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Based on review of one (1) of five (5) medical records (#8), staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that all patients, or their designated representative, receive a written notification of their patient rights.

Findings include:

Reference: Facility policy, "Patient Rights" states, "... 1. All patients receive written information regarding all aspects of their hospital stay, including a "Patients Rights" policy... New Jersey Patient Rights... Pursuant to New Jersey law, every patient of [name of facility] shall have the following rights and privileges... 6. The right to receive a summary of his or her rights as a patient that includes the name and telephone number of the hospital staff member whom the patient may contact with any questions or complaints regarding his or her rights as a patient. ... ."

1. Review of Medical Record #8 on 5/6/21 lacked evidence of a signed copy of the "Patient Bill of Rights Acknowledgement" form. The form states, "I acknowledge receipt of a copy of the Patient Bill of Rights."

2. Upon interview on 5/6/21 at 1:00 PM, Staff #2 stated that patients and/or their designated representative are required to sign the form to confirm that a summary of the patient's rights was provided.

Based on review of one (1) of five (5) medical records (#10), staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure assessments and monitoring of patients in restraints, is documented.

Findings include:

Reference: Facility policy, "Observation of Patients in PES and Inpatient Units" states, "... Procedure (Special Observation): 1. Initiate special observation upon physician or nursing order as stated in policy. ... 4. Document use of restraints and/or seclusion by: a. Checking alternate measures used prior to restraint/seclusion. b. Entering the time therapy is initiated and discontinued. c. Placing a check in the appropriate box to note use of restraints and or/or seclusion (Quiet Room). d. Entering the time and brief explanation for use of therapy. e. Entering the time and check to signify that the therapy and behavioral expectation for discontinuing have been explained to the patient. ... 7. Document the patients status once during the every 15 minute/1 hour observation period for the duration of the patients stay by: a. Denoting the behavioral code(s) which best describes the patient behavior... 11. Document additional monitoring and care of patients in restraints by: Completing sections required for restraint therapy... d. Placing a check every two (2) hours that restrained extremities have been checked for redness, edema, and skin alterations and to note if circulation is satisfactory or if an alteration is identified... f. Placing a check every two (2) hours that extremities were released and exercised... 12. Discontinue special observation when restraints and/or seclusion therapy are discontinued or patient required less intensive monitoring based on team discussion... c. Note the time the 1:1 observation/restraint/seclusion was discontinued and the time of any change in level of observation. ... ."

1. Upon interview on 5/5/21 at 11:40 AM, Staff #6 and Staff #7 confirmed that nurses are required to document on the "Violent/Self Destructive Behavior RN Restraint/Seclusion Flow Sheet" for patients placed in seclusion or restraints.

a. Review of the "Violent/Self Destructive Behavior RN Restraint/Seclusion Flow Sheet" revealed that documentation on the flow sheet includes the following: initiation of restraints, time of therapy, explanation for use of therapy, psychosocial assessment, behavioral codes, physical assessments, monitoring, and discontinuation of treatment.

2. Review of Medical Record #10 on 5/6/21 revealed the following:

a. A restraint order was placed by the physician on 4/11/21 at 8:37 AM for a "Physical Hold," initiated at 8:15 AM and discontinued at 8:20 AM.

(i) There was no evidence of a "Violent/Self Destructive Behavior RN Restraint/Seclusion Flow Sheet" for the restraint order for a "Physical Hold."

b. A restraint order was placed by the physician on 4/11/21 at 8:37 AM for a "Mechanical Limb" restraint initiated at 8:25 AM and discontinued at 12:25 PM.

(i) There was no evidence of a "Violent/Self Destructive Behavior RN Restraint/Seclusion Flow Sheet" for the restraint order for a "Mechanical Limb."

3. Staff #1 and Staff #2 confirmed the above findings on 5/6/21 at 3:07 PM.

A. Based on review of five (5) of eleven (11) medical records (#3, #4, #5, #8, #10), staff interviews, and review of the State of NJ Nurse Practice Act, it was determined that the facility failed to ensure that patient care treatment and interventions are executed in accordance with a physician's order and that nurses provide care within their scope of practice.

Findings include:

Reference: The New Jersey Board of Nursing Statutes 45:11-23, Nurse Practice Act states, " ... b. The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. ... ."

1. Review of Medical Record #3 on 5/6/21 revealed the following:

a. The "Observation Record" form dated 5/5/21 states, "Special Observation Initiated By: MD Order; Reason(s): Other (specify): Unpredictable; Type: 1:1 Monitoring ('While in Restraints' is handwritten next to 1:1 Monitoring)."

b. There was no evidence of a physician's order for one-to-one (1:1) monitoring while the patient is in restraints, as indicated on the "Observation Record" form.

2. Review of Medical Record #4 on 5/6/21 revealed the following:

a. The "Observation Record" form, dated 5/5/21, states, "Special Observation Initiated By: MD Order; Reason(s): Fall Risk, Other (specify): Unpredictable; Type: 1:1 Monitoring."

(i) There was no evidence of a physician's order for 1:1 monitoring, as indicated on the "Observation Record" form.

b. A "New Medical Order/Order Summary" form, dated 4/16/21, indicated the following order was entered for the patient: "Fall Precaution."

(i) The order was entered on 4/16/21 at 7:57 PM by Staff #17, an RN. There was no evidence of a physician's order for "Fall Precaution."

3. Review of Medical Record #5, on 5/6/21, revealed the following:

a. The "Observation Record" form dated 1/18/21 states, "Special Observation Initiated By: MD Order; Reason(s): New Admission, Fall Risk, Seizure Precaution, Type: 1:1 Monitoring."

(i) There was no evidence of a physician's order for 1:1 monitoring, as indicated on the "Observation Record" form.

4. Review of Medical Record #8, on 5/6/21, revealed the following:

a. The "Observation Record" form dated 4/15/21 - 4/16/21 states, "Special Observation Initiated By: MD Order; Reason(s): New Admission, Assaultive, Fall Risk, Seizure Precaution, Other (specify): Unpredictable; Type: 1:1 Monitoring ('While Awake' is handwritten next to 1:1 Monitoring)."

(i) There was no evidence of a physician's order for 1:1 monitoring while the patient is awake, as indicated on the "Observation Record" form.

b. A "New Medical Order/Order Summary" form, dated 4/16/21, indicated the following orders were entered for the patient: "Fall Precaution, Seizure Precautions, Safety/Precautions/Privileges, and Nursing Orders-1:1 continuous observation while awake."

(i) The orders were entered on 4/16/21 at 3:51 AM by Staff #18, an RN. There was no evidence of a physician's order for "Fall Precaution, Seizure Precautions, or Safety/Precautions/Privileges."

5. Review of Medical Record #10, on 5/6/21, revealed the following:

a. The "Observation Record" form dated 4/9/21-4/10/21 states, "Special Observation Initiated By: MD Order, RN Assessment."

(i) There was no evidence of a physician's order for 1:1 monitoring, as indicated on the "Observation Record" form.

6. Upon interview on 5/6/21 at 11:40 AM, Staff #2 stated, "Our nurses write the order for 1:1. It's in our policy. It's a nursing order based on the nurse's assessment of the needs of the patient."

7. Upon interview, on 5/6/21 at 12:05 PM, Staff #11 stated, "Nurses can initiate 1:1 and only have to tell the doctor that the patient is on a 1:1 - the doctors don't have to write an order for 1:1. The nurses can order it."

8. Staff #1 and Staff #2 confirmed the above findings, on 5/6/21 at 12:18 PM.

B. Based on review of two (2) of eleven (11) medical records (#4, #8), staff interviews, review of facility policy and procedure, and review of the State of NJ Nurse Practice Act, it was determined the facility failed to ensure that policies and procedures addressing nursing care and services align with the nurse's scope of practice, as indicated in the State of NJ Nurse Practice Act.

Findings include:

Reference #1: The New Jersey Board of Nursing Statutes 45:11-23, Nurse Practice Act states, " ... b. The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. ... ."

Reference #2: Facility policy, "Observation of Patients in PES and Inpatient Units" states, "... The charge nurse assigns nursing personnel to 1:1 monitoring, line of sight observation, observation at least once during every 15 minute period, or routine observation based on physician or nursing orders. The level of observation needed is reviewed at least daily and discontinued by a physician or nursing order based on who initiated the order. ... Procedure (Special Observation): 1. Initiate special observation upon physician or nursing order as stated in policy. ... Routine Observation & Adult Inpatient... Any adult inpatient determined not to require special observation in one of the above forms is placed on routine observation by a physician's order or by a Registered Nurse in collaboration with the attending/covering physician. ... Child Inpatient... All children admitted to the inpatient unit are assigned to a group based on their age and level of functioning. ... If a patient cannot attend the daily activity schedule, their level of observation will be raised to special observation. ... The level of special observation will be initiated by Physician Order or by a Registered Nurse in collaboration with attending/covering Physician. ... ."

1. Review of Medical Record #4 and Medical Record #8 revealed orders written on a "New Medical Orders/Order Summary" form for 1:1 observation. The orders were entered and signed by an RN.

2. Upon interview on 5/6/21 at 11:40 AM, Staff #2 stated, "Our nurses write the order for 1:1. It's in our policy. It's a nursing order based on the nurse's assessment of the needs of the patient."

3. Upon interview on 5/6/21 at 12:05 PM, Staff #11 confirmed, "Nurses can initiate 1:1 and only have to tell the doctor the patient is on a 1:1 - the doctors don't have to write an order for 1:1. The nurses can order it."

4. The facility's policy and procedure allows nurses prescriptive power outside their scope of practice.

5. Staff #1 and Staff #2 confirmed the above findings on 5/6/21 at 3:07 PM.


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C. Based on review of one (1) of three (3) medical records (#10), staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure documentation of restraint initiation, use, and discontinuation, is documented on the Observation Record form in the patient's medical record.

Findings include:

Reference: Facility policy, "Observation of Patients in PES and Inpatient Units" states, " ... PROCEDURE (Special Observation)... 3. Initiate an observation sheet and replace it daily at 7:00 AM... 4. Document use of restraint and/or seclusion by... a. Checking alternate measures used prior to restraint/seclusion. b. Entering the time therapy is initiated and discontinued. c. Placing a check in the appropriate box to note use of restraints and/or seclusion (Quiet Room)."

1. Review of Medical Record #10 on 5/6/21 revealed the following:

a. A restraint order was placed by the physician, on 4/12/21 at 9:17 AM, for a "Physical Hold," initiated at 8:09 AM and discontinued at 8:10 AM.

b. Review of the "Observation Record" form, dated 4/12/21, lacked evidence of documentation that indicated the restraint use, initiation, and discontinuation times.

2. Staff #1 and Staff #2 confirmed the above finding on 5/6/21 at 3:07 PM.