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Based on interview and record review, the hospital failed to ensure the weight was measured as per the hospital's P&P and physician's order for two of three sampled patients (Patients 1 and 2). This failure had the potential to result in unsafe care and poor clinical outcomes to the patient.

Findings:

Review of the hospital's P&P titled Weighing the Patient dated 8/9/22, showed all patients will be weighed on admission.

1. On 4/24/25, Patient 1's closed medical record was reviewed with the Accreditation and Regulatory Compliance Supervisor in the presence of the Sr. Principle Regulatory Compliance and Corporate Facilities.

Patient 1's medical record showed the following:

* Patient 1 was admitted to the ICU on 2/25/25 and was transferred to the Medical-Surgical-Telemetry unit on 3/3/25.
* Patient 1 was transferred to the ICU on 3/4/25.
* Patient 1 was admitted to the ARU on 3/8/25 and was transferred to the ICU on 3/31/25.
* Patient 1 was discharged on 4/23/25.

Review of the Physician's Order dated 2/25/25 at 1633 hours, showed to weigh Patient 1 daily.

Review of the Physician's Order dated 3/8/25 at 1350 hours, showed to weigh Patient 1 on admission to the ARU.

Review of the Weights documentation showed Patient 1 was not weighed daily as per the physician's order.

The Weights documentation showed Patient 1 was weighed on 2/25, 2/26, 3/1, 3/2, 3/3, 3/4, 3/5, 3/10, 3/16, 3/27, and 3/31/25.

2. On 4/24/25, Patient 2's medical record was reviewed with the Accreditation and Regulatory Compliance Supervisor in the presence of the Sr. Principle Regulatory Compliance and Corporate Facilities.

Patient 2's medical record showed Patient 2 was admitted on 4/8/25.

Review of the Weights documentation showed Patient 2 was not weighed upon admission on 4/8/25. The first weight measurement documented, was on 4/10/25 (two days after the admission).

On 4/24/25 at 1550 hours, the Accreditation and Regulatory Compliance Supervisor and Sr. Principle Regulatory Compliance and Corporate Facilities verified the above findings.

Based on interview and record review, the hospital failed to ensure the discontinuation of the restraint was documented for one of three sampled patients (Patient 3). This failure posed the risk of substandard outcomes to the patient.

Findings:

Review of the hospital's P&P titled Use of Restraints and Restraint Reduction dated 10/4/24, showed RESTRAINT DOCUMENTATION...the following must be documented in the electronic health record (EHR):

* A description of the patient's behavior and the intervention used...

* The reason for early removal (if applicable).

On 4/24/25, Patient 3's closed medical record was reviewed.

Patient 3's closed medical record showed Patient 3 was admitted to the hospital on 2/28/25.

Review of the Physician's Order for restraints violent or self-destructive adult dated 3/1/25 at 0001 hours, showed to apply hard restraints to the right and left wrists and to the right and left ankles.

Review of the Emergency Department History and Physical dated 2/28/25, showed the ED physician performed the face-to-face assessment on 3/1/25 at 0003 hours.

Review of the Nursing Flowsheets under Restraint Type dated 3/1/25, showed the restraints were initiated at 0001 hours and continued at 0100 and 0200 hours.

Review of the medical record did not show documentation when the hard restrains were discontinued.

On 4/24/25 at 1550 hours, the Accreditation and Regulatory Compliance Supervisor and Sr. Principle Regulatory Compliance and Corporate Facilities verified the above findings.