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Based on document review and interview, the hospital failed to ensure the medical record (MR) of patient who were restrained and/or secluded (R/S) contained documentation of the patients response to the interventions used for 1 of 4 patients (P2) with R/S and the hospital failed to ensure documentation included Post Seclusion and/or Restraint patient debriefing for 3 of the 4 R/S patients (P2, P5, and P9)

Findings include:

1. Review of the policy titled Seclusion and Behavioral Restraint, last reviewed August 2021 (page 1)/January 2022 (page 2-10), indicated the following:
Any patient placed in Seclusion or Restraint shall be assessed by an RN (Registered Nurse) or LPN (Licensed Practical Nurse) every 15 minutes and immediately after discontinuation of the Seclusion or Restraint for (not all inclusive): Respiratory Status, Vital signs.
For any patient placed in Seclusion and/or Restraint, the following documentation is required in the Medical Record (not all inclusive): Patient's response to the intervention used. Post Seclusion and/or Restraint staff and patient debriefing.

2. a. The MR of patient P2 indicated the patient experience R/S on 4/16/22 at 1215 hours. The MR lacked evidence of the patient's response to interventions as follows: The 15 minute observation log indicated Respiratory Status - with (rate, oximetry, effort, noises) was to be recorded every 15 minutes. The Respiratory Status key listed the following: L=labored, SOB=Shortness of Breath, E=Easy, N=Normal. The key codes indicated the following: Document UTD (unable to determine) if unsafe or unable to obtain VS (vital signs, then obtain VS ASAP (as soon as possible). Documentation at 1215 hours and 1245 hours was recorded as UTD (unable to determine). Patient/Staff Debriefing documentation indicated the following: Patient Debriefing: fell asleep. Unable to sign. All questions and patient signature were blank. The MR lacked documentation of patient debriefing for the restraint and seclusion.

b. The MR of patient P5 indicated that on 4/25/22, Seclusion and Mechanical Restraint were initiated at 0835 hours. Patient/Staff Debriefing documentation indicated the following: Patient Debriefing: Patient unable to participate d/t (due to): altered mental status. Unable to sign. All questions and patient signature were blank. The MR lacked documentation of patient debriefing for the restraint and seclusion. On 4/26/22 at 1245 hours, Seclusion, Mechanical Restraint, Physical Restraint and Spit Hood were initiated at 1245 hours. Patient/Staff Debriefing documentation indicated the following: Patient Debriefing: How could staff have assisted you in preventing this episode? "We know" was written in the blank. Other question responses were written in as unable to understand/unable to comprehend. The form lacked patient signature and MR lacked documentation of further attempt for patient debriefing.

c. The MR of patient P9 indicated that on 4/25/22, Seclusion and Mechanical Restraint were initiated at 0415 hours. Patient/Staff Debriefing documentation indicated the following: Patient Debriefing: All areas of patient debriefing questions were blank. Patient debriefing indicated: Patient unable to participate d/t (due to): altered mental status. The section also lacked evidence of Nurse/Therapist Signature. The MR lacked documentation of post R/S patient debriefing.

3. On 5/19/22, beginning at approximately 1:45 PM, A3, Quality RN, indicated respiratory assessment with rate, effort, and noises could be observed/recorded even at times the patient is uncooperative and verified the MR of P2 lacked evidence of adequate respiratory assessment during restraint/seclusion and that the MR lacked documentation of post-restraint/seclusion patient debriefing. Beginning at approximately 4:30 PM, A3 verified the MRs of patient P5 and P9 lacked documentation of patient debriefing post restraint/seclusion.

Based on document review and interview, the medical staff failed to enforce Medical Staff (MS) Bylaw Rules and Regulations regarding home medication reconciliation for 1 of 10 patients (P2).

Findings include:

1. Review of MS Bylaws/Rules and Regulations, amended February 16, 2018, indicated the following:
The admitting practitioner shall be responsible for providing the hospital with any know information concerning the patient. Such attending physician shall be responsible for the medical care and treatment.
Orders must be written clearly, legibly and completely. Medication orders must include the name of drug, dosage, route, frequency and clinical indication. Blanket reinstatements of previous orders for medications are not acceptable, e.g., "resume home meds" is no acceptable. All medications orders are reviewed at admission.
A complete medical record (MR) shall include but not limited to: History including: Current medications and previous medication hypersensitivites.
Ordering physicians shall evaluate the patient's home medications prior to prescribing them to be continued during hospital stay.

2. The MR of patient P2 indicated the following: On 4/16/22, the patient was admitted to the hospital. The MR contained two (2) Home Medication Lists. One which indicated Medication List Attached with "previously sent" handwritten below the marked box; the form was void of any medications and was signed by the patient on 4/16/22 at 0140 hours. A second document with like hand writing and and signature of patient with the same date and time listed the following medications: Horizant, Belbuca, Pramipexole, Diflucan, Medrodose Pak, and Tramadol. The Medication Reconciliation Form, signed 4/19/22, listed Horizant, Belbuca, Pramipexole, and Tramadol, but lacked indication of which medications were to be Continued/Discontinued/Modified. The History and Physical (H&P), dated 4/16/22 at 08:47 AM, indicated the following: After home mediation (sic) reconciliation is established, home meds (medications) will be addressed. The MR lacked documentation of the home medications having been addressed.

3. On 5/19/22, beginning at approximately 1:45 PM, A3, Quality RN, verified that medication reconciliation for that patient had not been completed prior to discharge and the patient did not receive any of his/her listed home medications.

Based on document review and interview, the hospital failed to ensure nursing care was evaluated for appropriateness in accordance with standards and/or policy for 1 of 1 patients (P2) who experiences an acute change in condition.

Findings include:

1. Review of the policies titled Rapid Response (Acute Change in Condition), last revised Sept. 2020, indicated the following: The following criteria are examples of ACUTE changes and are not all inclusive: Heart rate <40 or >130 bpm (beats per minutes); Systolic BP (blood pressure) <90 mmHg (millimetre of mercury), complete a physical assessment (including vitals) and initiate interventions based on the findings.

2. The medical record (MR) of patient P2 indicated the following: On 4/17/22 at 1400 hours: Patient was complaining of chest pain (CP) this morning and after EKG/ECG (electrocardiogram) was reviewed, patient received beta blocker prescribed by nurse practitioner. The MAR indicated propranolol ( a beta blocker) was administered "NOW" on 4/17/22 at 12:04 hours. ECG documentation indicated the following Interpretation: Accelerated junctional rhythm with occasional premature ventricular complexes. Septal infarct, age undetermined. Inferior injury pattern **Acute MI (Myocardial Infarction)**. Abnormal ECG. The MR lacked documentation of the vital signs (VS) taken at the time of patient CP complaint.

3. On 5/19/22, beginning at approximately 1:45 PM, A3, Quality RN, verified the MR of P2 lacked documentation of VS having been taken at the time the patient experienced chest pain (an acute change) and that nursing should have recorded VS at the time of the event.