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Based on observation, interview, and record review, the hospital failed to ensure one of eight sampled patients' (Patient 4) whiteboard in the room was updated with pertinent information. This failure posed the risk of the patient to not be involved or knowledgeable of his plan of care.

Findings:

Review of the hospital's P&P titled Hourly Rounding dated May 2022 showed the nurses will make the hourly patient rounds to ensure patient safety, comfort and encourage patient participation in his or her daily care. Rounding will be documented on either the white board or paper, depending on the patient care unit. Nurses will make rounds every hour focusing on pain, positioning, bathroom needs, patient safety, and equipment safety. Patients will be educated and encouraged to participate in the rounding process.

On 10/22/24 at 1307 hours, an observation of Patient 4 in Bed A was conducted with the Director of Clinical Quality Improvement. Patient 4's whiteboard was observed on the wall to the left of the patient's bed. The whiteboard was blank. The areas to show the date, RN and NA name, diet, activity, and care goals were not filled in.

The Director of Clinical Quality Improvement acknowledged the findings and stated the whiteboard was being immediately corrected.

Based on observation, interview, and record review, the hospital failed to ensure the medical record was secured for one of eight sampled patients (Patient 3). This failure posed the risk of violating the patient's rights.

Findings:

Review of the hospital's P&P titled Information Management Plan dated October 2024 showed the patients' individual records are deemed confidential.

On 10/22/24 at 0910 hours, the ED was toured with the ED Director and Director of Clinical Quality Improvement. When toured the triage area in the ED, Patient 3's electric medical record was observed in the computer screen. Patient 3's electric medical record was opened unattended. The Director of Clinical Quality Improvement verified the above findings.

Based on interview and record review, the hospital failed to ensure one of eight sampled patients' (Patient 4) care plan was updated to reflect the use of non-violent restraints during the hospitalization. This failure created the risk of substandard outcomes for the patient.

Findings:

Review of the hospital's P&P titled Restraint Orders, Application, and Management dated June 2024 showed use of restraints must be addressed in the patient's modified plan of care.

On 10/22/24, Patient 4's open medical record review was initiated with RN 3 and Nurse Manager 2.

Patient 4's medical record showed Patient 4 was admitted to the hospital on 10/21/23.

Review of physician's order dated 10/22/24 at 0405 hours, showed the non-violent BUE soft limb restraints were ordered for Patient 4.

Review of the Restraint Flowsheet dated 10/22/24 at 0230 and 0430, showed Patient 4 was restrained on the BUE with soft limb restraints.

However, further review of Patient 4's medical record failed to show the patient's care plan was updated to address the use of non-violent restraints.

On 10/23/24 at 0930 hours, the above findings were shared and acknowledged by the Directof of Clinical Quality Improvement.

Based on interview and record review, the hospital failed to ensure the physician's phone read-back orders for non-violent restraint telephone order were authenticated for two of eight sampled patients (Patients 4 and 5). This failure created the risk of substandard outcomes to the patients.

Findings:

Review of the hospital's General Rules and Regulations dated 3/22/24, showed the restraint orders will be authenticated, dated and times by the prescriber or the attending physician responsible for the patient's care at the time the orders are given or covering physician within 24 hours.

1. On 10/22/24, Patient 4's open medical record review was initiated with RN 3 and Nurse Manager 2.

Patient 4's medical record showed Patient 4 was admitted to the hospital on 10/21/23.

Review of the physician's order dated 10/22/24 at 0405 hours, showed the non-violent BUE soft limb restraints were ordered for Patient 4. The order source showed RN 4 entered a "Phone Read Back - Authorization Required" for MD 1 for non-violent BUE soft limb restraints on Patient 4.

On 10/23/24 at 0930 hours, the Director of Clinical Quality Improvement verified the restraint order had not been authenticated by MD 1.

2. On 10/22/24, Patient 5's open medical record review was initiated with Nurse Manager 2.

Patient 5's medical record showed Patient 5 was admitted to the hospital on 10/13/24.

Review of the physician's order dated 10/16/24 at 2300 hours, showed the non-violent BUE soft wrist restraints were ordered for Patient 5. The order source showed RN 5 entered the order as a "Phone Read Back - Authorization Required" for MD 2. Further review of the validation portion of the order showed MD 2 signed the order on 10/18/24 at 0124 hours.

Review of the physician's order dated 10/18/24 at 2000 hours, showed the non-violent BUE soft wrist restraints were ordered for Patient 5. The order source showed RN 6 entered the order as a "Phone Read Back - Authorization Required" for MD 2. Further review of the validation portion of the order showed MD 2 refused the signature authentication on 10/19/24 at 1020 ours. The refusal reason showed, "Not my patient - Please forward to..." MD 3.

On 10/23/24 at 0930 hours, the above findings were shared and acknowledged by the Director of Clinical Quality Improvement.

Based on interview and record review, the hospital failed to ensure one of eight sampled patients (Patient 5) had the progress notes from the physician which addressed the need for continued use of non-violent restraints every calendar day. This failure created the risk of substandard outcomes to the patient.

Findings:

Review of the hospital's P&P titled Restraints Orders, Application, and Management dated June 2024 showed the physician's progress note must address the need for continued use of non-violent restraints every calendar day.

On 10/22/24, Patient 5's open medical record review was initiated with Nurse Manager 2. Patient 2 was admitted to the hospital on 10/13/24.

Patient 5's medical record showed Patient 5 was admitted to the hospital on 10/13/24.

Review of the physician's order dated 10/19 at 0755 hours and 10/20/24 at 2102 hours, showed Patient 5 was placed on nonviolent BUE soft limb restraints.

However, review of the physician progress notes failed to show the covering physician addressed the need for continued use of restraints on Patient 5 on 10/19 and 10/20/24.

On 10/23/24 at 0930, the Director of Clinical Quality Improvement was informed and acknowledged the above findings.