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Based on interview, medical record review, and policy review, the hospital failed to ensure the effective delivery of nursing services to provide safe and quality care to patients when:

A. Nursing staff failed to complete fall risk assessments and implement fall prevention interventions for one of 9 sampled patients (Patient 1) who was a high risk for falls and was placed in a recliner chair without a chair alarm. Patient 1 fell out of the recliner, which resulted in facial injuries. Nursing staff on the evening shifts continued to not complete fall risk assessments for Patient 1 after his fall, according to the facility's Fall Prevention and Management policy and procedure. (refer to A-0398) and

B. Nursing staff entered type of restraint orders that did not match the indication for restraints for two of 12 patients (Patient 4 & Patient 8) (refer to A-0398).

The cumulative effect of these failures resulted in the hospital's inability to provide effective, safe and quality nursing services in accordance with the statutorily-mandated Conditions of Participation Nursing Services.

Based on interview and record review, the facility failed to ensure staff monitored patient safety and condition while in restraints when three of 12 patients in restraints (Patients 4, 5, and 6) were not monitored at the frequencies specified by facility policy.

This failure had the potential to result in a decline in patient condition, injury, or death.

Findings:

During a review of Patient 4's History and Physical (H&P), dated 3/8/25, the H&P indicated Patient 4 presented to hospital on 3/8/25 with flu-like symptoms and inadequate consumption of fluid and food. The H&P indicated Patient 4's medical history included dementia (a progressive state of decline in mental abilities.)

During a review of Patient 4's orders, orders indicated to place Patient 4 in violent/self-destructive restraints (VR) for 4 hours, on 3/9/25, at 0:48 a.m.

During a concurrent interview and record review, on 4/3/25, at 10:40 a.m., with Nurse Educator (NE) 1, Patient 4's restraint flowsheet (RFS), dated 3/9/25, was reviewed. The RFS indicated restraints were applied on 3/9/25, at 1 a.m., and safety checks were completed at 3 a.m. and 5 a.m. NE 1 confirmed these findings and stated 15 to 30 minute safety checks were not completed as required per facility policy.

During a review of Patient 5's H&P, dated 2/21/25, the H&P indicated Patient 5 presented to hospital on 2/21/25, following a syncopal episode (a brief loss of consciousness caused by a temporary decrease in blood flow to the brain). The H&P indicated Patient 5's medical history included dementia

During a review of Patient 5's orders, two orders to place Patient 5 in VR for 4 hours were noted: one for 2/21/25, at 6:38 p.m. and one for 2/24/25, at 12:55 p.m.

During a concurrent interview and record review on 4/3/25, at 10 a.m., with NE 1, Patient 5's RFS, dated 2/21/25, was reviewed. RFS indicated restraints were applied at 6:50 p.m., and monitoring occurred at 7:30 p.m., 9 p.m. and 11 p.m. NE 1 stated, when in VR, patients should be monitored every 15 minutes, and the RFS did not show monitoring was done as required.

During a concurrent interview and record review on 4/3/25, at 10 a.m., with NE 1, Patient 5's RFS, dated 2/24/25, was reviewed. RFS indicated restraints were applied at 12:55 p.m. and removed at 2 p.m. NE 1 confirmed RFS did not indicate monitoring was done during the one-hour period Patient 5 was in VR.

During a review of Patient 6's H&P, dated 3/27/25, the H&P indicated Patient 6 presented to hospital on 3/27/25 with a foot infection. The H&P indicated Patient 6's medical history included alcohol abuse, Wernicke's encephalopathy (brain disorder caused by a vitamin deficiency) with mental process and memory impairment.

During a review of Patient 6's orders, orders indicated to place Patient 6 in VR for 4 hours, on 3/29/25, at 10:52 a.m., for "violent/aggressive behavior".

During a concurrent interview and record review, on 4/3/25, at 11:20 a.m., with NE 1, Patient 6's RFS, dated 3/29/25, was reviewed. The RFS indicated restraints were applied on 3/29/25, at 10:30 a.m., and safety checks were completed at 12 p.m. NE 1 confirmed these findings and stated safety checks were not completed every 15 to 30 minutes as required per facility policy.

During an interview, on 4/4/25, at 12:15 p.m., with Nursing Director (ND) 2, ND 2 stated "Violent restraints require more frequent monitoring and documentation to keep patients safe."

During a review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion, Nursing Management of", dated 4/2/13, the P&P indicated, "Patients placed in restraints or seclusion for violent or self-destructive behavior should be assessed approximately every 15 to 30 minutes."

Based on interview and record review, the facility failed to ensure the medical provider completed a face-to-face evaluation within one hour of placing two of four patients (Patient 4 and Patient 5) in restraints for violent behavior.

This failure had the potential to delay identification and treatment of the cause of violent behavior and to violate the patients' right to be free of unnecessary restraints.

Findings:

During a review of Patient 4's History and Physical (H&P), dated 3/8/25, at 11:54 p.m., the H&P indicated Patient 4 presented on 3/8/25 with flu-like symptoms and inadequate consumption of fluid and food. The H&P indicated Patient 4's medical history included dementia (a progressive state of decline in mental abilities).

During a review of Patient 4's orders, orders indicated to place Patient 4 in violent/self-destructive restraints (VR) for 4 hours, on 3/9/25, at 0:48 a.m.

During a concurrent interview and record review on 4/3/25, at 10:40 a.m., with Nurse Educator (NE) 1, Patient 4's medical record (MR) was reviewed. The ME contained a Physician Note (PN), dated 3/9/25, at 3:50 p.m. NE 1 confirmed there was not a PN within one hour of the VR order and neither the PN nor the H&P addressed the need for violent behavior restraints.

During a review of Patient 5's H&P, dated 2/21/25, the H&P indicated Patient 5 presented to hospital on 2/21/25, following a syncopal episode (a brief loss of consciousness caused by a temporary decrease in blood flow to the brain). The H&P indicated Patient 5's medical history included dementia. The H&P indicated Patient 5 "Received Ativan [medication to treat anxiety] prior to evaluation as apparently she was attempting to hit her husband and staff."

During a review of Patient 5's orders, two orders to place Patient 5 in violent/self-destructive restraints (VR) for 4 hours were noted: one for 2/21/25, at 6:38 p.m. and one for 2/24/25, at 12:55 p.m.

During a concurrent interview and record review, on 4/3/25, at 10 a.m., with NE 1, Patient 5's MR was reviewed. The MR contained multiple PN, dated as followed: 2/21/25, at 11:57 p.m.; 2/22/25, at 5:23 p.m.; 2/23/25, at 4:07 p.m.; 2/24/25, at 5:13 p.m.; and 2/25/25, at 12:32 p.m. NE 1 confirmed there was not a PN within one hour of the VR order of 2/21/25 nor was there a PN within one hour of the VR order of 2/24/25. NE 1 stated there were no indications in the notes that a face-to-face interaction had occurred after restraints were placed, and "None of the notes met the face-to-face requirement."

During a concurrent interview and record review, on 4/2/25, at 3 p.m., with Nursing Director (ND) 1, the facility's policy and procedure (P&P) titled, "Restraint and Seclusion, Nursing Management of", dated 4/2/13, was reviewed. The P&P indicated, "When restraint is used to manage violent or self-destructive behavior, a physician or other LP [license independent practitioner], a registered nurse (RN) or physician assistant (PA) trained in accordance with this policy must see the patient face-to-face within one (1) hour after the initiation of the intervention." ND 1 stated RNs were not trained in the facility to perform the face-to-face evaluation.

Based on interview and record review, the facility failed to ensure that nursing staff followed facility policies and procedures when:

1. Nursing staff failed to complete the fall risk assessment and ensure fall prevention interventions were in place for one of 9 sample patients who had falls during their hospital stay (Patient 1).
2. Nursing staff entered type of restraint orders that did not match the indication for restraints for two of 12 patients (Patient 4 & Patient 8).

These failures resulted in Patient 1 falling out of a chair resulting in facial injuries, Patient 8 receiving less safety checks and behavioral assessments while in restraints per the facility policy which had the potential for Patient 8 injuring herself or others, and Patient 4 not receiving an order consistent with facility policy which had the potential to delay meeting patient's therapeutic goals.

Findings:

1. A review of the hospital's policy and procedure (P&P) titled, "Fall Prevention and Management Policy and Procedure," dated 12/15/22, indicated, "Assessment and Reassessment: A. The patient's fall risk will be assessed at the time of initial physical assessment, at the time of admission, every shift...Evidenced-based fall risk interventions will be implemented based upon an age-appropriate Fall Risk Assessment Tool (FRAT) ...Adult - John Hopkins Fall Risk Assessment Tool (greater than age 18)...Implementation of Interventions...Individualized application of the interventions according to the risk factors identified for the patient...Implement Adult Fall prevention Interventions based on John Hopkins Fall Risk Assessment Tool ...Communication of Fall Risk...The patient's fall risk status must be communicated to members of the healthcare team via report, nursing documentation, and standardized signage...Fall risk is included in handoff communication/report between caregivers at shift change and transfer of patient between units/departments...Documentation...Document fall risk score using appropriate Fall Risk Assessment Tool (FRAT) in the medical health record upon admission, every shift, upon transfer to another level of care or after a patient fall."

Review of Patient 1's clinical record titled, "History and Physical [H&P]," dated 3/7/25, at 3:49 a.m., indicated Patient 1 was admitted to the hospital for intracranial hemorrhage (bleeding in the head). The H&P indicated Patient 1 was paralyzed on the right side of his body.

Review of Patient 1's clinical record titled, "John Hopkins Fall Risk Assessment [FRA]", dated 3/9/25 at 11:46 a.m., indicated Patient 1's FRA score was 10, which indicated Patient 1 was a low risk for falls. The nurse selected basic safety measures which did not include using a chair alarm.

Review of Patient 1's FRA, dated 3/10/25 at 10:41 a.m., indicated the nurse made no selections resulting in a fall risk score of zero, which indicated Patient 1 was a low risk for falls. The nurse selected basic safety measures which did not include using a chair alarm.

Review of Patient 1's clinical record titled, "Nurse's Progress Notes," dated 3/10/25, at 1 p.m., indicated Patient 1 fell out of the recliner chair to the floor and was placed back in the bed with assistance of nursing staff and a total lift (a mechanical device used to safely transfer patients who cannot support their own weight between surfaces like beds, chairs, and wheelchairs).

Review of Patient 1's clinical record titled, "Physician's Progress Notes", dated 3/10/25 at 3:50 p.m., indicated, "[Patient 1] placed in chair for early mobility encouragement and was found on the floor by nursing staff who immediately responded after apparent bowel movement and patient's attempt to rise from bed without assistance."

Review of Patient 1's clinical record titled, "Discharge summary", dated 3/29/25, at 8:18 a.m., indicated Patient 1 had a ground level fall with bruising and discoloration around the eyes.

During an interview on 4/3/25 at 1:15 p.m. with Registered Nurse (RN)1, RN 1 stated she was on break when Patient 1 had a fall on 3/10/25 and that Patient 1 was already in bed when she came back from break. RN 1 further stated she applied an ice pack to Patient 1's right eye and stated the bruise was small and became bigger over time.

During an interview on 4/3/25, at 1:38 p.m. with RN 2, RN 2 stated on 3/10/25, "I got the patient back in bed with the help of other nurses and the total lift. There was a huge bump on his eyebrow."

During an interview on 4/3/25, at 2:10 p.m. with Physio Therapy Assistant (PTA- helps individuals regain or improve their physical function), PTA stated, "I saw him a day after the fall, on March 11th, I saw a blackening, a little bruising on his eye, do not recall the side."

During a concurrent interview and record review with Manager for Physio Therapy (MPT) on 4/3/25, at 2:15 p.m., Patient 1's "Physical Therapist Initial Eval," dated 3/9/25 at 4:13 p.m. was reviewed. MPT stated, based of the Physical Therapist evaluation, Patient 1 was high risk for falls.

During a concurrent interview and record review on 4/4/25, at 9:30 a.m. with Nurse Shift Manager (NSM) 2, Patient 1's Fall Risk Assessments, dated 3/9/25 and 3/10/25 were reviewed. NSM2 stated that during the evening shift on 3/9/25 there was no FRA done and during the day shift on 3/10/25 the FRA was not complete.

During a concurrent interview and record review on 4/4/25, at 9:45 a.m. with Safe Patient Handling Coordinator (SPHC), Patient 1's FRA, dated 3/10/25, was reviewed. SPHC stated, "It was safe to put patient in the recliner if proper safety precautions were implemented, the safety precautions were not in place. The nurses could have used additional safety measures, they could have put chair alarm ..."

During a concurrent interview and record review on 4/4/25, at 10 a.m., with NSM 1, Patient 1's FRA, dated 3/10/25, was reviewed. NSM1 stated that there was no chair alarm used for Patient 1 on 3/10/25 when patient was put in the recliner before the fall.

During a concurrent interview and record review with Intensive Care Unit Director (ND)1, on 4/4/25, at 10:40 a.m., Patient 1's RFAs were reviewed. The ND1 stated the nurse had not done the FRA on 3/10/25 during the day shift and did not put the chair alarm on before Patient 1 fell out of the recliner. ND1 further stated, "Nurses have to do their assessments and evaluation in order to provide safe patient care."

During a concurrent interview and record review on 4/4/25, at 1:15 p.m., with Quality & Patient Safety Program Manager (QPSPM), Patient 1's FRAs, dated 3/9/25 through 3/29/25 were reviewed. The QPSPM confirmed the FRAs indicated the following:
1. On the evening shift of 3/9/25 the RFA was not documented;
2. On the morning shift of 3/10/25 the RFA was documented incomplete;
3. On the evening shift of 3/14/25 the RFA was not documented;
4. On the evening shift of 3/15/25 the RFA was not documented;
5. On the evening shift of 3/20/25 the RFA was not documented; and
6. On the evening shift of 3/26/25 the RFA was not documented.



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2. During a review of Patient 8's H&P, dated 3/20/25, the H&P indicated Patient 8 presented to hospital on 3/20/25 following a fall. The H&P indicated Patient 8's medical history included high blood pressure and encephalopathy (brain disorder affecting behavior, mental processes and memory).

During a review of Patient 8's Medical Record (MR), a Nursing Progress Note (NPN), dated 3/21/25, at 3:27 p.m. was reviewed. The NPN indicated, "Patient threatened to hurt RN [registered nurse], saying 'I will hit you if you come near me' and began to swing at RN. Multiple staff members arrived to assist patient back to bed. Patient continued to swing and kick staff members. Bilateral wrist restraints placed. MD [medical doctor] notified." The MR indicated a physician order was placed on 3/21/25 at 3:58 p.m. for Restraints-Non-Violent/Non-destructive.

During a review of Patient 8's MR, a review of a Physician Note (PN), dated 3/26/25 at 10:36 p.m. was reviewed. The PN indicated, "Started patient on restraints due to patient being agitated and combative per RN." The MR indicate a physician order on 3/26/25 at 10:36 p.m. for Restraints-Non-Violent/Non-destructive.

In a concurrent interview and record review, on 4/2/25, at 3 p.m. with Nursing Director (ND) 1, Patient 8's NPN, dated 3/21/25, and PN, dated 3/26/25, were reviewed. ND 1 stated Patient 8's behaviors described in the notes indicated Patient 8 should be in restraints for violent behaviors.

3. In a review of a facility P&P titled, "Restraint and Seclusion, Nursing Management of," dated 4/2/13, the P&P indicated, "Ordering of restraint or seclusion for violent or self-destructive behavior ...for the management of violent or self-destructive behavior ... that jeopardizes the immediate physical safety of the patient, a staff member, or others."

During a review of Patient 4's H&P, dated 3/8/25, the H&P indicated Patient 4 presented to hospital on 3/8/25 with flu-like symptoms and inadequate consumption of fluid and food. The H&P indicated Patient 4's medical history included dementia (a progressive state of decline in mental abilities).

During a review of Patient 4's orders, the orders included a violent/self-destructive restraints order (VRO), entered as a verbal order by a nurse from a Medical Doctor, dated 3/9/25, at 0:48 a.m. The VRO included, "Pt [patient] pulling IV [intravenous, a catheter placed in vein] lines."

During a review of Patient 4's Restraint Flowsheet (RFS), dated 3/9/25, the RFS indicated bilateral mitten restraints were applied at 1 a.m., patient was "confused/restless", and "clinical justification [was] attempting to pull IV line".

During a concurrent interview and record review, on 4/3/25, at 10:40 a.m., with Nurse Educator (NE) 1, Patient 4's H&P, dated 3/8/25, at 11:54 p.m., was reviewed. The H&P indicated Patient 4 was "very confused". NE 1 confirmed the H&P contained no mention of violent/self-destructive behavior and the VRO did not indicate behavior which would justify violent/self-destructive restraints. NE 1 stated, "Order should have been for safety/non-violent restraints."

In a review of a facility P&P titled, "Restraint and Seclusion, Nursing Management of", dated 4/2/13, the P&P indicated, "Orders for restraint for safety/non-violent/ non self-destructive behavior [are] to address a patient's medical care-related needs (safety)."