HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 2 patients' (Pt. #2 and Pt. #3) clinical records reviewed regarding treatment planning, the hospital failed to ensure that documentation regarding patients receipt of information and participation in treatment planning were documented.

Findings include:

1. On 3/31/2025, the hospital's policy titled, Rights and Responsibilities of the Individual" (10/2023) were reviewed and included, "Purpose... to define the patient rights... in relation to their healthcare... Procedure/Process... Attachment A... You have the right to... participate in your care plan in a way you understand. To receive information regarding medical diagnosis, procedures, treatment... "

2. On 3/31/2025, the clinical record for Pt. #2 was reviewed. On 3/28/2025, Pt. #2 was admitted to the hospital with a diagnosis of hematuria (blood in urine). The providers/physicians' progress notes on 3/29/2025, 3/30/2025 and 3/31/2025 did not include documentation that Pt. #2 received information and participated in the treatment planning.

3. On 3/31/2025, the clinical record for Pt. #3 was reviewed. On 3/28/2025, Pt. #3 was admitted with a diagnosis of black stool. The providers/physicians' progress notes on 3/29/2025, 3/30/2025, and 3/31/2025 did not include documentation that Pt. #3 received information and participated in treatment planning.

4. On 3/31/2025 at approximately 10:45 AM, findings were discussed with MD #1 (Assistant Medical Director). MD #1 stated that to ensure that patients are informed of their care, the practice is to document in the progress notes that the care (plan) was discussed with the patient, and that patient's questions or concerns were addressed.

Based on document review and interview, it was determined that for 2 of 4 patients' (Pt. #4 and Pt. #5) clinical records reviewed for restraints, the hospital failed to ensure that the required hourly monitoring was documented.

Findings include:

1. On 3/31/2025, the hospital's policy titled, "Restraint and Seclusion" (4/2024) was reviewed and included, "Purpose: To ensure safety of our patients... Procedures/Process... C... 2. Medical Non-Violent/Non-Self Destructive Behavior. The patient's behavior and physical needs are monitored and documented upon restraint placement and every 1 hour: a. Respiratory and Circulatory Status... b. Skin inspection. c. Range of motion... E. Restraint Discontinuation: 1. At the earliest possible time... restraint will be discontinued..."

2. On 3/31/2025, the clinical record for Pt. #4 was reviewed. On 3/15/2025, Pt. #4 was admitted to the hospital with a diagnosis of acute heart failure. On 3/21/2025 at 5:15 AM, a physician's order was made to place Pt. #4 in two-point soft restraints for medical/non-violent behavior. There was no required hourly monitoring on 3/21/2025 at 9:00 AM and on 3/22/2025 at 8:00 PM, while Pt. #4 was in restraints.

3. On 3/31/2025, the clinical record for Pt. #5 was reviewed. On 3/1/2025, Pt. #5 was admitted to the hospital with a diagnosis of abdominal pain. On 3/3/2025 at 5:47 AM, a physician's order was made to place Pt. #5 in two-point restraints for medical/non-violent behavior. There was no required hourly monitoring (or documentation when restraints were discontinued) on 3/3/2025 from 7:30 AM through 10:20 AM.

4. On 3/31/2025 between approximately 12:45 PM through 1:00 PM, findings were discussed with E #8 (Clinical Nurse Leader). E #8 validated that there was no documentation of the hourly monitoring while the patients were in restraints. E #8 stated that the hourly monitoring should have been documented.