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Based on interview and record review, the facility failed to follow its policy to ensure documentation was completed timely for one of three sampled patients (Patient 3) who was placed in restraint (physical or chemical method that limit a patient's ability to move, often to prevent harm to themselves or others).

This failure had the potential to compromise the safety and comfort of Patient 3 while in restraint.

Findings:

Patient 3 was admitted to the facility on 7/11/25 with diagnoses which included cerebrovascular accident (blood flow to the brain is disrupted, causing brain damage), per Patient 3's Facesheet.

An interview with the Director of Regulatory Affairs (DOR) was conducted on 8/13/25 at 2:59 P.M. The DOR stated it was the facility's policy for the Registered Nurse (RN) to document on the restraint flowsheet (a part of the medical record where nurses document the nursing assessment related to restraints) at the beginning of the nurse's shift, and then an attestation at the end of the nurse's shift, indicating that the patient on restraints was monitored every two hours during the shift.

A review of Patient 3's medical record was conducted on 8/14/25 at 1:15 P.M. with Nurse Manager (NM) 1.

Patient 3's medical record included a physician's order, dated 8/1/25 at 12:52 A.M., for restraints to both wrists.

A review of Patient 3's restraint flowsheet, dated 8/1/25, was conducted. There was no documentation at the end of the RN 1's shift. NM 1 stated there were no other notes related to assessing Patient 3's restraints on 8/1/25, in Patient 3's medical record. NM 1 stated that RN 1 should have completed the end-of-shift documentation on the restraint flowsheet, at the end of the shift.

Patient 3's medical record included a physician's order, dated 8/5/25 at 12:16 A.M., for restraints to both wrists.

A review of Patient 3's restraint flowsheet, dated 8/5/25, was conducted. There was no documentation at the end of the RN 2 and RN 3's shift on 8/5/25. NM 1 stated that there were no other notes from RN 2 and RN 3 in the medical record, related to assessing Patient 3's restraints for their shifts. NM 1 stated that RN 2 and RN 3 should have completed the end-of-shift documentation on the restraint flowsheet at the end of their shifts.

A review of Patient 3's medical record was conducted on 8/15/25 at 10:01 A. M. with the Quality Compliance Specialist (QCS). The restraint flowsheet was reviewed. The row titled, End of Shift: Restraint Evaluation, included the options to indicate range of motion (movement) was provided to the patient, hygiene was provided to the patient, restraints were secured properly, and skin assessment was completed.

An interview was conducted with Senior Nursing Director (SND) on 8/15/25 at 10:06 A.M. The SND acknowledged it was important to document an end-of-shift attestation to ensure Patient 3's needs were being met while in restraints, and for Patient 3's safety, per the facility's policy.

A review of the facility's policy titled Non-Violent Restraint, revised 7/5/24, indicated " ...IV. Non-Violent Restraint Monitoring: A. Patients will be assessed every 2 hours at a minimum ...Document end-of-shift evaluation on restraint flowsheet, regarding observations and care provided at two-hour intervals. Including; Activity, circulation, range of motion, fluids, food/meals, and toileting ..."

Based on interview and record review, the facility failed to follow its policy when:

1. The facility failed to ensure a pain reassessment was completed for one of 30 sampled patients (Patient 14).

2. The facility failed to ensure pain was managed timely for one of 30 sampled patients (Patient 8).

These failures had the potential for Patient 14 and Patient 8's pain to be mismanaged and unrelieved.


Findings:

1. Patient 14 was admitted to the facility on 8/7/25 with diagnoses which included cholecystitis (swelling and irritation of the gallbladder, a small organ in the right side of the stomach), per Patient 14's History and Physical (H&P).

A review of Patient 14's physician's orders, dated 8/8/25, indicated "Oxycodone (medication for pain relief) 5 mg (milligrams) every 6 hours as needed for moderate pain (Pain Score 4-6)" was ordered.

On 8/13/25 at 1:30 P.M., a concurrent interview and review of Patient 14's medical record was conducted with Registered Nurse (RN) 13. Patient 14's medication flow sheet (record of medication administration) indicated that on 8/12/25 at 8:35 P.M., Oxycodone 5 mg was administered for a pain score of 5. Further review of Patient 14's flowsheet records indicated that a reassessment of Patient 14's pain was not completed after the administration of the Oxycodone. RN 13 stated that the nurse should have reassessed Patient 14's pain, 45 to 75 minutes after the administration of the pain relief medication, to ensure if it was effective, if it was too strong, or if other pain relief resources were needed.

According to the facility's policy titled "Pain Clinical Practice Guideline" dated 6/2022, " ...Pain should be assessed and reassessed ...After each pain management intervention or at the peak of a pharmacological intervention's effect (approximately 45-75 minutes ...) ...Nurses are responsible to perform and document pain assessments ..."


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2. Patient 8 was admitted to the facility on 8/12/25 with diagnoses which included falls, according to Patient 8's History & Physical (H&P), dated 8/13/25. The H&P indicated Patient 8 experienced chronic (ongoing) pain from severe osteoarthrosis (degenerative joint disease- joints wear down over time, leading to pain) of the hips and left shoulder. Patient 8's H&P indicated the plan of care included pain management.

A concurrent interview and review of Patient 8's medical record was conducted on 8/14/25 at 11:04 A.M. with the Senior Nursing Director (SND):

Patient 8's Medication Administration Record (MAR; record where nurses document what medications were given) dated 8/13/25, indicated that Patient 8 had pain medications, Tylenol and Oxycodone, ordered to help relieve pain. Pain was defined in the MAR as mild pain (pain score 1-3), moderate pain (pain score 4-6), and severe pain (pain score 7-10).

A review of Patient 8's pain flowsheet (part of the medical record where nurses document the nursing assessment related to pain) dated 8/13/25, indicated Patient 8's pain was assessed at 4:56 P.M. with a pain score of four out of ten, moderate pain.

A review of the pain flowsheet row, titled Pain Interventions(s) on 8/13/25 at 4:56 P.M. was not completed. Patient 8's pain score remained a four out of ten on 8/13/25 at 8 P.M.

A review of the pain flowsheet row, titled Pain Intervention(s) on 8/13/25 at 8 P.M. indicated "Medication (See eMAR)" indicating medication was given to help relieve Patient 8's pain.

A review of the MAR was conducted. There was no documentation that indicated a pain medication was administered to Patient 8 at or around 8 P.M. on 8/13/25.

The SND stated there were no other pain interventions including non-pharmacological interventions (other ways to manage pain that does not include medications) that were documented in the flowsheets or notes, related to treating Patient 8's pain at 4:56 P.M. and 8 P.M. on 8/13/25. Further, the SND stated there was no documentation in the medical record that the physician was notified that Patient 8's pain goal of two out of ten was not met on 8/13/25 at 4:56 P.M. and 8 P.M. Patient 8 did not receive another pain medication until 8/14/25. The SND acknowledged Patient 8 did not receive any pain management interventions on 8/13/25 at 4:56 P.M. and 8 P.M.

A follow-up interview was conducted on 8/15/25 at 10:06 A.M. with the SND. The SND stated that patients have different thresholds for pain, and a pain of "four out of ten" did not meet Patient 8's needs, as Patient 8's pain goal was "two out of ten".

A review of the facility's policy titled Pain Management, revised 7/5/24, indicated " ...This policy establishes guidelines relevant to achieving optimal patient comfort through a proactive pain management program ...requires a balance between pain relief, safety, and the side effects of interventions ...pain is subjective, that only the person who has the pain knows exactly how severe it is, and that people with pain have the right to assessment and treatment ...Pain assessment and re-examination of the pain management plan continue until the pain reduction is satisfactory to the patient ...The patient's provider will be contacted for further assessment if the ordered interventions are not effective in providing a reduction in the self-report pain score ...Definitions ...VII. Pain Goal: the patient's stated acceptable level of pain ..."