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Based on an unannounced Complaint investigation ACTS Intake PR00000672 survey conducted on October 06, 2022 trought October 07, 2022, review of twenty-five medical records and policies, procedures, and interview with Institutional Program Director (employee #3), it was identified that facility failed to protect and promote each patient's rights. Which makes this Condition of Participation : §482.13 Patient Rights Not Met. (Cross Reference Tags A 130 A 132, A 144, A 145, A 164, A 166 and A 168 ).

Based on an unannounced Complaint investigation ACTS Intake PR00000672 survey conducted on October 06, 2022, through October 07, 2022, review of twenty-five clinical records, policies/procedure and interview with the with Institutional Program Director (employee #3), it was determined that facility failed to promote the right of patients to participate in the development and implementation of his or her plan of care. This deficient practice was identified on 3 out of 25 records reviewed (RR # 5, RR# 16 and R.R #21)

Findings include:

1. During sample selection for review five Covid-19 cases were selected to identify appropriateness of services provided to patients with this diagnosis. The following findings was identified during records reviewed on 10/06/2022 and 10/07/2022 from 9:00 AM to 2:00 PM.

a. RR #21 is a 41-year-old male patient admitted on 09/02/2022 with a diagnosis of Urinary Tract Infection, patient had history of kidney transplant and he is blind.
Patient was receiving treatment on the 6th floor. On 09/07/2022 was transferred to the 9th floor due to a positive Covid-19 test results. This patient used to be accompanied by his mother while receiving treatment on the 6th floor. When was admitted to the 9th floor who is the hospital isolation Covid-19 unit it was not permitted that his mother accompanied him.

No evidence was found documented on the medical record who correspond to the orientation of this patient relative regarding the restriction for onsite visits due to Covid-19 isolation procedures.

Facility issues a memo dated June 16, 2022, for procedures to be followed for onsite hospital visits on cases isolated due to Covid-19

Based on the information issued in this memo that was reviewed 10/06/2022 at 1:18 PM, onsite visits are not permitted on cases admitted or transferred to hospital units designated for Covid-19 isolation or cohort.

This memo stated that there must be circumstances were exceptions could be granted after being considered, those exceptions include reasonable access to patient's caregivers or relatives on case where the patient had any disability or need a person who provide support during hospitalization.

On this case the possibility of this exception was not requested. There is no evidence documented that patient relative was oriented about onsite visit restriction when the patient was transferred to the 9th floor. There is no evidence documented that this patient relative was informed by healthcare personnel in relation with patient health status, plan of care implementation and the outcomes that patient was obtained as result of care and treatment provided.

b. RR #5 is an 83-year-old male patient admitted on 10/03/2022 with a diagnosis of Bronchopneumonia and Covid-19. Patient had a nasogastric tube, was receiving enteral nutrition and was disoriented. Patient was admitted to the 9th floor. There is no evidence documented on the medical record that information that onsite visits are restricted due to Covid-19 isolation was notified to patient relative, or caregiver.

There is no evidence documented that this patient relative was informed by healthcare personnel in relation with patient health status, plan of care implementation and the outcomes that patient was obtained as result of care and treatment provided.

This case is reviewed as an active case, it was reviewed with QAPI officer (employee #5) on 10/07/2022 at 9:10 AM.

c. RR #16 is a 57-year-old male patient admitted on 09/29/2022 with a diagnosis of Acute Kidney Injury and Covid-19. Patient was admitted to the 9th floor. There is no evidence documented on the medical record that information that onsite visits are restricted due to Covid-19 isolation was notified to patient relative, or caregiver.

There is no evidence documented that this patient relative was informed by healthcare personnel in relation with patient health status, plan of care implementation and the outcomes that patient was obtained as result of care and treatment provided. This case is reviewed as an active case, it was reviewed with QAPI officer (employee #5) on 10/07/2022 at 9:35 AM.

d. During interview on 10/06/2022 at 1:18 PM Institutional Program Director (employee #3), stated that facility issue a memo dated June 16, 2022, that was going to be in effect on June 20, 2022, establishing procedures to be followed for onsite hospital visits on cases isolated due to Covid-19.

She explains that based on the information issued in this memo onsite visits are not permitted on cases admitted or transferred to hospital units designated for Covid-19 isolation or cohort.

This memo stated that there must be circumstances were exceptions could be granted after being considered, those exceptions include reasonable access to patient's caregivers or relatives on case were the patient had any disability or need a person who provide support during hospitalization. This memo establishes general procedures to be implemented in cases admitted or transferred to hospital units designated for Covid-19 isolation or cohort.

Institutional Program Director (employee #3), stated on interview on 10/07/2022 at 2:00 PM that general procedures established related with onsite visits are in effect, however due to admission department manager resignation during September 2022 patient's caregivers, relatives and support persons related with patients were not being informed related with onsite visit restrictions during admission process to the facility.

Institutional Program Director (employee #3), did not precise during her explanation on 10/06/2022 at 1:40 PM of onsite visits restrictions due to Covid-19; who is the person or healthcare personnel in charge to explain to patient's caregivers, relatives and support persons related with patients on site visits restriction due to Covid-19 when patients are not admitted with a diagnosis of Covid-19 diagnosis but they were transferred to a Covid-19 unit or cohort area.

e. In an interview with Nursing manager 9th floor (employee #4) and Director of Nursing (employee #1) on 10/07/22 at 11:05 AM it came in the discussion that all patient care interventions carried out in the Covid-19 area require careful infection control precautions in order to prevent an outbreak.

"Care and services provided on Covid-19 areas are based on patient clinical condition, needs and preferences however this area is characterized by continues patient condition change worsening or improvement and daily routine change or is altered based on present patient's outcomes.

There is documentation who evidence cares and services provided to the patients, that there is a possibility that complete documentation with all details and circumstances where services are provided maybe are not included in the nursing progress notes and documentation.

Based on an unannounced Complaint investigation ACTS Intake PR00000672 survey conducted on October 06, 2022 through October 07, 2022, five records reviewed (R.R), Do Not Resuscitate (DNR) Policies and Procedures, it was determined that the facility failed to ensure that patients or their representatives formulate advance directive and comply with these directives related to written DNR orders in accordance to the patient's signed consent for DNR for 4 out of 5 records reviewed (R.R #7, #8, #9, and #11 ).

Findings include:

1. The facility failed to ensure that the physician meets with facility DNR policy and procedure respect to write the DNR order and justification Progress note the same date that patient or patient representative signs the DNR order and comply with these directives related to DNR order requests as reviewed on October 07, 2022, from 9:15 AM till 4:00 PM:

a.R.R #7 is a 74-year-old female who was admitted on 08/30/2022 with a diagnosis of Noninfective Gastroenteritis and Colitis, unspecified, Bacteremia End Stage Renal Failure with Renal Transplant and Diabetes Mellitus (DM). On 10/07/2022 at 08:50 AM the record was reviewed with the Quality Assistant Officer (employee #11) and Quality Officer (employee #5).

It was found that the patient's representative signed a DNR consent on 09/22/2022 at 12:58 PM and on 09/23/2022 at 07:37 AM. Evidence was found of the physician's written DNR order on 09/23/2022 at 7:13 AM and no evidence was found related to the physician progress note that justify the DNR order, the physician writes in an addendum note that family was oriented about DNR and sign.

b. R.R #8 is a 75-year-old female who was admitted on 10/04/2022 with a diagnosis of Septic Shock, Hypertension (HTN), Diabetes Mellitus (DM), Alzheimer. On 10/07/2022 at 11:38 AM the record was reviewed with the Quality Assistant Officer (employee #11) and Quality Officer (employee #5). It was found that the patient's representative signed a DNR consent on 10/03/2022 at 06:17 PM. Evidence was found of the intern physicians of the Emergency Room written DNR order on 10/03/2022 at 08:04 AM, the intern physician progress note documented on 10/03/2022 at 5:28 PM that "family member 2 son oriented about DNR/DNI. they agree do not perform heroic measure at their mom. When time come to provide comfort care. DNR document Sign, Education given to family instruct/Education about Treatment, Condition: Critical." No evidence was found that the patient primary physician counter signs the DNR order.

c. R.R #9 is an 81-year-old female who was admitted on 09/24/2022 with a diagnosis of Septic Shock. On 10/07/2022 at 1:38 PM the record was reviewed with the Quality Officer (employee #5). It was found that the patient's signed a DNR consent on 09/25/2022 at 09:15 AM. Evidence was found of the physician's written DNR order on 09/25/2022 at 09:45 AM, the physician progress note documented on 09/25/2022 at 09:51 AM that "patient sign a DNR." However, no evidence was found that the physician justified the DNR order.

d. R.R #11 is an 88-year-old male who was admitted on 09/27/2022 with a diagnosis of Pneumonia. On 10/07/2022 at 02:30 PM the record was reviewed with the Quality Officer (employee #5). It was found that the patient's representative signed a DNR consent on 09/28/2022 at 01:53 PM. Evidence was found of the physician's written DNR order on 09/29/2022 at 07:05 PM, the physician progress note documented on 09/28/2022 at 04:16 PM that "DNR Sign." However, no evidence was found that the physician justified the DNR order.

2. According to the facility's policies and procedure related to the DNR order reviewed on 10/06/2022 at 2:00 PM it states "That the same date that obtain patient or family signature, the physician writes in the medical record the order and the justification of the DNR. In Case of an emergency the intern physician calls the primary patient physician and take the verbal or telephonic order. All verbal or telephonic order must be countersign by the patient primary physician before 24 hours. The intern physician has to documented in a progress note the justification of the DNR order."

Based on an unannounced Complaint investigation ACTS Intake PR00000672 survey conducted on October 06, 2022, through October 07, 2022, twenty-five records reviewed (R.R), review of Policies and Procedures, with DON employee # 1, it was determined that the facility failed to promote the right of each patient to receive care in a safe setting which can affect XXX out of XX admited patients.

Findings include:

1. On 10/06/2022 at 10:30 AM review of the staff personnel training and education related to Abuse and Neglect, Restraint, Blood Administration, Skin care, Falls Prevention and Pain Management with the DON employee #1, it was found the following:

a. The facility provide evidence that have 776 nursing staff, during the review of Staff development program, it was found that the nursing personnel do not meet with the annual Mandatory nursing activities that include training of Abuse and Neglect, Restraint, Blood Administration, Skin care, Falls Prevention and Pain Management that provides to the nursing staff the skills and mechanism to ensure a safe care to all patient in the hospital. The nursing staff that complies with the Mandatory nursing activities was 187 out of 776 (24 %), a 76% of the nursing staffing not in compliance with all annual Mandatory nursing activities as of October 6, 2022.

Based on an unannounced Complaint investigation ACTS Intake PR00000672 survey conducted on October 06, 2022, through October 07, 2022, review of Annual Mandatory Nursing Activities, review of Policies and Procedures, with Director of Nursing- DON employee # 1, it was determined that the facility failed to ensure patient right to be free from all forms of abuse or harassment related to ensure that all nursing personnel that provide care to patient was qualified and trained with Abuse and Neglected, Restraint, Falls Prevention and Pain Management training which can affect 355 out of 355 admited patients.

Findings include:

1. On 10/06/2022 at 10:30 AM review of the Nursing Staff Personnel training and education related to Abuse and Neglect, Restraint, Falls Prevention and Pain Management with the DON employee #1, it was found the following:

a. The facility provide evidence that have 776 nursing staff, during the review of Staff development program, it was found that the nursing personnel do not meet with the Annual Mandatory Nursing Activities that include training of Abuse and Neglect, Restraint, Falls Prevention and Pain Management that provide to the nursing staff the skill and mechanisms to ensure a safety care, free of Abuse and Neglect to all patient in the hospital.

The nursing staff that complies with the Mandatory Nursing Activities was 187 out of 776 (24 %), and a 589 out of 776 (76%) of the nursing staffing are not in compliance with all Annual Mandatory Nursing Activities as of October 6, 2022.

Based on an unannounced Complaint investigation ACTS Intake PR00000672 survey conducted on October 06, 2022, through October 07, 2022, six Record Review (R.R.), review restraint of Policies and Procedures (P&P), with Quality Assessment Performance Improvement- QAPI Officer employee # 5, it was determined that the facility failed to ensure that restraint used when less restrictive interventions, be ineffective to protect the patient a staff member, or others from harm and failed to ensure physician's orders specify the reason for restraint and physician justify the order for 6 out of 6 records reviewed with restraint. (R.R. #1 through #6)

Findings include:

1. On 10/07/2022 at 2:45 PM till 4:00 PM review of the six active records reviewed related to patient restraint with Quality officer employee #5, it was found the following:

a. R.R #1 is a 69-year-old male who was admitted on 10/04/2022 with a diagnosis of Pleural Effusion. On 10/07/2022 at 04:18 PM the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 10/04/2022 at 11:52 AM that patient arrive from emergency room with endotracheal tube, restraint, intubate, non-cooperative, sedated during the admission.

No evidence was found related to the initial restraint date on 10/04/2022 at 11:52 AM.

Evidence was found of a verbal physician order for restraint patients with soft limb right and left wrist on 10/04/2022 at 1:26 PM, 1 hour and 32 minutes after initiated the restraint.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/5/2022 at 12:00 PM on 10/05/2022 at 2:17 PM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/06/2022 at 12:00 PM on 10/06/2022 at 3:32 PM.

No evidence was found of the less restrictive measure taken previously to restraint.

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restrain on the patient.

The facility failed to ensure that the physician responsible for the care of the patient place a restraint order prior to the application of the restraint.

b. R.R #2 is a 70-year-old female who was admitted on 09/28/2022 with a diagnosis of Diverticulitis of large intestine without perforation or abscess without bleeding. On 10/07/2022 at 03:18 PM the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 09/28/2022 at 4:05 PM that patient arrives from operation room post operate of Laparoscopy with endotracheal tube, unable to follow commands, calm with Nasogastric Tube, Foley Catheter #16, Colostomy, a Penrose in the right inferior quadrant, and was restraint during the admission.

No evidence was found related to the initial restrain date on 09/28/2022.

Evidence was found of a Telephonic physician order for restraint patients with soft limb right and left wrist on 09/29/2022 at 11:30 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal of physician order for restraint patients with soft limb right and left wrist started 09/30/2022 at 11:30 AM on 09/30/2022 at 01:19 PM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/01/2022 at 12:00 PM on 10/01/2022 at 12:18 PM, no evidence that the physician countersign the order.

Telephonic physician order for renewal of the physician order for restraint patients with soft limb right and left wrist started 10/02/2022 at 12:00 PM on 10/02/2022 at 12:07 PM, no evidence that the physician countersign the order.

Telephonic physician order for renewal of the physician order for restraint patients with soft limb right and left wrist started 10/03/2022 at 10:00 AM on 10/03/2022 at 9:47 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal of the physician order for restraint patients with soft limb right and left wrist started 10/04/2022 at 10:00 AM on 10/04/2022 at 11:13 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal of the physician order for restraint patients with soft limb right and left wrist started 10/05/2022 at 10:00 AM on 10/05/2022 at 10:01 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal of the physician order for restraint patients with soft limb right and left wrist started 10/06/2022 on at 10:00 AM on 10/06/2022 at 1:04 PM, no evidence that the physician countersign the order.

Telephonic physician order for renewal of the physician order for restraint patients with soft limb right and left wrist started 10/7/2022 at 10:00 AM on 10/07/2022 at 10:36 AM, no evidence that the physician countersign the order.

No evidence was found of the less restrictive measure taken previously to restraint

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restrain on the patient.

The facility failed to ensure that the physician responsible for the care of the patient place a restraint order prior to the application of the restraint

c. R.R #3 is a 65-year-old male who was admitted on 09/28/2022 with a diagnosis of Respiratory Failure. On 10/07/2022 at 02:51PM the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 09/29/2022 at 2:18 AM, that patient was comatose, non-expressive, right-side weakness and move the left arm, that patient not verbalized information per condition and arrive with restraint, no relative available during the admission.

Evidence was found of a Telephonic physician order for the initial physician order for restraint patients with soft limb right and left wrist on 09/29/2022 at 4:00 AM, the physician countersign the order on 09/29/2022 at 10:03 AM.

Telephonic physician order for renewal physicians' order for restraint patients with soft limb right and left wrist started 09/30/2022 at 4:00 AM on 09/30/2022 at 5:48 AM, the physician countersign the order on 09/30/2022 at 9:33 AM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/01/2022 at 4:00 AM on 10/01/2022 at 4:21 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/02/2022 at 4:00 AM on 10/02/2022 at 5:04 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/03/2022 at 4:00 AM on 10/03/2022 at 4:45 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/05/2022 at 4:00 AM on 10/05/2022 at 4:22 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/06/2022 on at 4:00 AM on 10/06/2022 at 7:04 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/7/2022 at 4:00 AM on 10/06/2022 at 23:41 PM, no evidence that the physician countersign the order.

No evidence was found of the less restrictive measure taken previously to restraint

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restrain in the patient.

The facility failed to ensure that the physician responsible for the care of the patient place a restraint order prior to the application of the restraint.

d. R.R #4 is a 75-year-old male who was admitted on 09/24/2022 with a diagnosis of Hepatic Failure. On 10/07/2022 at 04:35 PM the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 09/24/2022 at 4:00 PM that patient was restraint, at 6:13 PM patient was restraint, with Nasogastric Tube, at 7:00 PM nurse documented that patient was disoriented, confuse, and restraint, at 9:30 PM patient was transferred from emergency room to ward on the 9th floor and arrive restraint, order finish at 11:55 PM.

No evidence was found related to the initial restraint order from 09/24/2022 at 4:00 PM that initiate the restraint.

No evidence was found related to initiate restraint order from 09/26/2022, that the nurse documented that patient was with restraint at 12:00 AM, at 2:00 AM, at 4:00 AM, at 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM.

No evidence was found related to initiate restraint order from 09/29/2022, that the nurse documented that patient was with restraint at 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, and 4:00 AM.

Evidence was found of a verbal physician order for initiate physician order for restraint patients with soft limb right and left wrist on 09/29/2022 at 3:14 PM, started on 09/29/2022 at 02:00 PM, 7 hour after initiate the restraint.

Telephonic physician order for initiate physician order for restraint patients with soft limb right and left wrist on 09/29/2022 at 4:48 PM, started 09/29/2022 at 08:00 AM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 09/30/2022 at 03:52 PM started on 09/30/22 at 2:00 PM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/01/2022 at 04:01 PM started on 10/01/22 at 2:00 PM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/02/2022 at 02:45 PM started on 10/02/22 at 2:00 PM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/03/2022 at 02:45 PM started on 10/03/22 at 2:00 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/04/2022 at 06:41 AM started on 10/04/22 at 2:00 AM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/05/2022 at 04:40 AM started on 10/05/2022 at 2:00 AM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/06/2022 at 02:56 AM started on 10/06/2022 at 2:00 AM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/07/2022 at 03:02 AM started on 10/07/2022 at 2:00 AM.

No evidence was found of the less restrictive measure taken previously to restraint.

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restrain in the patient.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 09/29/2022 at 4:00 PM, 6:00 PM, 8:00 PM and 10:00 PM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 09/30/2022 at 4:00 PM and 6:00 PM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/03/2022 at 12:00 AM, at 2:00 AM, at 4:00 AM and at 6:00 AM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/04/2022 at 6:00 AM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/05/2022 at 10:00 AM, at 12:00 PM, at 2:00 PM, at 4:00 PM, at 6:00 PM, at 8:00 PM, and 10:00 PM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/06/2022 at 12:00 AM, at 2:00 AM, at 4:00 AM, at 6:00 AM, at 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 4:00 PM, at 6:00 PM, at 8:00 PM and at 10:00 PM.

The facility failed to ensure that the physician responsible for the care of the patient place a restraint order prior to the application of the restraint.

e. R.R #5 is an 83-year-old male who was admitted on 10/03/2022 with a diagnosis of Bronchopneumonia. On 10/07/2022 at 05:05 PM the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 10/04/2022 at 1:30 AM that patient arrive restraint, at 12:00 PM the nurse documented that patient was uncooperative, disoriented, and was restraint.

No evidence was found related to the initial restraint order from 10/03/2022 at 01:30 AM that arrive restraint to the ward.

Evidence was found of a telephonic physician order for initiate physician order for restraint patients with soft limb right and left wrist on 10/04/2022 at 12:14 PM, started on 10/04/2022 at 12:00 PM, 10 hours after initiate the restraint, no evidence that the physician countersign the order.

No evidence was found of the physician restraint order for 10/05/2022, However, evidence was found that the patient continue restraint on 10/05/2022 at 12:00 PM, at 2:00 PM, at 4:00 PM at 6:00 PM, at 8:00 pm, at 10:00 PM, on 10/6/2022 at 12:00 AM, at 2:00 AM, at 4:00 AM, at 6:00 AM, at 8:00 AM, at 10:00 AM and at 12:00 PM without a restraint order.

Telephonic physician order for initiate physician order for restraint patients with soft limb right and left wrist on 10/06/2022 at 3:57 PM, started 10/06/2022 at 12:00 PM, no evidence that the physician countersign the order.

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restraint in the patient.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/05/2022 at 8:00 AM and at 10:00 AM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/07/2022 at 4:00 AM and at 6:00AM.

The facility failed to ensure that the physician responsible for the care of the patient place a restraint order prior to the application of the restraint.

f. R.R #6 is a 77-year-old male who was admitted on 09/13/2022 with a diagnosis of Acute Ischemic Heart Disease. On 10/07/2022 at 02:00 PM the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 09/15/2022 at 7:00 PM that patient was uncooperative, anxious, agitated, combative, disoriented, and Unable to follow direction, that stated with restraint upper and lower limb restraint on 09/15/2022 at 7:00 PM.

Evidence was found of a telephonic physician order for initiate physician order for restraint patients with soft limb right and left wrist and right and left ankle on 09/15/2022 at 10:36 PM, started 09/15/2022 at 7:00 PM, the physician countersign the order on 09/18/2022 at 11:41 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/16/2022 at 7:46 PM, started 09/16/2022 at 7:00 PM, the physician countersign the order on 09/18/2022 at 11:41 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/17/2022 at 8:18 PM, started 09/17/2022 at 7:00 PM, the physician countersign the order on 09/18/2022 at 11:41 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/18/2022 at 8:52 PM, started 09/18/2022 at 7:00 PM, the physician countersign the order on 09/21/2022 at 12:47 PM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/19/2022 at 6:27 PM, started 09/19/2022 at 6:00 PM, the physician countersign the order on 09/23/2022 at 06:22 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/20/2022 at 7:01 PM, started 09/20/2022 at 6:00 PM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist on 09/22/2022 at 6:18 AM, started 09/22/2022 at 3:30 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/23/2022 at 3:30 AM, started 09/23/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/24/2022 at 2:32 AM, started 09/24/2022 at 2:00 AM, the physician countersign the order on 09/27/2022 at 16:43 PM.

No evidence was found that the physician places a restraint order for the date of 09/25/2022.

No evidence was found that the physician places a restraint order for the date of 09/26/2022.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/27/2022 at 2:09 AM, started 09/27/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/28/2022 at 5:44 AM, started 09/28/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist on 09/29/2022 at 5:32 AM, started 09/29/2022 at 2:00 AM, the physician countersign the order on 09/30/2022 at 9:14 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/30/2022 at 2:04 AM, started 09/30/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/01/2022 at 2:41 AM, started 10/01/2022 at 2:00 AM, the physician countersign the order on 10/01/2022 at 12:37 PM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/02/2022 at 2:58 AM, started 10/02/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/03/2022 at 6:41 AM, started 10/03/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/04/2022 at 3:00 AM, started 10/04/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist on 10/05/2022 at 4:37 AM, started 10/05/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/06/2022 at 3:02 AM, started 10/06/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/07/2022 at 3:19 AM, no specific when started the restraint.

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restraint in the patient.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 09/17/2022 at 8:00 PM and at 10:00 PM.

On 09/21/2022 at 4:00 PM the nurse documented that restraint was removed due to patient alert, and don't try to interrupt the treatment. No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/07/2022 at 4:00 AM and at 6:00 AM.

On 09/22/2022 at 3:30 AM the nurse documented that patient fall, disoriented, confuse, and started restriction.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 09/23/2022 at 10:00 AM and at 2:00 PM.

Evidence was found that the nursing personnel restraint patient without a restraint order on 09/25/2022 from 8:00 AM through 09/26/2022 at 12:00 AM.

Evidence was found that the nursing personnel restraint patient without a restraint order on 09/26/2022 from 8:00 AM through 09/27/2022 at 12:00 AM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/03/2022 at 8:00 AM, 6:00 PM, 8:00 PM and at 10:00 PM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/05/2022 from 12:00 PM through 10:00 PM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/06/2022 at 2:00 AM.

The facility failed to ensure that the physician responsible for the care of the patient place a restraint order prior to the application of the restraint.

Based on an unannounced Complaint investigation ACTS Intake PR00000672 survey conducted on October 06, 2022, through October 07, 2022, six records reviewed (R.R.), Policies and Procedures (P&P) for restraint with Quality Assessment Performance Improvement- QAPI Officer employee # 5, it was determined that the facility failed to ensure that restraint be used when less restrictive interventions be ineffective to protect the patient and staff member, or others from harm and failed to ensure physician's orders specify the reason for restraint and physician justify the order, according to the plan of care for 6 out of 6 records reviewed for restraint (R.R. #1 through #6).

Findings include:

1. On 10/07/2022 at 2:45 PM till 4:00 PM review of the six active record review related to patient restraint with Quality officer employee #5, it was found the following:

a. R.R #1 is a 69-year-old male who was admitted on 10/04/2022 with a diagnosis of Pleural Effusion. On 10/07/2022 at 04:18 PM the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 10/04/2022 at 11:52 AM that patient arrive from emergency room with endotracheal tube, arrive restraint, intubate, non-cooperative, sedated during the admission.

No evidence was found related to the initial restraint date on 10/04/2022 at 11:52 AM.

Evidence was found of a verbal physician order for initiate physician order for restraint patients with soft limb right and left wrist on 10/04/2022 at 1:26 PM, a 1 hour and 32 minutes after initiate the restraint.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/5/2022 at 12:00 PM on 10/05/2022 at 2:17 PM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/06/2022 at 12:00 PM on 10/06/2022 at 3:32 PM.

No evidence was found of the less restrictive measure taken previously to restraint

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restrain in the patient.

The facility failed to ensure that the physician responsible for the care of the patient place an restraint order prior to the application of the restraint.

b. R.R #2 is a 70-year-old female who was admitted on 09/28/2022 with a diagnosis of Diverticulitis of large intestine without perforation or abscess without bleeding. On 10/07/2022 at 03:18 PM the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 09/28/2022 at 4:05 PM that patient was arrive from operation room post operate of Laparoscopy with endotracheal tube, unable to follow commands, calm with Nasogastric Tube, Foley Catheter #16, Colostomy, a Penrose in the right inferior quadrant, and was restraint during the admission.

No evidence was found related to the initial restrain date on 09/28/2022.

Evidence was found of a Telephonic physician order for initiate physician order for restraint patients with soft limb right and left wrist on 09/29/2022 at 11:30 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 09/30/2022 at 11:30 AM on 09/30/2022 at 01:19 PM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/01/2022 at 12:00 PM on 10/01/2022 at 12:18 PM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/02/2022 at 12:00 PM on 10/02/2022 at 12:07 PM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/03/2022 at 10:00 AM on 10/03/2022 at 9:47 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/04/2022 at 10:00 AM on 10/04/2022 at 11:13 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/05/2022 at 10:00 AM on 10/05/2022 at 10:01 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/06/2022 on at 10:00 AM on 10/06/2022 at 1:04 PM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/7/2022 at 10:00 AM on 10/07/2022 at 10:36 AM, no evidence that the physician countersign the order.

No evidence was found of the less restrictive measure taken previously to restraint

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restrain in the patient.

The facility failed to ensure that the physician responsible for the care of the patient place an restraint order prior to the application of the restraint

c. R.R #3 is a 65-year-old male who was admitted on 09/28/2022 with a diagnosis of Respiratory Failure. On 10/07/2022 at 02:51 PM the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 09/29/2022 at 2:18 AM, that patient was comatose, non-expressive, right-side weakness and move the left arm, that patient not verbalized information per condition and arrive with restraint, no relative available during the admission.

Evidence was found of a Telephonic physician order for initiate physician order for restraint patients with soft limb right and left wrist on 09/29/2022 at 4:00 AM, the physician countersign the order on 09/29/2022 at 10:03 AM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 09/30/2022 at 4:00 AM on 09/30/2022 at 5:48 AM, the physician countersign the order on 09/30/2022 at 9:33 AM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/01/2022 at 4:00 AM on 10/01/2022 at 4:21 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/02/2022 at 4:00 AM on 10/02/2022 at 5:04 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/03/2022 at 4:00 AM on 10/03/2022 at 4:45 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/05/2022 at 4:00 AM on 10/05/2022 at 4:22 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/06/2022 on at 4:00 AM on 10/06/2022 at 7:04 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/7/2022 at 4:00 AM on 10/06/2022 at 23:41 PM, no evidence that the physician countersign the order.

No evidence was found of the less restrictive measure taken previously to restraint

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restrain in the patient.

The facility failed to ensure that the physician responsible for the care of the patient place a restraint order prior to the application of the restraint.

d. R.R #4 is a 75-year-old male who was admitted on 09/24/2022 with a diagnosis of Hepatic Failure. On 10/07/2022 at 04:35 PM the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 09/24/2022 at 4:00 PM that patient was restraint, at 6:13 PM patient was restraint, with Nasogastric Tube, at 7:00 PM nurse documented that patient was disoriented, confuse, and restraint, at 9:30 PM patient was transferred from emergency room to ward on the 9th floor and arrive restraint, order finish at 11:55 PM.

No evidence was found related to the initial restraint order from 09/24/2022 at 4:00 PM that initiate the restraint.

No evidence was found related to initiate restraint order from 09/26/2022, that the nurse documented that patient was with restraint at 12:00 AM, at 2:00 AM, at 4:00 AM, at 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM.

No evidence was found related to initiate restraint order from 09/29/2022, that the nurse documented that patient was with restraint at 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, 4:00 AM.

Evidence was found of a verbal physician order for initiate physician order for restraint patients with soft limb right and left wrist on 09/29/2022 at 3:14 PM, started on 09/29/2022 at 02:00 PM, a 7 hour after initiate the restraint.

Telephonic physician order for initiate physician order for restraint patients with soft limb right and left wrist on 09/29/2022 at 4:48 PM, started 09/29/2022 at 08:00 AM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 09/30/2022 at 03:52 PM started on 09/30/22 at 2:00 PM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/01/2022 at 04:01 PM started on 10/01/22 at 2:00 PM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/02/2022 at 02:45 PM started on 10/02/22 at 2:00 PM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/03/2022 at 02:45 PM started on 10/03/22 at 2:00 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/04/2022 at 06:41 AM started on 10/04/22 at 2:00 AM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/05/2022 at 04:40 AM started on 10/05/2022 at 2:00 PM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/06/2022 at 02:56 AM started on 10/06/2022 at 2:00 AM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/07/2022 at 03:02 AM started on 10/07/2022 at 2:00 AM.

No evidence was found of the less restrictive measure taken previously to restraint.

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restrain in the patient.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 09/29/2022 at 4:00 PM, 6:00 PM, 8:00 PM and 10:00 PM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 09/30/2022 at 4:00 PM and 6:00 PM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/03/2022 at 12:00 AM, at 2:00 AM, at 4:00 AM and at 6:00 AM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/04/2022 at 6:00 AM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/05/2022 at 10:00 AM, at 12:00 PM, at 2:00 PM, at 4:00 PM, at 6:00 PM, at 8:00 PM, and 10:00 PM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/06/2022 at 12:00 AM, at 2:00 AM, at 4:00 AM, at 6:00 AM, at 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 4:00 PM, at 6:00 PM, at 8:00 PM and at 10:00 PM.

The facility failed to ensure that the physician responsible for the care of the patient place a restraint order prior to the application of the restraint

e. R.R #5 is an 83-year-old male who was admitted on 10/03/2022 with a diagnosis of Bronchopneumonia. On 10/07/2022 at 05:05 PM the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 10/04/2022 at 1:30 AM that patient arrive restraint, at 12:00 PM the nurse documented that patient was uncooperative, disoriented, and was restraint.

No evidence was found related to the initial restraint order from 10/03/2022 at 01:30 AM that arrive restraint to the ward.

Evidence was found of a telephonic physician order for initiate physician order for restraint patients with soft limb right and left wrist on 10/04/2022 at 12:14 PM, started on 10/04/2022 at 12:00 PM a 10 hour after initiate the restraint, no evidence that the physician countersign the order.

No evidence was found of the physician restraint order for 10/05/2022, However, evidence was found that the patient continue restraint on 10/05/2022 at 12:00 PM, at 2:00 PM, at 4:00 PM at 6:00 PM, at 8:00 PM, at 10:00 PM on 10/6/2022 at 12:00 AM, at 2:00 AM, at 4:00 AM, at 6:00 AM, at 8:00 AM, at 10:00 AM and at 12:00 PM without a restraint order.

Telephonic physician order for initiate physician order for restraint patients with soft limb right and left wrist on 10/06/2022 at 3:57 PM, started 10/06/2022 at 12:00 PM, no evidence that the physician countersign the order.

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restraint in the patient.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/05/2022 at 8:00 AM and at 10:00 AM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/07/2022 at 4:00 AM and at 6:00 AM.

No evidence was fund that the nursing personnel activate restraint plan of care.

The facility failed to ensure that the physician responsible for the care of the patient place a restraint order prior to the application of the restraint.

f. R.R #6 is a 77-year-old male who was admitted on 09/13/2022 with a diagnosis of Acute Ischemic Heart Disease. On 10/07/2022 at 02:00 PM the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 09/15/2022 at 7:00 PM that patient was uncooperative, anxious, agitated, combative, disoriented, and Unable to follow direction, that stated t with restraint upper and lower limb restraint on 09/15/2022 at 7:00 PM.

Evidence was found of a telephonic physician order for initiate physician order for restraint patients with soft limb right and left wrist and right and left ankle on 09/15/2022 at 10:36 PM, started 09/15/2022 at 7:00 PM, the physician countersign the order on 09/18/2022 at 11:41 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/16/2022 at 7:46 PM, started 09/16/2022 at 7:00 PM, the physician countersign the order on 09/18/2022 at 11:41 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/17/2022 at 8:18 PM, started 09/17/2022 at 7:00 PM, the physician countersign the order on 09/18/2022 at 11:41 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/18/2022 at 8:52 PM, started 09/18/2022 at 7:00 PM, the physician countersign the order on 09/21/2022 at 12:47 PM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/19/2022 at 6:27 PM, started 09/19/2022 at 6:00 PM, the physician countersign the order on 09/23/2022 at 06:22 PM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/20/2022 at 7:01 PM, started 09/20/2022 at 6:00 PM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist on 09/22/2022 at 6:18 AM, started 09/22/2022 at 3:30 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/23/2022 at 3:30 AM, started 09/23/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/24/2022 at 2:32 AM, started 09/24/2022 at 2:00 AM, the physician countersign the order on 09/27/2022 at 16:43 PM.

No evidence was found that the physician places a restraint order for the date of 09/25/2022.

No evidence was found that the physician places a restraint order for the date of 09/26/2022.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/27/2022 at 2:09 AM, started 09/27/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/28/2022 at 5:44 AM, started 09/28/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist on 09/29/2022 at 5:32 AM, started 09/29/2022 at 2:00 AM, the physician countersign the order on 09/30/2022 at 9:14 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/30/2022 at 2:04 AM, started 09/30/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/01/2022 at 2:41 AM, started 10/01/2022 at 2:00 AM, the physician countersign the order on 10/01/2022 at 12:37 PM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/02/2022 at 2:58 AM, started 10/02/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/03/2022 at 6:41 AM, started 10/03/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/04/2022 at 3:00 AM, started 10/04/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist on 10/05/2022 at 4:37 AM, started 10/05/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/06/2022 at 3:02 AM, started 10/06/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/07/2022 at 3:19 AM, no specific when started the restraint.

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restraint in the patient.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 09/17/2022 at 8:00 PM and at 10:00 PM.

On 09/21/2022 at 4:00 PM the nurse documented that restraint was removed due to patient alert, and don't try to interrupt the treatment. No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/07/2022 at 4:00 AM and at 6:00 AM.

On 09/22/2022 at 3:30 AM the nurse documented that patient fall, disoriented, confuse, and started restriction.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 09/23/2022 at 10:00 AM and at 2:00 PM.

Evidence was found that the nursing personnel restraint patient without a restraint order on 09/25/2022 from 8:00 AM through 09/26/2022 at 12:00 AM.

Evidence was found that the nursing personnel restraint patient without a restraint order on 09/26/2022 from 8:00 AM through 09/27/2022 at 12:00 AM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/03/2022 at 8:00 AM, 6:00 PM, 8:00 PM and at 10:00 PM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/05/2022 from 12:00 PM through 10:00 PM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/06/2022 at 2:00 AM.

The facility failed to ensure that the physician responsible for the care of the patient place a restraint order prior to the application of the restraint.

Based on an unannounced Complaint investigation ACTS Intake PR00000672 survey conducted on October 06, 2022, through October 07, 2022, six records reviewed (R.R.), review of restraint Policies and Procedures (P&P), with Quality Assessment Performance Improvement Program- QAPI Officer employee # 5, it was determined that the facility failed to ensure that restraint is in accordance with a physician order responsible for the care of the patient and authorized to order restraint by hospital policy in accordance with State law for 6 out of 6 records reviewed for restraint (R.R. #1 through #6)

Findings include:

1. On 10/07/2022 at 2:45 PM till 4:00 PM review of the six active record review related to patient restraint with Quality officer employee #5, it was found the following:

a. R.R #1 is a 69-year-old male who was admitted on 10/04/2022 with a diagnosis of Pleural Effusion. On 10/07/2022 at 04:18 PM the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 10/04/2022 at 11:52 AM that patient arrives from emergency room with endotracheal tube, arrive restraint, intubate, non-cooperative, sedated during the admission.

No evidence was found related to the initial restraint date on 10/04/2022 at 11:52 AM.

Evidence was found of a verbal physician order for initiate physician order for restraint patients with soft limb right and left wrist on 10/04/2022 at 1:26 PM, a 1 hour and 32 minutes after initiate the restraint.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/5/2022 at 12:00 PM on 10/05/2022 at 2:17 PM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/06/2022 at 12:00 PM on 10/06/2022 at 3:32 PM.

No evidence was found of the less restrictive measure taken previously to restraint

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restrain in the patient.

The facility failed to ensure that the physician responsible for the care of the patient place a restraint order prior to the application of the restraint.

b. R.R #2 is a 70-year-old female who was admitted on 09/28/2022 with a diagnosis of Diverticulitis of large intestine without perforation or abscess without bleeding. On 10/07/2022 at 03:18 PM the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 09/28/2022 at 4:05 PM that patient was arrive from operation room post operate of Laparoscopy with endotracheal tube, unable to follow commands, calm with Nasogastric Tube, Foley Catheter #16, Colostomy, a Penrose in the right inferior quadrant, and was restraint during the admission.

No evidence was found related to the initial restrain date on 09/28/2022.

Evidence was found of a Telephonic physician order for initiate physician order for restraint patients with soft limb right and left wrist on 09/29/2022 at 11:30 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 09/30/2022 at 11:30 AM on 09/30/2022 at 01:19 PM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/01/2022 at 12:00 PM on 10/01/2022 at 12:18 PM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/02/2022 at 12:00 PM on 10/02/2022 at 12:07 PM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/03/2022 at 10:00 AM on 10/03/2022 at 9:47 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/04/2022 at 10:00 AM on 10/04/2022 at 11:13 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/05/2022 at 10:00 AM on 10/05/2022 at 10:01 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/06/2022 on at 10:00 AM on 10/06/2022 at 1:04 PM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/7/2022 at 10:00 AM on 10/07/2022 at 10:36 AM, no evidence that the physician countersign the order.

No evidence was found of the less restrictive measure taken previously to restraint

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restrain in the patient.

The facility failed to ensure that the physician responsible for the care of the patient place a restraint order prior to the application of the restraint

c. R.R #3 is a 65-year-old male who was admitted on 09/28/2022 with a diagnosis of Respiratory Failure. On 10/07/2022 at 02:51 PM the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 09/29/2022 at 2:18 AM, that patient was comatose, non-expressive, right-side weakness and move the left arm, that patient not verbalized information per condition and arrive with restraint, no relative available during the admission.

Evidence was found of a Telephonic physician order for initiate physician order for restraint patients with soft limb right and left wrist on 09/29/2022 at 4:00 AM, the physician countersign the order on 09/29/2022 at 10:03 AM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 09/30/2022 at 4:00 AM on 09/30/2022 at 5:48 AM, the physician countersign the order on 09/30/2022 at 9:33 AM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/01/2022 at 4:00 AM on 10/01/2022 at 4:21 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/02/2022 at 4:00 AM on 10/02/2022 at 5:04 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/03/2022 at 4:00 AM on 10/03/2022 at 4:45 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/05/2022 at 4:00 AM on 10/05/2022 at 4:22 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/06/2022 on at 4:00 AM on 10/06/2022 at 7:04 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist started 10/7/2022 at 4:00 AM on 10/06/2022 at 23:41 PM, no evidence that the physician countersign the order.

No evidence was found of the less restrictive measure taken previously to restraint

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restrain in the patient.

The facility failed to ensure that the physician responsible for the care of the patient place a restraint order prior to the application of the restraint.

d. R.R #4 is a 75-year-old male who was admitted on 09/24/2022 with a diagnosis of Hepatic Failure. On 10/07/2022 at 04:35 PM the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 09/24/2022 at 4:00 PM that patient was restraint, at 6:13 PM patient was restraint, with Nasogastric Tube, at 7:00 PM nurse documented that patient was disoriented, confuse, and restraint, at 9:30 PM patient was transferred from emergency room to ward on the 9th floor and arrive restraint, order finish at 11:55 PM.

No evidence was found related to the initial restraint order from 09/24/2022 at 4:00 PM that initiate the restraint.

No evidence was found related to initiate restraint order from 09/26/2022, that the nurse documented that patient was with restraint at 12:00 AM, at 2:00 AM, at 4:00 AM, at 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM.

No evidence was found related to initiate restraint order from 09/29/2022, that the nurse documented that patient was with restraint at 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, 4:00 AM.

Evidence was found of a verbal physician order for initiate physician order for restraint patients with soft limb right and left wrist on 09/29/2022 at 3:14 PM, started on 09/29/2022 at 02:00 PM, a 7 hour after initiate the restraint.

Telephonic physician order for initiate physician order for restraint patients with soft limb right and left wrist on 09/29/2022 at 4:48 PM, started 09/29/2022 at 08:00 AM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 09/30/2022 at 03:52 PM started on 09/30/22 at 2:00 PM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/01/2022 at 04:01 PM started on 10/01/22 at 2:00 PM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/02/2022 at 02:45 PM started on 10/02/22 at 2:00 PM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/03/2022 at 02:45 PM started on 10/03/22 at 2:00 AM, no evidence that the physician countersign the order.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/04/2022 at 06:41 AM started on 10/04/22 at 2:00 AM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/05/2022 at 04:40 AM started on 10/05/2022 at 2:00 AM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/06/2022 at 02:56 AM started on 10/06/2022 at 2:00 AM.

Telephonic physician order for renewal physician order for restraint patients with soft limb right and left wrist on 10/07/2022 at 03:02 AM started on 10/07/2022 at 2:00 AM.

No evidence was found of the less restrictive measure taken previously to restraint.

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restrain in the patient.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 09/29/2022 at 4:00 PM, 6:00 PM, 8:00 PM and 10:00 PM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 09/30/2022 at 4:00 PM and 6:00 PM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/03/2022 at 12:00 AM, at 2:00 AM, at 4:00 AM and at 6:00 AM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/04/2022 at 6:00 AM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/05/2022 at 10:00 AM, at 12:00 PM, at 2:00 PM, at 4:00 PM, at 6:00 PM, at 8:00 PM, and 10:00 PM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/06/2022 at 12:00 AM, at 2:00 AM, at 4:00 AM, at 6:00 AM, at 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 4:00 PM, at 6:00 PM, at 8:00 PM and at 10:00 PM.

The facility failed to ensure that the physician responsible for the care of the patient place an restraint order prior to the application of the restraint

e. R.R #5 is an 83-year-old male who was admitted on 10/03/2022 with a diagnosis of Bronchopneumonia. On 10/07/2022 at 05:05 PM the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 10/04/2022 at 1:30 AM that patient arrive restraint, at 12:00 PM the nurse documented that patient was uncooperative, disoriented, and was restraint.

No evidence was found related to the initial restraint order from 10/03/2022 at 01:30 AM that arrive restraint to the ward.

Evidence was found of a telephonic physician order for initiate physician order for restraint patients with soft limb right and left wrist on 10/04/2022 at 12:14 PM, started on 10/04/2022 at 12:00 PM a 10 hour after initiate the restraint, no evidence that the physician countersign the order.

No evidence was found of the physician restraint order for 10/05/2022, However, evidence was found that the patient continue restraint on 10/05/2022 at 12:00 PM, at 2:00 PM, at 4:00 PM at 6:00 PM, at 8:00 PM, at 10:00 PM on 10/6/2022 at 12:00 AM, at 2:00 AM, at 4:00 AM, at 6:00 AM, at 8:00 AM, at 10:00 AM and at 12:00 PM without a restraint order.

Telephonic physician order for initiate physician order for restraint patients with soft limb right and left wrist on 10/06/2022 at 3:57 PM, started 10/06/2022 at 12:00 PM, no evidence that the physician countersign the order.

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restraint in the patient.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/05/2022 at 8:00 AM and at 10:00 AM.
No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/07/2022 at 4:00 AM and at 6:00 AM.

The facility failed to ensure that the physician responsible for the care of the patient place an restraint order prior to the application of the restraint.

f. R.R #6 is a 77-year-old male who was admitted on 09/13/2022 with a diagnosis of Acute Ischemic Heart Disease. On 10/07/2022 at 02:00 pm the record was reviewed with the Quality Officer (employee #5). It was found that the nurse documented on 09/15/2022 at 7:00 PM that patient was uncooperative, anxious, agitated, combative, disoriented, and Unable to follow direction, that stated t with restraint upper and lower limb restraint on 09/15/2022 at 7:00 PM.

Evidence was found of a telephonic physician order for initiate physician order for restraint patients with soft limb right and left wrist and right and left ankle on 09/15/2022 at 10:36 PM, started 09/15/2022 at 7:00 PM, the physician countersign the order on 09/18/2022 at 11:41 PM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/16/2022 at 7:46 PM, started 09/16/2022 at 7:00 PM, the physician countersign the order on 09/18/2022 at 11:41 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/17/2022 at 8:18 PM, started 09/17/2022 at 7:00 PM, the physician countersign the order on 09/18/2022 at 11:41 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/18/2022 at 8:52 PM, started 09/18/2022 at 7:00 PM, the physician countersign the order on 09/21/2022 at 12:47 PM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/19/2022 at 6:27 PM, started 09/19/2022 at 6:00 PM, the physician countersign the order on 09/23/2022 at 06:22 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/20/2022 at 7:01 PM, started 09/20/2022 at 6:00 PM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist on 09/22/2022 at 6:18 AM, started 09/22/2022 at 3:30 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/23/2022 at 3:30 AM, started 09/23/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/24/2022 at 2:32 AM, started 09/24/2022 at 2:00 AM, the physician countersign the order on 09/27/2022 at 16:43 PM.

No evidence was found that the physician places a restraint order for the date of 09/25/2022.

No evidence was found that the physician places a restraint order for the date of 09/26/2022.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/27/2022 at 2:09 AM, started 09/27/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/28/2022 at 5:44 AM, started 09/28/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist on 09/29/2022 at 5:32 AM, started 09/29/2022 at 2:00 AM, the physician countersign the order on 09/30/2022 at 9:14 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 09/30/2022 at 2:04 AM, started 09/30/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/01/2022 at 2:41 AM, started 10/01/2022 at 2:00 AM, the physician countersign the order on 10/01/2022 at 12:37 PM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/02/2022 at 2:58 PM, started 10/02/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/03/2022 at 6:41 AM, started 10/03/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/04/2022 at 3:00 AM, started 10/04/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist on 10/05/2022 at 4:37 AM, started 10/05/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/06/2022 at 3:02 AM, started 10/06/2022 at 2:00 AM.

Evidence was found of a telephonic physician order for Renew physician order for restraint with soft limb right and left wrist and right and left ankle on 10/07/2022 at 3:19 AM, no specific when started the restraint.

No evidence was found in the physician order that physician specify the reason for restraint.

No evidence was found in the physician progress note that the physician performed a comprehensive assessment, evaluate, and justified the need for use restraint in the patient.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 09/17/2022 at 8:00 PM and at 10:00 PM.

On 09/21/2022 at 4:00 pm the nurse documented that restraint was removed due to patient alert, and don't try to interrupt the treatment. No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/07/2022 at 4:00 AM and at 6:00 AM.

On 09/22/2022 at 3:30 AM the nurse documented that patient fall, disoriented, confuse, and started restriction.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 09/23/2022 at 10:00 am and at 2:00 PM.

Evidence was found that the nursing personnel restraint patient without a restraint order on 09/25/2022 from 8:00 AM through 09/26/2022 at 12:00 AM.

Evidence was found that the nursing personnel restraint patient without a restraint order on 09/26/2022 from 8:00 AM through 09/27/2022 at 12:00 AM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/03/2022 at 8:00 AM, 6:00 PM, 8:00 PM and at 10:00 PM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/05/2022 from 12:00 PM through 10:00 PM.

No evidence was found in nursing documentation of the restraint reassessment every 2 hr., on 10/06/2022 at 2:00 AM.

The facility failed to ensure that the physician responsible for the care of the patient place a restraint order prior to the application of the restraint.

Based on an unannounced Complaint investigation ACTS Intake PR00000672 survey conducted on October 06, 2022 trought October 07, 2022, review of medical staff bylaws and interview with Institutional Program Director (employee #3), it was found that the facility failed to ensure that medical staff had in place updated bylaws to carry out its responsibilities.

Findings include:

1. Review of medical staff bylaws on 10 06/2022 at 1:55 PM evidence that the last time that this document who include provisions to outline how medical staff organization is run, was from year 2016.

2. During interview on 10/06/2022 at 2:50 PM Institutional Program Director (employee #3), stated that medical staff bylaws must be review every two years accordingly with hospital governing body regulations. She stated that medical staff review the bylaws and facility sent the document to the legal department for the final approve.

3. Facility failed to enforced and revise medical by laws as necessary, and required by governing body regulations.

Based on an unannounced Complaint investigation ACTS Intake PR00000672 survey conducted on October 06, 2022, through October 07, 2022, review of twenty-five clinical records and policies/procedure with the Director of Nursing (DON) (employee #3), it was found that the facility failed to ensure that nursing staff develop appropriate nursing interventions and implement care plans for 1 out of 25 records reviewed (R.R #21)

Findings include:

1. RR #21 is a 41-year-old male patient admitted on 09/02/2022 with a diagnosis of Urinary Tract Infection, patient had history of kidney transplant and he is blind. Patient was receiving treatment at the 6th floor. On 09/07/2022 was transferred to the 9th floor due to a positive Covid-19 test results. This patient used to be accompanied by his mother while receiving treatment on the 6th floor. When was admitted to the 9th floor that is the hospital's isolation Covid-19 unit it was not permitted that his mother accompanies him.

On 09/08/22 while receiving treatment on the 9th floor he began to present disorientation and it was necessary to place on restraint at 4:00 PM. Patient was on restraint since 09/08/2022 at 4:00 PM until 09/11/2022 at 2:00 PM.

No plan of care for restraint was developed or implemented for this patient accordingly with information reviewed with the Quality Assessment and Performance Improvement Program QAPI officer (employee #5) on 10/07/2022 at 10:30 AM.

A nursing care plan based on the assessment of the patient's nursing care needs while on restraint was not found documented. There is no evidence of the notification of this patient relative before the use of restraint. There is no evidence of a patient on restraint plan of care to be used to guide interventions and to establish continuity of care of this patients' needs.