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Based on observation, interview, and record review, the facility failed to protect and promote the rights of 1 (P-2) of 15 patients reviewed, resulting in the potential for unsatisfactory outcomes. Findings include:

See tags:
A-0145 Failure to ensure patients were free from neglect.
A-0165 Failure to remove restraints at the earliest possible time.

Based on observation, interview, and record review, the facility failed to ensure nursing staff implemented interventions for prevention and treatment of changes in skin integrity for 2 (P-1, P-7) of 3 patients reviewed for skin integrity resulting in the potential for alterations in skin integrity for all patients at risk for pressure injury. Findings include:

See tags:
A-0395 Failure to document nursing assessments, including wound prevention measures.

Based on observation, interview, and record review, the facility failed to ensure patients were free from neglect for one (P-2) of seven patients reviewed for neglect from a total of 15 patients, resulting in poor outcomes for P-1. Findings include:

On 8/20/2025 during document review of patients with extended length of stay, it was noted that P-2 was admitted on 01/18/2025 due to mental health concerns. P-1 was ambulatory at the time of admission and documented as being combative with staff requiring restraints. The patient has been in the facility for 211 days when he was observed on 08/20/2025 to be calm, malnourished, smelled of urine, and was in bilateral soft wrist restraints with a 1:1 safety sitter. Review of safety sitter documentation revealed during the last 5 days (8/21/2025 - 8/26/2025), P-2 had calm cooperative behavior with no evidence of restraint justification.

Record review revealed the following: since admission to the facility on 1/18/2025, P-2 has had a 40lb weight loss. On admission P-2 had a documented weight of 64 kg (141 pounds) and on 03/06/2025 P-2 was documented as weighing 52.5 kg (116 pounds), decreased oral intake due to "tooth pain", went from running in the halls to requiring 70% assistance for mobility and continued to remain in restraints without evidence of restraint justification.

Based on record review, interview, and observation, the facility failed to use the least restrictive type of restraint for one (P-2) of three patients reviewed for restraint use, resulting in the loss of the patient's right to be free from restraint at the earliest possible time. Findings include:

On 08/21/2025 at 1400, a review occurred of P-2's medical record. P-2 was described as a 48-year-old male that was cognitively impaired with a documented history of schizophrenia and acute psychosis. P-2 arrived at the emergency department (ED) on 01/18/2025 with a petition and was certified for aggressive behavior at the nursing home where he resided. P-2 was documented as having a history of psychosis, hypertension, schizophrenia, and brain injury. P-2 remained in the ED crisis center until 01/23/2025, when a psychiatric resident documented P-2 as not meeting the criteria for admission to the in-patient behavioral health unit. The psychiatric resident continued to document that P-2 did not meet in-patient behavioral health unit admission criteria. However, P-2's documented diagnosis remained psychosis with history of schizophrenia.

P-2 was located in the ED crisis center from 01/18/2025 to 01/24/2025. ED crisis center nursing progress notes described P-2 as "oriented x 4, siderails up, resting comfortably on stretcher." The nursing progress note on 01/19/2025 documented the following: "The patient is resting comfortably on the stretcher, denies shortness of breath, denies distress, patient verbalizes understanding of treatment plan, including the use of restraints." On the same date 01/19/2024, at 20:25, the ED physician placed an order for 2-point restraints due to P-2 being "unable to follow safety instructions." P-2 remained in the ED crisis center until being transferred to the 5 W (medical surgical, telemetry unit) on 01/24/2025. While in the emergency department from 1/19 to 1/24, P-2 was documented as in restraints with no order for restraint found.

Review of the medical record revealed that P-2 was placed in 2-point, 3-point, and 4-point restraints, as well as having a sitter 1:1 at the bedside during his 215-day hospitalization (to present 08/21/2025).
On 08/21/2025 at 0900 during a tour of 5 W, P-2 was observed in room 521 with soft restraints on bilateral wrists. P-2 was smiling, grinding his teeth, and mumbling. At the time of observation, a safety attendant (sitter) Staff O, was observed in room 521 sitting in a chair.

On 08/21/2025 at 0901, an interview was conducted with staff O. Staff O was asked to explain her role and responsibilities as a safety attendant. Staff O stated, "I fill out the form." Staff O provided the document for review. The document was titled, "Constant Observer Flow Sheet." The following categories were listed included activity, behavior, location codes, and initials for every entry point.
The frequency of observations was marked constant and documented at a minimum of every 15 minutes.

At the time of observation, the 08/21/2025 document was reviewed and revealed the following: "Activity: #1 - sleeping, and #4 - lying still or sitting," ..."Behavior: #21 - quiet, #5 - mumbling incoherently, and #4 - cursing," and "Location: #1 - patient room." Staff O was queried why P-2 was in restraints, and if the restraints were removed when P-2 was documented as sleeping, quiet, and/or lying still. Staff O stated, "I don't have anything to do with the restraints ...I just sit here and write down stuff every 15 minutes."

A review occurred of the "Constant Observer Flowsheets" from 08/18/2025 - 8/20/2025. The "constant observer" documents reviewed revealed similar results. Random reviews (admission to current) of the documents were conducted with the same outcome with an occasional #2 - screaming, #17 - confusion, #18 - agitation, 19 - impulsive, and #25 - spitting. Record review of P-2's medical record revealed P-2 was receiving antipsychotics and antianxiety medications.

P-2's medical record revealed that upon admission P-2 was ambulating without assist, with the ability to "run in the halls." P-2's admission weight was documented as 141 pounds (64 kg), on 03/06/2025 documented as 116 pounds (52.5 kg). P-2 was also documented as having decreased oral intake since admission.

Physical therapy progress notes dated 08/13/2025 revealed P-2 now required 70% assistance to ambulate 400 feet.

On 08/21/2025 at 1510, review occurred of the facility's policy titled, "Restraint or Seclusion in the non-psychiatric," effective date 02/01/2024. According to section IV of the policy the following is revealed:

"Based on an individualized patient assessment, the use of restraint or seclusion is limited to those situations where it is necessary to ensure the immediate physical safety of the patient, staff members, or others. The type of techniques of restraint or seclusion must be the least restrictive intervention that will be effective to protect the patient or others from harm. Restraint or seclusion is discontinued as soon as safely possible.
A. All patients have the right to be free from physical or mental abuse and corporal punishment. All patients have the right to be free from restraint or seclusion of any form imposed as a means of coercion, discipline, or convenience. For retaliation by staff, restraints or seclusion may only be imposed to ensure immediate physical safety of the patient or others with appropriate physical assessment and adequate clinical justification. To facilitate the discontinuation of restraint or seclusion as soon as possible based on an individualized patient assessment and reevaluation.
B. As an adjunct to planned care, restraints may be used in response to unsafe behavior. The decision to use restraints is not driven by diagnosis or location, but by comprehensive individual patient assessment concluding that for this patient currently, the use of less restrictive measures poses a greater risk than the risk of using a restraint. Based on the patient's clinical presentation, the physician makes the determination for use of restraints, including type of restraints. 1. Staff will apply restraint or seclusion only when less restrictive interventions are ineffective. 2. Staff will use the least restrictive form of restraint or seclusion that protects the physical safety of the patient, staff or others."

Based on observation, interview, and record review, the facility failed to ensure nursing staff implemented interventions for prevention and treatment of changes in skin integrity for 2 (P-1, P-7) of 3 patients reviewed for skin integrity resulting in the potential for alterations in skin integrity for all patients at risk for pressure injury. Findings include:

On 8/20/2025 at 1425 a review occurred of P-1's medical record. P-1's initial nursing assessment on 07/08/2025 revealed that a "4-eyes" skin assessment was not completed. The initial nursing assessment included a Braden scale for P-1. P-1's documented Braden score was 16, indicating P-1 was at risk for pressure injury. Further review of the medical record revealed that on 07/13/2025 orders were placed for pressure injury prevention and management per policy.

On 08/20/2025 between 1000 and 1345, during a tour of the facility units of interest, registered nurses were asked if putting the EMR pressure injury prevention order set in place required a physician order. Nursing staff were aware of the prevention order sets and that they did not have to notify a physician prior to using the orders. Staff did admit that they don't always use the available preventative measures as they could or should.

On 08/20/2025 at 1555, P-7 was observed in a specialty bed in room 517. At the time of observation Patient Care Aide (PCA), Staff F was observed in room 517 conducting an accucheck (blood glucose monitoring test) on P-7. Staff F was asked to explain the purpose of P-7 being on a specialty bed, and if he assisted with every two-hour turns. Staff F stated, "is that a specialty bed? No, I haven't turned him ...maybe the turn team does that."

On 08/20/2025 at 1607, just outside of room 517, an interview was conducted with Staff X, Registered Nurse. Staff X was queried regarding P-7 whom she stated was her assigned patient. Staff X was asked what time her shift started that day, if she knew why P-7 was on a specialty bed, and if P-7 had pressure wounds. Staff X stated, "My shift started at 0700 ...I am not sure why he has a specialty bed." Staff X was unable to answer if P-7 had pressure wounds. Staff X scrolled through the Electronic Medical Record and was unable to locate a Braden scale and whether P-7 had any pressure wounds or why he was on a specialty bed. Staff X was then asked to show the documentation of every two-hour repositioning over the past 24 hours. Staff X was unable to find any documented turns for P-7 and stated, "maybe the turn team is turning him."

On 08/20/2025 at 1610, Staff C, the Director of Quality, was asked where the "turn team" documents patient turns in the EMR, and if she could show the turns completed for P-7 in the past 24 hours. Staff C went to the 5W nurses station and inquired as to where the documentation for turns completed by the turn team could be found. An RN at the nurses station stated P-7 is not on the turn team schedule for turning. Staff C stated, "it appears that P-7 has not been turned in the past 24 hours."

On 08/21/2025 a review occurred of the policy titled, "Pressure Injuries: Prevention and Management," policy 2 PC 5202, dated 04/14/2025. The following was revealed:

"A. RN assesses each patient admitted to an inpatient unit for risk pressure injury risk using the Braden Scale and performing the 4 'eyes' assessment.
1.Braden Scale score of <18 or low subscale scores indicates that the patient is at risk for pressure injury development. Interventions targeting risk areas are implemented to prevent and manage pressure injuries.
2. Patients with actual or healed pressure injuries are considered high risk, especially if found on admission.
B. RN's use the policies for basic nursing interventions and enter EMR orders aimed at the prevention and management of pressure injuries.
1. Provide assessment, planning, documentation and evaluation of skin, pressure injuries, and wound management with shift assessment. Pressure injuries are measured on admission, every Monday, upon development, or deterioration. 4 'eyes' assessment are performed on admission.
2. Assess patient by performing 4 'eyes' upon admission and transfer.
3. Assess the patient ' s risk using the Braden Scale.
4. Reposition patient to side lying position ensuring bony prominences are offloaded at least every 2 hours while in bed, unless contraindicated.
5. Initiate EMR orders for pressure injury prevention and management based on patient risk assessment and/or presence of pressure injuries directed toward specific subscale risk factors.
6. Identify and modify factors contributing to pressure injury development and/or delayed healing or worsening of existing pressure injuries.
8. Document, Altered Tissue Integrity as Plan of Care every shift for patients with pressure injuries, healed pressure injuries, or at risk for pressure injuries based on low subscales or Braden Scale Score < 18.
9. Consult dietitian for Braden Scale Score < 18 or Braden subscale nutrition score of < 2 or actual pressure injury.
10. Assess patient outcomes. Revise plan of care as needed.
11. Assure continuity of care through communication of plan to health care team members.
12. Consult the WOCC©/CWOCN/APRN/wound specialist for stage 3, stage 4, unstageable, deep tissue pressure injuries, medical device related pressure injuries or mucosal membrane pressure injuries pressure injuries and any hospital acquired injuries.
13. Enter hospital acquired pressure injuries into incident reporting database (MIDAS)."