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Based on review of facility documents, medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure there were daily provider assessments for non-violent restraint use for two of two medical records reviewed (MR10 and MR11) and failed to complete vital signs (VS) per physician order in one of one medical record (MR1).

Findings include:

1. Review on July 6, 2022, of facility policy, "Restraints," last reviewed August 25, 2021, revealed "Policy: The medical and hospital staff of Robert Packer Hospital (RPH) is committed to preventing and reducing, the use of restraints while maintaining the patient's safety and dignity. A. Definition ... 3. Restraint for Non-Violent Behavior (Also known a Physical Healing)- behavior related to a non-psychiatric medical condition or symptom that indicates the need for intervention to protect the individual from harm. ... D. Restraints for Non-Violent/Non-Self Destructive (NV/NSD) Behavior (Also known as Physical Healing or Medical) ... 2. Restraint Order ... IV. The provider shall perform an in-person assessment of the restrained patient at least once every calendar day to assess medical and behavioral condition to determine if restraint shall be either re-ordered or discontinued. The assessment is documented in the progress note. ..."

Review on July 6, 2022, of MR10, revealed the patient was admitted on June 21, 2022, to the 9 South-West (SW) Med/Surg Unit. The patient was intubated and had chest tubes. Bilateral, soft-wrist, non-violent restraints were ordered on June 21, 2022, at 0844, due to restlessness and pulling at the tubes. The restraints were discontinued on June 22, 2022, at 0800. There was no documentation of the provider in-person assessment on June 21, 2022.

Interview with EMP4, on July 6, 2022, at 1030, confirmed the patient was admitted on June 21, 2022, to the 9 South-West (SW) Med/Surg Unit. The patient was intubated and had chest tubes. Bilateral, soft-wrist, non-violent restraints were ordered on June 21, 2022, at 0844, due to restlessness and pulling at the tubes. The restraints were discontinued on June 22, 2022, at 0800. There was no documentation of the provider in-person assessment on June 21, 2022. EMP4 confirmed the provider was to document an in-person assessment every day when non-violent restraint(s) were in use.

Interview with EMP1, on July 6, at 1035, confirmed the provider was to document an in-person assessment every day when non-violent restraint(s) were in use.

Review on July 6, 2022, of MR11, revealed the patient was admitted on June 16, 2022, to the the Intensive Care Unit. The patient had numerous fractures and was intubated. Bilateral, soft-wrist, non-violent restraints were ordered on June 17, 2022, at 0205, due to restlessness and pulling at the tubes. The restraints were discontinued on June 22, 2022, at 1000. There was no documentation the provider completed in-person assessments on June 17, 2022, June 18, 2022, June 19, 2022, June 20, 2022, and June 21, 2022.

Interview with EMP4, on July 6, 2022, at 1035, confirmed MR11 was admitted on June 16, 2022, to the Intensive Care Unit. The patient had numerous fractures and was intubated. Bilateral, soft-wrist, non-violent restraints were ordered on June 17, 2022, at 0205, due to restlessness and pulling at the tubes. The restraints were discontinued on June 22, 2022, at 1000. There was no documentation the provider completed in-person assessments on June 17, 2022, June 18, 2022, June 19, 2022, June 20, 2022, and June 21, 2022. EMP4 confirmed the provider was to complete in-person assessments every day when non-violent restraint(s) were in use.

2. Review on July 6, 2022, of facility policy "Documentation of Vitals on Med/Surg Floors," last reviewed March 2, 2021, revealed "Applies to: All Inpatient acute care units Purpose: Ensuring patients' vital signs are documented Process: Document all patients' vital signs within the EHR [electronic health record] in the set parameter ...4. ...Vital signs must be completed within the set parameters. A provider's order is required to change frequency of vital sign order. ..."

Review on July 6, 2022, of facility policy "Patient Rights and Responsibilities," last reviewed July 13, 2021, revealed "... Patient Rights: ... 3. ...You have the right to good quality care and high professional standards that are continually maintained and reviewed. ..."

Review on July 5, 2022, of MR1, revealed the patient had a surgical procedure on June 22, 2022. The patient was transferred from recovery to the 7 Main Unit, at 1658. Physician orders were for vital signs (VS) every 15 minutes until stable, then every 30 minutes x four, then every hour x 6, then QID (four times a day). There were no vital signs documented from the patient ' s admission on 7 Main, at 1719, until 2048, when MR1 was found unresponsive and pulseless. MR1 was pronounced at 2119.

Interview with EMP1, on July 5, 2022, at 1452, confirmed the patient had a surgical procedure on June 22, 2022. The patient was transferred from recovery to the 7 Main Unit, at 1658. Physician orders were for vital signs (VS) every 15 minutes until stable, then every 30 minutes x four, then every hour x 6, then QID (four times a day). There were no vital signs documented from the patient's admission on 7 Main, at 1719, until 2048, when the patient was found unresponsive and pulseless. MR1 was pronounced deceased at 2119. EMP1 confirmed the order for the VS was not followed.

Interview with EMP2, on July 6, 1500, confirmed facility's expectation was the nurse was to follow the provider's VS order.

Based on review of facility policy, medical records (MR's) and staff (EMP) interview, it was determined the facility failed to administer pain medications as per physician order in two of 12 records reviewed (MR1 and MR12) and failed to ensure nursing staff conducted pain assessments and/or reassessments for administered as needed (prn) pain medications per facility policy in four of 12 records reviewed (MR1, MR4, MR5 and MR12).

Findings include:

Review of facility policy "Pain Management," last revised August 17, 2021, revealed "Policy: All admitted patients should be assessed for pain initially with admission assessment, and then subsequently thereafter according to assessment findings. Patients should receive treatment for pain relief as warranted and be monitored for effectiveness. 1. Assessment: a. Every patient is assessed upon admission as part of admission database and minimally every twelve (12) hours to determine comfort level and daily functional goals. Pain control is tailored to meet individualized patient needs ... b. When pain is identified, either acute or chronic, a more comprehensive assessment will be performed and include the following items: Intensity, Location, Description, Onset, Duration, Time Pattern, Alleviating Factors, Aggravating Factors and Comfort Goals c) Frequency of assessment should be increased and individualized for patients experiencing uncontrolled pain, breakthrough pain, or when changes in the pain management plan of care are initiated. (i.e. surgery). ... d. Pain intensity can be determined by the use of a pain-rating scale appropriate for the patient's stage of growth and development and cognitive ability / NRS or 0 - 10 scale for adults with no verbal or cognitive impairment, as well as in procedural areas, LDRP, BHU, ED, PACU; SMILES or FACES for pediatric/adolescents from 3 years to 17 years of age, or adults with some verbal deficits or cognitive impairment; FLACC should be used for pediatrics 1 to 2 years of age as well as non-verbal patients or patients intubated and not using the CPOT); CPOT (Critical-Care Pain Observation Tool-Pain scale uses non-verbal observations such as facial expression, body movement, muscle tension and compliance with ventilator.); PAIN-AD for patients with advanced dementia and either non-verbal or non-cognitive patients; NIPS is to be used for the Neonate from 0-2 months of age. e. 'No pain or denies pain equals 0 on the numeric pain scale' ... 2. Reassessment: Effectiveness of PRN pain medications and other interventions must occur within 30 - 90 minutes after administration, or when therapeutic effectiveness can be assessed. ...3. Pain Scales a. Adult / Pediatric - to be used in Pediatric population/adults with language deficit or understanding Smiles or Wong-Baker Faces Pain Rating Scale ... e. CPOT- Critical-Care Pain Observation Tool ... This scale should be used in ICU for either ventilated or non-ventilated/non-verbal patients. ... 6. Documentation: documentation of pain experience is ongoing following assessment and includes pain rating scores, (using appropriate scale) interventions, and individual patient responses. ..."

Review of facility policy "As Needed (PRN) Medication Orders," last approved April 8, 2022, revealed "Policy: As needed (PRN) orders are those medication orders acted upon based on the occurrence of specific indication or symptom. Procedure: ... 2. If more than one medication with the same PRN indication is ordered, prescribers should include clear guidance as to when to use one medication over another. 3. When more than one medication is ordered for the same PRN indication and specific instructions are not included (as to when to use one medication over another) contact the physician/provider to clarify the PRN medication order. 4. A licensed registered nurse may administer a drug ordered for a patient in the dosage and manner prescribed (PA Code 21.14) ... 6. Reassessment of the effectiveness of PRN medication administration should occur within 30-90 minutes ..."

Review on July 6, 2022, of facility policy "Prescribing and Ordering Medications - General Practices," last reviewed March 1, 2022, revealed "Policy: The Hospital will develop, implement and maintain policies and procedures to support prescribing and ordering of drugs to assist with the safe and legal use of medications. ... G. As needed "prn" orders ... 2. 'PRN' orders are required to have a reason(s) for use. a. The 'PRN' reason must provide clear guidance as to the circumstance under which each medication is to be administered b. The provider should be contacted to clarify 'PRN' medication orders that do not provide clear guidance ..."

Review on July 6, 2022, of facility policy "Patient Rights and Responsibilities," last reviewed July 13, 2021, revealed "... Patient Rights: ... 27. You have the right to effective pain management. ..."

1. Review on July 5, 2022, of MR1,with EMP1 revealed physician orders for Oxycodone 10 mg. oral (po), every four hours prn (as needed) for severe pain (pain scale 7-10) - 1st line, if immediate effect not required and patient can tolerate po; and Morphine 4 mg. intravenous (IV), every 3 hours prn for moderate pain (scale 4-6) - 1st line, if immediate effect required or patient cannot tolerate po, and severe pain (scale 7-10), if immediate effect required or patient cannot tolerate po. The patient received Oxycodone 10 mg. po and Morphine 4 mg IV, at 1719 for a pain scale of 8 (severe pain).

There was no documentation the physician was contacted to clarify the PRN medication order for the Oxycodone and Morphine that were both given on July 5, 2022 at 1719.

Interview on July 5, 2022, at 1445, EMP1 stated the Oxycodone 10 mg. po and Morphine 10 mg. IV may be given together as the Oxycodone po was for long term relief and the Morphine IV was for immediate effect.

Interview on July 5, 2022, at 1215, EMP6 stated the Oxycodone 10 mg. po and Morphine 4 mg. IV are able to be given together as the Oxycodone PO was for long term relief and the Morphine IV was for immediate effect.

Review of MR12 with EMP4 on July 6, 2022, at 1030, revealed the patient was ordered Tylenol 650 mg every 4 hours prn mild pain (pain scale 1-3) p.o. and Oxycodone IR 2.5 mg every 4 hours prn moderate pain (pain scale 4-6) p.o. On July 5, 2022, at 0509, nursing documented the patient's pain as 8. No intervention was documented. On July 5, 2022, at 0930, nursing documented the patient's pain as 10. Provider was notified and new orders were obtained for Oxycodone IR 10 mg every 6 hours prn severe pain (pain scale 7-10). This medication was administered on July 5, 2022, at 1035.

2. Review on July 5, 2022, of MR1, revealed the patient received Oxycodone 10 mg. po and Morphine 4 mg IV, at 1719. There was no documentation of the pain reassessment following the administration of the pain medications given on June 22, 2022, at 1719.

Interview with EMP1 and EMP2, on July 5, 2022, at 1445, confirmed MR1 received Oxycodone 10 mg. po and Morphine 4 mg IV, at 1719, and no pain reassessment was documented following the administration of the pain medications given on June 22, 2022, at 1719. EMP1 confirmed a pain reassessment was required 30-90 minutes after the patient received the pain medication.

Review of MR4 with EMP4 on July 6, 2022, at 0910, revealed the patient was assessed. The patient's pain level was 5. The patient was administered Oxycodone IR 5 mg as ordered by the physician. There was no documentation of a pain reassessment within 90 minutes.

Review of MR5 on July 6, 2022, at 1000, with EMP4 revealed the patient was administered Percocet 10-325 mg tablet on July 4, 2022, at 0821. There was pain documented on July 4, 2022, at 0830 as yes. No numeric scale was given. The intervention was listed as medicated. There was no documentation of a pain reassessment. On July 4, 2022, at 1743 the nursing assessment for pain stated "right" without a location (i.e. lower extremity, upper extremity). No numeric scale was documented. Percocet 10-325 mg tablet was administered on July 4, 2022, at 1743. There was no documentation of a pain reassessment within 90 minutes.

Review of MR12 with EMP4 on July 6, 2022, at 1030, revealed on July 5, 2022, at 0509, the patient's pain assessment scale was 8. No intervention was documented. There was no reassessment of pain until July 5, 2022, at 0930. The pain assessment scale was 10. The provider was notified. New orders were obtained for Oxycodone IR 10 mg every 6 hours prn for severe pain scale 7-10. Pain medication was administered on July 5, 2022, at 1035.