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Based on observation, interview, and record review, the hospital failed to ensure the patients received care in a safe environment for two of four sampled patients (Patients 1 and 2) as evidenced by:

1. For Patient 1, the nursing staff failed to perform pain assessment and reassessment as per the hospital's P&P. The hospital's P&P for pain management and the physician's order for pain medication for Patient 1 were not consistent. There was no consistent documentation of meal intake for Patient 1.

2. For Patient 2, there was no documentation of education to patient/family member regarding virtual sitter as per the hospital's P&P.

These failures created the risk of substandard healthcare outcomes to the patients in the hospital.

Findings:

1. During a concurrent interview and record review on 9/10/25 at 1034 hours, with the Patient Safety Officer, Patient 1's medical record was reviewed.

Patient 1's closed medical record showed Patient 1 was admitted to the hospital on 7/29/25 and discharged on 8/1/25.

Review of the physician's order dated 7/29/25 at 1935 hours, showed an ED admit request for Patient 1.

During a review of the physician's order dated 7/29/25 at 2234 hours, the physician's order showed to admit Patient 1 to the cardiac telemetry unit.

a. Review of the hospital's P&P titled Pain Management dated November 2024 showed patients admitted to an inpatient care setting shall receive an initial screen at the time of admission to identify the presence pain. If the screen is positive, then the patient shall receive an assessment to gather sufficient information to identify the pain. The information that may be obtained during this assessment includes, but is not limited to:

- The intensity of pain using age or condition appropriate assessment tools
- The location and nature of pain
- The patient's tolerance to pain and acceptable intensity of pain (pain goal)
- The patient's history of analgesic use or abuse
- The patient's respiratory risk factors

During a review of the "Pain/Comfort/Sleep" dated 7/30/25 at 0140 hours, the "Pain/Comfort/Sleep" showed Patient 1 complained of pain with the pain level of three out of 10 (0 being no pain and 10 being the worst pain) to bilateral legs and lower back. Further review of Patient 1's medical record failed to show Patient 1's acceptable intensity of pain.

b. Review of the hospital's P&P titled Pain Management dated November 2024 showed if a treatment intervention for pain is provided, the response to that intervention should be assessed to include progress toward pain goal and side effects. Reassess the patient when drug approximately reaches peak effect: After at least 60 minutes for PO/IM/SQ/Rectal/Topical/Other Non-IV Route administration.

During a review of the Pain/Comfort/Sleep dated 7/30/25 at 0426 hours, the Pain/Comfort/Sleep showed Patient 1 complained of pain with the pain level of seven out of 10 to bilateral legs and lower back.

Review of the MAR showed on 7/30/25 at 0426 hours, Patient 1 received acetaminophen (a pain medication) 650 mg, PO.

During a review of the Pain/Comfort/Sleep dated 7/30/25 at 0526 hours, the Pain/Comfort/Sleep showed Patient 1 was calm. Further review of Patient 1's medical record failed to show Patient 1's pain level progress toward the pain goal or side effects following the pain intervention.

During an interview on 9/10/25 at 1034 hours, with the Patient Safety Officer, the Patient Safety Officer verified the above findings.

c. Review the hospital's P&P titled Pain Management dated November 2024, showed the Pain Management Upon Transfer from ER/Procedural Area/PACU section showing patient often presents with moderate-severe pain upon arrival to the floor despite receiving IV opioid in ER/PACU/procedure area. The goal of pain management upon patient's arrival to the floor:

- To maintain continuity of pain management from ER/Procedure area/PACU to the inpatient care area. For initial pain medication choice upon transfer, RN may choose IV opioid to provide more timely pain management if IV opioid was already administered in ER/procedure area/PACU.

Review of the MAR showed on 7/29/25 at 1813 and 2136 hours, Patient 1 received hydromorphone (an opioid pain medication) 1 mg IV.

Review of the MAR showed the following orders:

* Acetaminophen tablet 650 mg every four hours PRN for pain, to be started on 7/29/25 at 2233 hours.
* Hydrocodone-acetaminophen (Norco, an opioid pain medication) 5-325 mg per tablet, 1-2 tablets every four hours PRN, for moderate and severe pain, to be started at 7/29/25 at 2233 hours.
* Hydromorphone injection 0.3 - 0.6 mg IV every two hours PRN, for moderate and severe pain, to be started on 7/29/25 at 2233 hours. The administration instructions for hydromorphone injection 0.3-0.6 mg was to give the medication if pain is not controlled with oral pain medications, or if not ordered, or if the oral route is not an option.

During a concurrent interview and review of the hospital s P&P on 9/10/25 at 1034 hours, with the Patient Safety Officer, the Patient Safety Officer verified that the hospital's P&P and the medication administration instructions were conflicting.

d. Review of the Orders showed the following:

* On 7/29/25 at 2331 hours, Patient 1 was on NPO.
* On 7/31/25 at 0009 hours, Patient 1 was on a general diet.

Review of the Flowsheets for Intake showed the following:

* The Diet/Feeding Assistance section showed the tray was set up for Patient 1 on 7/30/25 at 2330 hours, 7/31/25 at 2030 hours, and 8/1/25 at 0900 hours.

* The Percent Meals Eaten (%) section showed on 8/1/25 at 0900 hours, Patient 1 consumed 50% of the meal. Further review of Patient 1 ' s medical record failed to show the percentage of the meal consumed by Patient 1 on 7/30/25 at 2330 hours and 7/31/25 at 2030 hours.

During an interview on 9/10/25 at 1426 hours, with the Patient Safety Officer, the Patient Safety Officer stated there was no P&P for meal intake documentation. The Patient Safety Officer stated it was standard nursing practice to document how many percentages of meals the patient consumed. The Patient Safety Officer verified there was inconsistent meal intake documentation for Patient 1.

2. During a review of the hospital's P&P titled, "TeleSitter: Continuous Visual Remote Patient Monitoring," dated June 2023, the P&P indicated "...Nurse will provide patient/family education and facilitate introduction to the TeleSitter Tech."

During a tour of the unit on 9/10/25 at 1010 hours, with RN 1 in the presence of the Patient Safety Officer, the TeleSitter was observed in Patient 2's room. The TeleSitter appeared as a tower with a camera, and Patient 2 was present in the room.

During a concurrent interview and record review on 9/10/25 at 1400 hours, with the Patient Safety Officer, the medical record for Patient 2 was reviewed. Patient 2's medical record showed the patient was admitted to the hospital on 9/4/25. Further review of Patient 2's medical record failed to show documentation of patient/family education on TeleSitter Tech. The Patient Safety Officer verified the findings.

Based on interview and record review, the hospital failed to ensure nursing staff obtained order for the restraint for one of four sampled patients (Patient 3). This failure created a risk of unsafe care and poor clinical outcomes to the patient.

Findings:

Review of the hospital's P&P titled Restraint for Non-Violent/ Non-Self-Destructive Behavior dated May 2022 showed restraints for non-violent, non-self-destructive behavior may include but are not limited to side rails x 4 when intended as restraint, i.e., used to prevent patient from voluntarily getting out of bed (two side rails are encouraged for patient safety).

During a concurrent interview and record review on 9/11/25 at 1048 hours, with the Patient Safety Officer, the medical record for Patient 3 was reviewed. Patient 3's medical record showed Patient 3 was admitted on 7/28/25 and discharged on 8/5/25.

Review of the Flowsheets for the Functional Level Screening dated 7/31/25 at 0800 hours, showed Patient 3 required moderate assistance for mobility and transfers.

Review of the physician's order dated 7/31/25, showed to apply chest vest and the order expired on 8/1/25 at 1444 hours.

During a review of the "Restraint Monitoring" flowsheets showed on 7/31/25 at 1445 hours, the restraint was started; and the restraint type was vest and side rails X 4.

Further review of Patient 3's medical record did not show the physician's order for the use of side rails x 4.

The Patient Safety Office verified the above findings.

Based on interview and record review, the hospital failed to ensure one of four sampled patients (Patient 3) was monitored during the use of restraints as per the hospital's P&P. This failure had the potential to result in unsafe care and adverse clinical outcomes for the patient.

Findings:

During a review of the hospital's P&P titled Restraint for Non-Violent/Non-Self-Destructive Behavior dated May 2022, the P&P showed each episode of restraint will be documented in the patient's medical record and will include the following elements:

B. Individual patient reassessment by RN every two hours

1. Proper placement of restraints
2. LOC, orientation, behavior, response to restraint
3. Type of restraint with alternatives used
4. Skin and circulation assessment with ROM
5. Offer of nutrition/hydration, assistance with toileting/hygiene, comfort measures

During a concurrent interview and record review on 9/11/25 at 1048 hours, with the Patient Safety Officer, the medical record for Patient 3 was reviewed.

Patient 3's medical record showed the patient was admitted on 7/28/25 and discharged on 8/5/25, was reviewed.

Review of the physician's order dated 7/31/25, showed to apply chest vest and the order expired on 8/1/25 at 1444 hours.

During a review of the "Restraint Monitoring" flowsheets showed on 7/31/25 at 1445 hours, the restraints were started.

Review of the Restraint Monitoring flowsheets dated 7/31/25 and 8/1/25, showed the restraint status and type, observed behavior, hydration, nutrition, elimination, ROM/repositioning, and signs of injury were assessed every two hours. Further review of Patient 3's medical record failed to show the skin and circulation assessment as per the hospital's P&P. The Patient Safety Officer verified the above findings.