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The facility failed to ensure patient representative was informed decisions regarding patient's care and treatment. This deficient practice was identified on 2 out of 20 records reviewed (RR #1 and RR # 5).

Findings include:

1. RR #5 is a 30-year-old male patient admitted on 02/08/2023 at 11:00 PM with a diagnosis of Cannabis Dependence with Psychotic Disorder. Due to patient mental disorganization and behavior presented while receiving treatment Geodon (an antipsychotic medication used to treat mood disorders) 20 mgs Intramuscular was ordered to be administered on 02/08/2023 at 2:10 AM.

The facility Operational Director (employee #3), stated during an interview on 09/06/2023 at 11:40 AM that chemical "restriction" (restraint) is used to reduce agitation, aggression and violent or erratic behavior. She stated that chemical restriction is indicated with this patient because due to his behavior he poses danger to himself, others and hospital property. She also stated that due to risks associated with the use of chemical restriction there are interventions that must be performed by personnel in charge of patient.

No evidence was found documented on the medical record related to notification to patient's relative or family member of patient disruptive behavior or circumstances that provoke that chemical restriction is being applied to the patient.

During interview on 09/07/2023 at 11:55 AM the facility Operational Director (employee #3) stated that accordingly with facility policy title: " Uso Correcto y Manejo de Restricciones Fisicas/Químicas y Aislamiento " Correct Use and Management of Physical/Chemical Restraint and Isolation last update on December 2022 section 1.2.2 the notification of the use of chemical restriction must be performed and registered on the medical record.

The facility Operational Director (employee #3) stated that usually social worker is the person who notify to patient's relative or family member of patient disruptive behavior who required chemical restriction must be performed.


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2. RR #1 is a 43-year-old female patient admitted on 09/29/2021 at 8:00 PM with a diagnosis of Bipolar Disorder, Obesity Medication abuse. During the record review performed on 09/06/2021 at 10:14 PM it was found that the
patient arrives and is registered at the facility at 7:30 PM.

Patient was evaluated by the facility personnel at 8:00 PM and was an Involuntary admission due to Puerto Rico Mental Health Law 408, Involuntary admission (Mechanism for the involuntary hospitalization of a person for a period of no more than 15 days after a team of mental health professionals evaluates the person and certifies the need for involuntary treatment. When ordering the involuntary admission of a person, the Court will indicate follow-up hearings that are necessary until the participant's recovery).

Due to physical aggression with family, no sign or symptom of sleep apnea, accordance to the nurse evaluation, patient was illogical, incoherent, with psychiatric and aggressive history, and refuse to provide information.

The patient's mother refers during call that patient have medication abuse and was incoherent, denied homicide, suicidal ideas, and hallucinations. Patients use Ativan 2 mg, Motrin, Neurontin, Baclofen, Seroquel 200 mg no specified the dose and frequency, and parent did not know.

Patient mental status was untidy, alert oriented in person, was anxious, poor attention, thought illogic y disorganized.

The physician note on 09/29/2021 at 8:00 PM at the stabilization room indicate that "was received from the transferring hospital with a Law 408 due to physical aggression with family, Patient with disorganized and illogical thoughts. Mother indicates abuse of over the counter (OTC) medications, including Motrin (non steroid anti-inflammatory drug). Likewise, she requests Tramadol (analgesic) and Baclofen (skeletal muscle relaxant). Patient arrives disorganized and is transferred to the unit for stabilization.

Physician Admission order performed at 09/29/21 at 8:00 PM indicate aggressive risk precaution, Interdisciplinary Therapy: Individual, Group, Occupational and Recreative Therapy, and Family session. Vital Sign twice daily and at bedtime Oxymetry every 4 hour and at bedtime. Psychiatric evaluation ASAP (as soon as possible).

On 09/29/2021 at 8:10 PM The physician ordered Haldol (antipsychotic agent) 5 milligram (mg) intramuscular (IM) stat, Ativan (management of anxiety disorder) 2 mg IM stat, the nurse takes the order at 8:30 PM.

At 8:15 PM the nurse performed The Management of Specific Psychotropic Medications sheet and evaluate patient vital sign at 8:15 PM was B/P 159/79 millimeter of mercury (mm/Hg), Pulse (P): 106, Respiration (R): 17, Temperature (Temp): 36.5, patient vital sign at 8:45 PM was B/P 155/73 mm/Hg, P: 98, R: 17, patient vital sign at 9:15 PM was B/P 140/72 mm/Hg, P: 95, R: 17

The Nurse documented in the progress note of 09/29/2021 at 8:10 PM that patient arrive to the unit Close Observation Unit (COU) with paramedical personnel, patient was observed disorganized, discouraged, quiet and suspicious. Patient on an ambulance stretcher with soft restrictions on the hands, is placed in a quiet room, the Vital Sign: Blood Pressure (B/P): 159/79 millimeter of Mercury (mm/Hg), Pulse (P): 106, Respiration (R): 17 Temperature 36.5 grade Fahrenheit, Oxymetry 97%.

At 8:30 PM Haldol 5 mg IM stat, Ativan 2 mg IM stat was administrated to optimize the treatment in the left gluteus.

At 9:30 PM the Mental Health Technician observed patient sitting on the bed agitated and rapid breathing.

The nurse goes to the Quit Room to verify the vital sign. The patient becomes rigid and with involuntary movements, orange code (medical emergency) is activated, the patient is observed with a purple face and green code (cardiorespiratory arrest) is activated. At 9:30 PM CPR was started providing manual respiration.

At 10:08 PM the patient was declared dead by the doctor.

No evidence was found related to the Chemical Restriction and patient relative notification of restraint.

Accordingly with information provided by the facility Operational Director (employee #3), on 09/06/2023 at 11:00 AM while reviewing and discussing the case, a plan of care must be prepared on this case after chemical restriction with this medication was performed.

The Operational Director (employee #3), stated on 09/06/2023 at 11:40 AM during interview that chemical restriction is used to reduce agitation, aggression and violent or erratic behavior. She stated that chemical restriction is indicated with this patient because due to behavior poses danger to self, other and hospital property. She also stated that due to risks associated with the use of chemical restriction there are interventions that must be performed by personnel in charge of patient. The plan of care guide interventions that personnel must follow.

During the review of this case it was evident the lack of plan of care for chemical restriction with interventions crucial to be performed to assess continuously patient status and vital signs and monitor patient health status while patient was under the effects of medications used to subdue and sedate patient.

The facility failed to observe and assess patients when medication are used for behavior to provide protection for the patient's emotional health and safety. This deficient practice was identified on 1 out of 20 records reviewed. (RR#17).

Findings include:

1. RR# 17 is a 45-year-old female patient admitted to the facility on 08/23/2023 with diagnosis of Schizophrenia Paranoid. Due to patient mental mispronunciation the psychotic behavior escalated and became to getting worse, it was necessary to make interventions and physician order Ativan 2 mg intramuscular STAT administrated on 08/24/2023 at 12:30 AM.

During review of the clinical record there was no evidence of interventions performed to continually assess the patients' condition and health while the patient was being treated with this medication.

According with the information provided by the facility Operational Director (employee#3) on 09/06/2023 at 1:30 PM while reviewing and discussing the case a plan of care must be prepared after chemical restriction with medication is performed. According to the information provided by facility Operational Director (employee #3), on 09/06/2023 at 1:35 PM during the interview, the chemical restraint is used to reduce agitation, hallucinations, mood swings and uncooperative behavior. She also stated that due to risk associated with the use of chemical restriction in elderly patient there are intervention that must be performed by personnel in charge of type of patient.

Based on interview and records reviewed (RR), the facility failed to develop care plans related to restraints for 5 of 20 patients (RR #1, 5,13,16 and 17) reviewed.

Findings include:

Upon review of the facility's policy on 09/07/2023 at 1:50 PM title: " Uso Correcto y Manejo de Restricciones Fisicas/Químicas y Aislamiento " (Correct Use and Management of Physical/Chemical Restrictions and Isolation), last update on December 2022. Policy clearly stated that a revision of patient plan of treatment must be performed by the register nurse in charge of the unit where patient is located with the treatment interdisciplinary team in cases where the behavior of the patient is considered dangerous and the modality of chemical or mechanical ( physical ) restraint is applied. Policy establishes that the plan of treatment must be modified after a face-to-face assessment of the patient is performed and information related to patient status and behavior is discussed by the patient physician. The policy also establishes that register nurses must review and update the patient's plan of care within a period of 8 hours.

1. RR #5 is a 30-year-old male patient admitted on 02/08/2023 at 11:00 PM with a diagnosis of Cannabis Dependence with Psychotic Disorder. Due to patient mental disorganization and behavior presented while receiving treatment Geodon (an anti-psychotic medication used to treat mood disorders) 20 mgs Intramuscular was ordered to be administered on 02/08/2023 at 2:10 AM.

Accordingly with information provided by the Facility Operational Director (employee #3), on 09/06/2023 at 11:00 AM while reviewing and discussing the case a plan of care must be prepared on this case after chemical "restriction" (restraint) with this medication was performed.

On this case accordingly with information provided by Facility Operational Director (employee #3), on 09/06/2023 at 11:40 AM during interview, chemical restriction is used to reduce agitation, aggression and violent or erratic behavior. She stated that chemical restriction is indicated with this patient because due to his/her behavior poses danger to self, others, and hospital property. She also stated that due to risks associated with the use of chemical restriction there are interventions that must be performed by personnel in charge of patient. The plan of care guide interventions that personnel must follow.

2. RR #13 is a 66-year-old male patient admitted on 02/22/2023 at 1:00 PM with a diagnosis of Alcohol Detox. Due to patient mental disorganization and psychotic behavior presented while receiving treatment, physician order Ativan (sedative used to relieve anxiety) 2 mgs Intramuscular STAT (a one time order is administered without delay due to urgency of the circumstances) on 02/22/2023 at 4:50 PM. Patient psychotic behavior escalated and became to getting worse and it was necessary to make interventions and physician order to administer Haldol "(an anti-psychotic medication used to treat certain types of mental disorders)" 5 mgs Intramuscular and Benadryl (an antihistamine to treat allergic reactions) 50 mgs Intramuscular STAT on 02/22/2023 at 7:10 PM. On 02/22/2023 at 7:30 PM patient psychotic behavior continue getting worse and after assessment physician order physical "restriction" in 4 points (extremities).

Accordingly with information provided by the facility Operational Director (employee #3), during interview on 09/07/2023 at 9:30 AM while reviewing and discussing the case, a plan of care must be prepared on this case after chemical (a restrictive practice that involves the use of a medication or chemical substance to influence a persons behavior) and physical restriction with this patient was performed.

On this case accordingly with information provided by the facility Operational Director (employee #3), on 09/07/2023 at 10:00 AM, during interview that chemical and physical restraint is used in this case to manage abrupt alcohol cessation behavior characterized by visual, auditory, or tactile hallucinations. She also stated that due to risks associated with the use of chemical restriction and physical restriction there are interventions that must be performed by personnel in charge of patient. The plan of care guide interventions that personnel must follow.

During the review of this case, it was evident the lack of plan of care for chemical and physical restraint with interventions crucial to be performed to assess continuously patient status and vital signs and monitor patient health status while patient was under the effects of medications used to subdue and sedate patient and when physical; restraint is used to ensure safety and maintain necessary treatment in patients that pose critical risk.

3. RR #16 is an 80-year-old female patient admitted on 08/20/2023 at 5:00 PM with a diagnosis of Psychosis and Paranoia. Due to patient mental disorganization and behavior presented while receiving treatment Haldol "(an anti-psychotic medication used to treat certain types of mental disorders)" 2 mgs Intramuscular STAT (a one time order is administered without delay due to urgency of the circumstances) was ordered to be administered on 08/30/2023 at 11:30 AM. Ativan (sedative used to relieve anxiety) 2 mgs Intramuscular STAT was ordered to be administered on 09/04/2023 at 5:50 PM.

Accordingly with information provided by the facility Operational Director (employee #3), on 09/06/2023 at 1:30 PM while reviewing and discussing the case a plan of care must be prepared on this case after chemical restriction with medications was performed.

The facility Operational Director (employee #3), on 09/06/2023 at 1:45 PM during interview, chemical restriction is used to reduce agitation, hallucinations, mood swings and uncooperative behavior. She stated that chemical restriction is indicated with this patient because due to her behavior she poses danger to herself and others. She also stated that due to risks associated with the use of chemical restriction in elderly patients there are interventions that must be performed by personnel in charge of this type of patient. The plan of care guide interventions that personnel must follow.

During the review of this case it was evident the lack of plan of care for chemical restriction with interventions crucial to be performed to assess continuously patient status and vital signs and monitor patient health status while patient was under the effects of medications used to subdue and sedate patient.


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5. RR #1 is a 43-year-old female patient admitted on 09/29/2021 at 8:00 PM with a diagnosis of Bipolar Disorder, Obesity Medication abuse. During the record review performed on 09/06/2023 at 10:14 AM it was found that: The patient arrives and is registered at the facility on 9/29/2021 at 7:30 PM.

Patient was evaluated by the facility personnel at 8:00 PM and was an involuntary admission. Puerto Rico Mental Health Law 408, Involuntary admission (Mechanism for the involuntary hospitalization of a person for a period of no more than 15 days after a team of mental health professionals evaluates the person and certifies the need for involuntary treatment. When ordering the involuntary admission of a person, the Court will indicate follow-up hearings that are necessary until the participant's recovery).

The physician note on 09/29/2021 at 8:00 PM at the stabilization room indicate that "was transferred from a hospital at Caguas with a Law 408 due to physical aggression with family, Patient with disorganized and illogical thoughts. Patient arrives disorganized and is transferred to the unit for stabilization.

Physician Admission order performed at 09/29/21 at 8:00 PM indicate aggressive risk precaution,Vital Sign twice daily and at bedtime Oxymetry every 4 hour and at bedtime. Psychiatric evaluation ASAP (as soon as possible).

On 09/29/2021 at 8:10 PM The physician ordered Haldol (antipsychotic agent) 5 mg IM stat, Ativan (management of anxiety disorder) 2 mg IM stat, the nurse takes the order at 8:30 PM.

At 8:15 PM The nurse performed The Management of Specific Psychotropic Medications sheet and evaluate patient vital sign at 8:15 PM was B/P 159/79 mm/Hg, P: 106, R: 17, Temp: 36.5, patient vital sign at 8:45 PM was B/P 155/73 mm/Hg, P: 98, R: 17, patient vital sign at 9:15 PM was B/P 140/72 mm/Hg, P: 95, R: 17

The Nurse documented in the progress note of 09/29/2021 at 8:10 PM that patient arrive to the unit Close Observation Unit (COU) with paramedical personnel, patient was observed disorganized, discouraged, quiet and suspicious. Patient on an ambulance stretcher with soft restrictions on the hands, is placed in a quiet room, the Vital Sign: Blood Pressure (B/P): 159/79 millimeter of Mercury (mm/Hg), Pulse (P): 106, Respiration (R): 17, Temperature 36.5 grade Fahrenheit, Oxymetry 97%. At 8:30 PM Haldol (antipsychotic agent) 5 mg IM stat, Ativan 2 mg IM stat was administrated to optimize the treatment in the left gluteus.

At 9:30 PM the Mental Health Technician observed a patient sitting in the bed agitated and rapid breathing. The nurse goes to the Quit Room to verify the vital sign. The patient becomes rigid and with involuntary movements, orange code (medical emergency) is activated, the patient is observed with a purple face and green code (cardio respiratory arrest- CPR) is activated. At 9:30 PM CPR was started providing manual respiration.

Accordingly with information provided by the facility Operational Director (employee #3), on 09/06/2023 at 11:00 AM while reviewing and discussing this case, she stated a plan of care must be prepared on this case after chemical restriction with this medication was performed.

On this case accordingly with information provided by facility Operational Director (employee #3), on 09/06/2023 at 11:40 AM during interview, chemical restriction is used to reduce agitation, aggression and violent or erratic behavior. She stated that chemical restriction is indicated with this patient because due to his/her behavior he/she poses danger to self, others and hospital property. She also stated that due to risks associated with the use of chemical restriction there are interventions that must be performed by personnel in charge of patient. The plan of care guide interventions that personnel must follow.


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4. RR# 17 is a 45 years old female patient admitted to the facility on 08/23/2023 with diagnosis of Schizophrenia Paranoid. Due to patient mental disorganization the psychotic behavior escaleted and became to getting worse, it was necessary to make interventions and physician order Ativan 2 mg intramuscular STAT administrated on 08/24/2023 at 12:30 AM.

According with the information provided by the facility Operational Director (employee#3) on 09/06/2023 at 1:30 PM while reviewing and discussing the case a plan of care must be prepared after chemical restriction with medication is performed. According to the information provided by facility Operational Director (employee #3), on 09/06/2023 at 1:35 PM during the interview, the chemical restraint is used to reduce agitation, hallucinations, mood swings and uncooperative behavior. She also stated that due to risk associated with the use of chemical restriction in elderly patient there are intervention that must be performed by personnel in charge of type of patient. The plan of care guide interventions that personnel must be follow.

During the review of RR#17 it was evidence the lack of plan of care for chemical restriction with interventions performed to continually assess the patient's condition and health while the patient was being treated with these medication.

The facility failed to ensure that when patients are on restraint or seclusion, patients are evaluated face- to- face and assessment are performed by the physician. This deficient practice was identified on 2 out of 20 records reviewed (RR) (RR #1 and RR#2).

Findings include:

Upon review of the facility's policy on September 07, 2023 at 2:45 PM title: "Uso correcto y Manejo de Restricciones física/ Química y Aislamiento" Correct Used of Physical/ Chemical Restraint and Isolation last update in December 2022, section 5.0 Face-to-face evaluation by physician: Within one hour of initiation of restraint or isolation, the patient will be evaluated in person by a doctor. A phone call or telemedicine methodology is not permitted for these evaluations. The evaluation will be documented in the medical record to include the following: 5.1 The date and time of the evaluation. 5.2 An evaluation of the patient's immediate situation. 5.3 An evaluation of the patient's reaction to the intervention. 5.4 An evaluation of the patient's medical and behavioral condition, including a complete review of systems assessment, behavioral assessment, as well as review and evaluation of the patient's history, medications, most recent laboratory tests, etc. 5.5 An evaluation of the need to continue or end restraint/isolation. At the time of the in-person evaluation, the Physician performing the evaluation works with the patient and staff to identify ways to help the patient regain control, make necessary revisions to the patient's treatment plan, and if necessary, provide a new order.

1. RR# 2 is a 55-year-old male patient admitted on 10/09/2022 at 11:06 PM, diagnosis of Schizophrenic Paranoid with history of Diabetes Mellitus, Convulsion, High Blood Pressure and Incontinence urinary. On 10/10/2022 at 12:20 PM the yellow code was activated, patient was aggressive, combative, uncooperative, agitated and did not follow instructions. By medical order, Haldol (antipsychotic agent) 5 mg intramuscularly and Ativan (management of anxiety disorder) 2 mg intramuscularly STAT (a one time order is administered without delay due to urgency of the circumstances) were administered. Chemical restraint are ordered to avoid imminent harm to oneself and others.

At the time of evaluating the clinical record, the physician face-to-face evaluation was not found.

On 10/11/2022 at 5:00 PM a yellow code, "Psychiatric Emergency" was activated, the patient was aggressive, uncooperative, kicking and upset. The physician was notified, and he ordered Haldol 5 mg intramuscularly and Ativan 2 mg intramuscularly STAT.

At the time of evaluating the clinical record, the doctor's face-to-face evaluation was not found.

On 10/11/2022 at 9:00 PM yellow code, Psychiatric Emergency was activated, the patient was aggressive, uncooperative, kicking, and upset. The physician orders mechanical restriction on all four extremities due to agitation and physical aggression.

During interview to the facility Operational Director (employee #3) on 09/06/2023 at 1:25 PM explains that during the first hour of restraint the patient will be evaluated face- to- face by the physician.

During the evaluation of this record, the lack of face-to-face evaluation by the doctor was evident.



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2. RR #1 is a 43-year-old female patient admitted on 09/29/2021 at 8:00 PM with a diagnosis of Bipolar Disorder, Obesity Medication abuse. During the record review performed on 09/06/2023 at 10:14 AM it was found that:

The patient arrives and is registered at the facility on 9/29/2021 at 7:30 PM.

Patient was evaluated by the facility personnel at 8:00 PM and was an Involuntary admission due to Puerto Rico Mental Health Law 408 , Involuntary admission (Mechanism for the involuntary hospitalization of a person for a period of no more than 15 days after a team of mental health professionals evaluates the person and certifies the need for involuntary treatment. When ordering the involuntary admission of a person, the Court will indicate follow-up hearings that are necessary until the participant's recovery).

Due to physical aggression with family, no sign or symptom of sleep apnea, accordance to the nurse evaluation patient was illogical, incoherent, with psychiatric and aggressive history, and refuse to provide information. The patient's mother refers during call that patient have medication abuse and was incoherent, denied homicide, suicidal ideas, and hallucinations. Patients use Ativan (management of anxiety disorder) 2 milligram (mg), Motrin (non-steroid anti-inflammatory drug), Neurontin (relieve pain for some conditions), Baclofen (skeletal muscle relaxant), Seroquel (antipsycotic agent) 200 mg no specified the dose and frequency, and parent did not know.

Patient mental status was untidy, alert oriented in person, was anxious, poor attention, thought illogic y disorganized.

The physician notes 09/29/2021 at 8:00 PM at the stabilization room indicate that "was transferred from transferring hospital with a Law 408 due to physical aggression with family, Patient with disorganized and illogical thoughts. Mother indicates abuse of over the counter (OTC) medications, including Motrin (non-steroid anti-inflammatory drug). Likewise, she requests Tramadol (analgesic) and Baclofen (skeletal muscle relaxant). Patient arrives disorganized and is transferred to the unit for stabilization. Physician Admission order performed at 09/29/21 at 8:00 PM indicate aggressive risk precaution, Interdisciplinary Therapy: Individual, Group, Occupational and Recreative Therapy, and Family session. Vital Sign twice daily and at bedtime Oxymetry every 4 hour and at bedtime. Psychiatric evaluation as soon as possible.

On 09/29/2021 at 8:10 PM the physician ordered Haldol (antipsycotic agent) 5 mg intramuscular (IM) stat, Ativan 2 mg IM stat, the nurse takes the order at 8:30 PM.

At 8:15 PM the nurse performed The Management of Specific Psychotropic Medications sheet and evaluate patient vital sign at 8:15 p.m. was Blood Pressure (B/P) 159/79 millimeter of Mercury (mm/Hg), Pulse (P): 106, Respiration (R): 17, Temperature (Temp): 36.5, patient vital sign at 8:45 p.m. was B/P 155/73 mm/Hg, P: 98, R: 17, patient vital sign at 9:15 p.m. was B/P 140/72 mm/Hg, P: 95, R: 17

The Nurse documented in the progress note of 09/29/2021 at 8:10 PM that patient arrive to the unit Close Observation Unit (COU) with paramedical personnel, patient was observed disorganized, discouraged, quiet and suspicious.

Patient on an ambulance stretcher with soft restrictions on the hands, is placed in a quiet room, the Vital Sign: Blood Pressure (B/P): 159/79 millimeter of Mercury (mm/Hg), Pulse (P): 106, Respiration (R): 17 Temperature 36.5 grade Fahrenheit, Oximetry 97%. At 8:30 PM Haldol (antipsychotic agent) 5 mg IM stat, Ativan (management of anxiety disorder) 2 mg IM stat was administrated to optimize the treatment in the left gluteus. At 9:30 PM the Mental Health Technician observed a patient sitting in the bed agitated and rapid breathing.

The nurse goes to the Quit Room to verify the vital sign. The patient becomes rigid and with involuntary movements, code orange (medical emergency) is activated, the patient is observed with a purple face and green code (cardiorespiratory arrest) is activated. At 9:30 PM Cardiopulmonary resuscitation (CPR) was started providing manual respiration.

Accordingly with information provided by the Facility Operational Director (employee #3), on 09/06/2023 at 11:00 AM while reviewing and discussing the case a plan of care must be prepared on this case after chemical restriction with this medication was performed. On this case the employee #3 stated on 09/06/2023 at 11:40 AM that chemical restraint is used to reduce agitation, aggression and violent or erratic behavior. She stated that chemical restriction is indicated with this patient because due to his/her behavior poses danger to self, others and hospital property. She also stated that due to risks associated with the use of chemical restriction there are interventions that must be performed by personnel in charge of patient. The plan of care guide interventions that personnel must follow.

No evidence was found related to the physician performance the Face to Face evaluation to the patient.

Review of twenty clinical records, policies/procedures and interviews with the facility Quality Assessment Performance Improvement QAPI officer (employee # 3), it was determined that the facility failed to document in the patient's medical record the date and time when a patient dies in a period within 24 hours after the patient has been removed from restraint. This deficient practice was identified on 2 out of 20 records reviewed (RR # 1 and RR#2). Facility failed to ensure that electronic information of Form CMS-10455 used to report Hospital death associated with the use of restraint or seclusion contain accurate information related with this event. This deficient practice was identified on 1 out of 20 records reviewed (RR#2).

Findings include:

Upon review of the facility's policy on 09/07/2023 at 2:45 PM title: " Uso Correcto y Manejo de Restricciones Fisicas/Químicas y Aislamiento"Correct Used of Physical/ Chemical Restraint and Isolation "last update on December 2022. The Policy did not include provisions or procedures to ensure personnel in charge of a patient who dies in a period within 24 hours after the patient has been removed from restraint, document in the patient's medical record the date and time the death was reported to CMS.

During interview on 09/07/2023 at 2:55 PM facility QAPI Officer (employee #3), stated that facility did not have provisions or procedures on the policy to ensure that personnel in charge of a patient who die in a period within 24 hours after the patient has been removed from restraint document in the patient's medical record the date and time the death was reported to CMS. She also stated that the report of CMS electronic information on the form CMS-10455 used to report Hospital death associated with the use of restraint or seclusion was verified and sent by facility Corporate Headquarters.