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Based on review of medical records, review of policy and procedures, review of the grievance log, and staff interview, it was determined the facility failed to implement and follow policies and procedures that protect and promote each patient's rights to safe care and freedom from restraint.

Findings included:

The facility failed to ensure that restraints were discontinued at the earliest possible time for three (#2, #4 and #5) of thirteen patients sampled. (refer to A0154)

The facility failed to implement behavioral restraint usage safely and in accordance with policies and procedures (refer to A0167)

The facility failed to ensure each order for restraint, used for the management of violent or self-destructive behavior, was renewed every 4 hours for adults 18 years of age or older for up to a total of 24 hours (refer to A0171)

The facility failed to ensure restraints were discontinued at the earliest possible time. (refer A0174)

The facility failed to ensure the condition of the patient, who was restrained, was monitored per facility policy and procedures. (refer to A0175)

The facility failed to ensure patients restrained for the management of violent or self-destructive behavior that jeopardized the immediate physical safety of the patient, a staff member, or others, the patient was seen face-to-face within 1-hour after the initiation of the intervention. (refer to A0178)

The facility failed to ensure documentation of the one hour face-to-face medical and behavioral evaluation was present in the medical record for patients restrained for management of violent or self-destructive behavior (refer to A0184)

Based on review of medical records, review of policy and procedures and staff interview it was determined the facility failed to ensure that restraints were discontinued at the earliest possible time for three (#2, #4 and #5) of thirteen patients sampled.

Findings included:

Review of the policy titled, "Restraint Management," dated 10/2020, stated the following: ... "to limit and/or eliminate the use of restraint. Conversely, clinically and developmentally appropriate alternatives to restraints to be attempted, documented and found to be ineffective prior to the use of restraint if possible... Neither restraint nor seclusion may be used as a means of coercion, discipline, or convenience and may only be used in a setting where staff have been educated according to policy. Restraint and seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others based on an individual assessment, as ordered by a physician or licensed independent practitioner and must be discontinued at the earliest possible time once the unsafe situation ends regardless of the scheduled expiration of the order. The type of restraint is limited to the least restrictive device possible ... Violent or Self-Destructive Behavior: Any behavior or verbalization that jeopardizes the immediate physical safety of the patient, a staff member or others..."

Violent, Self-destructive:
When restraint is used for the management of violent or self-destructive behaviors that jeopardizes the immediate physical safety of the patient, a staff member, or others the patient must be seen face to face within one hour after initiation of the intervention by a physician or a trained registered nurse.

Renewal orders for restraint of the patient with violent or self-destructive behaviors shall occur every 4 hours for an adult aged 18 years or older.

Monitoring and assessment of violent restraints: Upon application and removal nurse must document under restraint initiation and discontinuation:
Every one hour -Type and location of restraint, alternatives attempted, restraint affect, physical assessment: circulation, mental status, neurological status, restraint affect and behavior
Every 15 minutes- positioning or range of movement, hydration/nutrition, and elimination
Every two hours-vital signs (Blood Pressure, Heart Rate, Respirations, and Oxygen Saturation)


Review of Patient Care/Activity notes revealed Patient #2 was placed in "Violent restraints" (leather locked restraints) on 12/26/2021 at 7:15 am and discontinued, 8 days later, on 1/2/2022 at 10:00 pm (approximately 182.75 hours).

Review of Patient #2's Restraint Monitoring Log revealed:

15-minute monitoring and assessment for positioning, hydration/nutrition, and elimination was not conducted 547 times out of 731 opportunities.
One hour monitoring and assessment for neurological, mental status, restraint affect and behavior was not conducted 31 times out of 182 opportunities.

Review of Patient #2's "IView" vital signs documentation revealed 2-hour monitoring and assessment of vital signs were not conducted 31 times out of 91 opportunities.

Review of the physician orders for Patient #2 revealed 4 hour renewal orders for restraint of the patient with violent or self-destructive behaviors was not completed 25 times out of 47 opportunities.

Review of the Patient Care/Activity log for Patient #2 revealed violent restraint of the patient was initiated on 12/26/2021 at 7:30 am. Review of that documentation revealed the patient remained in violent restraints until 1/2/2022 at 10:00 pm. Review of the medical record for documented evidence of the 1-hour face-to-face evaluation by the physician, licensed practitioner, or trained registered nurse revealed no evidence the evaluation was completed.


Review of nursing documentation revealed Patient #4 was placed in violent restraints (leather locked restraints) on 7/09/2021 at 7:26 pm and discontinued on 07/10/2021 at 1:05 am (for approximately 5.5 hours).

Review of Patient #4's Restraint Monitoring Log revealed 15 minute monitoring and assessment for positioning, hydration/nutrition, and elimination was not completed 15 times out of 22 opportunities.

Review of nursing documentation for Patient #4 on the Vitals/Metrics Log revealed 2 hour vital sign monitoring was conducted at 07/09/2021 at 8:30 PM and 12:30AM. No 10:30AM vital signs monitoring was conducted.

Review of the physician orders for Patient #4 revealed a 4 hour renewal order for the continued application of the violent restraint should have been obtained at approximately 11:26 pm on 7/09/2021. No renewal order could be located in the medical record despite the continued use of the violent restraints until 7/10/2021 at 1:05 am.

Review of nursing and physician assessments for Patient #4 revealed no evidence a face-to-face assessment within one hour was conducted by a physician or a trained registered nurse after initiation of violent behavioral restraints on 7/09/2021 at 7:26 pm.


Review of nursing documentation revealed Patient #5 was placed in violent restraints (leather locked restraints) on 1/30/2021 at 2:20 pm and discontinued on 01/30/2021 8:45 pm (for approximately 6.5 hours).

Review of the physician orders for Patient #5 revealed a 4 hour renewal order for the continued application of the violent restraint should have been obtained at approximately 6:20 pm on 1/30/2021. No renewal order could be located in the medical record despite the continued use of the violent restraints until 01/30/2021 8:45 pm.

On 01/05/2022 at 12:20 pm, Staff O, Director of Patient Safety/Risk Management, confirmed that Patient #2 was restrained without orders, assessments, and observations for a period of approximately 4 days, stating, "this should not happen."

On 01/05/2022 at 3:00 pm, Nurse Manager T reviewed Patient #2's chart and the Restraint policy. She stated, I can see the facility did not renew the order every 4 hours as required, nor conduct a face to face prior to renewing the violent restraint order, nor conduct every 2 hour and 15-minute assessments of the patient. This was sad, so many opportunities here that were missed on this patient.

On 1/5/2022 at 3:30 pm, Nurse Manager U said she was aware of Patient #2's Baker Act expiring. She said she didn't do anything about it, but the feedback she was receiving from her team lead after multidisciplinary rounds was that the patient was waiting on psych placement.

On 1/6/2022 at 9:55 am, the Director of Quality, Lead Quality Coordinator, and Risk Manager confirmed the above findings for Patient #2, #4, and #5.

On 1/05/2022 at 3:30 pm, an interview and review of the record was conducted with Nurse Managers (Staff T and Staff U). They both confirmed the above findings.

Based on review of medical records, review of policy and procedures and staff interview it was determined the facility failed to implement the use of violent restraints using safe and appropriate restraint techniques as determined by hospital policy for three (#2, #4 and #5) of thirteen patients sampled.

Findings included:

Review of the policy titled, "Restraint Management," dated 10/2020, stated the following: ... "to limit and/or eliminate the use of restraint. Conversely, clinically and developmentally appropriate alternatives to restraints to be attempted, documented and found to be ineffective prior to the use of restraint if possible... Neither restraint nor seclusion may be used as a means of coercion, discipline, or convenience and may only be used in a setting where staff have been educated according to policy. Restraint and seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others based on an individual assessment, as ordered by a physician or licensed independent practitioner and must be discontinued at the earliest possible time once the unsafe situation ends regardless of the scheduled expiration of the order. The type of restraint is limited to the least restrictive device possible ... Violent or Self-Destructive Behavior: Any behavior or verbalization that jeopardizes the immediate physical safety of the patient, a staff member or others..."

Violent, Self-destructive:
When restraint is used for the management of violent or self-destructive behaviors that jeopardizes the immediate physical safety of the patient, a staff member, or others the patient must be seen face to face within one hour after initiation of the intervention by a physician or a trained registered nurse.

Renewal orders for restraint of the patient with violent or self-destructive behaviors shall occur every 4 hours for an adult aged 18 years or older.

Monitoring and assessment of violent restraints: Upon application and removal nurse must document under restraint initiation and discontinuation:
Every one hour -Type and location of restraint, alternatives attempted, restraint affect, physical assessment: circulation, mental status, neurological status, restraint affect and behavior
Every 15 minutes- positioning or range of movement, hydration/nutrition, and elimination
Every two hours-vital signs (Blood Pressure, Heart Rate, Respirations, and Oxygen Saturation)


Review of Patient Care/Activity notes revealed Patient #2 was placed in "Violent restraints" (leather locked restraints) on 12/26/2021 at 7:15 am and discontinued, 8 days later, on 1/2/2022 at 10:00 pm (approximately 182.75 hours).

Review of Patient #2's Restraint Monitoring Log revealed:

15-minute monitoring and assessment for positioning, hydration/nutrition, and elimination was not conducted 547 times out of 731 opportunities.
One hour monitoring and assessment for neurological, mental status, restraint affect and behavior was not conducted 31 times out of 182 opportunities.

Review of Patient #2's "IView" vital signs documentation revealed 2-hour monitoring and assessment of vital signs were not conducted 31 times out of 91 opportunities.

Review of the physician orders for Patient #2 revealed 4 hour renewal orders for restraint of the patient with violent or self-destructive behaviors was not completed 25 times out of 47 opportunities.

Review of the Patient Care/Activity log for Patient #2 revealed violent restraint of the patient was initiated on 12/26/2021 at 7:30 am. Review of that documentation revealed the patient remained in violent restraints until 1/2/2022 at 10:00 pm. Review of the medical record for documented evidence of the 1-hour face-to-face evaluation by the physician, licensed practitioner, or trained registered nurse revealed no evidence the evaluation was completed.


Review of nursing documentation revealed Patient #4 was placed in violent restraints (leather locked restraints) on 7/09/2021 at 7:26 pm and discontinued on 07/10/2021 at 1:05 am (for approximately 5.5 hours).

Review of Patient #4's Restraint Monitoring Log revealed 15 minute monitoring and assessment for positioning, hydration/nutrition, and elimination was not completed 15 times out of 22 opportunities.

Review of nursing documentation for Patient #4 on the Vitals/Metrics Log revealed 2 hour vital sign monitoring was conducted at 07/09/2021 at 8:30 PM and 12:30AM. No 10:30AM vital signs monitoring was conducted.

Review of the physician orders for Patient #4 revealed a 4 hour renewal order for the continued application of the violent restraint should have been obtained at approximately 11:26 pm on 7/09/2021. No renewal order could be located in the medical record despite the continued use of the violent restraints until 7/10/2021 at 1:05 am.

Review of nursing and physician assessments for Patient #4 revealed no evidence a face-to-face assessment within one hour was conducted by a physician or a trained registered nurse after initiation of violent behavioral restraints on 7/09/2021 at 7:26 pm.


Review of nursing documentation revealed Patient #5 was placed in violent restraints (leather locked restraints) on 1/30/2021 at 2:20 pm and discontinued on 01/30/2021 8:45 pm (for approximately 6.5 hours).

Review of the physician orders for Patient #5 revealed a 4 hour renewal order for the continued application of the violent restraint should have been obtained at approximately 6:20 pm on 1/30/2021. No renewal order could be located in the medical record despite the continued use of the violent restraints until 01/30/2021 8:45 pm.

On 01/05/2022 at 12:20 pm, Staff O, Director of Patient Safety/Risk Management, confirmed that Patient #2 was restrained without orders, assessments, and observations for a period of approximately 4 days. "This should not happen."

On 01/05/2022 at 3:00 pm, Nurse Manager T reviewed Patient #2's chart and the Restraint policy. She stated, I can see the facility did not renew the order every 4 hours as required, nor conduct a face to face prior to renewing the violent restraint order, nor conduct every 2 hour and 15-minute assessments of the patient. This was sad, so many opportunities here that were missed on this patient.

On 1/5/2022 at 3:30 pm, Nurse Manager U said she was aware of Patient #2's Baker Act expiring. She said she didn't do anything about it, but the feedback she was receiving from her team lead after multidisciplinary rounds was that the patient was waiting on psych placement.

On 1/6/2022 at 9:55 am, the Director of Quality, Lead Quality Coordinator, and Risk Manager confirmed the above findings for Patient #2, #4, and #5.

On 1/05/2022 at 3:30 pm an interview and review of the record was conducted with Nurse Managers (Staff T and Staff U). They both confirmed the above findings.

Based on review of medical records, review of policy and procedures and staff interview it was determined the facility failed to ensure each order for restraint, used for the management of violent or self-destructive behavior, was renewed every 4 hours for adults 18 years of age or older for up to a total of 24 hours for three (#2, #4, #5) of thirteen patients sampled.

Findings included:

Review of the physicians' orders for Patient #2, dated 12/26/2021 at 7:30 am, revealed an order for behavioral violent restraints (locked leather restraints on both arms and legs).
Review of Patient Care/Activity note revealed Patient #2 was placed in violent restraints on 12/26/2021 at 7:15 am and discontinued on 1/2/2022 at 10:00 pm.
Review of the physician orders for Patient #2 revealed renewal orders for restraint of the patient with violent or self-destructive behaviors was not completed every 4 hours for 25 out of 47 opportunities.

Review of the physicians' orders for Patient #4 revealed a physician order, dated 7/9/2021 at 7:26 pm, for behavioral violent restraints.
Review of the Patient Care/Activity documentation revealed Patient #4 was placed in violent restraints on 7/09/2021 at 7:26 pm for 5.5 hours.
Review of the physician orders for Patient #4 revealed renewal orders for restraint of the patient with violent or self-destructive behaviors was not completed within 4 hours.

Review of Patient care/Activity documentation revealed Patient #5 was placed in violent restraints on 1/30/2021 at 2:20 pm for 6.5 hours. Review of the physician orders revealed no evidence of renewal orders after 4 hours.

Review of the facility policy, "Restraint Management," dated 10/2020, stated: Renewal orders for restraint of the patient with violent or self-destructive behaviors are 4 hours for an adult aged 18 years or older. ...Each episode of restraint or seclusion must be ordered by a physician

On 01/05/2022 at 3:00 pm, Nurse Manager T reviewed Patient #2's chart and the Restraint policy. She stated, I can see the facility did not renew the order every 4 hours as required. This was sad, so many opportunities here that were missed on this patient.

Based on review of medical records, review of policy and procedures and staff interview it was determined the facility failed to ensure restraints were discontinued at the earliest possible time for one (#2) out of thirteen sampled patients.

Findings included:

Review of the facility policy, "Restraint Management," dated 10/2020, states; 3) must be discontinued at the earliest possible time, once the unsafe situation ends; 2) the patient shall be monitored at regular intervals consistent with physician orders and/or patient condition. Assessments to assure patient is free from adverse events and to determine if restraint or seclusion can be discontinued will be documented. When the restraint is no longer needed, it may be discontinued at the direction of a physician, LIP (Licensed Independent Provider) or trained Registered Nurse or Physician's Assistant.

Review of physician orders for Patient #2, dated 12/26/2021 at 7:30 am, revealed an order for Violent Restraints (locked leather restraint) for violent behavior. Review of the Patient Care/Activity documentation revealed the patient remained in behavioral/violent restraint until 1/02/2022, a total of eight days.

Review of the Restraint Monitoring Log for Patient #2 revealed that the patient's behavior was documented as "calm," beginning on 12/31/2021 at 3:00 am, 50 times out of the next 66 hours until his release from "violent" restraints into "non-violent restraints" (2 point soft restraints).


An interview was conducted on 01/05/2022 at 3:30 p.m. with Staff U, the Nurse Manager of the Progressive Care Unit (PCU). Staff U confirmed Patient #2 was located on her unit for 9 days, 12/23/2021 - 1/1/2021. Staff U confirmed there was no documentation that attempts were made to discontinue the patient's restraints at the earliest possible time. Staff U confirmed there were opportunities, during his admission on the unit, the patients' restraints could have been discontinued.

An interview was conducted on 1/5/2021 at 1:00 pm with Staff T, the Nurse Manager of the Medical Unit. Staff T reviewed the record and stated, "Based on this patient's documentation, restraints were used inappropriately." She confirmed the restraints should have been discontinued earlier. She confirmed that no attempts were made to ensure restraints were discontinued at the earliest possible time. She confirmed there were many opportunities during this time that the patients' restraints should have been removed.

Based on medical record review, review of policy and procedures, and staff interviews it was determined the facility failed to ensure trained staff performed assessments of restrained patients, per specified intervals of the facility policy and procedures for one (#2) of thirteen patients sampled.

Findings included:

Review of the facility policy, "Restraint Management," dated 10/2020, required staff: "monitoring and assessment of violent restraints -

Every 15 minutes: hygiene and elimination, nutrition and hydration, ROM (range of motion), positioning of patient
Every one hour: type and location of restraint, alternatives attempted, restraint effect, restraint behavior, physical assessment: circulation, mental status, neurological status, signs of injury must be observed and documented.
Every two hours vital signs: Blood Pressure, Heart Rate, respirations, and oxygen saturations.
Renewal orders for restraints and/or seclusion of the patient with violent or self-destructive behaviors shall be obtained... (a) 4 hours for an adult aged 18 years and older.

Review of the physician's orders for Patient #2 revealed an order, dated 12/26/2021 at 07:30 am, for behavioral/violent restraint of the patient. Review of Patient Care/Activity documentation revealed the patient was restrained from 12/26/2021 at 7:30 am until 1/2/2022 at 10:00 pm, a total of 8 days.

Review of nursing documentation for Patient #2 on the Restraint Monitoring Log, revealed evidence that monitoring was not conducted every 15 minutes for positioning, hydration, and elimination 547 out of 731 possible opportunities.

Review of nursing documentation for Patient #2 on the Restraint Monitoring Log, revealed evidence that monitoring was not conducted every one hour for physical, neurological, mental status, restraint affect or behavior 31 out of 182 opportunities.

Review of nursing documentation for Patient #2 on the Restraint Monitoring Log, revealed evidence that vital sign monitoring was not conducted every 2-hours for 31 out of 91 opportunities.

On 01/05/2022 at 12:20 pm, Staff O, Director of Patient Safety/Risk Management, stated she could confirm that Patient #2 was restrained without assessments and observations for a period of approximately 4 days. This should not happen.

On 01/05/2022 at 3:00 pm, Nurse Manager T reviewed Patient #2's chart and the Restraint policy. She stated, I can see the facility did not conduct every 2 hour and 15-minute assessments of the patient. This was sad, so many opportunities here that were missed on this patient.

Based on record review, policy and procedure review, and staff interviews it was determined the facility failed to ensure patients restrained for violent or self-destructive behavior were evaluated face-to-face within 1-hour after the initiation by a physician, licensed practitioner, or trained registered nurse for two (#2, #4) of thirteen patients sampled.

Findings included:
Review of the facility policy, "Restraint Management," dated 10/2020, instructs staff: when restraint and/or seclusion is used for the management of violent or self-destructive behaviors that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face to face within one hour after initiation of the intervention by a physician or a trained registered nurse...

Review of the Patient Care/Activity documentation for Patient #2 revealed Violent Restraint (locked leather restraint) of the patient was initiated on 12/26/2021 at 7:30 am and remained in violent restraints until 1/2/2022 at 10:00 pm. Review of the medical record revealed no evidence of the 1-hour face-to-face evaluation by the physician, licensed practitioner, or trained registered nurse was completed after the initiation of the restraints.

Review of Patient Care/Activity documentation for Patient #4 revealed the patient was placed in locked restraints for violent behavior, on 7/9/2021 at 7:26 pm for 5.5 hours. Review of the medical record revealed no evidence of the 1-hour face-to-face evaluation by the physician, licensed practitioner, or trained registered nurse was completed after the initiation of the restraints.

On 01/05/2022 at 12:20 pm, Staff O, Director of Patient Safety/Risk Management, stated she could confirm that Patient #2 was restrained without orders, assessments, and observations for a period of approximately 4 days. This should not happen.

On 01/05/2022 at 3:00 pm, Nurse Manager T reviewed Patient #2's chart and the Restraint policy. She stated, I can see the facility did not conduct a face to face prior to renewing the violent restraint order. This was sad, so many opportunities here that were missed on this patient.

Based on medical record reviews, policy and procedure review, and staff interviews, it was determined the facility failed to ensure the medical record of patients restrained for violent or behavioral conduct contained documentation of the 1-hour face-to-face medical and behavioral evaluation for two (#2, #4) of thirteen patients sampled.

Findings included:

Review of the facility policy, "Restraint Management," dated 10/2020, instructs staff: when restraint and/or seclusion is used for the management of violent or self-destructive behaviors that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face to face within one hour after initiation of the intervention by a physician or a trained registered nurse...

Review of the Patient Care/Activity log for Patient #2 revealed violent restraint of the patient was initiated on 12/26/2021 at 7:30 am. Review of that documentation revealed the patient remained in violent restraints until 1/2/2022 at 10:00 pm. Review of the medical record revealed no documented evidence of the 1-hour face-to-face evaluation by the physician, licensed practitioner, or trained registered nurse.

Review of the Patient Care/Activity documentation for Patient #4 revealed nursing documented the patient was placed in locked restraints for violent behavior, on 7/9/2021 at 7:26 pm for 5.5 hours. Review of the medical record for documented evidence of the 1-hour face-to-face evaluation by the physician, licensed practitioner, or trained registered nurse revealed no evidence the evaluation was completed.

On 01/05/2022 at 3:00 pm, Nurse Manager T reviewed Patient #2's chart and the Restraint policy. She stated, I can see the facility did not renew the order every 4 hours as required, nor conduct a face to face prior to renewing the violent restraint order, nor conduct every 2 hour and 15-minute assessments of the patient. This was sad, so many opportunities here that were missed on this patient.

An Immediate Jeopardy (IJ) was identified beginning on 6/29/2021 and was determined to be on-going at the time of survey exit. The facility failed to maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program.

Based on facility document review and staff interview it was determined the facility failed to ensure quality indicator data related to violent and behavioral restraint of patients was comprehensive to ensure the effectiveness and safety of services and quality of care was monitored accurately to ensure quality patient care and improved patient safety (see A0273).

Based on staff interviews, policy and procedure reviews, medical record reviews, observations, and facility document reviews the hospital failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan, including a complete analysis of an adverse event, development of an effective plan of correction, and measures in place to track performance and success, for a patient who was ordered cardiac monitoring (see A0286).

On 1/28/2022 at 1:00 pm, the Director of Patient Safety & Risk Management was informed of the Immediate Jeopardy (IJ) situation which began on 6/29/2021. The cumulative deficits place the patients at risk for not having their needs met resulting in the Condition of Participation being out of compliance.

Based on facility document review and staff interview it was determined the facility failed to ensure quality indicator data related to violent and behavioral restraint of patients was comprehensive to ensure the effectiveness and safety of services and quality of care was monitored accurately to ensure quality patient care and improved patient safety.

Findings included:

Review of the facility PI (Performance Improvement) project opportunities revealed the plan was to monitor, record and report utilization and compliance of patient restraints to ensure safe and appropriate usage. The facility utilized an interactive monitoring tool to collect data.

Review of the collected data dated January 2021 to January 05, 2022, specifically for patient's restrained for violent behavior, revealed lack of comprehensive data collection. Review of two patients restrained for violent behavior (#2 restrained 12/23 - 1/02/2022 and #4 restrained on 7/09/2021) revealed no evidence these two patients were included in the facility's data.

An interview on 1/06/2022 at 2:30 pm was conducted with the Director of Patient Safety/ Risk Management. Following review of the data it was confirmed patients #2 and #4 were not included in the reported data. She confirmed the data should include 100% of patients restrained in violent/behavioral restraint.

Based on review of hospital policy and procedures, review of medical records, and staff interview it was determined the facility failed to ensure an established facility committee analyzed a patient mortality, identified a potential cause or delay in care, and implemented preventive actions that included learning throughout the hospital.

Findings included:

Review of the facility policy, "Telemetry Monitoring and Assessment of Patients," dated 2/2021, stated telemetry monitoring is initiated on a provider's order. The admission strip is collected and then scanned into the patient's electronic health record (EHR); (C) Patient Monitoring, (4) the cardiac rhythm of patients receiving cardiac monitoring will be continuously monitored by a qualified and competent staff member; (5) the monitor technician will measure and print/upload a strip every 12 hours and also with any rhythm changes.

Review of the medical record for patient #1 revealed on 6/29/2021 at 10:56 pm the patient arrived at the facility for complaint of shortness of breath. Review of the record revealed the patient had been discharged 2 days prior to arrival. During the patient's first admission the patient's cardiac rhythm was monitored throughout her admission and she had a cardiac consultation and treatment for new onset atrial fibrillation with RVR (Rapid Ventricular Rate), per the cardiac consultation dated 7/01/2021.

Upon readmission, on 6/29/2021, the patient denied chest pain however she complained of chest tightness. On 6/30/2021 at 12:04 am a physician order was written for cardiac monitoring, stat. On 6/30/2021 at 1:00 pm a history and physical (H&P) was completed. The H&P revealed a plan which included consult to cardiology for elevated troponins and need to adjust cardiac medication. (Levels of troponin in the blood are measured to determine whether the heart is damaged and if a heart attack (acute myocardial infarction) has occurred).

On 7/1/2021 at 6:10 pm, per nursing documentation, the record revealed the patient's family member called nurses into the patient's room to check the patient's pulse. The RN (Registered Nurse) noted the patient was unresponsive with no pulse, and code blue (cardiac/respiratory arrest) was called. Despite attempts to resuscitate, the patient expired at 6:57 pm.

Review of the record revealed no evidence the physician order for cardiac monitoring was followed. An interview with the Director of Quality and Lead Quality Coordinator on 1/6/2022 at 9:40 am confirmed the finding.

An interview with the Director of Quality and Lead Quality Coordinator was conducted on 1/06/2022 at 9:40 am regarding the activities of the mortality review committee. The Director of Quality confirmed the mortality committee reviews 100% of the facility's patient mortalities. She confirmed the record for patient #1 was reviewed and the committee did not identify any opportunities. At the time of the interview the Lead Quality Coordinator reviewed the record for patient #1 and confirmed there was an order for cardiac monitoring with no evidence the monitoring was implemented.

An Immediate Jeopardy (IJ) was identified beginning on 6/29/2021 and was determined to be on-going at the time of survey exit. Failure to ensure an RN (Registered Nurse) verified and implemented physicians' orders for cardiac monitoring was identified.

Based on review of personnel files, job descriptions, and staff interviews it was determined the facility failed to ensure hospital nursing staff for whom current licensure is required was valid and current for one of five sampled staff personnel files (see A0394).

Based on staff interviews, policy and procedure reviews, observations and medical record reviews, the hospital failed to ensure policies governing cardiac monitoring of patients were followed for assessment and monitoring of patient's cardiac rhythm and failed to ensure the provision of services was provided timely to protect the health and safety of all patients. This posed an immediate and serious threat to the health and safety of patients #1,7,8,9,10,11, and 12. The facility also failed to ensure nursing assessments were completed for two patients (#2, #4) in restraints of thirteen patients sampled (see A0395).

On 1/28/2022 at 1:00 p.m., the Director of Patient Safety & Risk Management was informed of the IJ situation which began on 6/29/2021. The cumulative deficits place the patients at risk for not having their needs met resulting in the Condition of Participation being out of compliance.

Based on review of personnel files, job descriptions, and staff interviews it was determined that the facility failed to ensure hospital nursing staff for whom current licensure is required was valid and current for one ("S") of five sampled staff personnel files.

Finding included:

On 1/27/2022 at 1:25 pm an interview was conducted with staff "S" in the Emergency Department. She stated she was an ER tech and also monitored the telemetry monitors. She was responsible for patient care under the supervision of the RN (Registered Nurse).

Review of the hospital staff personnel files for sampled staff "S" revealed a job description titled, "ER (Emergency Room) Tech II," signed on 1/17/2017. Review of the job description revealed certification requirement from Florida State as a Certified Nursing Assistant (CNA). Review of the personnel file revealed no evidence of certification as a CNA.

On 1/28/2022 at 9:54 am an interview was conducted with the Director of Patient Safety & Risk Management. She confirmed staff "S" did not have current certification as a CNA.

Based on review of medical records, review of policy and procedures and staff interview it was determined the facility failed to ensure a registered nurse followed physician prescribed orders for cardiac monitoring for seven patients (#1, #7, #8, #9, #10, #11, #12) and the facility failed to ensure nursing assessments were completed for two patients (#2, #4) in restraints of thirteen patients sampled.

Findings included:

1. Review of the medical record for patient #1 revealed on 6/29/2021 at 10:56 pm the patient arrived to the facility for complaint of shortness of breath. Review of the record revealed the patient had been discharged 2 days prior to arrival. During the patient's first admission the patient's cardiac rhythm was monitored throughout her admission and she had a cardiac consultation and treatment for new onset onset atrial fibrillation with RVR (Rapid Ventricular Rate), per the cardiac consultation dated 7/01/2021.

Upon readmission, on 6/29/2021, the patient denied chest pain however she complained of chest tightness. On
6/30/2021 at 12:04 am a physician order was written for cardiac monitoring, stat. On 6/30/2021 at 1:00 pm a history and physical (H&P) was completed. The H&P revealed a plan which included consult to cardiology for elevated troponins and need to adjust cardiac medication. (Levels of troponin in the blood are measured to determine whether the heart is damaged and if a heart attack (acute myocardial infarction) has occurred).

Review of the facility policy, "Telemetry Monitoring and Assessment of Patients," dated 2/2021, stated telemetry monitoring is initiated on a provider's order. The admission strip is collected and then scanned into the patient's electronic health record (EHR); (C) Patient Monitoring, (4) the cardiac rhythm of patients receiving cardiac monitoring will be continuously monitored by a qualified and competent staff member; (5) the monitor technician will measure and print/upload a strip every 12 hours and also with any rhythm changes.

On 7/1/2021 at 6:10 pm, per nursing documentation, the record revealed the patient's family member called nurses into the patient's room to check the patient's pulse. The RN (Registered Nurse) noted the patient was unresponsive with no pulse, and code blue (cardiac/respiratory arrest) was called. Despite attempts to resuscitate, the patient expired at 6:57 pm.

Review of the record revealed no evidence the physician order for cardiac monitoring was followed, as evidenced by failing to initiate the stat cardiac monitoring as per MD orders. An interview with the Director of Quality and Lead Quality Coordinator on 1/6/2022 at 9:40 am confirmed the finding.

2. Review of the medical record for patient #7 revealed on 10/05/2021 the patient arrived to the facility ED (Emergency Department) for complaint of rectal bleeding. Review of the record revealed the ED physician ordered cardiac monitoring. Review of the record revealed no evidence the initial admission telemetry strip was present in the patient's medical record. There was no evidence the RN assessed and documented the patient's cardiac rhythm.

3. Review of the medical record for patient #8 revealed on 1/01/2022 the patient arrived to the facility ED for complaint of rectal bleeding. Review of the record revealed the ED physician ordered cardiac monitoring. Review of the record revealed no evidence the initial admission telemetry strip was present in the patient's medical record. There was no evidence the RN assessed and documented the patient's cardiac rhythm.

4. Review of the medical record for patient #9 revealed on 1/02/2022 the patient arrived to the facility ED for complaint of shortness of breath and chest pain. Review of the record revealed the ED physician ordered cardiac monitoring on 1/02/2022 at 1:27 pm. Review of the record revealed no evidence the initial admission telemetry strip was present in the patient's medical record. There was no evidence the RN assessed and documented the patient's cardiac rhythm.

On 01/06/2022 at 3:07 pm an interview conducted with the Emergency Department (ED) Nurse Leader confirmed that they do not print telemetry strips. If they come by EMS (Emergency Management Services) and EMS did a telemetry strip we will scan that into the record. Our vital signs interface and cross over to the medical record but it does not interpret the readings. We have a telemetry tech that does nothing but watch the telemetry monitors and pick-up the line from EMS when they call.

On 01/07/2022 at 11:00 am an interview conducted with the Director of Patient Safety/ Risk Management confirmed the telemetry monitoring policy encompassed the ED and nursing staff must follow the policy for printing the admission strip for inclusion in the medical record.

5. Review of the medical record for patient #10 revealed on 1/22/2022 the patient arrived to the facility ED for complaint of chest pain. Review of the record revealed the physician ordered cardiac monitoring on 1/22/2022 at 8:13 am. Review of the record revealed no evidence the initial admission telemetry strip was present in the patient's medical record. The first documented cardiac strip in the medical record was on 1/22/2022 at 4:32 pm.

Interview with the Director of Patient Safety & Risk Management on 1/28/2022 at 4:45 pm confirmed the findings in the medical record.

6. Review of the medical record for patient #11 revealed on 1/26/2022 the patient arrived to the facility ED for complaint of chest pain. Review of the record revealed the physician ordered cardiac monitoring on 1/26/2022 at 11:38 am. Review of the record revealed no evidence the initial admission telemetry strip was present in the patient's medical record. The first documented cardiac strip in the medical record was on 1/26/2022 at 9:00 pm.

Interview with the Director of Patient Safety & Risk Management on 1/28/2022 at 4:45 pm confirmed the findings in the medical record.

7. Review of the medical record for patient #12 revealed on 1/06/2022 the patient arrived to the facility ED for complaint of shortness of breath and worsening chest pain. Review of the record revealed the physician ordered cardiac monitoring on 1/06/2022 at 8:13 am. Review of the record revealed no evidence the initial admission telemetry strip was present in the patient's medical record. The first documented cardiac strip in the medical record was on 1/06/2022 at 7:52 pm.

Interview with the Director of Patient Safety & Risk Management on 1/28/2022 at 4:45 pm confirmed the facility failed to ensure that their telemetry policy and procedure was followed as evidenced by failing to initiate the admission telemetry strips timely:

Eight (8) hours late initiation of telemetry admission strips for patient #10;
Twelve (12) hours late initiation of telemetry admission strips for patient #11; and
Thirteen (13) hours late initiation of telemetry admission strips for patient #12.

8. Review of the policy titled, "Restraint Management," dated 10/2020, stated the following: ... "to limit and/or eliminate the use of restraint. Conversely, clinically and developmentally appropriate alternatives to restraints to be attempted, documented and found to be ineffective prior to the use of restraint if possible... Neither restraint nor seclusion may be used as a means of coercion, discipline, or convenience and may only be used in a setting where staff have been educated according to policy. Restraint and seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others based on an individual assessment, as ordered by a physician or licensed independent practitioner and must be discontinued at the earliest possible time once the unsafe situation ends regardless of the scheduled expiration of the order. The type of restraint is limited to the least restrictive device possible ... Violent or Self-Destructive Behavior: Any behavior or verbalization that jeopardizes the immediate physical safety of the patient, a staff member or others..."

Violent, Self-destructive:
When restraint is used for the management of violent or self-destructive behaviors that jeopardizes the immediate physical safety of the patient, a staff member, or others the patient must be seen face to face within one hour after initiation of the intervention by a physician or a trained registered nurse.

Renewal orders for restraint of the patient with violent or self-destructive behaviors shall occur every 4 hours for an adult aged 18 years or older.

Monitoring and assessment of violent restraints: Upon application and removal nurse must document under restraint initiation and discontinuation:
Every one hour -Type and location of restraint, alternatives attempted, restraint affect, physical assessment: circulation, mental status, neurological status, restraint affect and behavior
Every 15 minutes- positioning or range of movement, hydration/nutrition, and elimination
Every two hours-vital signs (Blood Pressure, Heart Rate, Respirations, and Oxygen Saturation)


9. Review of Patient Care/Activity notes revealed Patient #2 was placed in "Violent restraints" (leather locked restraints) on 12/26/2021 at 7:15 am and discontinued, 8 days later, on 1/2/2022 at 10:00 pm (approximately 182.75 hours).

Review of Patient #2's Restraint Monitoring Log revealed:

15-minute monitoring and assessment for positioning, hydration/nutrition, and elimination was not conducted 547 times out of 731 opportunities.
One hour monitoring and assessment for neurological, mental status, restraint affect and behavior was not conducted 31 times out of 182 opportunities.

Review of Patient #2's "IView" vital signs documentation revealed 2-hour monitoring and assessment of vital signs were not conducted 31 times out of 91 opportunities.

Review of the Patient Care/Activity log for Patient #2 revealed violent restraint of the patient was initiated on 12/26/2021 at 7:30 am. Review of that documentation revealed the patient remained in violent restraints until 1/2/2022 at 10:00 pm. Review of the medical record for documented evidence of the 1-hour face-to-face evaluation by the physician, licensed practitioner, or trained registered nurse revealed no evidence the evaluation was completed.

On 01/05/2022 at 12:20 pm, Staff O, Director of Patient Safety/Risk Management, confirmed that Patient #2 was restrained without orders, assessments, and observations for a period of approximately 4 days, stating, "this should not happen."

On 01/05/2022 at 3:00 pm, Nurse Manager T reviewed Patient #2's chart and the Restraint policy. She stated, I can see the facility did not renew the order every 4 hours as required, nor conduct a face to face prior to renewing the violent restraint order, nor conduct every 2 hour and 15-minute assessments of the patient. This was sad, so many opportunities here that were missed on this patient.

On 1/5/2022 at 3:30 pm, Nurse Manager U said she was aware of Patient #2's Baker Act expiring. She said she didn't do anything about it, but the feedback she was receiving from her team lead after multidisciplinary rounds was that the patient was waiting on psych placement.


10. Review of nursing documentation revealed Patient #4 was placed in violent restraints (leather locked restraints) on 7/09/2021 at 7:26 pm and discontinued on 07/10/2021 at 1:05 am (for approximately 5.5 hours).

Review of Patient #4's Restraint Monitoring Log revealed 15 minute monitoring and assessment for positioning, hydration/nutrition, and elimination was not completed 15 times out of 22 opportunities.

Review of nursing documentation for Patient #4 on the Vitals/Metrics Log revealed 2 hour vital sign monitoring was conducted at 07/09/2021 at 8:30 PM and 12:30AM. No 10:30AM vital signs monitoring was conducted.

Review of nursing and physician assessments for Patient #4 revealed no evidence a face-to-face assessment within one hour was conducted by a physician or a trained registered nurse after initiation of violent behavioral restraints on 7/09/2021 at 7:26 pm.

Review of nursing documentation revealed Patient #4 was placed in violent restraints (leather locked restraints) on 7/09/2021 at 7:26 pm and discontinued on 07/10/2021 at 1:05 am (for approximately 5.5 hours).

Interview with the Director of Quality, Lead Quality Coordinator and Risk Manager on 1/6/2022 at 9:55 am, confirmed the findings related to restraints for Patient #2 and Patient #4.

An interview and review of the record was conducted with Nurse Managers (Staff T and Staff U) on 1/05/2022 at 3:30 pm. They both confirmed the findings related to restraints for Patient #2 and Patient #4.