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Based on interviews and record review, the hospital failed to demonstrate they had a process in place to ensure safety of residents that required additional monitoring, which resulted in the use of unnecessary restraint by placing all four side rails up to prevent one patient (P)1 from climbing out of bed. P1 was not capable of making his own decisions regarding his care and the hospital did not involve his Power of Attorney (POA) in his treatment/care planning. In addition, they did not follow their own policies. Due to the nature of the deficiencies, the facility was determined not to be in compliance at the Condition level of Patient Rights.

Findings included:

1) Reviewed the hospital policy titled "Patient Rights, PCS 10-390 last revised 03/2007, which included the following statements:
- "The patients' right to be informed about and participate in decisions regarding his or her care."
- "The issue of designating a decision maker in case the patient is incapable of understanding a proposed treatment or procedure or is unable to communicate his or her wishes regarding care."
- "Staff members clearly explain any proposed treatment or procedures to the patient and, when appropriate to the family. The explanation includes: 1. Potential benefits and drawbacks ...5. Any significant alternatives...."
- "Care sometimes requires that people other than ...the patient be involved in decisions about the patient's care. This is especially true when the patient does not have the mental or physical capacity to make care decisions ..."

Review of the hospital "Patient Rights & Responsibilities" document in the admission packet revealed it included the following: "The patient has the right to be free from chemical or physical restraints and seclusion, except as authorized by a doctor or in an emergency when it is necessary to protect the patient or others from injury. If restraint are indicated, the least restrictive method will be used in accordance with Medical Center policy, and the patient will be monitored."

2) Cross Reference A-0130 Patient Rights; Participation in Care Planning
The hospital failed to provide the Power of Attorney (POA) of one incapacitated patient (P)1 the right to participate in the development, implementation and revision of his care plan. In addition, the hospital did not take reasonable steps to notify the POA when P1's condition changed.

3) Cross Reference A-0144 Patient Rights; Care in a Safe Setting
The facility failed to demonstrate one patient (P1) was provided the additional supervision/monitoring needed to ensure he was safe when he exhibited increased confusion and new behaviors that included impulsivity and trying to get out of bed. The facility used a physician order of "enhanced monitoring," but staff did not have a uniform understanding of what the order meant, and the facility did not have a policy/procedure to define nursing responsibilities related to the order. Due to that deficiency, P1's monitoring was inconsistent.

4) Cross Reference A-0154 Use of Restraint Or Seclusion
All four of P1's bed rails were placed in the up position to prevent him from attempting to get out of bed. There was no documentation of a physician order, less restrictive measures attempted (ie 1:1), or monitoring during the restraint.

Based on interviews and record review (RR), the hospital failed to provide the Power of Attorney (POA) of one incapacitated patient (P)1 the right to participate in the development, implementation and revision of his care plan. In addition, the hospital did not take reasonable steps to notify the POA when P1's condition changed.

Findings include:

1). P1 was a 75 year old male admitted to the hospital on 01/03/23. He presented to the Emergency Department (ED) by ambulance with altered mental status. P1 had been living independently and at baseline had been alert, talkative and appropriate, but had been confused for about a week. His daughter, who lives on mainland and POA called 911 because she was concerned about the increased confusion and wanted him transported to the hospital. P1's medical history included congestive heart failure, high blood pressure, Type 2 diabetes, heart arrhythmia (abnormal heart rhythm) and underlying dementia. He was admitted for further care with diagnosis of influenza A, generalized weakness, altered mental status, and dehydration.

2) Record review included the following:
01/03/2023: A consent to treat form revealed P1's POA gave phone (verbal) consent for treatment when P1 was in the ED.

Nursing progress notes revealed P1 became increasingly confused and aggressive and included but not limited to the following:
01/04/2023 at 01:36 PM: "Continues to be 1:1 for impulsive, confused, fall risk."
01/06/2023 at 00:11 AM: "Patient appeared restless from the start of shift. Patient attempting to climb out of bed and yelling out. Repositioned patient back into bed multiple times, patient would appear comfortable and at rest for a few minutes and then became restless once again. Notified MD, new order for one time haloperiodol (haldol-antipsychotic) 2 mg (milligrams) and Quetiapine (Seroquel-antipsychotic) 50 mg PO (orally) to be given at HS (hour of sleep)... Bed in low position, side rails up x 2 and call light with reach.
01/06/ 2023 at 05:22 AM: "Pt (P1) a&ox1 (alert and oriented to name only), confused. Pt restless, frequent attempts to climb out of bed, yelling out throughout shift. One time order of Quetiapine 12.5 mg PO per MD as ordered ... Bed in low position, side rails up x 4 and call light within reach. Bed exit alarm on at all times. pt room near nurses station, frequent roundings done throughout the shift"
01/06/2023 at 08:40 AM, Nursing: "...lungs decreased in bases with audible crackles, Dr. notified. No new orders."
01/06/2023 at 06:00 PM, Nursing: "Reported by CNA (certified nursing assistant) that pt (P1) twisted her arm when redirecting pt back to bed. Pt continues to throw gown and sheets on floor... Dr notified new order received for one time Haldol IM (intramuscular)..."
01/08/2023 at 05:57 AM: "...Received pt lethargic (abnormally drowsy). ..."
01/08/2023 at 11:30 AM: "Pt unable to take morning medications due to being too lethargic to safely swallow. ..."
01/08/2023 at 03:30 PM: "Ate 0% of meals this shift. ... speech is slow and incoherent. Desats (oxygen saturation decreases) on RA (room air) at 70's (normal over 90 if lung disease), wearing 2-3 L (liters) NC (oxygen by nasal cannula)"
01/08/2023 at 05:00 PM: "Pt refusing to wear O2 (oxygen) NC. ..."
01/09/2023 at 04:38 AM: "Patient increasing work of breathing and abnormal apnea (when you stop breathing) during the night. MD notified. EKG (electrocardiogram) ordered and showed ST with frequent PVC's and BBB (abnormal EKG reading). 20 mg IV (intravenous) lasix (diuretic) given. ... Increased tachycardia (rapid heart rate) and PVC's noted. ..."
01/09/2023 at 05:58 AM: "CODE BLUE. .. Patient time of death 1744. Attempted to call family members on face sheet numbers- no answer."

Review of MD progress notes revealed the following entry:
01/08/2023 at 10:06 PM, MD2: "Called by RN. Pt with irregular rhythm on auscultation and noted increase O2 requirements from 1 L NC > 4 L NC. On exam, pt with transmission of upper airway sounds and also with wet/course sounding lungs. ... CXR (Chest x-ray) read shows worsening pulm (pulmonary) edema. ...Overall concerned for pt's prognosis. ...-goals of care discussion with family recommended."

3) The record review revealed P1's patient representative (POA) was not notified by the Physicians or Nursing staff after he was admitted during his hospitalization, and was not involved in his care plan or treatment plan. P1 had significant new behavioral changes that required MD notification and was treated with antipsychotic's, but there were no documented attempts to notify the POA of his behavior change and involve her in the treatment plan. The MD was notified again on 01/06/2023 for abnormal lung sounds and P1 showed additional signs of decline on 01/08/2023 with lethargy, not eating, and low oxygen saturation, yet the POA was not contacted to discuss his medical condition until after he expired on 01/09/2023.

4) RR revealed the Social Worker was able to contact the POA to discuss and work with her on P1's discharge planning.

Based on interviews and document review, the facility failed demonstrate they had a process in place to provide additional monitoring of patients ensure safety. One patient (P1) had a physician order for "enhanced monitoring," but the nursing staff did not have a common understanding what the order meant, and did not provide the monitoring in a consistent manner. As a result of this deficiency, there was the potential P1 did not have the monitoring needed to ensure his safety, which put him at risk of harm. This deficient practice has the potential to affect any patient that needs additional monitoring for safety.

Findings include:

1) P1 was a 75 year old male admitted to the hospital on 01/03/23. He presented to the Emergency Department (ED) by ambulance with altered mental status. P1 had been living independently and at baseline had been alert, talkative and appropriate, but had been confused for a week. His daughter, who lives on mainland and is Power of Attorney, called 911 because she was concerned about his increased confusion. P1's medical history included congestive heart failure, high blood pressure, Type 2 diabetes, heart arrhythmia (abnormal rhythm) and underlying dementia. He was admitted for further care with Influenza A, generalized weakness, altered mental status, and dehydration.

2) Reviewed of P1's care plan (CP), which included the problem "Altered Mental Status (Delirium)." The description was "To accurately identify cause of the Altered Mental Status and provide appropriate treatment plan. To prevent any complication due to the change of mental status: i.e. safety. ..." The goal was "PT (P1) will not have falls or injury. ..."

Reviewed P1's nursing notes which included:
01/04/2023 at 04:35 AM: "Oriented to self only. Disoriented and confused. Occasionally agitated and impulsive. High fall risk. Pulled out IV x 1. Incontinent of urine ...bed in lowest position and frequent rounds done to monitor for safety. Remains confused and occasionally impulsive. Bed alarm on. No falls overnight."
01/04/2023 at 09:22 AM: "Per night nurse pulled out IV (intravenous fluid access) x 2. Pt very impulsive on 1:1, per RN. MD1 notified..."
01/04/2023 at 01:36 PM: "...Continues to be 1:1 due to being impulsive, confused, fall risk."
01/05/2023 at 03:53 PM: "...Patient is confused and combative, aggressive with staff. Patient has been calling out and whaling in bed...Patient is unaware that he is in the hospital. Patient is very weak and continues to request to stand and ambulate in room. ...Patient appeared very unsteady and wobbling when attempted to take a step. Patient was unable to take a step, even with one person assisting. ...Patient placed on enhanced observation. Will continue to monitor patient status."
01/06/2023 at 00:11 AM: "Patient appeared restless from the start of shift. Patient attempting to climb out of bed and yelling out. Repositioned patient back into bed multiple times, patient would appear comfortable and at rest for a few minutes and then became restless once again. Notified MD, one time order for haloperiodol (antipsychotic) 2 mg (milligrams) IM (intramuscularly) and Quetiapine (Seroquel - antipsychotic) 50 mg PO (oral) to be given at bedtime. ...Bed in low position, side rails up x 2, and call light within reach. Bed exit alarm on at all times and room near nurses station."
01/06/2023 at 05:22: "...Pt restless, frequent attempts to climb out of bed, and yelling out throughout shift. One time order of Quetiapine 12.3 mg PO per MD. ...Bed in low position, side rails up x 4 and call light within reach. Bed exit alarm on at all times. Pt room near nurses station, frequent rounds done throughout shift."
01/06/2023 at 08:40 AM: "... has poor concentration and needs to be redirected. Pt continues to pull things off and throw things on the floor. ... Bed is low and locked."
01/06/2023 at 06:00 PM: "Reported by CNA (Certified Nursing Assistant) that pt twisted her arm when redirecting pt back to bed. Pt continues to throw gown and sheets on the floor. Attempted to help feed pt and he spit out his food. Dr. notified new order received for one time Haldol IM. Bed alarm on, continue to monitor frequently."
01/07/2023 at 03:59 PM: "...Patient less aggressive today and more calm. ... Close to nursing station for monitoring and has not attempted to hit staff or get fully out of bed."
01/08/2023: notes revealed P1 became lethargic and condition declined. Monitoring at this point was not needed for behaviors and safety, but for declining medical condition.
01/09/2023: P1 expired.

Review of P1's orders revealed there was an order placed by MD1 for "Enhanced Patient Observation" on 01/05/2023 at 10:43 AM. The order was canceled after P1 expired on 01/09/2023. The order details included:
Procedure: "Sitter for constant observation."
Process Instructions: "Enhanced observation (Medical Sitter) at the bedside is selectively utilized during periods of temporary altered mental status and when all other options to promote and ensure patient safety have been exhausted, or medical limitations prevent use of alternative options. Staff acting as an enhanced observer should focus on reorienting patient and training patient to be safe and independent to reduce continued need for sitter use. This order is managed by attending medical provider. See linked policy for sitter criteria and nursing procedures."
Order Questions: "Reason for enhanced observation: Confusion, fall risk."

3) The Director of Nursing (DON) said the hospital (H)1 did not have a policy for enhanced observation, and the "linked policy" referenced in the order was another hospital's (H2) policy that is part of their system.

4) Review of the linked policy revealed it was H2's policy titled "Enhanced Patient Observation Policy, 610-21-322-B, last revised 01/2023 and applicability included H2 + H3. H1 is part of the same Health System, which has four major hospitals throughout Hawaii, but the policy did not indicate it was applicable to H1. The linked policy included several additional measures to ensure patient safety which included, but not limited to:
- Monitor frequently by visual contact (no less than every 30 minutes). Increase purposeful rounding if appropriate. Relocate patient to a room near the nursing station if possible."
- Consult Pharmacy to evaluate medications.
- Enhanced observation orders expire in 24 hours and will not renew automatically.

5) Conducted a telephone interview with RN1, who was assigned P1 the night shift 1/05/2023. She said P1 had been anxious and restless since the start of her shift (07:00 PM) and wanted to keep getting out of bed. She said they repositioned him to make sure he was comfortable, but after a short period of time again he would attempt to get out of bed again. RN1 said she placed the top side rails up and contacted the physician who ordered medication. She went on to say P1 continued being anxious and again contacted the MD for further orders. Additional medication was ordered at the time of the second call. Asked RN1 what the order enhanced monitoring meant, and she said the patient needed to be watched more closely than the routine rounding checks (every four hours) or it could be moving the patient closer to the station. She said the order did not mean a sitter had to be present in the room at all times. RN1 said that night they tried to do rounding every hour, but they were able to round about every two hours due to workload and staffing. She said she did not contact the house supervisor to request additional staff or a sitter.

6) On 03/16/2023 at 01:30 PM, during an interview with the Director of Nursing (DON), she said the facility had a "suicide sitter policy," but did not have a policy for behavioral issues/enhanced observation. She said the enhanced observation order is good until discontinued by the physician and means someone should be sitting in the room at all times to watch the patient. The DON said 1:1's should be documented on the Nursing Assignment sheets.

7) On 03/16/2023 at 02:30 PM, during an interview with MD1, whose roles included Hospitalist, Medical Director and Chief of Staff, he said his understanding was the order enhanced observation did not have a time limit and meant the patient required a higher level of care in terms of monitoring, but it was not the expectation someone sit with the patient 24 hours a day and nursing judgement would determine what type of monitoring was appropriate for the behaviors at that time. Interventions could include but not limited to moving the patient room closer to the station or a "windowed room" or staff in the room.

8) A review of the "Nurse Assignment"staffing sheets from 01/04/2023 through 01/09/2023 was completed with the DON. The enhanced monitoring was ordered 01/05/2023 at 10:43 AM. The assignments documented 1:1 monitoring was provided for P1 night shift on 01/04/23. There were no other notations of assigned staff 1:1 for P1. As noted above, there were nursing notes on 01/04/2023 day shift P1 had 1:1 monitoring some time during the shift, but it is unknown the amount of time.

Based on record review (RR), the nursing staff placed all four rails of P1's bed up for an unknown period of time to prevent him from attempting to get out of bed. There was no physician order for the restraint, documentation of ongoing assessments during the restraint or attempts of less restrictive methods (i.e. sitter) to ensure his safety. Due to P1's medical condition, the use of all four side rails placed an additional risk of increased injury or entanglement.

Findings include:

1) P1 was a 75 year old male admitted to the hospital on 01/03/23. He presented to the Emergency Department (ED) by ambulance with altered mental status. P1 had been living independently and at baseline had been alert, talkative and appropriate, but had been confused for about a week. P1's medical history included congestive heart failure, high blood pressure, Type 2 diabetes, heart arrhythmia (abnormal rhythm) and underlying dementia. He was admitted for further care with diagnosis of influenza A, generalized weakness, altered mental status, and dehydration.

2) Cross Reference A0144 Patient Rights in Safe Setting.
The facility failed to demonstrate P1 was provided the additional supervision/monitoring needed to ensure he was safe when he had increased confusion and exhibited new behaviors that included impulsivity and trying to get out of bed. The facility used a physician order of "enhanced monitoring," but staff did not have a uniform understanding of what that meant, and did not have a policy/procedure that defined nursing responsibilities related to the order. As a result of this deficiency, when P1 required additional monitoring needed to ensure his safety, staff interventions varied which put his safety at risk with potential of harm.

3) Review of P1's medical records revealed the following nursing progress note:
01/06/2023 at 00:11 AM: "Patient appeared restless from the start of shift. Patient attempting to climb out of bed and yelling out. Repositioned patient back into bed multiple times, patient would appear comfortable and at rest for a few minutes and then became restless once again. Notified MD, new order for one time haloperiodol (haldol-antipsychotic) 2 mg (milligrams) and Quetiapine (Seroquel-antipsychotic) 50 mg PO (orally) to be given at HS (hour of sleep)... Bed in low position, side rails up x 2 and call light with reach.

01/06/ 2023 at 05:22 AM: "Pt (P1) a&ox1 (alert and oriented to name only), confused. Pt restless, frequent attempts to climb out of bed, yelling out throughout shift. One time order of Quetiapine 12.5 mg PO per MD as ordered ... Bed in low position, side rails up x 4 and call light within reach. Bed exit alarm on at all times. pt room near nurses station, frequent roundings done throughout the shift.

Review of P1's orders revealed there was an order placed by MD1 for "Enhanced Patient Observation" on 01/05/2023 at 10:43 AM. The order details included:
Procedure: "Sitter for constant observation."
Process Instructions: "Enhanced observation (Medical Sitter) at the bedside is selectively utilized during periods of temporary altered mental status and when all other options to promote and ensure patient safety have been exhausted, or medical limitations prevent use of alternative options. Staff acting as an enhanced observer should focus on reorienting patient and training patient to be safe and independent to reduce continued need for sitter use. This order is managed by attending medical provider. See linked policy for sitter criteria and nursing procedures."
Order Questions: "Reason for enhanced observation: Confusion, fall risk."
There was no additional order for the use of side rails x 4 on 01/06/2023.

4) On 03/17/2023 at approximately 09:30 AM, during an interview with the Director of Nursing (DON), informed her during RR had noted use of side rails on P1, and asked if side rails were considered a restraint. She said two side rails up is not, but four rails was considered a restraint. DON provided the restraint policy. At the time of the interview and survey exit the additional note of the x 4 rails up had not been reviewed, and was noted on 03/21/2023.

5) Reviewed the facility policy titled "Restraint, Use of," last revised 01/2021 which included:
- "Definitions: Restraint: Any manual method, physical or mechanical device, material or equipment that immobilized or reduces the ability of a patient to move his or her arms, legs, body or head freely. ..."
- "The hospital uses restraint only when it is clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff or others."
- "The hospital uses restraint only to protect the immediate physical safety of the patient, staff or others."
- "The hospital uses restraint only when less restrictive interventions are ineffective."
- "The hospital discontinues restraint at the earliest possible time, regardless of the scheduled expiration of the order."
- "Care Plan: The patients written care plan shall be modified to include restraint."
- "If a restraint is necessary, the nurse should obtain an order from the attending physician..."
- Medical Restraint indications included when "The patient's actions are endangering himself, for example if the patient is thrashing around in bed or attempting to get out of bed in a way or under conditions where it might cause harm..."
- "An order for restraints must include the following: restraint type, behavior requiring restraint, and alternatives considered or attempted."
- Documentation of "Less restrictive alternatives attempted that were ineffective" is required, and "Monitoring activities shall be performed every two hours or more frequently if indicated by the condition of the patient. ... Documentation shall occur on the restraint/documentation flow sheet. ..."