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Based on record review, staff interview, and facility policy review, the facility failed to meet the condition of participation for patient rights. The facility failed to protect and promote patient's rights of being free from improper use of restraints, restraint orders, and monitoring of restraints for two patients (P) (P#4, P#5) of two patients reviewed for restraints.


Findings included:


Cross refer to A-0154 as it relates to the facility's failure to protect the patient's right of being free from improper use of restraints.

Cross refer to A-0168 as it relates to the facility's failure to ensure restraints were only in accordance with an order.

Cross refer to A-0169 as it relates to the facility's failure to ensure that restraint orders were not on an as needed basis.

Cross refer to A-0175 as it relates to the facility's failure to ensure patients restrained or secluded due to violent behavior were monitored.

Based on review of facility policies, record review, and staff interview it was determined that the facility failed to protect patients' right of being free from improper use of physical restraints, which affected one patient (P) (P#5) of two patients reviewed for restraints.


Findings included:

A facility policy titled, "Restraint," dated 04/12/2023, indicated, "[Facility Name] hospitals do not use restraint or seclusion as a means of coercion, discipline, convenience or retaliation."


A facility policy titled, "Patient's Rights and Responsibilities," dated 09/08/2021, revealed, "All patients at [Facility Name] are entitled to the rights listed below:" to include "Be free from restraint/seclusion used as a means of coercion, discipline, convenience or retaliation by staff."


The hospital record for P#5 revealed that P#5 arrived at the emergency department (ED) on 07/27/2024 at 2:53 p.m. for aggressive behavior. The record revealed an order dated 07/28/2024 at 10:19 p.m. for "Restraints Violent or self-destructive adult (age 18 and older)." Further review revealed the order was for two-point soft wrist restraints continuous for four hours due to the patient being a danger to themself.


A "Non-Violent Restraints" flowsheet dated 07/28/2024 at 10:06 PM, revealed staff documented the clinical indication was for "Fall prevention."


During an interview on 09/25/2024 at 10:34 AM, Nurse Education Coordinator (NEC) #10 stated that restraints should never be used for fall prevention. She stated that restraints could be indicated for patient safety but should not be used for falls.

Based on review of facility policies, medical records, and staff interview it was determined that the facility failed to ensure restraints were used only in accordance with an order, which affected one patient (P) (P#4) of two patients reviewed for restraints.


Findings included:


Review of facility policy titled "Restraint," dated 04/12/2023, indicated, "1. Therapeutically Unsafe or Disruptive Behavior (Medical Restraints)" included "a. A physician's order is required to initiate restraint use." The policy also indicated, "3) The order must be dated and timed, contain reason or clinical justification for restraint, type of intervention/device, and time limit of use."


The hospital record for P#4 revealed the facility admitted the patient on 07/06/2024 for generalized weakness. The record revealed an order dated 07/06/2024 at 10:29 p.m., for "Restraints non-violent or non-self-destructive." The record revealed the order was for 24 hours for right upper extremity and left upper extremity wrist restraints due to "Interference with medical treatment."


A "Restraint Type" flowsheet dated 07/06//2024 at 10:54 PM, revealed staff documented a left mitt, right wrist restraint, and left wrist restraint were started.


During an interview on 09/25/2024 at 10:44 a.m., Nurse Education Coordinator (NEC) #10 stated that the order for P#4 on 07/06/2024 at 10:29 p.m. was only for bilateral upper wrists, but the nurse documented that the patient was placed in a left mitt as well.

Based on review of facility policies, medical records, and staff interview it was determined that the facility failed to ensure that orders for the use of a restraints were not written on an 'as needed' basis, which affected one patient (P) (#4) of two patients reviewed for restraints.


Findings included:


Review of facility policy titled "Restraint," dated 04/12/2023, indicated, "PRN [pro re nata, as needed] orders cannot be used to authorize the use of restraint."


The hospital record for P#4 revealed the facility admitted the patient on 07/06/2024 for generalized weakness. The record revealed an order for "Restraints non-violent or non-self-destructive" that was electronically signed by the medical doctor on 07/07/2024 at 7:32 p.m.. Further review revealed the order was for 24 hours for right upper extremity and left upper extremity limb restraints due to interference with medical treatment. Review of the medical record did not reveal that the patient was placed in restraints during this time.


During an interview on 09/25/2024 at 10:55 a.m., Nurse Education Coordinator (NEC) #10 stated that the order for P#4 on 07/07/2024 at 7:32 p.m., for bilateral upper wrist restraints was never documented as started and was not discontinued until the system discharged the patient.

Based on review of facility policies, medical records, and staff interview it was determined that the facility failed to ensure patients who were restrained or secluded due to violent behavior were monitored, which affected one patient (P) (P#5) of two patients reviewed for restraints.


Findings included:

Review of facility policy titled "Restraints," dated 04/12/2023, indicated, "Patients restrained/secluded due to violent or self-destructive behavior will be assessed every 15 minutes." The policy also indicated, "Continuous Monitoring and Care of the Restrained Patient" included "1. The condition of the patient and the restrained used must be continually assessed, monitored, re-evaluated, and documented. Frequency of re-assessment is dependent upon the condition of the patient." The policy revealed, "b. If violent or self-destructive behavioral restraints are necessary, those individuals are monitored and assessed a minimum of every 15 minutes, with vital signs obtained every 2 hours (if safe to do so), upon discontinuation of intervention or as needed. c. If the patient is in seclusion, those individuals are monitored and assessed every 15 minutes, with vital signs obtained upon discontinuation of intervention.


The hospital record for P#5 revealed that the patient arrived at the emergency department on 07/27/2024 at 2:53 p.m. for aggressive behavior. The record revealed an order dated 07/28/2024 at 11:35 a.m. for "Restraints Violent or self-destructive adult (age 18 and older)." Further review revealed the order was for seclusion due to the patient being a danger to others and to themself. The record revealed that the order was for four hours and was renewed on 07/28/2024 at 3:23 p.m.


The "Violent Restraints or Self-Destructive Restraints" flowsheets for P#5 did not reveal when the seclusion was started. The Violent Restraints or Self-Destructive Restraints flowsheets indicated that the seclusion was continued on 07/28/2024 at 1:35 p.m. but revealed no documentation of 15-minute assessments of the patient.


During an interview on 09/25/2024 at 11:21 a.m., Unit Director (UD) #14 stated that the record showed P#5 was transferred into a seclusion room on 07/28/2024 at 11:34 a.m., but that the nurse did not document that in the restraint flowsheets.

Based on review of facility policies, medical records, and staff interview it was determined that the facility failed to ensure that licensed nurses adhered to hospital policies, which affected 4 four patients (P) (P#1. P#3, P#6, and P#7) of six patients reviewed for following hospital policies.


Findings include:

1. A facility policy titled, "Patient's Rights and Responsibilities," dated 09/08/2021, indicated, "All patients at [Facility Name] are entitled to the rights listed below," which included "Have a family member involved in decisions about care, treatment and services."


A facility policy titled, "Certificate Authorizing Transport to Emergency Receiving Facility," dated 10/01/2022, indicated, "F. Responsibilities of the Care Team Prior to Transfer" included "4. The staff will attempt to notify the patient's family/significant other prior to transfer or as soon as possible."


The hospital record for P#1 revealed the P#1 arrived at the emergency department on 05/31/2024 for a mental evaluation and was admitted that day. An "H&P [History and Physical]" dated 05/31/2024, revealed that P#1 presented with new onset psychosis with auditory hallucinations telling the patient to kill their family member. The record revealed that it was determined that the patient required psychiatric hospitalization for crisis stabilization, medication management, and discharge planning.


A "Discharge Summary" dated on 06/02/2024, revealed P#1 had been disorganized and delusional and was transferred to a "1013 receiving facility." Further review of the medical record revealed no documentation that the patient's family was notified of their transfer.


2. The hospital record for P#3 revealed the patient arrived at the emergency department on 06/08/2024 for "mental health."


An "Initial Psychiatric Assessment," dated 06/09/2024, revealed that P#3 was admitted due to being unable to care for their self because of mental illness. The record revealed the patient had worsening agitation, confusion, and paranoia since beginning on antidepressant medication. The record revealed that during the provider's interview with the patient, the patient was noted to have delusional thought content, believed they were being shot in the back of the head, disorientation, and paranoia against their family.


"Form 1013-Certificate Authorizing Transport to Emergency Receiving Facility & Report of Transportation (Mental Health)," dated 06/09/2024, for P#3 revealed P#3 required involuntary treatment in that they appeared to be mentally ill and appeared to be unable to care for their own physical health and safety as to create an imminently life-endangering crisis. The record revealed that at the time of evaluation, the patient appeared to be mentally ill based on the observation of "psychosis." The record revealed that the patient presented an imminently life endangering crisis to their self because they were unable to care for their own health and safety due to "disorganized thought content/process," paranoia, and delusions.


"Progress Notes," dated 06/10/2024, revealed P#3 was cleared for transfer to a receiving facility and would be transported at around 3:00 p.m.


A "Discharge Summary," dated 06/10/2024, revealed that P#3 remained delusional at the time of discharge, and that a transfer to a "1013 receiving facility" was appropriate. Further review of the medical record revealed no documentation that the patient's family was notified of their transfer.


During an interview on 09/24/2024 at 1:33 p.m., Social Worker (SW) #4 stated that there were various levels of involvement for social work staff with a patient that was under an involuntary commitment via a 1013 form. He stated that usually, the process began in the emergency department, and the patient was moved to the behavioral health or medicine department while the 1013 acceptance was pending at an emergency receiving facility. He stated that the social work staff's primary role in the 1013 process was arranging transportation and sending records. He stated that the expectation was that nursing staff or social work staff notified family of a transfer. He stated that he was unsure whether there was a policy that outlined whose responsibility it was to notify the family.


During an interview on 09/24/2024 at 2:08 p.m., Registered Nurse (RN #3) stated notification to the family about transfer varied in responsibility. He stated that it could be done by nursing staff or social work staff, but he believed it was primarily the responsibility of social work staff. He stated that family or next of kin would be notified if the patient wanted them to. He stated that if the patient was not able to make decisions for themself, their next of kin would be notified.


During an interview on 09/25/2024 at 11:00 a.m., RN #13 stated the nurse's discharge note was where nursing staff would document family notification of transfer.
During an interview on 09/25/2024 at 12:10 p.m., RN #13 stated that they could not find any notification that family was notified of Patient #1's or Patient #3's transfer to an emergency receiving facility. She stated that social work staff or care coordination staff would normally document the notification in a note.


3. A facility document titled, "IV [intravenous] catheter removal," revised 08/19/2024, indicated, "Removal of a short peripheral IV catheter should occur as soon as the catheter is no longer indicated for the patient's plan of care or when the catheter hasn't been used for at least 24 hours."


A facility document titled, "Discharge," revised 05/20/2024, indicated, "Implementation" included "Ensure proper removal of all devices discontinued by the ordering practitioner, such as IV catheters, indwelling urinary catheters, and drains, before discharge to avoid potential complications."


An e-mail dated 09/26/2024 at 12:26 p.m., revealed the Accreditation Manager (AM) stated that there was no specific facility policy for ensuring accurate documentation. The email revealed they "pretty much go by the honor system."


The hospital record for P#6 revealed the facility admitted the patient on 09/14/2024 for rectal bleeding. The record revealed the facility discharged P#6 on 09/20/2024 at 9:27 p.m.


An "IV Assessment" flowsheet revealed P#6 had a posterior, right wrist peripheral IV line that was documented as removed on 09/20/2024 at 11:33 p.m., and a posterior, right hand peripheral IV line documented as removed on 09/20/2024 at 11:33 p.m.


During an interview on 09/25/2024 at 11:49 a.m.,, Nurse Education Coordinator (NEC) #10 stated that the best practice would be to document lines were removed prior to patient discharge. She stated that there was no other documentation that showed P#6 peripheral IV lines were removed prior to discharge.


4. The hospital record for P#7 revealed the facility admitted the patient on 08/29/2024 for hypoxia. An "Events" flowsheet revealed that P#7 was discharged on 09/01/2024 at 2:30 p.m.


An "IV Assessment" flowsheet revealed staff documented that P#7 right antecubital peripheral IV line was removed on 09/01/2024 at 4:34 p.m.


The record revealed "Clinical Notes," dated 09/01/2024 at 6:22 p.m., entered by Registered Nurse (RN) #6, revealed that the nurse documented the patient's IV line and remote telemetry had been discontinued intact.


During an interview on 09/26/2024 at 12:10 PM, RN #6 stated IV lines should be removed when a patient was discharged. She stated they do not take them out until right before a patient left in case there was an emergency with the patient while they waited to be picked up. She stated that she documented when the IV line was taken out. She stated that it was a shared responsibility between the patient care technicians (PCTs) and nursing staff. Per RN #6, if the PCT removed it, they usually notified the nurse that it was taken out. She stated that she was unsure of what the protocol was for if a patient discharged with an IV line. She stated that she remembered that P#7 family member called and reported that the patient had gone home with an IV line in place. She stated that she did not remember who discharged the patient, she had been floated to the unit that day, and did not remember if she did the discharge fully on her own. She stated that she did not remember whether the patient did or did not have an IV line when they left. She stated that she normally removed a patient's IV line when she was going over discharge instructions with the patient but could not remember if they were the one who went over the instructions with P#7 that day. She stated that she entered a note that the IV line was removed. RN #6 stated that she always wrote a note and addressed what the patient had removed based on what the patient had in place. She stated that she was "pretty sure" she had taken out the IV line, or she would not have documented it.