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Based on clinical record review, document review and interview, it was determined that the facility failed to ensure care was provided in a safe setting by not performing neuro checks and/or calling MRT (Medical Response Team) for change in condition immediately for one (1) of four (4) Patients (Patient (P) # 2).

The findings include:

On April 18, 2023 at approximately 10:20 a.m., the clinical record review for Patient # 2 revealed the following:

On March 13, 2022 at 6:00 p.m., RN (Registered Nurse) note by Staff Member (SM) # 14 reads in part "Pt family now concerned about transferring to a med-surg unit and not receiving "the same level of care" on another unit. Having some push back regarding transfer."

On March 14, 2022 at 6:17 a.m., RN note by SM # 15 reads in part "Paged MD for a discussion per family concern with patient sleeping since prior to transfer from step down unit. Patient responded to pain with this nurse throughout shift for Heparin injection and IV placement. Patient responded to sternal rub with a shrug of the shoulders and pupils PERRLA (Pupils equal round reactive to light and accommodation). When this nurse started shift patient was restless with moving legs. Tylenol suppository given q4hrs (every 4 hours) as ordered and patient appeared to become more comfortable. Hydralazine given at 2:38 a.m. for b/p (blood pressure) 186/81. Patient responded well with a repeat b/p 137/67 and resting comfortably."

On March 14, 2022 at 8:54 a.m., RN note by SM # 16 reads in part "Bedside shift report completed with [RN]. Discussed evening care with [family] at bedside and reviewed current plan of care and discussed concerns to that point. Patient resting during conversation. At 8:00 a.m. called to patient's bedside by NCP (Nursing Care Partner). Family reports patient is still unresponsive as was all night, but states should be waking up as did yesterday. I performed sternal rub and noted shoulder movement with sternal rub. Noted right hand swelling. NCP obtained current vital signs. WNL (within normal limits), and obtained blood glucose, also WNL. Eyes PEARL (Pupils equal reactive to light accommodate).
Contacted [Physician], [staff name], and reviewed findings. Stated that patient was presenting as [patient] had last night and oncoming hospitalist would round on patient. [SM # 13] arrived to the room as I got off the phone with [Physician]. Discussed findings with [SM # 13] and family informed of changes noted. Sternal rub performed by [SM # 13] patient posturing. [SM # 13] ordered stat CT. MRT (Medical Response Team) called for assistance. [SM # 13] wanted to wheel patient to CT immediately. Accompanied [SM # 13] and PA (Physician Assistant) to elevator where MRT was met."

Clinical record review revealed there was no documentation of neurologic checks between March 13, 2022 at 6:00 p.m. and March 14, 2022 at 6:17 a.m. There was no MRT called immediately when concerns for change of condition was questioned. The MRT wasn't called until March 14, 2022 at 8:54 a.m. when SM # 13 arrived to the [P # 2's] room.

On April 18, 2023 at 10:45 a.m., an interview with SM # 8 revealed "there was an in person complaint on March 16, 2022 from [family] of P # 3."
A review of the facility's complaint/grievance policy revealed no deviation from policy.

At 11:00 a.m., an interview with SM # 9 revealed "I was present for all of the family meetings. [Medical Director at time] was also present for all of the meetings. [Medical Director at the time] revealed during the meeting the "neuro checks were not done"."

A review of the case summary provided by the facility staff revealed the following recommendations: "escalate neurological changes to MD immediately, when in doubt call an MRT (Medical Response Team) for extra eyes to assess pt and escalate through chain of command if physician does not share your concerns."

A review of the "Meeting with the [P # 2's family] - 5/31/2022" provided by the facility staff reads in part "Neuro checks were not documented in the medical record and not observed being performed by family members at the beside for 12 hour on the overnight of the intracranial rebleed."

A copy of the medical peer review was requested and the facility declined to share the documents during the on-site survey.

On April 18, 2023, the findings were discussed with Staff Members # 1, # 3, # 5 and # 6 during the exit interview.

Based on clinical record review, document review and interview, it was determined that the facility failed to ensure restraint orders were not written on an as needed basis for one (1) of four (4) Patients (Patient # 3).

The findings include:

On April 18, 2023 at 9:50 a.m., a clinical record review for Patient # 3 revealed a restraint order dated April 14, 2023 at 11:02 p.m.
The order read in part "Restraint device: belt, Type of belt: lap belt. Behavior(s) indication(s) to D/C restraints: responding to re-direction not to pull at tube(s) or medical equipment. Cooperating with care and treatment."

A review of nursing documentation, to include notes and flowsheets, revealed no restraint (lap belt) on Patient # 3.

Staff Member # 7 responded there was no documented restraint placed on [Patient # 3] when questioned about the lap belt.

Staff Member # 1 stated, "It's (the order) there if needed."

On April 18, 2023, a review of the facility policy provided by Staff Member # 1 titled "Restraint and Seclusion" reads in part "Physician order for restraint will not be on as needed basis."

On April 18, 2023, the findings were discussed with Staff Members # 1, # 3, # 5 and # 6 during the exit interview.

Based on clinical record review, document review and interview, it was determined that the facility failed to document offering fluids and nourishment, toileting/elimination, range of motion, exercise of limbs and systematic release of restrained limbs per the facility's policy and procedure for one (1) of four (4) restraint Patients (Patient # 4).

The findings include:

On April 18, 2023 at approximately 10:00 a.m., the Clinical Record for Patient # 4 was reviewed. The review revealed restraints were placed on Patient # 4 on April 15, 2023 at 5:00 p.m., with a Physician's order dated April 15, 2022.
There were Physician orders to continue restraints on April 16, 2023 and April 17, 2023.
Documentation revealed Patient # 4 had bilateral soft limb restraints to the upper extremities for non-violent behavior. Restraints initiated for safety due to Patient confusion and agitation.
During the Clinical record review, there was no documentation to include offering fluids and nourishment, toileting/elimination, range of motion, exercise of limbs and systematic release of restrained limbs after 6:00 a.m. on April 18, 2023.
The restraints remained in place on April 18, 2023 through the survey review.
There was no documentation to include offering fluids and nourishment, toileting/elimination, range of motion, exercise of limbs and systematic release of restrained limbs on April 16, 2023 between 6:00 a.m. and 8:52 a.m. and between 12:52 p.m. and 4:39 p.m.

An interview with Staff Members # 7 revealed "there is no documentation after 8:00 a.m."

On April 18, 2023, a review of the facility policy provided by Staff Member # 1 titled "Restraint and Seclusion Management: Non Violent or Self Destructive Behavior in Non Behavioral Health Area" reads in part "Monitor and document restraint safety according to patient need. Monitoring shall included circulation, range of motion, fluids, food/meal and elimination and shall be documented at least every 1.5 - 2.5 hours and may need to be more often; adjust to more often according to patient need."

In conclusion, the facility failed to monitor circulation, range of motion, fluids, food/meal and elimination and document at least every 1.5 - 2.5 hours per policy.

On April 18, 2023 the findings were discussed with Staff Members # 1, # 3, # 5 and # 6 during the exit interview.