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Based on document review and interview the registered nurse failed to assess a patient every two (2) hours while in non-violent restraints in one (1) of ten (10) medical records reviewed (Patient # 6).

Findings include:

1. The facility policy titled, Restraint Policy, PolicyStat ID 15400263, indicated on page seven (7) - section - V - Non-Violent Restraint Procedure - letter D - Assess, assist, and document approximately every two (2) hours to determine the following - proper application - criteria for release - personal needs met - repositioning - vital signs obtained - skin integrity - physical / psychological status and comfort, patient rights dignity and safety maintained, and whether less restrictive methods are possible. This policy was last revised on 04/04/2024.

2. Patient # 6's MR indicated the following:
The patient was a 59 y/o (year/old) who was admitted to H # 2 (Acute Care Hospital) on 05/01/2025 with a diagnosis of atrial fibrillation (afib). The patient was placed in non-violent restraints on 05/01/2025 at 7:36 pm because he/she was pulling on lines/tubes. The MR lacked documentation the patient was monitored/reassessed every two (2) hours on 05/03/2025 at 2:00 am, 4:00 am, and 6:00 am.

3. In interview on 05/08/2025 at approximately 11:40 am, with administrative staff member A # 6 (Nursing Director, Critical Care Services), confirmed Patient # 6 should have been assessed every two (2) hours while in non-violent restraints.

Based on document review and interview, the registered nurse failed to reassess a patient within sixty (60) minutes after administering pain medication for two (2) of ten (10) medical records reviewed (Patient # 5 and Patient # 10), and failed to assess a patient's pain every two (2) hours in one (1) of ten (10) medical records reviewed (Patient # 10).

Findings include:

1. The facility policy titled, Assessment of Pain Guideline, PolicyStat ID 17232741, indicated on page four (4) - Reassessment of Pain (after PRN-as needed pain medication administration and/or one-time pain medication order administration) - letter B - Reassessment of the patient will be within 60 minutes (from time that the prn or one-time medication is given). This policy was last revised in 12/27/2024.

2. The facility policy titled, Vital Signs and Assessment in Critical Care, PolicyStat ID 11231832, indicated on page one (1) - section - Definitions - number 1 - Pain, temperature, pulse, respirations, oxygen level (Sp02), and blood pressure are basic vital signs - on page two (2) - section - Procedure - number 1 - In ICU (Intensive Care Unit) vital signs complete assessment every four (4) hours. This policy was last revised on 03/22/2022.

3. The facility policy titled, Vital Signs in the Emergency Department Guideline, PolicyStat ID 12033547, indicated on page one (1) - section - Definitions - Full set of vital signs includes blood pressure, pulse, respiratory rate, oxygen saturation, temperature, and pain rating - on page two (2) - section - Guidelines - number 4 - Repeat vital signs will be obtained on patients according to the following guidelines - letter C - ESI (Emergency Severity Index) - level 3 - every two (2) hours. This policy was last revised on 09/10/2019.

4. Patient # 5's MR indicated the following:
The patient was a 15 y/o (year/old) who arrived at H # 2 (Acute Care Hospital-Emergency Department) on 05/06/2025 with a diagnosis of right wrist open displaced fracture. The patient received pain medication (Toradol) on 05/07/2025 at 2:00 pm for a pain score of eight (8) out of ten (10). The patient's pain was reassessed at 4:30 pm. The MR lacked documentation the patient's pain was reassessed within sixty (60) minutes after receiving the pain medication.

5. Patient # 10's MR indicated the following:
a. The patient was a 33 y/o who arrived at H # 2's ED on 01/20/2025 with a diagnosis of forearm fracture and was admitted.
b. History and Physical indicated the patient fell on the ice injuring his/her left arm with no loss of consciousness. X-ray report indicated an acute fracture involving the distal third of the left radial and ulnar diaphyses with an angulation.
c. The MR lacked documentation of a pain assessment on 01/20/2025 at 10:00 pm, 12:00 am, and on 01/21/2025 at 12:00 pm and 4:00 pm.
d. The MR lacked documentation the patient was reassessed within sixty (60) minutes after receiving Morphine 5 mg injection on 01/21/2025 at 10:18 pm.
e. Patient's vital signs were taken on 01/21/2025 at 5:30 am. The MR lacked documentation the patient's vital signs were taken on 01/21/2025 at 7:30 am.

6. In interview on 05/08/2025 at approximately 11:40 am, with administrative staff member A # 6 (Nursing Director, Critical Care Services), confirmed anytime a pain medication was administered there should be a sixty (60) minute pain reassessment of the patient (Patient # 5 & Patient # 10). Patient # 10's pain and vital signs should have been assessed every two (2) hours while in the Emergency Department.

Based on document review and interview the registered nurse failed to ensure the patient's care plan was updated per policy. (Patient # 10)

Findings include:

1. The facility policy titled, Plan of Care Policy, PolicyStat ID 13636719, indicated on page two (2) - section - Procedure - letter B - Review - letter a - The care plan must be reviewed and progression toward goals documented at minimum once per calendar day - letter C - Progress Towards Goals - letter a. The RN (Registered Nurse) caring for the patient will update the Plan of Care in the EMR (Electronic Medical Record) by documenting the patient's progress that occurred toward meeting the established goals - letter b. Document appropriate status: i. Progressing, ii. Not Progressing, iii. Adequate for Discharge, iv. Complete, v. Not Met - goal is no longer appropriate for patient, vi. Determine goals and appropriate goal date. This policy was last revised on 06/02/2023.

2. Patient # 10's MR indicated the following:
a. The patient was a 33 y/o (year/old) who arrived at H # 2 (Acute Care Hospital Emergency Department) on 01/20/2025 with a diagnosis of forearm fracture and was admitted.
b. History and Physical indicated the patient fell on the ice injuring his/her left arm with no loss of consciousness. X-ray report indicated an acute fracture involving the distal third of the left radial and ulnar diaphyses with an angulation.
c. The MR lacked updated appropriate status problem documentation and lacked the daily (01/22/2025) updated documentation problem list for anxiety, Fluid and Electrolyte Imbalance, Hemodynamic Status, Infection, Knowledge Deficit, Oxygenation/Respiratory Function, Pain, Psychosocial Needs, Universal Fall Precautions, and Risk for Impaired Skin Integrity.

3. In interview on 05/08/2025 at approximately 11:40 am, with administrative staff member A # 6 (Nursing Director, Critical Care Services), confirmed patient # 10's Plan of Care was not updated daily and appropriately reflecting progress toward goals.