HospitalInspections.org

Based on the review of facility policies and procedures, medical record reviews and staff interviews, facility staff failed to document application of a restraint and a fall while restrained for 2 of 8 sampled patients in restraints (Patient #2 and #22).

The findings include:

Review of policy titled "Restraints, Seclusion and Safety Devices" effective 09/23/2024 revealed, "...D. Monitoring for Non-Violent/ Non-Self Destructive and Violent/ Self Destructive restraints is individualized based on patient needs but at a minimum occurs once every 2 hours. E. Monitor and document the following every 2 hours: i. Type of restraint, ii. Restraint status (initiated, continued, discontinued), iii. Range of Motion exercises to restrained limbs, iv. Patient's physical comfort, v. Nutrition/hydration, vi. Elimination, vii. Skin Integrity in area in direct contact with restraint, viii. Respiratory status, ix. Circulation to restrained limbs, x. Patient's behavior/readiness for discontinuation of restraint, F. Assess if a less restrictive intervention may be appropriate."

Review of policy titled "Falls Reduction and Response- Adult" effective 09/05/2023 revealed, "Purpose: To prevent patient falls and falls with injury and to establish a uniform response method when a patient fall occurs...Audience: All hospital employees...Definitions: "A patient fall is a sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface (e.g. a counter), on another person, or on an object (e.g. a trash can)."...In the event a fall occurs, provide immediate assistance and care as necessary, notify appropriate staff members, document, and report event, and reassess the individual for future falls...I. In the event a fall occurs, see Falls Response Plan below...Falls Response Plan...4. Documentation- The nurse is responsible for documenting the fall. Documentation may include but is not limited to: a. witnessed or unwitnessed by staff, b. location of the fall, c. nursing assessment post fall, d. treatment provided, e. notification of provider, f. Notification of family (if applicable)...6. Reporting...b. The staff member responsible for the individual at the time of the fall and/or charge or designee completes a post-fall huddle form and submit to manager for review. 7. The responsible PCM (Patient Care Manager) reviews all falls."

Review of policy titled "Documentation by Nursing Personnel" effective 05/30/2024 revealed, "Purpose: To provide guidelines for documentation by nursing personnel to reflect status of patient, assist in developing a plan of care, describe care given, and provide for continuity of care. Documentation in a patient's medical record creates a valuable source of information for all members of the health care team...Definition: Health care documentation- a written account of pertinent patient data, clinical decisions and interventions, and patient responses in a patient's medical record. Policy: The patient's medical record reflects care given, as well as presenting a picture of what is happening with the patient while at the hospital. Personnel document patient data and the care given according to established guidelines.

Review of policy titled "Documentation in the Medical Record" effective 10/16/2020 revealed, "...Policy: Accurate and complete documentation is required in the medical record for creating a legal document that reflects the assessment, planning, and continuity of the patient's medical treatment and care. The medical record contains an assessment of the patient's condition, patient problem(s) and goal(s), action plan(s), the treatment and services provided, the evaluation of goal attainment and status and disposition of patient at the conclusion of treatment."

1. Closed medical record review of Patient #2 on 04/08/2025 revealed an 88-year-old woman admitted on 10/25/2024 as a transfer from an outside hospital for a history of generalized weakness and decreased oral intake for one week. Patient #2 was diagnosed with Acute Unilateral (one-sided) Obstructive Uropathy (blockage of the urinary tract) and Urinary Tract Infection (UTI). Emergency Department (ED) Timeline primary assessment on 10/25/2024 at 0202 revealed, patient was "confused with aggression". Doctor order for Restraints non-violent or non-self destructive: Restraint type: Vest was signed and released on 10/25/24 at 0719. Central supply request order for a "posey vest restraint size medium" was placed on 10/25/2024 at 0722. Restraint order for the vest was discontinued on 10/26/24 at 0253. Nursing note dated 10/25/2024 at 0737 revealed, "0600 Patient received from ED (Emergency Department) to room 509, confused, refused hospital gown, tele monitor leads placed with difficulty. IVF (Intravenous Fluid) started." Nursing note dated 10/25/2024 at 0741 (and deleted/ stricken on 10/25/2024 at 0856) revealed, "Patient (#2) is confused, impulsive and refusing tele and IVF. Restraints were initiated at 0730 this morning." Internal Medicine progress note dated 10/25/24 at 1353 revealed, "Patient (#2) was agitated upon arrival last night and received a dose of Haloperidol, soft restraints were also applied overnight. Patient is seen at bedside this morning with daughter at her side, she is resting comfortably." Internal medicine progress note dated 10/26/24 at 1816 revealed, "Patient in a pleasant mood, off restraint today...Patient's daughter at bedside who was updated in great detail about patient condition and our management plan...Hospital induced delirium- After admission patient was noted to have episode of agitation on 10/25/2024 requiring restraint and Haldol." Discharge summary dated 10/27/2024 at 1109 revealed, "...Patient (#2) has a history of dementia, she had episode of agitation after admission requiring Haldol and restraints, restraints were discontinued and patient (#2) has been very cooperative for more than 24 hours." No flow sheet documentation of restraints were found in the medical record.

Review of incident report for Patient #2 dated 10/28/2024 (date of incident- 10/25/2025) revealed, "Restraint nursing issue: missing documentation. Vest restraint ordered 10/25 0719...(Nursing) note from 10/25 0741 was deleted. This note mentions initiation of a restraint. A secure chat was sent to the nurse seeking clarity if the vest restraint was applied. Per secure chat, "vest was applied but came off immediately as daughter was sitting at bedside". No restraint flow sheet documentation."

Interview with Internal Medicine (IM) Physician #4 on 04/09/2025 at 1435 revealed, that they reviewed the case and it is difficult because this is referring to October of 2024. He stated that patient was already out of restraints by the time he saw patient. IM Physician #4 stated that patient possibly had wrist and vest restraints. IM Physician #4 stated that for geriatric (older adult) patients, we do not like to use restraints if there are other alternatives such as a if family can sit with the patient.

Interview with Nurse Auditor Supervisor #3 on 04/10/2025 at 1110 revealed, "It is hard to say, there is nothing on the flow sheet, no documentation other than the stricken note" in regard to documentation of initiation of the restraint.

The nurse that documented then deleted the note in regard to application of the restraint was not available for interview as they no longer work at the named facility.

2. Open medical record review of Patient #22 on 04/09/2025 revealed a 72-year-old male admitted on 03/31/2025 after an unwitnessed fall and was diagnosed with altered mental status likely due to metabolic encephalopathy (disruption of chemical processes that affect the brain). Patient #22 had a past medical history of hypertension (high blood pressure) and stroke. Secure messaging between Patient #22's nurse and attending provider revealed, "Patient (#22) squirmed around in the bed and was able to get his feet on the floor. I am told this is technically a fall. The patient says he is not hurt and his vitals are unchanged. His BP (blood pressure) is a little high, but seems to be where it has been. (Provider asked) But his feet only touched the floor and he did not actually fall on the floor? Just making sure I don't need to order anything. (Nurse responded) He was still attached to his restraints."

Review of Incident Report for Patient #22 dated 04/01/2025 revealed, "Patient attempted out of bed unassisted, bed alarm went off, when staff entered room, patient was still attached to bed via left wrist restraint on wall side but had 1 knee on the floor and the other foot on the floor. Patient did not complain of any pain. Assisted patient back to bed, resecured restraints. Vitals obtained; provider notified, bed alarm set more sensitive."

Interview with Quality Nurse #1 on 04/10/2025 at 1550 revealed, "the only documentation of a fall I see is the fall prior to admission."

Interview with Manager #2 on 04/10/2025 at 1705 revealed, "I did find a secure chat (the nurse) let the doctor know (about the fall) but I did not find a note (in the chart)." Manager #2 further stated that, "I would expect a note for a patient found on their knees on the floor." No provider note or nursing note was found in regards to the fall. Manager #2 stated, "It should be documented as per policy with all elements, we will provide (the nurse) with the policy and have them sign that they have receive it."

Based on policy review, observations, and staff interviews, the hospital's dietary staff failed to carry out duties in a competent manner to ensure correct concentration of the dishwashing soap in the dish water of the compartment sink; failed to document meal temperatures on the logs; and failed to secure beards in proper restraints for 1 of 1 kitchens toured.

The findings include:

A. Review of policy titled "Procedures: Pots & Pans/Cookware--Cleaning and Sanitizing--Manual Method: Procedure Steps: ...4. While pots and pans are soaking in Sink 1, fill Sink 2 (rinse sink) with hot water. Next fill Sink 3 (sanitizer sink) with a water and Sanitizer solution (Use 150 ppm-40pm for U.S.).....5. Use QT-40 Test Strips to ensure concentration of sanitizer in Sink 3 is within proper efficacy range. Note: Place a sample of solution from Sink 3 in a small container and allow to cool to room temperature. Dip test paper in container solution for 10 seconds. Remove and compare test paper color to the color chart on the test strip package."

Observation on 04/10/2025 at 1100 during tour of the kitchen revealed Dishwasher #1 was standing at the compartment sink. Dishwasher #1 demonstrated the technique for verifying the sanitizer strength of the dish water by allowing the test strip to stay submerged in the dish water more than 10 seconds. Dishwasher #1 then tore the test strip in half and again submerged the used test strip in the dish water. Dishwasher #1 did not use a time clock during the process.

Interview on 04/10/2025 at 1115 with Kitchen staff #2 revealed the test strip should not have been torn and submerged in the water longer than 10 seconds. Interview revealed policy was not followed.

B. Review of policy titled "Hot & Cold Food Serving Temperature Log" with revision date of 10/01/2021, revealed "Instructions: Use this log to record time/temperature controlled for safety food (TCS food--Time/Temperature Control for Safety) that is in cold and/or hot holding for service....Manager must review log within 7 days...(7) Starting Temp: Document the first temperature of the food at time of set up..."

Review of Daily Temperature Logs for Pod 1 from 03/31/2025 through 04/09/2025 revealed no food temperatures recorded on 03/31/2025 for dinner; 04/01/2025 for dinner; 04/04/2025 at dinner; 04/06/2025 at dinner; 04/08/2025 at lunch or dinner; and 04/09/2025 at dinner. Review of Daily Temperature Logs for Pod 3 from 03/31/2025 through 04/09/2025 revealed no food temperatures recorded on 03/31/2025 at lunch or dinner; 04/01/2025 at breakfast or dinner; 04/02/2025 at breakfast or dinner; 04/03/2025 at dinner; 04/04/2025 at dinner; 04/05/2025 at breakfast or dinner; 04/06/2025 at lunch or dinner; 04/07/2025 at breakfast or dinner; and 04/09/2025 at lunch or dinner. In summary, there was no documentation of food temperatures for 7 of 30 meals in Pod 1 and 15 of 30 meals in Pod 3.

Interview on 04/10/2025 at 1137 with Dipper #3 revealed the night staff "does not do temps." Interview revealed "I tell the supervisor but nothing changes."

Interview on 04/10/2025 at 1140 with Kitchen staff #2 revealed the log temps should be done before each meal.

C. Review of policy titled "Personal Appearance Food and Nutrition Employees" with effective date of 02/16/2024, revealed "...b. Facial Hair: Males are to be clean shaven or with neatly trimmed beards or mustaches. Beard guards are to be worn regardless of beard length...."

Observation on 04/10/2025 at 1100 revealed Kitchen Staff #3 building trays on the food line. Observation revealed Kitchen staff #3 had facial hair. Observation revealed no beard guard covered the facial hair.

Interview on 04/10/2025 at 1105 with Administrative staff #4 revealed all facial hair should be covered while in the kitchen.

NC00228940; NC00223657; NC00228332; NC00225156; NC00227400; NC00227511; NC00227344; NC00226219; NC00226021; NC00227331; NC00224558; and NC00225340.