HospitalInspections.org

Based on policy review, record review, and interview, the Hospital failed to ensure it met the requirements for Patient Rights Condition of Participation when the hospital failed to protect and promote each patient's rights and failed to provide care in a safe setting.

Findings Include:

The hospital failed to ensure nursing staff followed the restraint policy and procedures and failed to follow fall prevention guidelines for high fall risk patients as stated in their policies for 2 of 9 Patients (Patients 6 and 9). (Refer to tag A-0144)

Based on policy review, record review, and interview, the Hospital failed to ensure that 1 (Staff K, Registered Nurse (RN) of 3 nursing personnel reviewed, had valid and current licensure. The hospital failed to ensure nursing staff effectively assessed and evaluated patient care for 5 (Patient 2, 3, 6, 8, and 9) of 9 sampled patients. This deficient practice places any patient receiving care at this hospital at risk for serious injury or harm.

Findings Include:

1. The hospital failed to ensure that 1 (Staff K, RN) of 3 nursing personnel reviewed, had valid and current licensure that complies with Kansas State licensure law. (Refer to Tag A0394)

2. The hospital failed to ensure nursing care was evaluated by a registered nurse on an ongoing basis to ensure that staff were providing the appropriate assessment, care, and evaluation of patient's response to interventions for 5 of 9 (Patient 2, 3, 6, 8, and 9) patient records reviewed. (Refer to Tag A0395)

Based on policy review, record review, and interview, the hospital failed to provide care in a safe setting by not following hospital policy for restraint procedures and by the failure to follow fall prevention guidelines for 2 of 9 patients (Patient 6 and 9) at high risk for falls. This deficient practice places any patient in restraints or at risk for falls at risk for serious harm or injury.

Review of a hospital policy titled, "Patient Rights and Responsibilities," revised 06/09/23, showed, " ...Patients have the right to receive care in a safe setting ..."

Review of a hospital policy titled, "Restraint Management for Non Violent Behavior," revised 12/02/23, showed, " ...Non-physical alternatives must be attempted before applying restraints. Restraints may not be used unless less restrictive interventions have been determined to be ineffective and the use is necessary to ensure the immediate physical safety of the patient, a staff member or others. Sensitivity to the impact on especially vulnerable patients such as ...cognitively or physically limited patients ...is clinically addressed and managed ...a. Obtain a Provider order for restraints ...ii. The Provider is notified of initiation immediately and an order obtained. b. Obtain new order for restraint each calendar day ..."

Review of a hospital policy titled, "Restraints," revised 12/02/23, showed, " ...For non-violent patients' restraint may only be used if needed to improve the patient's well-being, and less restrictive, non-physical interventions have been determined to be ineffective to protect the patient from harm ..."

Review of a document provided by the hospital titled, "Posey Bed 8070 User Manual," dated 2017, showed, " ...Because the bed is a restraint, its use must be prescribed by a licensed doctor. Anyone interacting with the bed must complete the Posey Bed 8070 In-Service Training Program which includes the ability to use this manual ... RISKS Improper use of the Posey Bed 8070 may lead to serious injury or death. Patient monitoring should be determined by hospital protocol, a doctor, and the patient care plan. As with any less restrictive restraint system, it is important to understand when the Posey Bed 8070 is needed, when it should not be used, and the dangers related to entrapment, suffocation, choking, and falls ... REDUCING THE RISK OF ENTRAPMENT To help reduce the risk of entrapment, adhere to the following guidelines: o Keep the mattress flat. - If you need to elevate the head or torso of an at-risk patient, keep the mattress flat and use a cushion to position the patient. - If you must leave the head of the bed up while an at-risk patient is alone, use the Posey Filler Cushions ... Warnings and Precautions ... Canopy gaps present an entrapment risk for certain at-risk patients. Raising the head of the Posey Bed creates "gaps" or "pockets" between the head of the bed and the canopy. These areas pose an extreme risk of serious injury or death from entrapment for certain at-risk patients. Keep the mattress flat with the head of the bed down when an at-risk patient is alone ..."

Review of a policy titled, "Fall Risk and Injury Prevention," dated 12/15/23 showed, " ...4. Upon admission patients are assessed by nursing for risk of falls and prevention and reassessed every shift and with any change in condition using: A. The Hester Davis Scale (HDS) in adults over 17 years of age ... 3. Post-fall assessment will be conducted to identify patient injury and immediate care needs. a. Consider calling Rapid Response Team for additional resources to assist patient assessment and/or meeting immediate patient care needs. b. Notify provider, as appropriate to the care setting. c. Reassess fall risk and implement additional safety measures, as appropriate.
d. Conduct post-fall huddle/evaluation. Post-fall evaluation shall be completed by the patient care team to include at a minimum the primary care nurse, charge nurse and Nurse Leader. e. Discuss fall in safety huddles for one week after fall or until patient discharges ... B. Prevention 1. Evaluate at a minimum once a shift to determine if expected outcome is being met ... c. Interventions are tailored to the specific identified risk factors. 1. Activate the Fall Injury Risk Care Plan Guide for patients at moderate or high risk for fall and select appropriate interventions: Low Risk= 7-10 Moderate Risk= 11-14 High Risk= 15 ...Nurse's judgement as indicated based on risk factors (physiological functioning and ABCS factors) signs and symptoms of altered mental status impaired judgement e.g. confusion, dementia, forgetfulness, impulsive, overestimates or forgets limitations ..."

Patient 6

Review of Patient 6's medical record showed a 73-year-old admitted on 10/13/24 at 11:58 AM with a diagnosis of weakness, blurred vision and fall with closed head injury. Past medical history includes depression; diabetes; high cholesterol and heart failure.

Review of a document titled, "Fall Assessment Scale," dated 10/13/24 at 1:00 PM, showed, " ...Hester Davis Fall Risk Assessment ... Hester Davis Fall Risk Total: 10 Hester Davis Fall Risk Level: Low ..." The admitting diagnosis of weakness, blurred vision and fall with closed head injury should have resulted in a fall risk level of "High".

Review of a document titled, "ED [Emergency Department] Provider Notes," dated 10/13/24 at 3:23 PM, showed, "Patient was in the bathroom. She did have a very large bowel movement and fell off the toilet. I reassessed the patient [sic] is brought back to her room states she potentially hit her head she was also very shaky rechecked her temperature and she was febrile ... I did order repeat head CTs patient fell no other injury was noted. Charge nurse was present and assess the patient after fall. Likely patient has a vagal response codes the bowel movement she was will extremely large and was on the floor plus a toilet and patient did fall no other injury was noted ..."

The medical record failed to show a documented post fall assessment was completed at time Patient 6 fell.

Patient 9

Review of Patient 9's medical record showed a 91-year-old admitted inpatient on 11/03/24 at 1:21 AM with a diagnosis of altered mental status; unwitnessed fall and metabolic encephalopathy (condition in which brain function is disturbed due to underlying diseases or toxins in the body). Past medical history includes atrial fibrillation (irregular heart rhythm); Benign Prostatic Hyperplasia (BPH) (noncancerous enlargement of the prostate gland).

Review of the medical record showed that Patient 9 fell while in the hospital as indicated by a document titled, "Post Fall Assessment," dated 11/07/24 at 6:45 PM, showed, "Fall Date 11/07/24 Fall Time 1645 [4:45 PM] Notification Time 1840 [6:40 PM] ..."

The medical record showed that Patient 9 was placed in restraints after the fall, specifically an enclosure bed, as evidenced by a document titled, "Nursing Assessments," dated 11/07/24 at 7:50 PM, that showed, " ...Restraint Order Length of Order 24 hours ... Less Restrictive Alternative Verbal redirection; Increased frequency of nursing rounds; Diversionary activities; Reorientation to surroundings; Decreased stimulation; Alarm; Pain management; Reevaluate equipment;Repositioning ...Clinical Justification Removal of dressing; Pulling tubes; Removal of equipment Impulsive, high fall risk, fall on current hospitalization ... Restraint Monitoring Every 2 Hours.. Start Enclosure bed ..."

Review of the medical record for 11/07/24 failed to showed documented evidence that hospital staff notified a provider of behaviors leading to the use of an enclosure bed restraint for Patient 9.

Staff failed to follow Posey Bed manufacturer guidelines to prevent patient entrapment as evidenced by Patient 9's "Daily Cares/Safety" chart on 11/10/24 at 8:00 AM that showed, " ...HOB [head of bed] at 30-35 degrees ..." and "Daily Cares/Safety" chart on 11/09/24 at 11:00 AM that showed, " ...HOB at 30 degrees ..."

During an interview on 12/09/24 at 3:27 PM Staff Q, RN stated that restraint training is not specific to enclosure beds and that hands on training for use of a Posey Bed was not provided.

During an interview on 12/09/24 at 4:07 PM Staff R, RN stated that training on enclosure beds is done upon hire and that the beds are self-explanatory so hands on training is not provided.

During an interview on 12/09/2024 at 3:00 PM Staff O, Regulatory Compliance, stated, " ...there is not specific training on enclosure beds and no hands-on restraint training ..." .

Review of Patient 9's medical record showed from 11/10/24 at 1:39 PM through 11/10/24 at 7:16 PM, Patient 9 was sleeping for approximately 6 hours without removing restraint.

Further review of the medical record showed Patient 9 remained in the enclosure bed restraint without a physician's order every 24 hours as required per policy from 11/10/24 at 7:50 PM through 11/11/24 when Patient 9 was found deceased.

Review of a document titled, "Asset History," showed, " ...Period: 11/11/24 5:05:00 PM - 11/12/24 6:05:00 AM ...Asset: [Staff R, Registered Nurse (RN)] ..." last documented entry into Patient 9's room prior to his death at 4:30 AM was on 11/12/24 at 2:39AM.

Review of a document titled, "Asset History" showed, " ...Period: 11/11/24 5:05:00 PM - 11/12/24 6:05:00 AM ...Asset: [Staff P, Clinical Associates (CA)] ..." last documented entry into Patient 9's room prior to his death at 4:30 AM was on 11/12/24 at 2:39 AM.

Review of a document titled, "REPORT OF A HOSPITAL DEATH ASSOCIATED WITH THE USE OF RESTRAINT OR SECLUSION" dated 11/12/2024 at 3:34 PM showed, " ...Date and Time of Death 11/12/2024 0430 [4:30 AM] ... Date Patient Last Monitored 11/12/2024 Time Patient Last Monitored 04:00 [4:00 AM] ..."

The "REPORT OF A HOSPITAL DEATH ASSOCIATED WITH THE USE OF RESTRAINT OR SECLUSION" showed Patient 9 was last assessed on 11/12/24 at 4:00 AM before his death on 11/12/24 at 4:30 AM even though the tracer activity of Staff R, RN and Staff P, CA showed the last documented time Patient 9 was monitored was on 11/12/24 at 2:39 AM.

During an interview on 12/06/24 at 10:55 AM Staff A, RN stated that staff had been in Patient 9's room at 4:00 AM and then staff found Patient 9 deceased at 4:30 AM.

Review of Patient 9's "Restraint Monitoring," on 11/12/24 at 4:00 AM showed that a visual check was completed, and that Patient 9 was asleep with no sign of injury. Further review showed that Staff R, RN charted the 4:00 AM visual check at 7:07 AM. Review of Staff R's location tracking on 11/12/24 showed that Staff R did not enter Patient 9's room between 2:39 AM and 4:39 AM.

Review of a nurses note with a date of service on 11/12/24 at 7:00 AM was filed and signed by Staff R, RN on 11/23/24 at 1:17 AM (11 days after Patient 9's death.) The note stated, "Patient was rounded on every hour until 2200 [10:00 PM] and then every 2 hours beginning at 0000 [12:00 AM]. Patient slept all night with occasional groaning. At 0200 [2:00 AM] visit CA [Staff P] and I changed his purewick and brief and repositioned patient to right side. Patient moaned and tried to move our hands out of the way. At 0430 [4:30 AM] check, CA [Staff P] found patient without a pulse and called me in bed briefing. I immediately returned to floor to assess situation. Patient had passed."

Based on policy review, personnel record review, and interview, the hospital failed to ensure that 1 (Staff K, Registered Nurse (RN) of 3 nursing personnel reviewed had valid and current licensure that complies with Kansas State licensure laws. This deficient practice places any patient receiving care at risk for serious injury or harm.

Review of a hospital policy titled, "License, Certification, Registration Requirements," dated 12/13/2023 showed, " ...PURPOSE: To establish requirements for the verification, monitoring, and tracking of licenses, certifications, and registrations of all team members who are required by federal, state, and local laws, job description or as deemed required to perform the essential functions of the role, to possess a valid and current license, certification, and/or registration. POLICY: Team members must maintain required current and active licenses, certifications, and/or registrations, as required in their job description. This policy also establishes the requirement that all team members are to function within the limits of their scope of practice as defined by their professional practice act, Federal and State laws, and job description ... Team members must submit a copy of their renewed professional licenses, certifications, and/or registrations to their local human resources department not completed seven (7) days prior to the expiration date of such license or certification. Upon receipt (thereafter), a primary source verification will be run, ensuring it is in a clear and active status ..."

Review of a document titled, "Job Description," dated 10/2021 showed, " ...Title ...Registered Nurse ... LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED: Kansas Registered Nurse License ..."

During an interview on 12/05/24 at 1:23 PM, Staff K, RN, stated that she had been working at the hospital for a year and currently works Monday through Friday.

Review of Staff K, RN, personnel record on 12/06/24 showed Staff K's RN license expired 11/30/24.

Review of a document titled, "QuickConfirm License Verification Report," dated 12/06/24 at 1:11 PM, showed the status of Staff K's license as non-active and " ...License Status EXPIRED ...License Expiration Date 11/30/24 ..."

Review of a document titled, "List of Patients," showed that from 12/02/24 through 12/06/24 Staff K, RN had 24 encounters with patients.

Review of a document titled, "[Staff K] Notification Timeline] showed, "Timeline of Events on 12/5/24 RE: [Staff K]: 11:35 [11:35 AM]-15:03 [3:03 PM] Hours worked by [Staff K] on 12/5 [12/05/24] 14:58 [2:58 PM]- HR [Human Resources] called Quality to notify it appeared that [Staff K] license expired 11/30 [11/30/24]..."

During an interview on 12/06/24 at 10:42 AM, Staff L, Human Resources, stated that Staff K, RN, was put on administrative leave when the hospital became aware of the lapse in nursing license.

Based on policy review, record review, and interview, the hospital failed to ensure nursing care was evaluated by a registered nurse (RN) on an ongoing basis, specifically, providing an appropriate assessment, care, and evaluation of patient response to interventions for 5 of 9 (Patient 2, 3, 6, 8, and 9) patient records reviewed. This deficient practice places patients at risk for deterioration of current illness, and adverse outcomes.

Findings Include:

Review of a policy titled, "Wound and Skin Care," dated 07/26/2024 stated that it's electronic charting system "EPIC" utilized a tool named, "Non-Surgical Wound and Skin Nurse Panel". This panel defined the Braden Score (tool used in healthcare to assess a patient's risk for developing pressure injuries) as follows: 19-23 without wounds; 6-18 without a wound; 6-23 with a wound. These scores as written in the policy fail to show the risk level for developing pressure injuries as low risk; moderate risk; high risk; or very high risk. The policy stated that patients are required to be repositioned every 2-3 hours.

Review of an article titled, "Understanding the Braden Scale Assessment" dated 01/18/24 showed, " ...Interpreting Braden Scale scores: A total Braden Scale score ranges from 6 to 23, with lower scores indicating higher susceptibility to pressure ulcers. Healthcare professionals interpret the Braden Scale ranges as follows:18 or higher Low risk; 15-17 Moderate risk; 13-14 High risk; 12 or lower Very high risk ..."

Review of a policy titled, "Fall Risk and Injury Prevention," dated 12/15/23 showed, " ...4. Upon admission patients are assessed by nursing for risk of falls and prevention and reassessed every shift and with any change in condition using: A. The Hester Davis Scale (HDS) in adults over 17 years of age ... 3. Post-fall assessment will be conducted to identify patient injury and immediate care needs. a. Consider calling Rapid Response Team for additional resources to assist patient assessment and/or meeting immediate patient care needs. b. Notify provider, as appropriate to the care setting. c. Reassess fall risk and implement additional safety measures, as appropriate. d. Conduct post-fall huddle/evaluation. Post-fall evaluation shall be completed by the patient care team to include at a minimum the primary care nurse, charge nurse and Nurse Leader. e. Discuss fall in safety huddles for one week after fall or until patient discharges ... B. Prevention 1. Evaluate at a minimum once a shift to determine if expected outcome is being met ... c. Interventions are tailored to the specific identified risk factors. 1. Activate the Fall Injury Risk Care Plan Guide for patients at moderate or high risk for fall and select appropriate interventions: Low Risk=7-10; Moderate Risk=11-14; High Risk=15 ...Nurse's judgement as indicated based on risk factors (physiological functioning and ABCS factors) signs and symptoms of altered mental status impaired judgement e.g. confusion, dementia, forgetfulness, impulsive, overestimates or forgets limitations ..."

Review of a policy titled, "Care of the Deceased Patient," dated 04/25/24 showed, " ...1. Pronouncing Death ... notification that two RNs confirmed the patient is unresponsive with no pulse, respirations, blood pressure, and pupils fixed and dilated ...3. All providers and consultants will be notified of the patient death ...g. The patient's assigned RN is responsible for completion of the Release of Body Authorization and the expiration record. The Chaplain is called to fill out the Release of Body Authorization and obtain needed signatures, particularly in the event of an unexpected death ..." The policy also showed that at the time of death the expiration record is required to state by whom and when the pronouncement of death was made.

Review of document provided by the hospital titled, "Posey Bed 8070 User Manual" dated 2017, showed, " ...Because the bed is a restraint, its use must be prescribed by a licensed doctor. Anyone interacting with the bed must complete the Posey Bed 8070 In-Service Training Program which includes the ability to use this manual ... RISKS Improper use of the Posey Bed 8070 may lead to serious injury or death. Patient monitoring should be determined by hospital protocol, a doctor, and the patient care plan. As with any less restrictive restraint system, it is important to understand when the Posey Bed 8070 is needed, when it should not be used, and the dangers related to entrapment, suffocation, choking, and falls ... REDUCING THE RISK OF ENTRAPMENT To help reduce the risk of entrapment, adhere to the following guidelines: o Keep the mattress flat. - If you need to elevate the head or torso of an at-risk patient, keep the mattress flat and use a cushion to position the patient. - If you must leave the head of the bed up while an at-risk patient is alone, use the Posey Filler Cushions ... Warnings and Precautions ... Canopy gaps present an entrapment risk for certain at-risk patients. Raising the head of the Posey Bed creates "gaps" or "pockets" between the head of the bed and the canopy. These areas pose an extreme risk of serious injury or death from entrapment for certain at-risk patients. Keep the mattress flat with the head of the bed down when an at-risk patient is alone ..."

Patient 2

Review of Patient 2's medical record showed a 53-year-old that admitted to the Emergency Department (ED) on 07/04/24 at 10:02 PM and transferred to the Intensive Care Unit (ICU) on 07/05/24 at 12:29 AM with a diagnosis of respiratory failure with hypoxia (lack of oxygen in the blood.) Past medical history included diabetes melitus Type 2 (chronic high blood sugar). Patient 2 discharged home on 07/18/24 at 10:47 AM. Patient 2 returned to the ED on 07/19/2024 at 11:39 AM and was transferred to inpatient status 07/19/2024 at 4:50 PM with a diagnosis of generalized weakness and inability to care for self at home. Patient 2 discharged to an inpatient rehab facility on 07/23/24 at 1:00 PM. Concerns with medical record included a lack of repositioning and lack of glucose monitoring prior to medication administration.

1. Lack of repositioning:

Review of Patient 2's medical record showed the patient at high risk for skin breakdown as indicated by a "Braden Scale Assessment" dated 07/05/24 at 3:05 AM that showed, " ...Sensory Perceptions Completely limited ... Activity Bedfast ... Braden Scale Score 11[very high risk] ..."

Review of Patient 2's medical record failed to show documented evidence that the patient was turned or repositioned every two hours as recommended for a patient at very high risk for skin break down from 07/04/24 at 10:02 PM through 07/18/24 at 10:47 AM.

Review of Patient 2's, "Braden Scale Assessment" dated 07/20/24 at 1:20 AM showed, " ...Sensory Perceptions Completely limited ... Activity Bedfast ... Braden Scale Score 11 [very high risk] ..."

Review of Patient 2's medical record from 07/19/24 at 4:02 PM through 07/23/24 at 1:00 PM failed to show documented evidence that Patient 2 was turned or repositioned every two hours as recommended for a patient at high risk for skin break down.

2. Medication Administration

Review of Patient 2's medication orders dated 07/06/24 showed orders to have blood glucose levels checked within 30 minutes of breakfast, lunch, dinner, bedtime and 2:00 AM. The patient was to receive 2 units of insulin lispro (a rapid acting medication used to lower blood sugar levels) 5 times daily: with breakfast, lunch, and dinner if blood glucose results were 150-199. The 2:00 AM dose was only to be given for blood glucose levels > 199.

Review of Patient 2's "Medication Administration Record," dated 07/08/24 at 1:54 AM, showed a blood glucose of 33. At 2:28 AM there was a blood glucose of 158. The administration record at 2:40 AM showed 2 units of insulin lispro was administered despite Patient 2's blood sugar being below prescribed parameters. At 8:17 PM the record showed that 2 units of insulin lispro was administered without evidence that a blood glucose level was obtained within 30 minutes of administration as ordered. The facility failed to ensure that nursing staff followed orders for the administration of insulin for Patient 2.

Patient 3

Review of Patient 3's inpatient medical record showed an 89-year-old admitted to the Emergency Department on 11/22/24 at 3:55 PM. Patient 3 was admitted to inpatient status on 11/23/24 at 12:28 AM with a diagnosis of altered mental status. Patient 3 was inpatient at the time of record review. Concerns with this medical record included turning and repositioning.

Review of Patient 3's, "Braden Scale Assessment" dated 11/23/24 at 2:31 AM showed the patient at a high risk for developing pressure ulcers, " ...Sensory Perceptions Slightly limited ... Activity Bedfast ... Braden Scale Score 13 ..."

Review of Patient 3's medical record failed to show documented evidence of repositioning every two hours as recommended for a patient at high risk for skin break down from 11/23/24 at 3:55 PM through 12/04/24 at time of chart review.

Patient 6

Review of Patient 6's medical record showed a 73-year-old admitted on 10/13/24 at 11:58 AM with complaints of weakness, falls, blurred vision, and reported cognitive decline. Concern with this medical record includes the missing post fall assessment.

Review of an ED provider noted dated 10/13/24 at 3:23 PM showed that Patient 6 fell off the toilet while in the ED. A Computed Tomography (CT) [type of medical imaging technique] was ordered to rule out a head injury with no other injuries noted. Provider documented that the Charge Nurse was present and assessed Patient 6 after the fall.

The medical record failed to show documented evidence that a post fall physical assessment was completed on Patient 6 by the Charge Nurse or any nursing staff at time of fall.

Patient 8

Review of Patient 8's medical record showed a 99-year-old male admitted on 11/26/2024 at 4:50 PM with a diagnosis of Acute renal failure secondary to ureteral obstruction secondary to bladder mass, bilateral hydronephrosis. Past medical history includes hypertension (elevated blood pressure) and bladder cancer.

Review of a document titled, "Nursing Assessments" dated 11/26/24 at 8:02 PM showed, "Vital Signs Temp ...94.7 °F ..."

Review of a document titled, "Nursing Assessments" dated 11/27/24 at 12:33 AM showed, "Vital Signs Temp ...96.1 °F ..." (4 hours after low temperature reading)

Review of a document titled, "Nursing Assessments" dated 11/27/24 at 5:00 AM showed, "Vital Signs Temp ...95.5 °F ..."

Review of a document titled, "Nursing Assessments" dated 11/27/24 at 7:45 AM showed, "Vital Signs Temp ...95.1 °F ..."

Review of a document titled, "Nursing Assessments" dated 11/27/24 at 5:30 PM showed, "Vital Signs Temp ...85.7 °F ..."

The medical record failed to show documentation of interventions or provider notification for a low temperature.

Patient 9

Review of Patient 9's medical record showed a 91-year-old admitted to inpatient status on 11/03/24 at 1:21 AM with a diagnosis of acute encephalopathy (condition in which brain function is disturbed due to underlying diseases or toxins in the body) urinary tract infection (UTI).

Review of a document titled "Nursing Assessments (Flowsheets)" dated 11/07/24 at 7:50 PM showed that an order for an enclosure bed [Posey bed] (a restraint device used to protect patients at risk of injury from falling out of bed) was initiated with clinical justification documented as impulsiveness, high fall risk, and recent fall during hospitalization after Patient 9 sustained a fall.

Review of Patient 9's medical record and document review showed that Staff R, RN, falsified nursing assessment times that were provided on 11/11/24 - 11/12/24 as evidenced by "Nursing Assessments (Flowsheet)" and staff "Asset History" records (staff location tracking record) as follows:
1. Staff R, RN documented the completion of non-violent restraint assessments as performed at 10:00 PM. The location tracking record showed Staff R did not enter Patient 9's room until 10:33 PM. Staff R did not enter the assessment into the medical record until 3:29 AM.
2. Staff R, RN documented the completion of non-violent restraint assessments as performed on 11/12/24 at 2:00 AM. The location tracking record showed Staff R did not enter Patient 9's room until 2:10 AM. Staff R did not enter the assessment into the medical record until 3:32 AM.
3. Staff R, RN documented the completion of non-violent restraint assessments as performed on 11/12/24 at 4:00 AM. The location tracking record showed Staff R did not enter Patient 9's room until 4:29 AM. Staff R did not enter the assessment into the medical record until 7:07 AM.

Review of Patient 9's medical record showed that Patient 9 was found deceased in the Posey bed on the morning of 11/12/24 at 4:30 AM as indicated by a document titled, "REPORT OF A HOSPITAL DEATH ASSOCIATED WITH THE USE OF RESTRAINT OR SECLUSION," dated 11/12/2024 at 3:34 PM that showed, " ...Date and Time of Death 11/12/2024 0430 [4:30 AM] ... Date Patient Last Monitored 11/12/2024 Time Patient Last Monitored 04:00 [4:00 AM] ..." The facility's staff location tracking records showed that no staff entered Patient 9's room for monitoring at 4:00 AM. No staff entered Patient 9's room between 2:39 AM and 4:29 AM.

During an interview on 12/06/24 at 10:55 AM Staff A, RN stated that staff had been in Patient 9's room at 4:00 AM and then staff found Patient 9 deceased at 4:30 AM.

Review of the medical record showed staff failed to obtain vital signs every four hours as required as indicated by "Vital Signs" document review. Vitals were not obtained between 11/11/24 at 8:52 PM and 11/12/24 at 4:30 AM when patient was found deceased.

During an interview on 12/09/24 at 3:27 PM Staff Q, Registered Nurse (RN) stated that vital signs should be obtained every four hours unless otherwise ordered.

During an interview on 12/09/24 at 3:51 PM Staff S, RN stated that vitals should be obtained a minimum of every four hours.

During an interview on 12/09/24 at 4:07 PM Staff R, RN stated that vitals should be obtained a minimum of every four hours.