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

1. The facility failed to address and document the grievance (a formal complaint) for one of 30 sampled patients (Patient 1) concerning abnormal test results. These concerns were reported to the nursing staff by Patient 1's surrogate (a person legally authorized to make healthcare decisions for the patient) on 11/6/2024 at 10:00 p.m. but were not promptly addressed, in accordance with the facility's "Hospital Patient Grievance Policy."

This deficient practice caused emotional distress for Patient 1's surrogate, dissatisfaction with the care provided, and a loss of trust in the healthcare team. By not addressing and escalating the reported concerns, the facility missed the opportunity to ensure timely review and resolution of the patient's condition, potentially compromising the quality and safety of care. (Refer to A-0118)

2. The facility failed to ensure its physician and nursing staff followed the informed consent process (a process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) for one of 30 sampled patients (Patient 18), in accordance with the facility's policy and procedure regarding informed consent when:

2.a. Physician (MD 3) did not discuss and provide Patient 18's family member (FM 1) with the information including risks, benefits, and alternatives of tracheostomy (a surgical procedure to create an artificial opening through the neck usually for the relief of difficulty in breathing).

This deficient practice had the potential to result in Patient 18's family member (FM 1) to not fully understand the risks and benefits in order to make an informed decision and not giving opportunities for FM 1 to ask questions when signing the informed consent form for the procedure. (Refer to A-0131)

2.b. Nursing staff failed to provide and document Spanish translation use when witnessing three of seven informed consent forms (consent form, document signed by the patient or legally recognized health care decision maker [LRHCDM] to consent to the procedure or treatment) signed by Patient 18's family member (FM1).

This deficient practice had the potential to result in Patient 18's family member (FM 1) to not fully understand the risks and benefits in order to make an informed decision and not giving opportunities for FM 1 to ask questions when signing the informed consent form for the procedure. (Refer to A-0131)

3. The facility failed to ensure its nursing staff performed assessment and document restraints (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) monitoring every 2 hours, for 13 hours (from 6 a.m. to 7 p.m.) for one of 30 sampled patients (Patient 18), in accordance with the facility's policy and procedure regarding restraints. The facility also failed to ensure its nursing staff assessed Patient 18's condition including skin assessment when restraints were removed.

This deficient practice had the potential to put Patient 18 at risk for skin break down (damage to the skin) and other injury due to lack of assessment and monitoring with restraint use. (Refer to A-0175)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment.

Based on interviews and record reviews, the facility failed to address and document the grievance (a formal complaint) for one of 30 sampled patients (Patient 1) concerning abnormal test results. These concerns were reported to the nursing staff by Patient 1's surrogate (a person legally authorized to make healthcare decisions for the patient) on 11/6/2024 at 10:00 p.m. but were not promptly addressed, in accordance with the facility's "Hospital Patient Grievance Policy."

This deficient practice caused emotional distress for Patient 1's surrogate, dissatisfaction with the care provided, and a loss of trust in the healthcare team. By not addressing and escalating the reported concerns, the facility missed the opportunity to ensure timely review and resolution of the patient's condition, potentially compromising the quality and safety of care.

Findings:

During a review of Patient 1's History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/26/2024, the "H&P" indicated, Patient 1's past medical history included a liver and kidney transplant (surgeries to replace diseased organs with healthy ones), anoxic encephalopathy (brain damage caused by a lack of oxygen) from cardiac arrest (when the heart stops beating), and the use of a chronic Foley catheter (a tube inserted into the bladder to drain urine) with recurrent urinary tract infections (UTIs, infections in the bladder or urinary system). The H&P also indicated Patient 1 was transferred from a nursing home to the facility with complaints of mild confusion, high blood pressure and hyperglycemia (high blood sugar).

During a review of Patient 1's "Multi-Discipline Progress Note: Registered Nurse," documented by Registered Nurse (RN, nurse who has graduated from a college's nursing program or from a school of nursing and has passed a national licensing exam) 5, dated 11/7/2024, the note indicated:

- At 10:00 p.m., Patient 1's son (Patient 1's surrogate) approached the nurses' station appearing erratic. He requested to speak with charge nurse (the lead nurse for that shift) and primary doctor. He stated that the day-shift nurse misdiagnosed his mother and wanted to file a complaint. He also requested to speak with the Chief Nursing Officer (CNO, the head of nursing staff) and the Director of Nursing (DON, and administrator overseeing the nursing team). RN 1's notes indicated, "I told him they are off the campus that he can follow up next day that all the administration will be available."

-Patient 1's son expressed frustration about the lack of transparency regarding his mother's care and showed lab results from his phone (hemoglobin [a protein in the blood that carries oxygen from the lungs to the body's tissues and organs; Normal for females is 12-16 grams per deciliter- unit of measurement] 6.2, potassium [a mineral in the body that helps regulate fluid balance, muscle contractions, and nerve signals; Normal is 3.6 to 5.2 millimoles per liter- unit of measurement] 3.1, sodium [salt; Normal is between 135 to 145 milliequivalents per liter- unit of measurement] 132) claiming no action had been taken since the morning. RN 1's notes indicated, "MOD (Medical Physician on Duty) was notify (notified) but will order given. I spoke to him at lent (length), encourage him to address this tomorrow that nothing can be done tonight. He agreed to address the issue tomorrow. Pt (Patient 1's) son remain in the room and bedside with pt (Patient 1)."

During an interview on 1/7/2025 at 11:30 a.m. with the ICU (intensive care unit, a ward in the hospital that provides critical care and life support for acutely ill and injured patients) Manager (MN 3), MN 3 stated that grievances unresolved at the unit level should be escalated to Membership Services department. MN 3 stated that grievances must be addressed immediately, even during off-hours, by contacting the tele-physician (telemedicine physician, a licensed medical doctor who provides healthcare services to patients remotely using telecommunications technology, essentially allowing patients to consult with a doctor virtually through video calls, phone calls, or secure messaging platforms, instead of visiting them in person). MN 3 further stated if patient or patient's family grievances cannot be resolved at the unit level, they are to be escalated to supervisor and Membership Services for resolution. MN 3 also stated that grievances should be escalated immediately to ensure timely resolution.

During an interview on 1/10/2025 at 11:15 a.m. with the Charge Nurse (CN) 3, CN 3 stated that during after-hours, patient grievances during after-hours should be escalated to the Nurse Manager or MOD (Medical Physician on Duty). If they cannot be reached, the nurse must notify the supervisor or use alternative contact methods like the hospital operator. CN 3 confirmed that documentation in the Electronic Medical Record (EMR, digital version of paper chart) regarding details of the family's concerns and resolution, including the name of the physician contacted and the outcome of that communication, if an order or instructions were placed, was mandatory.

During a concurrent interview and record review on 1/10/2025 at 12:07 p.m. with the Quality Coordinator (QC 1), Patient 1' EMR titled, "Multi-Discipline Progress Note: Registered Nurse," and related areas, were reviewed. These records, dated from 11/6/2024 through 11/7/2024 contained no documentation indicating that Patient 1's son's concerns had been escalated to a physician, a manager, or a supervisor. Additionally, QC 1 confirmed there was no documentation of any physician's name to indicate that the lab (laboratory) results had been reported or discussed. QC 1 verified this lack of documentation and stated that the grievance should have been escalated and recorded as required by facility policy.

During a review of the facility's policy and procedure (P&P) titled, "Hospital Patient Grievance Policy," dated 7/27/2022, the P&P indicated, "A hospital patient and/or their representative have the right, without fear of recrimination, to voice concerns or complaints regarding any aspect of the care and/or service in connection with hospital licensed services. The hospital patient or their representative can use the hospital grievance process as a means to raise concerns or complaints immediately at the point of care and/or through a formal process ...This policy applies to all employees who are employed by the following entities ... Process for immediate resolutions of grievances while a patient is still hospitalized. When a patient and/or patient's representative expresses a grievance while still hospitalized about care and/or service, a member of the patient's health care team attempts to resolve the issue in the best interest of the patient. If the health care team member is unable to resolve a grievance, a health care team member brings the concern to the attention of their manager for assistance in resolving the grievance. If the manager is unable to provide assistance in resolving the grievance, the manager refers the grievance to the Member Services Department and informs the patient or the patient's representative of such referral. A grievance is considered "resolved" when the patient or patient representative is reasonably satisfied with the actions taken by the Hospital or the Hospital has taken all reasonable measures to resolve the matter and the patient or patient representative has not responded thereto."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibility," dated 10/17/2022, the P&P indicated, "receive information about your health status diagnosis prognosis course of treatment prospective for recovery and outcome of care parentheses including unanticipated eating unanticipated outcomes closed, in terms you can understand. You have the right to effective community location and to participate in the development and implementation of your plan of care you have the right to participate in ethical questions that arise in the course of your care. Including issue of conflict resolution withholding resuscitation services and forgoing or withdrawing life sustaining treatment."

During a review of the facility's policy and procedure (P&P) titled, "Patient Care Communication Process-Chain of Command/Escalation of Concern," dated 4/18/2022, the P&P indicated, "To provide guidelines for patient caregivers when communicating about patient conditions and to provide a mechanism for a higher level of discussion regarding the medical care being rendered to a patient. To establish a standard method of communication process and provide a mechanism to address issues regarding patient care and workplace safety concerns or interdisciplinary disputes at a higher level of command. To ensure safe, timely and appropriate quality and safe care for the patient when any aspect of patient care is in question or when conflict arises between health care team members. Every member of the health care team is responsible for delivering the most effective care and treatment to all patients at the appropriate time. All employees/staff are required to take action when there is a question or concern about the quality of care and or patient safety. Employees shall elevate communication to the next level of responsibility by utilizing the SBAR (Situation, Background, Assessment, and Recommendation, a communication tool for sharing information about a patient's health condition) process of communication ...Patient care concerns shall be resolved through communication between the members of the patient care team that includes the medical, nursing, and/or ancillary staff.
The first line of communication to discuss any aspect of patient care shall be between the ordering practitioner or designee and the nursing or ancillary staff providing the care.

a. Each practitioner shall provide a designee for coverage whenever he or she is unavailable and inform the appropriate person responsible for tracking the providers' duty schedules and the designated "charge" nurse or person as appropriate.
b. The most current list of the names of designees for coverage for all unavailable physicians is accessible through (name of the facility's) Telecommunications/Operator.
c. Unresolved concerns shall be brought up to the next level of the chain of command for discussion and appropriate resolution. If a higher level of care or staff is unavailable, proceed with the next level chain of command ...
Decision Making/Other Avenues for Consultation:
If in the first line of communication, the matter is not resolved, the unit/department supervisor and the physician in charge or physician on-call shall be included in the discussion for a quick negotiable resolution. If in the first line of communication a decision or conclusion is not reached, the department nursing leader and/or the next higher- or highest-level professional practice leader and the Medical Director or Chief of Service shall be the final deciding authorities."

Based on observation, interview and record review, the facility failed to ensure its physician and nursing staff followed the informed consent process (a process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) for one of 30 sampled patients (Patient 18), in accordance with the facility's policy and procedure regarding informed consent when:

1. Physician (MD 3) did not discuss and provide Patient 18's family member (FM 1) with the information including risks, benefits, and alternatives of tracheostomy (a surgical procedure to create an artificial opening through the neck usually for the relief of difficulty in breathing).

2. Nursing staff failed to provide and document Spanish translation use when witnessing three of seven informed consent forms (consent form, document signed by the patient or legally recognized health care decision maker [LRHCDM] to consent to the procedure or treatment) signed by Patient 18's family member (FM1).

These deficient practices had the potential to result in Patient 18's family member (FM 1) to not fully understand the risks and benefits in order to make an informed decision and not giving opportunities for FM 1 to ask questions when signing the informed consent form for the procedure.

Findings:

1. During a review of Patient 18's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/7/2024, the H&P indicated, Patient 18 was admitted to the facility with diagnoses including but not limited to severe sepsis (a body's overwhelming and life-threatening response to infection) with acute (new onset) organ dysfunction (when an organ is not working properly), community acquired pneumonia (lung infection), and acute respiratory failure (condition in which not enough oxygen passes from the lungs into the blood).

During a review of Patient 18's "Condition of Admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.)" form, dated 11/7/2024, the COA form indicated, Patient 18's family member (FM 1) signed the COA form for Patient 18. The COA form also indicated translation was used via phone/video remote interpreting with Spanish interpreter needed.

During a concurrent observation and interview on 1/7/2025 at 11:52 a.m. with Charge Nurse (CN) 2, at Patient 18's room, FM 1 was sitting in Patient 18's room. CN 2 stated FM 1 required Spanish interpretation. Observed CN 2 using the facility's phone to connect to a Spanish speaking interpreter and started to talk to FM 1.

During a concurrent interview and record review on 1/10/2025 at 1:36 p.m. with Registered Nurse (RN) 4, Patient 18's "Consent to Operation, Administration of Anesthetics, and the Rendering of other medical services" form (consent form, document signed by the patient or legally recognized health care decision maker [LRHCDM] to consent to the procedure or treatment), dated 11/24/2024, was reviewed. The consent form was in Spanish and indicated procedure of tracheostomy (a surgical procedure that creates an opening in the neck and inserts a tube into the windpipe [trachea]). The consent form indicated FM 1 signed the consent form on 11/24/2024 at 10:53 a.m. witnessed by RN 6 with the section of interpreter's name and identification number left blank.

During the same interview on 1/10/2025 at 1:36 p.m. with Registered Nurse (RN) 4 , RN 4 stated translator use should be documented on the consent form to indicate the use of translator. RN 4 stated it was important for nursing staff to utilize translation service (ensures that all patients receive the information they need in a language they understand) for non-English speaking patients and family when witnessing signature on consent form so that they would know what they were signing and would allow them to ask questions before signing the consent form. RN 4 stated if patient or family member still had questions, nursing staff should contact the physician and not to let them (Patient and/or designated patient representative/family member) sign the consent form.

During a concurrent interview and record review on 1/10/2025 at 2:08 p.m. with Registered Nurse (RN) 4, Patient 18's Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) Progress Notes (physician notes indicating patient's health condition, progress and treatment plan), dated from 11/23/2024 to 11/25/2024, was reviewed. The ICU Progress Notes indicated the following:

-On 11/23/2024, physician (MD 3)'s plans for today: "ventilator (an appliance for artificial respiration) support: will again try weaning (a process of transitioning patient from ventilator use to breathing on his own)" noted palliative (a medical approach that helps people with serious illness live with more comfort and dignity) conversation and if needed, patient's (Patient 18's) [family member] (FM 1) is willing to have patient (Patient 18) undergo tracheostomy;"

-On 11/24/2024, MD 3's plans for today: "ventilator support: patient (Patient 18) unable to wean: will pursue tracheostomy, likely tomorrow (11/25/2024);"

-On 11/25/2024, MD 3's plans for today: "tracheostomy today ... updated [family member] (FM 1) at bedside this morning via interpreter."

During the same interview on 1/10/2025 at 2:08 p.m. with Registered Nurse (RN) 4, RN 4 stated MD 3's progress notes did not show MD 3 had discussed any risks, benefits, and alternatives of tracheostomy with FM 1 prior to tracheostomy (procedure performed on 11/25/2024).

During a concurrent interview and record review on 1/10/2025 at 4:17 p.m. with the Chief of Staff (COS), Patient 18's Procedure Notes (operative notes), dated 11/25/2024, was reviewed. The operative notes indicated, Patient 18 had a placement of percutaneous (made through the skin) tracheostomy tube. The operative notes also indicated, "consent: consent was informed, signed by the patient's (Patient 18's) designee - [family member] (FM 1) and on the chart." COS stated there was no documentation of risks and benefits of the procedure and informed consent discussion with FM 1 by MD 3. COS stated during the informed consent process, the physician was responsible to explain the diagnosis, risks and benefits and provide alternatives with translation if needed for non-English speaking patient or patient's representative. COS stated the physician needed to document the informed consent discussion in their notes, typically in the operative notes.

During a review of the facility's policy and procedure (P&P) titled, "Informed Consent, Written Consent and Refusal of Consent," dated 3/2023, the P&P indicated, "Prior to consenting to any treatment or procedure, patients have the right to know the relevant risks of the treatment or procedure, expected or hoped for benefits of the treatment or procedure, treatment alternatives and potential problems that might occur during recuperation. Patient also have the right to receive information in a manner he or she understands. Based on patient's preferred language, interpreter and translation services are offered ... it is the physician/allied health practitioner (AHP, a category of health professionals)'s obligation to assure that the elements of informed consent have been discussed with and explained to the patient/legally recognized health care decision maker (LRHCDM) ... a critical part of the informed consent process is the discussion between the patient/LRHCDM and physician/AHP, which shall include an explanation of the risks, benefits, and alternatives to the recommended treatment or procedure, as well as potential problems that may occur during recuperation ... after the discussion, the physician/AHP must document in the patient's medical record that the physician discussed the proposed procedure with the patient/LRHCDM and obtained informed consent."

During a review of the facility's medical staff rules and regulation (rules and regulations) titled, "Rules and Regulations of the Professional Staff," dated 12/2023, the rules and regulations indicated, "Consent. The competent patient is entitled to be informed about the nature of the proposed diagnostic and therapeutic procedures, possible benefits, risks, reasonable alternatives to the proposed care or treatment, side effects related to the alternatives, risks of not receiving the proposed care, and potential complications. It is the Professional Staff's responsibility to convey the necessary information appropriate to the patient, and the circumstances, in language that the patient is likely to understand, and to document this discussion in a separately entry in the medical record. Except in emergencies, no patient shall be subjected to any surgical, diagnostic, or therapeutic procedure that involves a significant risk of bodily harm unless informed consent if obtained from the patient or his or her legally recognized representative and all other persons, if any, from whom consent is required by law."

2. During a review of Patient 18's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/7/2024, the H&P indicated, Patient 18 was admitted to the facility with diagnoses including but not limited to severe sepsis (a body's overwhelming and life-threatening response to infection) with acute (new onset) organ dysfunction, community acquired pneumonia (lung infection), and acute respiratory failure (condition in which not enough oxygen passes from the lungs into the blood).

During a review of Patient 18's "Condition of Admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.)" form, dated 11/7/2024, the COA form indicated, Patient 18's family member (FM 1) signed the COA form for Patient 18. The COA form also indicated translation was used via phone/video remote interpreting with Spanish interpreter needed.

During a concurrent observation and interview on 1/7/2025 at 11:52 a.m. with Charge Nurse (CN) 2, at Patient 18's room, FM 1 was sitting in Patient 18's room. CN 2 stated FM 1 required Spanish interpretation. Observed CN 2 using the facility's phone to connect to a Spanish speaking interpreter and started to talk to FM 1.

During a concurrent interview and record review on 1/10/2025 at 1:36 p.m. with Registered Nurse (RN) 4, seven of Patient 18's "Consent to Operation, Administration of Anesthetics, and the Rendering of other medical services" forms (consent form, document signed by the patient or legally recognized health care decision maker [LRHCDM] to consent to the procedure or treatment), dated from 11/7/2024 to 12/24/2024, were reviewed. Three of the consent forms were in Spanish and indicated the following:

-Consent form with procedure for Central line (CVC or Central Venous Catheter- a thin, flexible tube that is inserted into a large vein near the heart to give fluids, blood and medications) placement signed by Patient 18's family member (FM 1) on 11/7/2024 at 6:42 p.m. witnessed by RN 7 with no documentation of interpreter's name and identification number;

-Consent form with procedure for tracheostomy (a surgical procedure to create an artificial opening through the neck usually for the relief of difficulty in breathing) signed by FM 1 on 11/24/2024 at 10:53 a.m. witnessed by RN 6 with no documentation of interpreter's name and identification number;

-Consent form with procedure for placement of chest tube (a flexible tube that drains fluid, air or blood from the chest cavity) on left, signed by FM 1 on 12/16/2024 at 11:58 a.m. witnessed by RN 8 with no documentation of interpreter's name and identification number.

During the same interview on 1/10/2025 at 1:36 p.m. with Registered Nurse (RN) 4, RN 4 stated translator use should be documented on the consent form to indicate the use of translator. RN 4 stated it was important for nursing staff to utilize translation service for non-English speaking patients and family when witnessing signature on consent form so that they (Patient and/or designated family representative) would know what they were signing and would allow them to ask questions before signing the consent form. RN 4 stated if patient or family member still had questions, nursing staff should contact the physician and not to let them sign the consent form.

During a review of the facility's policy and procedure (P&P) titled, "Informed Consent, Written Consent and Refusal of Consent," dated 3/2023, the P&P indicated, "General principle: patients and legally recognized health care decision maker (LRHCDM) must be able to understand what they are being asked to authorize. The hospital must arrange for communication in a language or mode that can be understood by the patient or LRHCDM. Documentation of interpreter: when an interpreter is required, the name of the interpreter and date/time of if the universal language telephone line or video remote interpreting used, their interpreter identification number must be documented."

Based on observation, interview and record review, the facility failed to ensure its nursing staff performed assessment and document restraints (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) monitoring every 2 hours, for 13 hours (from 6 a.m. to 7 p.m.) for one of 30 sampled patients (Patient 18), in accordance with the facility's policy and procedure regarding restraints. The facility also failed to ensure its nursing staff assessed Patient 18's condition including skin assessment when restraints were removed.

This deficient practice had the potential to put Patient 18 at risk for skin break down (damage to the skin) and other injury due to lack of assessment and monitoring with restraints use.

Findings:

During a review of Patient 18's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/7/2024, the H&P indicated, Patient 18 was admitted to the facility with diagnoses including but not limited to severe sepsis (a body's overwhelming and life-threatening response to infection) with acute (new onset) organ dysfunction (when an organ is not working properly), community acquired pneumonia (lung infection), and acute respiratory failure (condition in which not enough oxygen passes from the lungs into the blood).

During a concurrent observation and interview on 1/7/2025 at 11:52 a.m. with Charge Nurse (CN) 2, at Patient 18's room, Patient 18 was in bed with bilateral (both) soft wrists restraints (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) on. CN 2 stated Patient 18 was on bilateral soft wrist restraints due to pulling lines.

During a review of Patient 18's "physician order (orders written by physicians to direct care and treatment)," dated 12/23/2024, the physician order indicated, there was need for bilateral wrists restraints due to pulling tube/lines and interfering with dressing, wounds, or devices.

During a concurrent interview and record review on 1/10/2025 at 2:27 p.m. with Registered Nurse (RN) 4, Patient 18's "restraints flowsheet (documentation of restraints use and assessment)," dated 12/24/2024, was reviewed. The restraint flowsheet indicated Patient 18 was on bilateral soft wrists restraints. The restraint flowsheet indicated an entry of assessment was completed on 12/24/2024 at 6 a.m. by RN 9. The next entry was on 12/24/2024 at 7 p.m. which indicated "discontinued. Not present on assessment," by RN 9.

During the same interview on 1/10/2025 at 2:27 p.m. with the Registered Nurse (RN) 4, RN 4 stated the following: Patient 18's restraints were removed sometime from 6 a.m. to 7 p.m. on 12/24/2024, but the day shift nurse did not document anything. There should be restraints assessment done every two hours by nursing staff to check for skin for any injury, circulation (blood flow), range of motion (ROM, the full movement potential of a joint, usually its range of flexion and extension), discoloration, and swelling while Patient 18 was on restraints. Nursing staff should document time of restraints removal along with post (after) restraints assessment to assess skin for any injury. There was no assessment done from 6 a.m. to 7 p.m. (13 hours). Patient 18 could be at risk for skin breakdown and injury due to lack of proper monitoring.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 9/2022, the P&P indicated, "Assessment, monitoring, and documentation of all restraint type: Registered Nurses (RN) are responsible for the assessment, monitoring and provision of care for patients in restraints ... Patient assessment by staff who have observed, examined or interacted directly with the patient will occur ... every two (2) hours for non-violent, non self-destructive restraints ... Patients in non-behavioral restraints are monitored and assessed at least every two (2) hours or sooner, as indicated by the condition of the patient and type of restraint. The assessment will be documented in the medical record. Assessment at least every two (2) hours include: behavior/mental status; circulation; nutritional needs (food/meal); hydration needs; elimination needs; range of motion (ROM); restraints released and reapplied, one limb at a time ...The patient shall be continually assessed to determine the patient's condition and whether restraint can be discontinued. The physician or nurse responsible for the patient's care has the authority to discontinue restraints based on patient assessment."