HospitalInspections.org

Based on observation, interviews and facility document review, it was determined the facility failed to inform patients/patient representatives of their patient rights and responsibilities upon entry to the facility.

The findings include:

On April 22, 2025 at 11:50 AM, Staff Member #6 conducted a tour of the facility's Adult ED waiting area. The location where the "Patient Rights and Responsibilities" signage was to be posted, was empty. Staff Member #6 did not know the reason that the signage was taken down. Staff Member #6 and the surveyor walked over to the separate Pediatric ED and found posted Patient Rights and Responsibilities signs in English and Spanish. The signs did not include information indicating how a patient could obtain a copy of their Patient Rights and Responsibilities.

On April 22, 2025 at 11:45 AM, an interview was conducted with Staff Member #6. Staff Member #6 stated that the Patient Registration personnel in the Emergency Department (ED) did not discuss patient rights information while registering patients. Staff Member #6 explained that Patient Rights and Responsibilities are posted on a sign in ED waiting room. Staff Member #6 explained that the script contained in the policy "Consent for Treatment Fact Sheet", effective 3/19/24, did not include any verbiage about Patient Rights. Staff Member #6 stated that if a patient requested a copy of their Patient Rights in a manner that they could understand (i.e. blind, speaks a language other than English or Spanish per the posted signs), then the patient would be provided with a copy or with an interpreter to review their rights. Staff Member #6 stated that Patient Registration used to provide printed brochures to patients, but they ran out of copies and did not know how to order any more.

On April 22, 2025 at 11:51 AM, an interview was conducted with Staff Member #14. When asked for a copy of the facility's "Patient Rights and Responsibilities", Staff Member #14 left the desk and retrieved a laminated, ringed copy of the facility's "Patient Agreement". Staff Member #14 pointed to the underlined headings - Consent to Medical Examination, Care & Treatment: Telehealth, Medical Education Programs and Affiliated Provider Fees, indicating that these were the Patients Rights and Responsibilities. Staff Member #14 did not provide a copy of the facility's Patient Rights and Responsibilities.

A review of a policy, (not affiliated with the facility) "Front End: Consent for Treatment Fact Sheet", effective date 3/19/24, did not contain any information related to the facility's Patient Rights and Responsibilities.

A review of the facility's policy "Individual's Rights and Responsibilities", effective date, 12/19/24, indicated in part: "...Patients/residents/clients shall receive patient rights information at the point of entry of service that informs them about their rights...".

A review of the facility's "Patient Agreement" retrieved from a sampled medical record and signed by a patient, indicated in part: "...I acknowledge that (facility) has made available to me those notices that are required by State or Federal law, including Patient Rights & Responsibilities documentation, and I understand that I may ask (facility) any questions about such notices...". This was the only reference to Patient Rights found in the entire agreement.

Based on staff interview and document review, it was determined the facility failed to obtain an accurate order for restraint use in one (1) of four (4) medical records of patients in restraints reviewed in the survey sample MR7 (Medical Record).

Findings:

A review of MR7 revealed a nursing progress note on April 9, 2025 at 11:28 PM that indicated the patient was anxious, crying, and yelling. The patient was offered medication for anxiety, but the patient refused. At midnight on April 10, 2025 the nurse documented that the patient was agitated and repetitively banging their head on the side rails, causing a cut on the forehead. Security was called and responded. The nurse documented at midnight, "Patient becoming more agitated, physically and verbally aggressive, and trying to harm self by constantly hitting head on bed rails. Soft wrist restraints were applied."

MR7 contained an order for restraints placed at 1:51 AM by the night shift nurse practitioner. The order was for "Restraints non-violent; non-self destructive...Soft bilateral wrist restraints." The documented reason for restraint was, "interference with medical treatment, pulling lines, tubes, dressing, equipment" despite no evidence in the medical record that the patient was pulling at lines or tubes. The only documented behaviors in the medical record necessitating restraints were related to self-destructive behaviors, but the practitioners orders for restraints were for non-violent restraints instead of violent or self-destructive restraints.

The facility's policy, Restraints or Seclusion for Violent, Self-Destructive Patient Situations (last revised 12/20/24), was reviewed and reads in part, "...any type of violent restraint....requires a provider order. In the absence of an order, the RN may initiate use of restraints or seclusion in an emergency situations. In emergency situations, the order must be obtained either during the emergency application of the restraint or initiation of seclusion or immediately (within a few minutes) after the restraint has been applied or seclusion has been initiated. Failure to immediately obtain an order is viewed as the application of restraint without an order." MR7 contained documentation that restraints were applied at midnight, and an order for the restraints was not obtained until 1:51 AM on April 10, 2025 (almost two hours after the initiation of restraints).

An interview was conducted with EMP16 at 11:58 AM on April 22, 2025. EMP16 confirmed that staff was trained on the application and monitoring of restraints on hire and annually. EMP16 confirmed that the order for MR7's restraints was for non-violent restraints and that there was no documentation in the medical record to support that the patient was pulling at lines or tubes. EMP16 confirmed the nurse had documented applying restraints due to the self-destructive behavior of hitting head on the bedrails causing injury and requiring security to be called.

Based on staff interview and document review, it was determined the facility failed ensure the patient's attending physician was notified of a patient being placed in restraints in one (1) of four (4) medical records of patients in restraints reviewed in the survey sample MR7 (Medical Record).

Findings:

MR7 contained an order for restraints placed at 1:51 AM by the night shift nurse practitioner. The order was for "Restraints non-violent; non-self destructive...Soft bilateral wrist restraints." The documented reason for restraint was, "interference with medical treatment, pulling lines, tubes, dressing, equipment" despite no evidence in the medical record that the patient was pulling at lines or tubes. The only documented behaviors in the medical record necessitating restraints were related to self-destructive behaviors, but the practitioners orders for restraints were for non-violent restraints instead of violent or self-destructive restraints.

The facility's policy, Restraints or Seclusion for Violent, Self-Destructive Patient Situations (last revised 12/20/24) reads, "...If violent restraints or seclusion was not ordered by the attending or the face-to-face evaluation is conducted by someone other than the attending physician...they must consult the attending physician or other licensed practitioner who is responsible for the care of the patient as soon as possible and/or after the completion of the 1-hour face-to-face evaluation...." MR7 contained no documentation that the patient's attending physician was made aware of the order for restraints.

An interview was conducted with EMP12 (employee) at 11:00 AM on April 22, 2025 who confirmed the lack of notification to the attending physician in MR7.

Based on staff interview and document review, it was determined the facility failed to ensure that patients in restraints were adequately monitored in one (1) of four (4) medical records of patients in restraints reviewed in the survey sample MR7 (Medical Record).

Findings:

MR7 contained an order for restraints placed at 1:51 AM by the night shift nurse practitioner. The order was for "Restraints non-violent; non-self destructive...Soft bilateral wrist restraints." The documented reason for restraint was, "interference with medical treatment, pulling lines, tubes, dressing, equipment" despite no evidence in the medical record that the patient was pulling at lines or tubes. The only documented behaviors in the medical record necessitating restraints were related to self-destructive behaviors, but the practitioners orders for restraints were for non-violent restraints instead of violent or self-destructive restraints.

MR7 contained documentation that the patient was placed in bilateral soft wrist restraints on April 10, 2025 at midnight, but contained no documentation of patient monitoring by the RN until 2:00 AM on April 10, 2025. The restraints were discontinued at 2:20 AM on April 10, 2025. The facility's policy, Restraints or Seclusion for Violent, Self-Destructive Patient Situations (last revised 12/20/24) reads in part, "...Minimum documentation in the medical record from restraints or seclusion related to violent and/or self-destructive behavior includes: Every 15 minutes assess the need for intervention on the following: A. Checking circulation and restraint applied properly; b. continuous observation; c. Physical comfort; d. psychological status...A minimum of every two hours, assess the need for intervention on the following: a. clinical justification criteria (RN only); b. hygiene and elimination needs; c. food/meals offered/nutritional status; d. fluids/hydration status; e. ROM reposition, skin integrity checked; f. Readiness for removal of restraints or discontinuing seclusion; g. assisting individuals to meet behavioral expectations of discontinuation of restraints or seclusion...."

An interview was conducted with EMP12 (employee) at 11:00 AM on April 22, 2025 who confirmed the lack of documentation of required monitoring for MR7.