current CMS regulations.
Definitions:
Alternatives - Restraints should only be used when other appropriate alternatives have been exhausted and ineffective, including but not limited to de-escalation, re-orientation, pain relief, repositioning, sleep, food, increased or decreased lighting / stimulation, ambulation with assistance, occupational therapies, TV or music, etc.

Comprehensive Individual Patient Assessment - This assessment includes physical assessment to identify medical problems that may be causing behavioral changes in the patient. Examples include temperature elevations, pain, hypoxia, hypoglycemia, electrolyte imbalances, drug interactions, and drug side effects that may cause confusion, agitation, and combative behaviors. The overriding goal is to maximize mobility and freedom of movement and preserve the patient's right to be free from all forms of abuse or harassment while utilizing the least restrictive method possible to protect patients and others.

Monitoring - Monitoring is intended to evaluate the physical and emotional well-being of the patient and the continued protection of his or her rights and dignity throughout the restraint process. Monitoring is accomplished by observation and interaction with the patient or related direct visual observation by qualified staff. Thus, monitoring would evaluate whether the patient's mental status is stable, respirations are even and regular and circulation is jeopardized, i.e. constricted in any restrained extremity. It also includes whether the patient is comfortable, too warm, or too cold, need fluids or food, use of the restroom, need for exercise or support for diagnostic or treatment procedures, and whether his/her restraint device is need to be continued or removed.

Policy:
C. Patients have the right to be free from restraints of any form that are imposed for coercion, discipline, convenience, or retaliation by staff, including medications that are used as restraints.
G. Whenever possible and appropriate, alternative less restrictive measures or interventions will be tried or considered prior to use of restraint or seclusion. These include a variety of modalities, both physical and non-physical, that may serve as distractions or reminders to the patient.
H. When used, restraint must be the least restrictive intervention that protects the safety of the patient and others after alternatives have been tried or considered and found to be ineffective.
I. Restraint must be discontinued at the earliest possible time based on clinical assessment of the patient's behavior.
Procedures:
B. Ordering/ Renewal
5. The ordering provider will notify the service/provider of the restraint order.
D. Observation, Monitoring and Documentation
1. The RN performs and documents in the EHR a nursing assessment every two (2) hours which consists of: skin integrity, psychological and medical status, physical comfort, and circulation status and vital signs when available. This also includes an evaluation of criteria for continuation or removal of the restraint. This assessment is documented in the HER.
2. Assistive staff monitors and documents in the EHR the patient every to (2) hours for nourishment, hygiene, elimination necessities, and range of motion. If any change in the patient's condition occurs the RN is immediately notified and the RN takes appropriate action including notification of the provider."