HospitalInspections.org

Based on interviews, medical record review and facility document review, the facility failed to use the least restrictive type of restraint for one (1) of four (4) restraint medical records reviewed.

The findings include:

A review of the facility's policy "Restraints Use: Prevention and Reduction Plan", last reviewed May 2021, indicated in part: "...Procedure...A. Prior to the use of restraint(s), staff will try alternative interventions and document these alternative interventions attempted. Document any emergency event that prevented the use of less restrictive alternative interventions...D. Restraints will be initiated using the least restrictive type of restraint that will be effective to protect the patient, staff members, or others from harm based on the assessed need of the patient...Restraint Types A. Least to Most Restrictive Devices...3. Mitts...4. Roll Belts...Care of the Violent/Self-Destructive Behavior Restraint (Behavioral Restraint) Patient...H. Chemical restraint assessment by the nurse includes medication effectiveness of the behavior trying to eliminate or change. I. Discontinuation...2. Chemical restraint monitoring can be discontinued when desired outcome of medication is obtained...Documentation of Violent/Self-Destructive Behavior Restraints (Behavioral Restraints)...B. Document all alternatives to restraint that were attempted prior to the application of a restraint...F. Patient's response to the intervention...".

On December 1 and 2, 2025, a review of Patient #7's medical record was conducted. The physician orders found in Patient #1's record indicated on November 10, 2025, that the patient was ordered a chemical restraint at 10:35 PM, a physical hold for danger to self, at 10:39 PM and non-violent restraints of mitts and a roll belt at 10:47 PM. The chemical restraint was administered at 10:42 PM and the mitts and roll belt were applied at 10:47 PM. The medical record did not contain documentation of the patient's response to the chemical restraint nor the patients behavior after administering the chemical restraint and prior to placing the patient in non-violent restraints.

In an interview on December 2, 2025 at , with Staff Member #15, Staff Member #15 verified that the medication administered to Patient #7 (geodon) was intended to be administered as a chemical restraint. The medical record indicated that the physician ordered the staff to give one (1) medication early, increase another medication, administer the geodon and place the patient in mitts and a roll belt. Staff Member #15 stated that staff told them that the physical hold did not happen because the patient had begun to calm down prior to the administration of the geodon. Staff Member #15 reviewed the record and indicated the patient's CIWA (Clinical Institute Withdrawal Assessment for Alcohol) scores indicated that the patient was still agitated and restless after the administration of the medications, chemical restraint and physical restraints. However, Staff Member #15 agreed that the documentation for the evaluation of the chemical restraint was lacking and did not paint a picture as to what was happening and the reason why the non-violent restraints were applied after the chemical restraint. Staff Member #15 also stated the physical hold order should have been discontinued since it did not occur.

Based on medical record review and facility document review, the facility failed to discontinue restraints at the earliest possible time for two (2) of four (4) medical records reviewed.

The findings include:

A review of the facility's policy "Restraints Use: Prevention and Reduction Plan", last revised May 2021, read in part: "...Procedure...I. Restraints will be discontinued at the earliest possible time, regardless of the scheduled expiration of the order...".

On December 1, 2025, a review of Patient #5's medical record revealed that the patient was placed in bilateral soft wrist restraints on November 6, 2025 prior to midnight. The nursing flowsheets documented that the patient was "asleep" on November 7, 2025 at 4:00 AM and 6:00 AM. The patient restraints were not removed until 10:00 AM on November 7, 2025.

On December 1, 2025, a review of Patient #6's medical record revealed that the patient was placed in bilateral mitts on November 25, 2025 at at 9:12 AM. The nursing flowsheets documented that the patient was "subdued" at 11:17 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM and 8:00 PM. The restraints were removed at 9:11 PM on November 25, 2025.

Based on interviews, medical record review and facility document review, the facility failed to monitor a restrained patient according to facility policy for one (1) of four (4) medical records reviewed.

The findings include:

A review of the facility's policy "Restraints Use: Prevention and Reduction Plan", last reviewed May 2021, indicated in part: "...Care of the Violent/Self-Destructive Behavior Restraint...D. Chemical restraint monitoring can be discontinued when the desired outcome of the medication is obtained. 1. Chemical restraint monitoring may include the following. a. Heart rate b. Respiration rate c. Blood Pressure d. Oxygen saturation. E. All patients in behavioral restraints will receive 1:1 care. 1. Safety CNA will provide continuous observation of the patient and document every fifteen (15) minutes. a. Continuous observation of patient b. Observations: agitated/restless, verbally abusive, tearful, hallucination, delusional, subdued, patient asleep, confused, or other...".

On December 1 and 2, 2025, a review of Patient #7's medical record was conducted. On November 10, 2025 at 10:42 PM, Patient #7 was administered the chemical restraint, geodon. The medical record did not contain evidence that the patient was monitored according to facility policy after the administration of the chemical restraint.

In an interview on December 2, 2025 at , with Staff Member #15, Staff Member #15 verified that the medication administered to Patient #7 (geodon) was intended to be administered as a chemical restraint. Staff Member #15 agreed that the monitoring documentation for the chemical restraint was lacking.

Based on interviews, medical record review and facility document review, the facility failed to document the patient's response to the intervention of a restraint and failed to document a description of the patient's behavior that warranted the use of restraints for one (1) of four (4) patient records reviewed.

The findings include:

A review of the facility's policy "Restraints Use: Prevention and Reduction Plan", last reviewed May 2021, indicated in part: "...Care of the Violent/Self-Destructive Behavior Restraint (Behavioral Restraint) Patient...H. Chemical restraint assessment by the nurse includes medication effectiveness on the behavior trying to eliminate or change...Documentation of Violent/Self-Destructive Behavior Restraints (Behavioral Restraints) A. Description of the patient's behavior or patient's condition or symptom/symptoms that warrants the use of the restraints...F. Patient's response to the intervention...I. When restraint interventions are discontinued the nursing assessment and restraint removal is documented along with the date and time restraints are discontinued...".

On December 1 and 2, 2025, a review of Patient #7's medical record was conducted. The physician orders found in Patient #1's record indicated on November 10, 2025, that the patient was ordered a chemical restraint at 10:35 PM and a non-violent restraint of mitts and a roll belt. The chemical restraint was administered at 10:42 PM and mitts and a roll belt restraints were applied to the patient at 10:47 PM. The medical record did not contain documentation of the patient's response to the chemical restraint, the patient's behavior prior to initiating the mitts and roll belt and the alternatives attempted prior to placing the non-violent restraints on the patient.

In an interview on December 2, 2025, with Staff Member #15, agreed that the restraint documentation for this incident with Patient #7 was lacking and did not give a picture as to what was happening with patient at that moment.

Based on interviews, medical record review and facility document review, the facility failed to follow facility policy when discharging a patient.

The findings include:

A review of the facility's policy "Alias", last revised March 2022, indicated in part: "...Alias Patient Discharge A. The AA, RN, or Physician will contact Patient Access prior to discharge and sending prescriptions electronically to the preferred pharmacy to have the Alias name removed. B. Patient Access Specialist will go under demographics and add the patient's legal name back on the MRN. C. Standard discharge procedure will be followed at this time and electronic prescriptions sent. D. The AA will send e-mail notification to the Alias Notification Group informing them of the patient's discharge. E. The AA prints labels and a face sheet with the patient's legal name for distribution to the Health Information management Department and the Patient Accounts Manager. F. The AA prints labels with the patient's legal name to place on every sheet of the medical record prior to sending the chart to the Health Information Management Department...".

On December 1, 2025, a review of Patient #1's medical record was conducted. The viewed medical record located in the facility's Electronic Medical Record (EMR) revealed Patient #1's real, legal name and a medical record number (MRN) (3...). Patient #1's consent for treatment was printed with an alias name and a different MRN (4...). Patient #1's discharge instructions included Patient #1's real name with parentheses next to it reading "Legal name: (alias name)" and MRN (4...). Name labels attached to the paperwork that had been scanned into Patient #1's medical record was printed as Patient #1's real name with parentheses next to it reading "Legal: (alias)...MRN (4...).

On December 2, 2025, at 2:30 PM, an interview was conducted with Staff Member #16. Staff Member #16 stated that when a patient record is set up as an alias, and the actual patient's medical record is discovered afterwards, Patient Access marked the medical record to "merge". The two (2) records could not be merged together until after the patient had discharged. Staff Member #16 confirmed that Patient #1's medical record was merged with the alias medical record on August 18, 2025 at 7:56 AM. Staff Member #16 stated that Patient Access was responsible for inputting the patient's legal name into the alias record.

On December 2, 2025, at 3:15 PM, an interview was conducted with Staff Member #12. Staff Member #12 stated that Patient Access updated Patient #1's legal name appropriately into Patient #1's alias record, but the update did not occur until the records were merged after discharge. Staff Member #12 stated that the clinical staff was responsible to contact Patient Access prior to the patient's discharge to change the legal name from the alias to the patient's real name. Staff Member #12 stated that Patient #1's discharge instructions contained the alias as the legal name because clinical staff did not alert Patient Access to make that switch prior to Patient #1's discharge.

On December 2, 2025 at 3:25 PM, in an interview with Staff Member's #2 and #6, Staff Member #6 stated in November, the facility updated their EMR system to allow for a notification to pop up in an alias patient's chart for the clinical staff. The alert would flag the clinical staff as a reminder to verify that the alias name was correct prior to discharge. This change to the EMR was intended to be a reminder and notification to prevent an error occurring in the future. Both Staff Member's #2 and #6 agreed that the mistake occurred with the clinical staff not contacting Patient Access to correct Patient #1's medical record prior to electronically sending Patient #1's prescriptions to the pharmacy and discharging the patient.