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Based on interview and record review, the hospital failed to ensure its P&P for complaints and grievances was followed. This failure created the risk of unresolved quality and safety concerns, as well as substandard patient care.

Findings:

Review of the hospital's P&P titled Patient/Visitor or Complaints and Grievances dated 2/9/24, showed if staff is unable to resolve a complaint to the patient/visitor's satisfaction within the same business day, the complaint becomes a grievance and shall be documented on a "Patient/Visitor Complaint Report" form and entered into the Grievance Tracking system. Grievances shall be acknowledged within seven business days of the stamped receipt date. The patient must receive a written response no more than 30 days after receipt of the complaint. The final written response should include the following: the name of the hospital contact person, steps taken on behalf of the patient to investigate the grievance, results of the grievance process and or investigation, corrective actions if indicated, and the date the investigation was completed.

On 4/2/25 at 0902 hours, a telephone interview was conducted with Complainant 1 who alleged that she emailed a grievance to the hospital on 2/27/25, with concerns about a lack of supplies and staffing. Complainant 1 stated she did not receive a written acknowledgement of the receipt of her grievance, nor did she receive a written response indicating the investigation outcome.

On 4/3/25 at 0935 hours, an interview and concurrent record review was conducted with Assistant Hospital Administrator 1 and the Licensing Coordinator. Review of the Patient/Visitor Complaint Report dated February 2025 showed Complainant 1 had emailed a grievance on 2/27/25. The report showed an acknowledgement letter was not sent to Complainant 1 and a final written response was due 4/10/25. Assistant Hospital Administrator 1 verified the final written response due date erroneously showed business days and stated the hospital did not send Complainant 1 an acknowledgement letter and final written response as per the hospital's P&P.

Based on interview and record review, the hospital failed to ensure the physician's order for the restraint use for one of 11 sampled patients (Patient 1) was renewed as per the hospital's Nursing Clinical Standard. This failure created the increased risk of the loss of freedom of movement for this patient.

Findings:

Review of the hospital's Nursing Clinical Standard titled Restraints: Non - Violent or Non-Self-Destructive Behavior dated July 2023 showed to ensure the restraint order is completed and specifies for time limits (must be reordered by the end of the next calendar day); and notify the provider of need for new order for expired order (if the condition necessitating restraints persists).

On 4/2/25, Patient 1's closed medical record was reviewed with Nurse Manager 1.

Patient 1's closed medical record showed Patient 1 was admitted to the hospital on 12/18/24 and left AMA on 12/24/24.

Review of the nursing assessment under the restraint episode showed Patient 1 was on restraints from 12/18/24 at 1810 to 12/20/24 at 0200 hours.

Review of the Physician's Order dated 12/18/24 at 1926 hours, showed to initiate non-violent restraint to all four extremities for Patient 1 due to unable to follow instructions and interfering with medical care device, and the order was valid for one calendar day.

Review of the Physician's Order dated 12/20/24 at 0155 hours, showed to renew non-violent restraint to right and left wrist for Patient 1 due to interfering with medical care devices.

However, further review of Patient 1's medical record failed to show the restraint renewal order for 12/19/24.

On 4/4/25 at 1020 hours, Assistant Nursing Director 2 verified the above findings.

Based on interview and record review, the hospital failed to ensure two of 11 sampled patients (Patients 1 and 5) were monitored for the use of restraints as per the hospital's P&P and Nursing Clinical Standard as evidenced by:

1. For Patient 1, the nursing staff failed to monitor the patient as per the hospital's Nursing Clinical Standard when the violent restraint was applied to the patient.

2. For Patients 1 and 5, the non-violent restraint monitoring was not consistently performed as per the hospital's Nursing Clinical Standard and hospital's P&P.

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

Findings:

Review of the hospital's P&P titled Restraints/Seclusion dated 6/10/23, showed the trained staff assess/monitor/perform at the initiation of restraints, prior to discontinuation, with every order obtained, or more frequently based on the patient's needs per the Restraints: Non-Violent or Non-Self- Destructive Behavior Nursing Clinical Standard and Restraints/Seclusion: Violent or Self-Destructive Behavior Nursing Clinical Standard protocols.

1. Review of the Nursing Clinical Standard titled Restraints/Seclusion: Violent or Self-Destructive Behavior dated July 2023 showed the following:

* Assess and document the following upon application of restraints and a minimum of every two hours or more frequently based on patient's condition: neurovascular check, restraint mental status assessment (level of consciousness, orientation assessment, affect/behavior), and restraint respiratory assessment.

* Monitor and document the following upon initiation of restraints or seclusion, every 15 minutes thereafter or more frequently based on patient's condition: BH Patient activity (e.g. awake, eye closed), restraint site evaluation (restraint type, location, and signs of injury related to restraints), and respiratory rate.
On 4/2/25, Patient 1's closed medical record was reviewed with Nurse Manager 1.

Patient 1's closed medical record showed Patient 1 was admitted to the hospital on 12/18/24 and left AMA on 12/24/24.

Review of the Physician's Order dated 12/23/24 at 1233 hours, showed to apply violent restraint for Patient 1 and the order was valid for four hours.

Review of the Physician's Order dated 12/23/24 at 1234 hours, showed restraint violent monitoring by RN.

Review of the Face to Face Evaluation dated 12/23/24 at 1231 hours, showed Patient 1 was agitated and combative. Patient 1's reaction to intervention was pulling at restraints, unable to follow commands, continued aggression towards staff despite restraint, and verbally threatening staff.

Review of the nursing assessment under the restraint episode showed Patient 1 was on 2- points soft restraints on 12/23/24 from 1200 to 1600 hours. However, further review of Patient 1's medical record showed the following:

* No neurovascular check between 1200 to 1600 hours on 12/23/24.
* No respiration assessment while on restraints between 1200 to 1600 hours on 12/23/24.
* The restraint mental status was assessed at 1200 and 1600 hours on 12/23/24. However, there was no restraint mental status assessment at 1400 hours on 12/23/24.

In addition, there was no documentation of BH patient activity, restraint site evaluation, and respiratory rate every 15 minutes as per the hospital's nursing clinical standard.

2. Review of the hospital's P&P titled Restraints/Seclusion dated 6/10/23, showed the non-violent or non-self-destructive patient in restraints is monitored as follows:
- At least every two hours or sooner based on patient need.
- By observation, interaction with the patient, or related direct examination of the patient by qualified staff.

Review of the Nursing Clinical Standard titled Restraints/Seclusion: Non-Violent or Non- self-Destructive Behavior dated July 2023 showed the following:

* Assess and document the following upon application of restraints and a minimum of every two hours or more frequently based on patient's condition: neurovascular check, restraint mental status assessment (level of consciousness, orientation assessment, affect/behavior), and restraint respiratory assessment.

* Provide for and document the following upon application of restraints and a minimum of every two hours thereafter: range of motion, nutrition/hydration, elimination, hygiene, and patient position (repositioning).

a. On 4/2/25, Patient 1's closed medical record was reviewed with Nurse Manager 1.

Patient 1's closed medical record showed Patient 1 was admitted to the hospital on 12/18/24 and left AMA on 12/24/24.

Review of the nursing assessment under the restraint episode showed Patient 1 was on non-violent restraints on 12/21, 12/22, and 12/23/24. However, further review of Patient 1's medical record showed restraint mental status assessment and restraint respiratory assessment were missing the following dates and times:

* On 12/21/24 at 2100 and 2300 hours
* On 12/22/24 at 0400, 0900, 1700, and 2200 hours.
* On 12/23/24 at 0200, 0600, 1000, 1400, 1800, and 2200 hours.

In addition, the restraint neurovascular check was performed on only 12/22/24 at 0254, 0540, 0656, 2012, 2200 hours and 12/23/24 at 0000 and 0200 hours. The neurovascular was not checked consistently every two hours as per the hospital's clinical nursing standard.

Review of the nursing assessment under the restraint episode showed there was no documentation of range of motion, nutrition/hydration, elimination, hygiene, and patient position (repositioning) between 1200 and 1600 hours on 12/23/24.

On 4/4/25 at 0956 hours, Nurse Manager 1 verified the above findings.


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b. Review of Patient 5's closed medical record was initiated on 4/2/25.

Patient 5's closed medical record showed the patient was admitted to the hospital on 2/3/25 and discharged on 2/20/25.

Review of Patient 5's physician orders showed an order dated 2/11/25 at 0800 hours, to initiate non-violent restraints to Patient 5's left and right wrist with the indication that Patient 5 was unable to follow commands and was unsafe.

Review of Patient 5's restraint monitoring flowsheet dated 2/11/25, found no restraint monitoring documented as described in the hospitals P&P at 1600 hours.

Review of Patient 5's restraint monitoring flowsheet dated 2/11/25, showed the restraints were discontinued for Patient 5 on 2/11/25 at 1915 hours.

On 4/2/25 at 1300 hours, an interview and concurrent review of Patient 5's medical record was conducted with Nurse Manager 2. Nurse Manager 2 was unable to locate the restraint monitoring for Patient 5 from 2/11/25 at 1600 hours. Nurse Manager 2 acknowledged restraint monitoring for Patient 5 should have been done every 2 hours as per the hospital's P&P.

On 4/4/25 at 1130 hours, the Licensing Coordinator was notified and acknowledged the above findings.

Based on interview and record review, the hospital failed to ensure the competency for the us of restraints for RN 9. This failure posed the risk of substandard outcomes to the patient.

Findings:

Review of the hospital's P&P titled Restraints/Seclusion dated 6/10/23, showed staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion before performing any of the above action, as part of the orientation, and every two years thereafter.

On 4/4/25, when requested for RN 9's restraint competency, Nurse Manager 1 provided the following documents:

* CMS Restraints Education and Roster dated 11/22/24.
* RN 9's Orientation/Reorientation Handbook dated 1/22/24 and 4/3/25.
* Nursing Staff Roles and Responsibilities during a Code Gold dated 5/10/24.
* AVADE - Workplace Violence Prevention dated 12/23/24 and 5/10/24.

Further review of the CMS Restraints Education and Roster dated 11/22/24, failed to showed RN 9 reviewed the hospital's Nursing Clinical Standards for Restraints/Seclusion: Violent or Self-Destructive Behavior, Restraints: Non-Violent or Non-Self-Destructive Behavior, and emphasis on the behavioral criteria necessitating each type of restraint use, and the documentation and patient monitoring requirements.

Further review of the educational material for Orientation/Reorientation Handbook, Nursing Staff Roles and Responsibilities during a Code Gold, AVADE - Workplace Violence Prevention failed to show the monitoring requirements of the restraints.

On 4/4/25 at 0956 hours, Nurse Manager 1 verified the above findings.

Based on observation, interview, and record review, the hospital failed to ensure the nursing staff labeled the IV fluid tubing as per the hospital's Nursing Clinical Standard for one of 11 sampled patients (Patient 6). This failure created the risk of poor health outcomes to the patient.

Findings:

Review of the hospital's Nursing Clinical Standard titled Intravenous Therapy dated June 2023 showed to change IV tubing every 24 hours for secondary lines (IV tubing used to intermittently administer a medication or fluid while the primary I.V. line is running); and label IV tubing every change with the following: date, time, initials, "IV" or name of continues medication close to insertion site.

On 4/2/25 at 1015 hours, an observation of Patient 6's medication pass was conducted with RN 3. Patient 6 was administered an IV solution of Zosyn (antibiotic medicattion) 3.375 grams via an electronic infusion pump. The IV tubing used to administer the Zosyn IV solution was not labeled with the nurse's initials, medication name, date, and time to show when the tubing needed to be changed.

On 4/2/25 at 1020 hours, an interview was conducted with RN 3. RN 3 stated the tubing for the Zosyn solution should be changed every 24 hours as per hospital's policy. RN 3 acknowledged Patient 6's tubing for the Zosyn solution IV was not labeled as per the hospital's P&P and there was no way to know when the IV tubing was due to be changed.

On 4/2/25 at 1022 hours, an interview was conducted with Nurse Manager 2. Nurse Manager 2 acknowledged there was no way to know when it would be time to change the IV tubing for Patient 6 since the IV tubing was unlabeled.

On 4/4/25 at 1130 hours, the Licensing Coordinator was notified and acknowledged the above findings.

Based on interview and record review, the hospital failed to ensure the nursing staff followed the hospital's P&P for the administration and documentation of blood and blood products for one of 11 sampled patients (Patient 9). This posed the risk to transfusion tracking and monitoring due to the insufficient documentation, potentially compromising patient safety.

Findings:

Review of the hospital's P&P titled Blood and Blood Products dated March 2025 showed the transfusion must be completed within six hours of the issuance from the blood bank and within four hours after the hermetic seal is broken. Documentation must be completed in accordance with the standards in iView and I&O: Blood Product Administration Navigator band and the Blood Products Transfusion Education.

On 4/3/25 at 1336 hours, medical record review for Patient 9 was initiated with Assistant Nursing Director 1.

Patient 9's medical record showed that the patient received two units of packed red blood cells on 4/1/25. The first unit was transfused at 0925 hours and completed at 1245 hours, with documentation indicating the patient received 325 ml of packed red blood cells and tolerated the transfusion well, with no suspected transfusion reaction. Further record review showed the second unit of packed red blood cells was transfused at 1345 hours; however, there was no documentation to indicate the time the transfusion was completed, making it unclear whether it was completed within four hours, or if the patient had any suspected transfusion reaction.

Following the interview and concurrent record review, Assistant Nursing Director 1 verified the findings.

Based on observation, interview, and record review, the hospital failed to ensure the preventative maintenance for three of seven observed overhead radiant heaters in the Burn Unit was conducted. This posed the risk of unsafe conditions for the patients.

Findings:

Review of the hospital's P&P titled Medical Equipment Management Plan dated 11/21/24, showed the purpose of the P&P is to provide an environment that minimizes the clinical and physical risks of equipment through the safe and effective use and maintenance of medical equipment in the hospital's inventory. All equipment items in the Clinical Engineering HSPMS program are tested according to manufacturer recommendation or at least annually after initial incoming testing. Items are affixed with an adhesive preventative maintenance sticker, which identifies to the operator that the equipment has been serviced and when the next inspection of the equipment is due.

On 4/2/25 at 1447 hours, a tour of the Burn Unit was conducted with Clinical Nursing Director 4, Assistant Nursing Director 1, Nurse Manager 5, and Supervising Staff Nurse 3.

During the tour, a total of seven overhead radiant heaters were observed: one in the hydrotherapy room and six in the Burn ICU rooms. Of the seven heaters observed, three displayed preventative maintenance stickers indicating their maintenance was past due (one in the hydrotherapy room and two in the Burn ICU rooms). The staff verified these findings.

On 4/2/25 at 1515 hours, an interview was conducted with the Biomedical Supervisor, who stated preventative maintenance must be performed annually on the overhead radiant heaters to ensure safety and safe use, per the manufacturer's recommendation and included checking for electrical safety, leakage tests, and proper grounding.