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Based on the review of medical records, policies/procedures, and staff interviews, it was determined that the facility failed in allowing one patient (P) (P#4) of four patients reviewed, the right to leave the facility at will, and without restraint.


Findings include:


P#4 was admitted to the facility on 9/4/24 at 12:50 p.m. with the diagnosis of Altered Mental Status (change in mental function). P#4 had a past medical history of Hypertension (High blood pressure).


A review of the physician's progress notes on 9/5/24 at 5:06 p.m. revealed that an inpatient consult to psychiatry was ordered on 9/5/24 at 1:03 p.m.


A review of an 'Initial Psychiatric Consult Note' electronically signed 9/5/24 at 5:29 p.m. revealed that P#4's legal status was voluntary, and psychiatry will follow up in 1-2 days.


A review of a 'Hospital Medicine Service Progress Note' dated 9/8/24 at 9:27 a.m. revealed that psychiatry was following patient, and a re-evaluation was pending.
Continued review of section titled 'Addendum'; no date/time revealed that the physician was requested to assist re-directing P#4. Physician arrived at the first floor of the facility and observed security surrounding P#4 and P#4 visibly upset and sweating. The physician escorted P#4 back to the patient's room. P#4 stated that he 'just wanted to go home'. P#4 agreed to stay and see psychiatry. Continued to review revealed that P#4 denied suicidal or homicidal ideations.

Continued review of the 'Note', section 'Addendum', no date/time revealed that the physician discussed with psychiatry who recommended medication, a 1013 and a sitter.

Continued review of the record revealed that a 1013 was executed on 9/8/24 at 2:36 p.m.


P#4 was discharged home in stable condition on 9/10/24 at 6:28 p.m. with the diagnosis of Acute Metabolic Encephalopathy (a condition that occurs when the brain is affected by a lack of oxygen, glucose, or vitamins). Documentation under the discharge summary on 9/10/24 at 6:28 p.m. revealed that at the time of discharge, P#4 had no psychosis (a mental disorder characterized by a disconnection from reality), no suicidal ideation, and was cleared by psychiatry for discharge.


A review of the facility's "Restraints/Seclusion Policy", Policy #14884005, last revised 1/3/24, stated that the purpose of this policy was to establish guidance in the use of restraint and/or seclusion in order to:

o Protect the dignity and safety of patients, staff, and visitors through a safe restraint process;
o Identify patients at risk for restraint and provide alternatives to restraint use;
o Provide guidelines for the use of least restrictive interventions to avoid restraint and/or seclusion use;
o Define the procedure to be followed when alternatives have proven ineffective and restraints are necessary to maintain patient safety; and
o Define staff training requirements related to safe restraint processes.

The policy was dedicated to fostering a culture that supports a patient's right to be free from restraint or seclusion. Restraint use will be limited to clinically justified situations, and the least restrictive restraint will be used with the goal of reducing and ultimately eliminating the use of restraints.


A review of the facility's "Leaving Against Medical Advice Policy", Policy #16933269, last revised 11/12/24, stated that it was the policy of the facility that an adult patient has the right to refuse to remain in the hospital regardless of whether caregivers agree with the decision.

Leaving Against Medical Advice
1. If a patient informs the nursing staff that he/she is leaving, the immediate supervisor and/ or immediate nursing leader will be notified of the patient's desire to leave.
2. The immediate supervisor and/or immediate nursing leader, a physician, or designee will inform the patient of the risks of leaving as defined by the physician.
3. The physician/nurse informing a patient of risks will document the conversation with the patient in the medical record.
4. The patient's nurse should have the patient read and sign the form entitled "Leaving Hospital Against Advice" as posted with this policy on the intranet.
5. If the patient refuses to sign such a statement, the form should be completed with the patient's name and date and witnessed by staff. Staff should write "signature refused" on the form and make a notation in the medical record.
6. The Clinical Manager or Administrative Supervisor will be informed of the patient's intent to leave the hospital against advice.
7. An RL file should be submitted
8. In the event a patient on a 1013 requests to leave AMA or attempts to leave the facility, staff will make a reasonable effort to maintain the patient using nonrestrictive measures. Security should be immediately called to assist. See policy/ policies related to Psychiatric and Substance Abuse Referral.
9. If the patient is deemed an imminent risk to self or others or becomes violent, Public Safety or trained staff may institute restraint procedures at the direction of a Registered Nurse/Physician. See Restraint Policy/Guideline.
10. Patients may be provided with discharge instructions, prescriptions, and assistance to leave the facility.


A review of a 'Apparent Cause Analysis-Debrief', no date/time, revealed that P#4 was prevented from leaving the facility by Public Safety related to miscommunication about the 1013 status.


A telephone interview took place in the facility's conference room on 2/5/25 at 10:00 a.m. with Registered Nurse (RN) PP, who stated that P#4 had expressed he wanted to leave after he was given his morning medications, and he (RN PP) tried to persuade him (P#4) to see the doctor as there was no discharge plan in the process. RN PP stated that he sent a message to the doctor to inform her and gave an update on P#4's request to leave; however, he (RN PP) got no response.

RN PP stated that about an hour later, P#4 had pulled out his IV (intravenous line), put on his 'street' clothes, and wanted a timeline of when he (P#4) might be going home. RN PP stated he tried to reassure him (P#4) that the doctor would come see him (P#4). Then, he (RN PP) reached out to the doctor again requesting that P#4 needs to be seen as soon as possible.

RN PP stated that after a while, the sitter with P#4 had informed him (RN PP) that P#4 was on the phone requesting an Uber ride, and he (RN PP) immediately went in to tell P#4 he should cancel the ride pending the time the doctor comes to see him, but P#4 told him (RN PP) to get out of his room. RN PP stated that about half an hour later, the Uber driver showed up in the patient's room, and he (RN PP) had to explain to the Uber driver that P#4 had not yet been discharged, and the Uber driver left. Shortly after, P#4 stood up and wanted to exit the room, and he (RN PP) stood in the way so P#4 would not leave, but because he (P#4) was getting agitated, he (RN PP) stepped out of the way, and P#4 started walking towards the exit and the elevator.

RN PP stated that he had to call security for help, and three public safety officers tried to de-escalate the situation, but P#4 became combative and two public safety officers had to physically restrain him (P#4). RN PP stated he had to go back to the unit to try and get the doctor, and the doctor told him (RN PP) to try to get the patient back on the unit so he could talk to him (P#4). However, P#4 was resisting and the doctor had to come downstairs to talk to P#4. RN PP stated that the doctor was able to de-escalate the situation and told the public safety officers to leave P#4 as he was not on 1013.

RN PP stated that he was just trying to ensure P#4 was seen by a doctor before he left the hospital as he had not been seen by any doctor since he was admitted to the unit, which was why he tried to hold him back as much as possible.


An interview took place in the facility's conference room on 2/5/25 at 10:30 a.m. with Public Safety Officer (PSO) PP who stated that they received a call from the nurse that help was needed to stop P#4 from leaving the hospital as he (P#4) was a 1013 patient and was trying to elope. PSO PP stated that three public safety officers tried to de-escalate the situation, but P#4 became combative and kept saying he did not want to go back to the unit. PSO PP stated that two public safety officers had to physically escort the patient to the elevator, and once at the elevator, P#4 fell face down on purpose, pulling both officers alongside him to the floor. PSO PP stated that no one sustained injuries, including the patient, and the doctor was able to come down and de-escalate the situation.

Based on the review of medical records, it was determined that the facility failed to provide wound care per Medical Doctor (MD) orders for one patient (P) (P#2) of four patients (P#1, P#2, P#3, and P#4) reviewed.


Findings include:


A review of P#2' s medical record revealed that P#2 was admitted to the facility on 12/4/24 at 12:57 p.m. via the emergency department with the diagnosis of Septic Shock (a widespread infection causing organ failure and dangerously low blood pressure).


A review of the History and Physical (H&P) on 12/5/24 at 2:44 a.m. revealed that P#2 had a past medical history of gunshot injury resulting in quadriplegia and requiring tracheostomy placement (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea from outside the neck).

Documentation under the nutrition consultation notes dated 12/6/24 at 3:20 p.m. revealed that P#2 had a:
- Pressure Injury Sacrum first assessed 12/5/24 and present on admission. Dressing was to be done daily.
- Pressure Injury Ischial Tuberosity Left, first assessed 12/5/24 and present on admission. The dressing was to be changed daily.
- Pressure Injury Ischial Tuberosity Right, first assessed 12/5/24 at 2:45 p.m. and present on admission. Dressing was to be done daily.
- Pressure Injury Back Midline, first assessed 12/5/24 and present on admission. Dressing was to be done daily.
- Pressure Injury Back Lateral Right first assessed 12/5/24 and present on admission. Dressing was to be done daily.
- Pressure Injury Back Left; Superior, first assessed 12/5/24 and present on admission. Dressing was to be done daily.
- Pressure Injury Shoulder Left; Posterior, first assessed 12/5/24 and present on admission. Dressing was to be done daily.
- Pressure Injury Leg Posterior; Right Superior, first assessed 12/5/24 and present on admission. Dressing was to be done daily.
- Pressure Injury Heel, Left, first assessed 12/5/24 and present on admission. Dressing was to be done every other day.
- Pressure Injury Heel, Right, first assessed 12/5/24 at 2:45 p.m. Dressing was to be done every other day.
- Malleolus Right Lateral, first assessed 12/5/24 and present on admission. Dressing was to be done every other day.
- Pressure Injury Foot Right; Lateral, first assessed 12/5/24 and present on admission. Dressing was to be done every other day.
- Pressure Injury Knee Right; Lateral, first assessed 12/5/24 and present on admission. Dressing was to be done every other day.
- Abdomen Left, first assessed 12/5/24 and present on admission. Dressing was to be done every other day.
- Pressure Injury Malleolus Left; Lateral, first assessed 12/5/24 and present on admission.
- Pressure Injury Knee Left, first assessed 12/5/24 and present on admission. Dressing was to be done every other day.
- Pressure Injury Foot; Medial, first assessed 12/5/24 and present on admission. Dressing was to be done every other day.
- Pelvis Midline first assessed 12/5/24 and present on admission. Dressing was to be done every other day.


A focused electronic medical record review (EMR) was conducted on 2/3/25 at 1:00 p.m. revealed that P#2's wound dressings were not changed per orders including:

1. The sacral dressing was ordered to be changed daily; however, the EMR failed to reveal a dressing change on 12/6/24; 12/8/24 through 12/10/24; 12/14/24 through 12/16/24; 12/18/24 through 12/20/24; and 12/22/24.

2. The malleolus (the bony prominence on each side of the human ankle) wound dressing was to be changed every other day. EMR review revealed that the dressing was changed on 12/13/24, 12/17/24, and 12/20/24.

3. Continued review of the EMR revealed that dressings to the Right and Left heel were to be changed every other day and was due to be changed on 12/10/24; however, documentation failed to reveal that the dressings were not changed until 12/13/24 and again on 12/21/25.


A review of the facility's policy titled "Nursing Patient Assessment/Reassessment Policy," Policy #12930386, last revised 1/16/23, revealed that it was the policy of the facility to ensure that all patients received the appropriate assessment (including initial screening and reassessment) provided by qualified individuals within the organization, that the assessment process is multi-disciplinary and interdisciplinary, and that assessing patients was a continuous, collaborative effort with all departments functioning as a team.

Assessments were completed upon admission to the facility at a variety of entry points and continued throughout the hospital stay.

Individual services will define specific requirements for reassessments based on nursing care needs.
Physician orders, consults, and progress notes serve as a mechanism for the Medical Staff to communicate the patients' care treatment needs, response to treatment, patient instruction, discharge plans, and continued care requirements as appropriate.


A review of the facility ' s policy titled " Scope of Care/Service: PRH - Wound Care and Hyperbaric Services, " Policy #15568459, last revised 4/3/24, revealed that each department will maintain a Scope of Service describing the kinds of care that patients can expect to receive and the general operation and organization the department along with its interactions with other departments and organizational functions. The Scope of Service will be consistent with the Hospital's mission and strategic goals. The Scope of Service sets the tone for and is consistent with departmental policies/procedures and staff knowledge and skill. Inpatients were seen by the wound care clinician and based on the collaboration with the consulting service a plan of care and discharge plan was created.


A review of the facility ' s "Leadership Statement of Support for Antimicrobial Management Program (AMP) ", dated 8/10/23, stated that the hospital ' s leadership indicates support of efforts to improve and monitor antimicrobial use through the formal Antimicrobial Management Program (AMP) at the facilities. The intention of the program was to promote antimicrobial stewardship practices in a manner that improved patient care and did not promote multi-drug-resistant organisms. The program was consistent with guidance set forth by the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, and the Clinical Services Group.


A review of the facility ' s document titled "Pressure Injury Prevention, " last revised 2/20/24, revealed that successful pressure injury treatment involved relieving pressure, restoring circulation, promoting adequate nutrition, and (if possible) resolving or managing related disorders.


A review of the facility ' s document titled "Skin Assessment", last revised 2/20/24 revealed that as part of a comprehensive skin assessment, a pressure injury risk assessment would be completed and documented on admission using a validated risk assessment tool, such as the Braden Scale or Norton Scale. Both the Braden scale and the Norton scale screen patients for risk factors linked to skin breakdown and pressure injury development. Subsequent risk assessments would be performed at regular intervals or when there is a significant change in the patient ' s condition according to the facility.


An interview took place in the facility ' s conference room on 2/4/25 at 9:40 a.m. with Wound Care Nurse (WCN) AA who stated that the nurse or the doctor usually puts in an order for a wound care consult irrespective of the type of wound a patient has on admission; it could be anything from a skin tear to an unstageable ulcer. WCN AA stated that a consult was put in for P#2 regarding the wound on his chest area; however, when she (WCN AA) got to P#2, he was complaining of pain in his sacrum, and that was when she (WCN) checked and saw a stage 3 ulcer on his (P#2) sacrum.

WCN AA stated that once a wound care order is put in, the floor nurses are required to do the dressings as per order. However, P#2 refused care and wound dressings most time. WCN AA also stated that as per the facility ' s policy, wound care nurses were not required to do a follow-up with patients once seen for an initial assessment unless there was a concern, and the staff put in another order for consultation.


An interview took place in the facility ' s conference room on 2/4/25 at 11:30 a.m. with Case Manager (CM) EE who stated that PA LL had put in a consult with her (CM EE) because she (PA LL) wanted her (CM EE) to call Adult Protective Services (APS) regarding the multiple wounds on P#2 ' s body as the wounds appeared to be signs of neglect/abuse. CM EE stated that she filed the report and informed P#2 ' s mum, which made her (P#2 ' s mum) very upset. CM EE stated that after speaking with the social worker at the other skilled nursing facility P#2 had been prior, it was clear P#2 had everything he needed and was well cared for, which she (CM EE) also relayed to APS.


A telephone interview took place in the facility ' s conference room on 2/4/25 at 12:00 p.m. with Risk Manager (RM) FF who stated that she received two incident reports about P#2 ' s refusal of care, which she passed on to the Nursing leadership team for follow-up. RM FF stated that there was also an incident report about isolation precautions. However, no harm was detected on all the incident reports she received regarding P#2.


An interview took place in the facility ' s conference room on 2/4/25 at 1:00 p.m. with Intensive Care Unit Manager (ICM) GG who stated that she recalled speaking with P#2 ' s mum because she (P#2 ' s mum) had complaints that she felt the staff were not adequately caring for P#2. ICM GG stated that P#2 was noncompliant and refused care, which the mum was also aware. ICM GG also stated that sometimes when a patient is on Levophed (a medication used to treat life-threatening low blood pressure), tube feeding may not be initiated because the stomach will not be able to absorb the feed.


A telephone interview took place in the facility ' s conference room on 2/4/25 at 2:30 p.m. with Registered Nurse (RN) JJ who stated that he could not recall P#2. However, strict diet orders were followed for any patient. RN JJ stated that a swallow test was usually done, and the doctor would put in the order for the nurses to follow. RN JJ also stated that the charge nurse would be informed and documented if a patient refused care.


A telephone interview took place in the facility ' s conference room on 2/4/25 at 4:00 p.m. with Physician Assistant (PA) LL who stated that P#2 came in with septic shock (a widespread infection causing organ failure and dangerously low blood pressure) and she (PA LL) had concerns about the multiple wounds on his (P#2) body with the possibility of a PEG (Percutaneous endoscopic gastrostomy - a surgical procedure to insert a feeding tube into the stomach) site tube infection, which was why she consulted CM EE.


A telephone interview took place in the facility ' s conference room on 2/5/25 at 1:00 p.m. with Physician Assistant (PA) OO who stated that P#2 was bedbound, septic on admission, and required mechanical ventilation. PA OO stated that P#2 ' s family member had come rushing to her (PA OO) during a shift to state that (P#2) could not breathe. PA OO stated that on assessing P#2, she found that he must have aspirated as he was cleared for diet, and family member had stated she gave him (P#2) water. PA OO stated that she had to put him (P#2) back on NPO (nil per os-nothing by mouth) as he (P#2) was wheezing.

PA OO stated that the next day, P#2 ' s family member was upset why P#2 was put on NPO, and she (PA OO) had to re-explain to P#2 ' s family member that he (P#2) was put back on NPO because he aspirated. PA OO also stated that P#2 was lethargic (feeling tired, sluggish, or lacking in energy), and the opioid pain medication he was on had to be titrated down for P#2 to get better, and P#2 ' s family member was fully aware and updated every step of the way regarding P#2 ' s treatment/care.