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Based on interview and record review, the hospital failed to ensure the unexplained skin tears to the left upper arm were investigated for one of nine sampled patients (Patient 1). This failure had the potential to result in unsafe care and poor clinical outcomes to the patient.

Findings:

On 11/5/24, Patient 1's closed medical record was reviewed. Patient 1's medical record showed Patient 1 was admitted to the hospital on 9/28/24 and discharged on 10/3/24.

Review of the Incision/Wound/Skin Abnormality dated 9/30/24 at 0200 hours, showed Patient 1 was identified to have scattered skin tear to the left upper arm. However, further medical record failed to show physician's notification and reason why the skin tears happened.

On 11/6/24 at 1130 hours, Nurse Manager 1 was interviewed in the presence of the Officer of Regulatory Office. When asked, Nurse Manager 1 stated the unexpected skin tears should be reported to charge nurse and management to investigate to rule out abuse.

On 11/6/24 at 1320 hours, Assistant Nursing Director 2 and the Licensing Coordinator verified the above findings.

Based on interview and record review, the hospital failed to ensure the less restrictive interventions were used prior to using the hard restraints for one of nine sampled patients (Patient 1). This failure had the potential to result in unsafe care and poor clinical outcomes to the patient.

Findings:

Review of the hospital's P&P titled Restraints/Seclusion dated 6/10/23, showed documentation of the use of restraints and/or seclusion shall be consistent with the clinical protocols and maintained as required by regulatory agencies. The documentation of restraint or seclusion consists of the alternatives or other less restrictive interventions used.

Review of the hospital's P&P titled Behavioral Response Team dated 8/16/21, showed the purpose is to describe the roles and responsibilities of the Behavior Response Team (BRT) in managing severely aggressive or self-destructive patient who places self or others in imminent danger. The development of the BRT shall assist the medical center in the accomplishment of this goal by utilizing the least restrictive form of restraint when restraint is necessary. Code Gold is for patient mental health and behavioral response episodes. In the event that a patient demonstrates an unanticipated severely aggressive of self-destructive behavior, which places the patient and others in imminent danger, the ward staff will utilize less restrictive measures. Less restrictive measures include, but are not limited to, verbal de-escalation, decrease stimulation, medication administration, and provision of diversion activities. When less restrictive measures are ineffective, the ward staff shall activate Code Gold.

On 11/5/24, Patient 1's closed medical record was reviewed with Clinical Nursing Director 1.

Patient 1's closed medical record showed Patient 1 was admitted to the hospital on 9/28/24, and discharged on 10/3/24.

Review of the ED Note-Nursing dated 9/28/24 at 0353 hours, showed Patient 1 was "resisting attempts to assess, slapping away attempted to bite MD and RN staff." Code Gold was called for staff safety.

Review of the nursing assessment under the restraint episode showed Patient 1 was on the 4- points hard restraints on 9/28/24 from 0409 to 0900 hours. However, further review of Patient 1's medical record failed to show the documented less restrictive measures were used prior to initiating the 4- points hard restraints for Patient 1.

On 11/5/24 at 1215 hours, Clinical Nursing Director 1 verified the above findings.

Based on interview and record review, the hospital failed to ensure one of nine sampled patients' (Patient 1) care plan was updated to reflect the use of violent restraints during the hospitalization. This failure created the risk of substandard outcomes to the patient.

Findings:

Review of the hospital's Nursing Clinical Standard titled Restraints/Seclusion: Violent or Self-Destructive Behavior dated July 2023 showed to document the initiation of individualized risk injury related to restrains interdisciplinary plan of care.

On 11/5/24, Patient 1's closed medical record was reviewed with Clinical Nursing Director 1.

Patient 1's medical record showed Patient 1 was admitted to the hospital on 9/28/24 and discharged on 10/3/24.

Review of the ED Note-Nursing dated 9/28/24 at 0353 hours, showed Patient 1 was "resisting attempts to assess, slapping away attempted to bite MD and RN staff." Code Gold was called for staff safety.

Review of the nursing assessment under the restraint episode showed Patient 1 was on 4- points hard restraints on 9/28/24 from 0409 to 0900 hours. However, further review of Patient 1's medical record failed to show the care plan was initiated to address the use of violent restraints on 9/28/24.

On 11/5/24 at 1215 hours, Clinical Nursing Director 1 verified the above findings.

Based on interview and record review, the hospital failed to ensure the physician ordered for the use of restraints for three of nine sampled patients (Patients 1, 2, and 4) as evidenced by:

1. For Patient 1, the physician's order was not obtained when using the 4-points hard restraints.

2. For Patient 2, the non-violent restraint was ordered when the patient was restrained for the violent behavior.

3. For Patient 4, the non-violent restraint was ordered when the patient was restrained for the violent behavior.

These failures had the potential to result in unsafe care and poor clinical outcomes to the patients.

Findings:

Review of the hospital's P&P titled Restraints/Seclusion dated 6/10/23, showed a licensed practitioner orders the use of restraint or seclusion.

1. On 11/5/24, Patient 1's closed medical record was reviewed with Clinical Nursing Director 1.

Patient 1's medical record showed Patient 1 was admitted to the hospital on 9/28/24 and discharged on 10/3/24.

Review of the ED Note-Nursing dated 9/28/24 at 0353 hours, showed Patient 1 was "resisting attempts to assess, slapping away attempted to bite MD and RN staff." Code Gold was called for staff safety.

Review of the nursing assessment under the restraint episode showed Patient 1 was on 4- points hard restraints on 9/28/24 from 0409 to 0900 hours. However, further review of Patient 1's medical record failed to show the physician's order for restraints.

On 11/5/24 at 1215 hours, Clinical Nursing Director 1 verified the above findings.

2. On 11/5/24 at 1222 hours, Patient 2's medical record was reviewed with Supervising Staff Nurse 1 and Supervising Staff Nurse 2.

Patient 2's medical record showed Patient 2 was admitted to the hospital on 11/4/24.

Review of the Behavioral Response Team Form dated 11/4/24 at 0134 hours, showed the BRT was activated due to grabbing/striking out at staff and threatening staff.

Review of the medical record showed Patient 2 was on 4-points hard restraints from 11/4/24 at 0143 hours.

Review of the physician's order showed the physician ordered non-violent restraints for Patient 2 on 11/4/24 at 0202 and 2223 hours.

Review of the Restraint Forms, Face to Face Evaluation dated 11/4/24 at 2223 hours, showed Patient 2 was agitated.

When asked, Supervising Staff Nurse 1 and Supervising Staff Nurse 2 stated Patient 2 was still on 4-points hard restraints due to violent behaviors towards to staff since the first BRT's intervention. Supervising Staff Nurse 1 and Supervising Staff Nurse 2 verified the non-violent restraints were ordered Patient 2 when the patient was restrained for the violent/self-destructive behaviors.

3. On 11/6/24 at 0854 hours, Patient 4's medical record was reviewed with Nurse Manager 2.

Patient 4's medical record showed Patient 4 was admitted to the hospital on 10/30/24.

Review of the Inpatient Progress Note-Nurse dated 11/4/24 at 2330 hours, showed Patient 4 screamed at staff, got agitated, and verbally abused to staff.

Review of the Behavioral Response Team Form dated 11/5/24 at 0058 hours, showed the BRT was activated.

Further review of Patient 4's medical record showed Patient 4 was on hard restraints to the right wrist and left ankle on 11/5/24 from 0107 hours to 0519 hours. However, review of the physician's order showed the non-violent restraint was ordered for Patient 4 on 11/5/24 at 0107 hours.

On 11/6/24, Nurse Manager 2 verified the above findings.

Based on interview and record review, the hospital failed to ensure the use of hard restraints for violent behavior was not renewed in four hours for four of nine sampled patients (Patients 1, 2, 4, and 9). These failures posed a risk of substandard outcomes for the patients.

Findings:

Review of the hospital's P&P titled Restraints/Seclusion dated 6/10/23, showed each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others may only be renewed in accordance with the following limits for up to a total of 24 hours:

* four hours for adults (18 years of age and over).

Review of the hospital's Nursing Clinical Standard titled Restraints/Seclusion: Violent or Self-Destructive Behavior dated July 2023 showed to ensure the restraint order is completed and specifies:

* Time limitation for four hours for ages 18 and older. Orders may be renewed according to the time limits for a maximum of 24 consecutive hours.


1. On 11/5/24, Patient 1's closed medical record was reviewed with Clinical Nursing Director 1.

Patient 1's medical record showed Patient 1 was admitted to the hospital on 9/28/24 and discharged on 10/3/24.

Review of the ED Note-Nursing dated 9/28/24 at 0353 hours, showed Patient 1 was "resisting attempts to assess, slapping away attempted to bite MD and RN staff." Code Gold was called for staff safety.

Review of the nursing assessment under the restraint episode showed Patient 1 was on 4- points hard restraints on 9/28/24 from 0409 to 0900 hours. However, review of the subsequent physicians' order showed the violent restraints were not renewed for approximately four hours and 51 minutes.

On 11/5/24 at 1215 hours, Clinical Nursing Director 1 verified the above findings.

2. On 11/5/24 at 1222 hours, Patient 2's medical record was reviewed with Supervising Staff Nurse 1 and Supervising Staff Nurse 2.

Patient 2's medical record showed Patient 2 was admitted to the hospital on 11/4/24.

Review of the Behavioral Response Team Form dated 11/4/24 at 0134 hours, showed the BRT was activated due to grabbing/striking out at staff and threatening staff.

Review of the physician's order showed the physician ordered non-violent restraints for Patient 2 on 11/4/24 at 0202 and 2223 hours.

Further review of Patient 2's medical record showed Patient 2 was on 4-points hard restraints from 11/4/24 at 0143 hours. However, the physician's order was not renewed every four hours.

Supervising Staff Nurse 1 and Supervising Staff Nurse 2 verified the above findings. When asked, Supervising Staff Nurse 1 and Supervising Staff Nurse 2 stated Patient 2 was still on 4-points hard restraints due to violent behaviors towards to staff since the first BRT's intervention.

3. On 11/6/24 at 0854 hours, Patient 4's medical record was reviewed with Nurse Manager 2.

Patient 4's medical record showed Patient 4 was admitted to the hospital on 10/30/24.

Review of the Inpatient Progress Note-Nurse dated 11/4/24 at 2230 hours, showed Patient 4 screamed at staff, got agitated, and verbally abused to staff.

Review of the Behavioral Response Team Form dated 11/5/24 at 0058 hours, showed the BRT was activated.

Further review of Patient 4's medical record showed Patient 4 was on hard restraints to the right wrist and left ankle on 11/5/24 from 0107 hours to 0519 hours (or for four hours and 12 minutes).

On 11/6/24, Nurse Manager 2 verified the above findings.


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4. On 11/6/24, Patient 9's closed medical record review was initiated with the Licensing Coordinator and Clinical Nursing Director 1.

Patient 9's medical record showed Patient 9's arrived to the ED on 6/6/24, for altered mental status.

Review of the ED Triage dated 6/6/24 at 1307 hours, shows Patient 9 was brought in by the fire department for evaluation of altered mental status. Patient 9 was combative and in moderate distress.

Review of the restraints monitoring on 6/6/24 from 1425 hours to 2130 hours, showed Patient 9 was on hard restraints to all four extremities for continued violent behavior.

Review of the physician's order dated 6/6/24 at 1425 hours, showed Patient 9 was placed on violent restraints for physical abuse to others. Patient 9 was ordered hard restraints to all four extremities. The special instructions showed the order was valid for four hours.

However, review of the subsequent physician's order on 6/6/24 at 2130 hours, showed the violent restraints were not renewed for approximately six hours and 55 minutes.

On 11/6/24 at 1139 hours, the above findings were shared and acknowledged by the Licensing Coordinator and Clinical Nursing Director 1.

Based on interview and record review, the hospital failed to ensure four of nine sampled patients (Patients 1, 2, 4, and 9) who were restrained were monitored as evidenced by:

1. For Patients 1, 2, and 4, the patients were not monitored every 15 minutes when the patients were restrained for violent behaviors as per the hospital's P&P.

2. For Patient 9, the face-to-face re-evaluation was not performed every four hours as per the hospitals' P&P.

These failures posed a risk of substandard outcomes for the patient.

Findings:

1. Review of the hospital's Nursing Clinical Standard titled Restraints/Seclusion: Violent or Self-Destructive Behavior dated July 2023 showed to monitor and document the following upon initiation of restraints or seclusion, every 15 minutes thereafter or more frequently based on patient's condition:

* Behavioral health patient activity (e.g. awake, eyes closed)
* Restraint site evaluation (restraint type, location, and signs of injury related to restraints)
* Respiratory rate.

a. On 11/5/24, Patient 1's closed medical record was reviewed with Clinical Nursing Director 1.

Patient 1's medical record showed Patient 1 was admitted to the hospital on 9/28/24 and discharged on 10/3/24.

Review of the ED Note-Nursing dated 9/28/24 at 0353 hours, showed Patient 1 was "resisting attempts to assess, slapping away attempted to bite MD and RN staff." Code Gold was called for staff safety.

Review of the nursing assessment under the restraint episode showed Patient 1 was on 4- points hard restraints on 9/28/24 from 0409 to 0900 hours. However, there was no documented evidence to show every 15 minutes monitoring for Patient 1 while Patient 1 was on hard restraints.

On 11/5/24 at 1215 hours, Clinical Nursing Director 1 verified the above findings.

b. On 11/5/24 at 1222 hours, Patient 2's medical record was reviewed with Supervising Staff Nurse 1 and Supervising Staff Nurse 2.

Patient 2's medical record showed Patient 2 was admitted to the hospital on 11/4/24.

Review of the Behavioral Response Team Form dated 11/4/24 at 0134 hours, showed the BRT was activated due to grabbing/striking out at staff and threatening staff.

Further review of Patient 2's medical record showed Patient 2 was on 4-points hard restraints from 11/4/24 at 0143 hours. There was no documented evidence to show every 15 minutes monitoring for Patient 2 as per the hospital's P&P.

When asked, Supervising Staff Nurse 1 and Supervising Staff Nurse 2 stated Patient 2 was still on 4-points hard restraints due to violent behaviors towards to staff since the first BRT's intervention. When asked, Supervising Staff Nurse 1 and Supervising Staff Nurse 2 stated the monitoring and assessment was performed for non-violent restraint protocol and was not performed for the violent restraint. Supervising Staff Nurse 1 and Supervising Staff Nurse 2 verified above findings.

c. On 11/6/24 at 0854 hours, Patient 4's medical record was reviewed with Nurse Manager 2.

Patient 4's medical record showed Patient 4 was admitted to the hospital on 10/30/24.

Review of the Inpatient Progress Note-Nurse dated 11/4/24 at 2230 hours, showed Patient 4 screamed at staff, got agitated, and verbally abused to staff.

Review of the Behavioral Response Team Form dated 11/5/24 at 0058 hours, showed the BRT was activated.

Further of review of Patient 4's medical record showed Patient 4 was on hard restraints to the right wrist and left ankle on 11/5/24 from 0107 hours to 0519 hours. There was no documented evidence to show every 15 minutes monitoring for Patient 4 as per the hospital's P&P.

On 11/6/24, Nurse Manager 2 verified the above findings.


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2. Review of the hospital's P&P titled Restraints/Seclusion dated 6/10/23, showed the licensed practitioner must conduct a face-to-face evaluation within one hour after initiation of the intervention of violent restraints. The licensed practitioner must conduct a face-to-face re-evaluation every four hours for violent restraints.

On 11/6/24, Patient 9's closed medical record review was initiated with the Licensing Coordinator and Clinical Nursing Director 1.

Patient 9's medical record showed Patient 9's arrived to the ED on 6/6/24, for altered mental status.

Review of the ED Triage dated 6/6/24 at 1307 hours, shows Patient 9 was brought in by the fire department for evaluation of altered mental status. Patient 9 was combative and in moderate distress.

Review of the physician's order dated 6/6/24 at 1425 hours, showed Patient 9 was placed on violent restraints for physical abuse to others. Patient 9 was ordered hard restraints to all four extremities. The special instructions showed the order was valid for four hours.

Review of the Face-to-Face Evaluation dated 6/6/24 at 1425 hours, showed the provider saw the patient at the time of initiation of the violent restraints.

Review of the physician's orders showed violent hard restraints were re-ordered as follows:

- On 6/6/24 at 2130 hours, Patient 9 was ordered hard restraints on all four extremities.

- On 6/7/24 at 0111 hours, Patient 9 was ordered hard restraints on all four extremities.

- On 6/7/24 at 0516 hours, Patient 9 was ordered hard restraints for the right wrist and the left ankle.

However, further review of Patient 9's medical record failed to show the provider performed a face-to-face re-evaluation as per the hospital's P&P for subsequent renewals of the violent restraint orders.

On 11/6/24 at 1239 hours, the above findings were shared and acknowledged by the Licensing Coordinator and Clinical Nursing Director 1.

Based on interview and record review, the hospital failed to ensure the face-to-face evaluation was performed within one hour of the initiation of the intervention for one of nine sampled patients (Patient 1). This failure had the potential to result in unsafe care and poor clinical outcomes to the patient.

Findings:

Review of the hospital's P&P titled Restraints/Seclusion dated 6/10/23, showed the following:

* A licensed practitioner must conduct a face-to-face patient evaluation within one hour after the initiation of the intervention.

* The evaluation consists of patient's immediate situation, patient's reaction to the intervention, patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion.

On 11/5/24, Patient 1's closed medical record was reviewed with Clinical Nursing Director 1.

Patient 1's medical record showed Patient 1 was admitted to the hospital on 9/28/24 and discharged on 10/3/24.

Review of the ED Note-Nursing dated 9/28/24 at 0353 hours, showed Patient 1 was "resisting attempts to assess, slapping away attempted to bite MD and RN staff." Code Gold was called for staff safety.

Review of the nursing assessment under the restraint episode showed Patient 1 was on 4- points hard restraints on 9/28/24 from 0409 to 0900 hours. However, further review of Patient 1's medical record failed to show the face-to-face evaluation was conducted within one hour after the initiation of the intervention.

On 11/5/24 at 1215 hours, Clinical Nursing Director 1 verified the above findings.