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Based on medical record review, staff interview, and policy review, the facility failed to ensure residents were not placed in restraints without appropriate physician orders.

See A171

Based on record review, interview and policy review, the facility failed to ensure residents were not placed in restraints without appropriate physician orders. Th:is affected two (Patients #9 and #10) patients placed in non-violent restraints.

Findings include:

1. Review of the medical record revealed Patient #9 admitted to the the hospital on 11/05/2023 at 5:21 A.M. with a diagnosis of subarachnoid hemorrhage.

Review of the medical record revealed Patient #9 had physician orders dated 11/05/2023 at 5:46 A.M. for bilateral soft wrist restraints related to unsafe mobility and poor safety judgement. The order was renewed on 11/07/2023 at 10:12 A.M. There was no renewal order on file for 11/06/2023.

During an interview on 11/08/2023 at 10:39 A.M. Associate Nurse Manager O verified Patient #9 did not have physician orders dated 11/06/2023 or 11/08/2023 to continue soft wrist restraints.

During an observation on 11/08/2023 at 2:02 P.M., Patient #9 was lying in bed with the eyes closed. The left wrist was held in soft restraint that was tied to bed frame.

2. Review of the medical record revealed Patient #10 admitted to the hospital on 11/02/2023 at 9:02 PM as a direct admit from another hospital with a diagnosis of symptomatic carotid stenosis.

Review of the medial record revealed Patient #10 had physician orders dated 11/02/2023 at 10:52 P.M. for bilateral soft wrist restraints and Swedish belt with a justification of impulsiveness. The order was discontinued on 11/05/2023. There were no orders to continue restraints on 11/03/2023, 11/04/2023, or 11/05/2023. Additional review revealed Patient #10's restraints were stopped on 11/03/2023 at 4:00 P.M. and restraints were restarted on 11/03/2023 at 5:45 P.M. without a new physician's order.

During an interview on 11/08/2023 at 10:39 A.M. Associate Nurse Manager O verified Patient #10 did not have physician orders to renew restraints every 24 hours and did not have a new physician order to initiate restraints after restraints had been stopped on 11/03/2023.


Review of policy titled "Premier Nursing Services Non-Violent Restraint Policy" dated 05/03/2022 revealed each order for non-violent restraints was limited to 24 hours for adults and if a patient's restraints were removed for any reason other than to provide patient care, a new order was required to reapply restraints.

Based on record review, interview and policy review, the facility failed to follow physician orders regarding feeding assistance and pressure injury prevention.

See A392

Based on record review, interview and policy review, the facility failed to follow physician orders regarding feeding assistance and repositioning which resulted in a patient developing an avoidable pressure ulcer. This affected Patient #3.

Findings include:

1a. Review of the medical record revealed Patient #3 was transferred to the hospital on 09/01/2023 from another hospital for hip surgery related to a fall at home on 08/29/2023. The patient was discharged to and Extended Care Facility (ECF) on 09/28/2023.

Review of Speech Therapy Care plan dated 09/15/2023 at 9:40 A.M. revealed Patient #3 had video fluoroscopy completed which observed silent aspiration with consecutive swallows of thin liquids. Recommendations included regular diet with nectar-thick liquids, no straws, alternate solids and liquids (one bite, then one drink), aspiration precautions, and 1:1 with all oral intake.

Review of diet orders revealed Patient #3's diet was changed on 09/21/2023 at 1:06 P.M. from regular diet to dysphagia level III diet with nectar-thick liquids, no straws, alternating solids and liquids (one bite, then one drink), aspiration precautions, and 1:1 with all oral intake.

Review of Nutrition flow sheets dated 09/19/2023 to 09/27/2203 revealed the FSP received partial assistance with setup for meals on 09/19/2023, setup assistance only from 09/21/2023 to 09/24/2023, and partial assistance with meals on 09/26/2023 and 09/27/2023.


1b. Review of Wound Care Medical Staff Progress note dated 09/12/2023 at 11:17 A.M. revealed Patient #3 was transferred to the hospital on 08/29/2023 after sustaining a fall that resulted in a left femoral neck fracture. The patient had left hip arthroplasty on 09/3/2023. Additionally, on 09/03/2023 vascular service was consulted regarding delayed wound healing of the left posterior calf and left heel, both present upon admission. An arterial duplex was completed which showed severe bilateral lower extremity arterial insufficiency. The patient was assessed for limb salvage ability and was scheduled for a left above the knee amputation on 09/11/2023. The plan of care included in the note stated Patient #3 was to have complete lateral turns on sides every two hours to avoid pressure and friction injury.

Review of flow sheets dated 09/01/2203 to 09/28/2023 revealed Patient #3 was positioned on his back in bed from 09/02/2023 at 10:00 P.M. to 09/03/2023 at 8:00 A.M.; from 09/03/2023 at 8:00 P.M. to 09/04/2023 at 2:00 A.M.; on 9/10/2023 from 2:00 A.M. to 8:00 A.M.; from 09/14/2023 at 6:00 P.M. to 09/15/2023 at 10:00 A.M.; from 09/15/2023 at 8:00 P.M. to 09/16/2023 at 8:00 A.M.; on 09/19/2023 from 2:00 P.M. to 10:14 P.M.; on 09/22/2023 from 4:00 A.M. to 4:39 P.M.; and from 09/25/2023 at 7:42 P.M. to 09/26/2203 at 3:31 A.M.

Additional review of nursing assessment skin flow sheets revealed the FSP developed a pressure injury to the upper middle back first discovered on 09/13/2203 at 10:23 P.M. The area was unmeasured and was described as dry and intact. The area was covered with a foam dressing and was unresolved upon discharge on 09/28/2023.

During an interview on 11/08/2023 at 3:50 P.M. Director of Quality A and Regulatory Coordinator Y verified there was no documentation in Patient #3's chart which indicated staff had offered or FSP had refused to be turned every two hours as ordered, and Patient #3 did not receive 1:1 feeding assistance as ordered.

Review of policy titled "Premier Nursing Services Skin Integrity Maintenance Program and Pressure Ulcer Prevention Program Initiatives", dated 12/13/2022, revealed patients were assessed for risk of pressure injury upon admission, twice daily, with changes in clinical status, and upon transfer. Nurses notified the attending provider of all suspected and actual pressure injuries and notified the appropriate wound service for stage III, stage IV, and deep tissue injuries. Efforts were made to use repositioning to minimize pressure.