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Based on interview and record review, the facility failed to ensure its physician and trained Registered Nuse (RN) performed a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) within an hour on two of 64 sampled patients (Patient 13 and Patient 14), in accordance with the facility's policy and procedure regarding restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) and seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) when:

1. Emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) physician did not document the time of face-to-face assessment performed after Patient 13 was placed on a 4-point (both upper and lower extremities) keyed polyurethane restraint (a type of restraint that utilizes a key-lock mechanism for closure) on 7/28/2025.

2. Registered Nurse (RN) performed face-to-face assessment two (2) hours after the administration of chemical restraint (use of medications to control a patient's behavior or restrict freedom of movement) on Patient 14 on 7/22/2025.

These deficient practices had the potential to result in Patient 13 and Patient 14 not receiving prompt assessment to evaluate response to restraint, possible side effects from medications and possible need for additional interventions to manage behavior.

Findings:

1. During a review of Patient 13's "Emergency Department Note - Physician (ED note, medical notes completed by ED physician)," dated 7/28/2025, the ED note indicated Patient 13 presented to the facility's ED for agitation (being upset, annoyed, angry, and physically disturbed) and bizarre (strange, unusual) behavior. The ED note also indicated Patient 13 exhibited signs of severe psychiatric distress and agitated delirium (a sudden, temporary state of confusion) representing an immediate physical danger to self and others.

During a review of Patient 13's physician order, dated 7/28/2025, the physician order indicated Patient 13 was placed on keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure) restraint for danger to others.

During a review of Patient 13's "Restraint Initiation (nursing document relating to application of restraint)" form, dated 7/28/2025, the "Restraint Initiation" form indicated, Patient 13 was placed on keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure) restraint to both upper and lower extremities on 7/28/2025 at 6:40 p.m.

During a concurrent interview and record review on 7/29/2025 at 2:51 p.m. with the Director (DIR 1) of Medical-Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery)/Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) Unit , Patient 13's "Emergency Department Note - Physician (ED note)," dated 7/28/2025, was reviewed. The ED note indicated, "I performed a face-to-face assessment within one hour of the restraint/seclusion at [time] ... restraints were [removed/continued]." DIR 1 stated the ED note did not indicate the exact time of face-to-face assessment performed. DIR 1 was unable to tell what time the face-to-face assessment was completed.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint," dated 7/2025, the P&P indicated, "Restraints will be used for clinically appropriate and adequately justified situations based on individually assessed patient need and behavioral risk factors ... Monitoring a. Restraints i. A Physician, their designee, or a qualified Registered Nurse must see (face to face) and evaluate the need for seclusion and restraints within one (1) hour after the initiation of this intervention. The evaluation must be documented in the patient medical record and the physician /their designee must be notified of the evaluation if performed by RN."

2. During an interview on 7/29/2025 at 11:08 a.m. with Registered Nuse (RN) 1, RN 1 stated the following: the facility Behavioral Health Unit (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) would use seclusion, physical restraints and/or chemical restraint (use of medications to control a patient's behavior or restrict freedom of movement) on patients depending on the situation and the physician order.

A chemical restraint was usually a combination of intramuscular (IM, into the muscles) injections with Benadryl (antihistamine [medication that treat allergy symptoms] that can have a calming or sedative effect), Haldol (medication to treat schizophrenia [(mental illness affecting how someone behaves, feels, and thinks] and acute [new onset] agitation [being upset, annoyed, angry and physically disturbed]) and Versed (medication used to produce drowsiness and has sedation [a state of calmness or drowsiness induced by drugs] effect). Within an hour after the injections were given, the RN would perform face-to-face assessment to make sure patient was responsive and check for the effectiveness of medications and potential side effects.

During a review of Patient 14's "Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health])," dated 7/22/2025, the Psych Eval indicated Patient 14 was admitted to the facility on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to others with admitting diagnosis of schizoaffective (a mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]), bipolar (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of the facility's BHU restraint log titled, "Restraint Documentation Verification," dated 7/22/2025, the restraint log indicated, Patient 14 received chemical restraint on 7/22/2025 at 9:05 p.m.
During a review of Patient 14's "Orders (physician orders)," dated 7/22/2025, the physician order indicated, Behavioral Restraint and/or Seclusion order set initiated with emergency medication administration restraint of Benadryl 50 milligrams (mg, a unit of measurement) IM once (one time only), Versed 5 mg IM and Geodon (medication to treat acute agitation in schizophrenia) 20 mg IM once."

During a review of Patient 14's Medication Administration Record (MAR, record of medications given to patients), dated 7/22/2025, Patient 14 received one time IM injections of Geodon 20 mg, Versed 5 mg and Benadryl 50 mg on 7/22/2025 at 9:05 p.m.

During a concurrent interview and record review on 7/29/2025 at 2:35 p.m. with the Nurse Manager (NM) 1 of BHU, Patient 14's "Progress Note Non-Physician (nurse notes)," dated 7/22/2025, was reviewed. The nurse notes indicated, "The patient (Patient 14) punched another patient ... multiple times on the right side of the face on the hallway .... (physician) was notified immediately and provided verbal orders for the following intramuscular medications: Geodon 20 mg, Versed 5 mg, Benadryl 50 mg. All orders were reviewed, verified and administered as directed ... A face-to-face assessment was conducted following medication administration." NM 1 stated the nurse notes did not indicate what time the face-to-face assessment was performed.

During a concurrent interview and record review 7/29/2025 at 2:40 p.m. with the Nurse Manager (NM) 1 of BHU, Patient 14's "BH Face to Face (face-to-face assessment, RN documentation of face-to-face assessment)," dated 7/22/2025, was reviewed. The face-to-face assessment indicated Registered Nuse (RN) 2 completed the face-to-face assessment for Patient 14 on 7/22/2025 at 11:09 p.m. NM 1 confirmed the entry time was beyond one hour from the medication administration time (2 hours after the medication administration time).

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint," dated 7/2025, the P&P indicated, "Restraints will be used for clinically appropriate and adequately justified situations based on individually assessed patient need and behavioral risk factors ... Monitoring a. Restraints i. A Physician, their designee, or a qualified Registered Nurse must see (face to face) and evaluate the need for seclusion and restraints within one (1) hour after the initiation of this intervention. The evaluation must be documented in the patient medical record and the physician/their designee must be notified of the evaluation if performed by RN."

During review of the facility's policy and procedure (P&P) titled, "Emergency Medications," dated 7/2025, the P&P indicated, "To provide guidelines for administering antipsychotic medications or intramuscular medications to a patient without his consent to maintain safety for the patient and other people on the unit ... Procedure ... A. Definition: An emergency exists when there is a sudden marked change in the patient's condition so that action is immediately necessary for preservation of the life or the prevention of serious bodily harm to the patient or others ... The nurse will reassess the patient within 1 hour of administering an emergency IM ... Chemical Restraint ... A medication used to control behavior or to restrict the patient's freedom of movement that is not a standard treatment for the patient's medical or psychiatric condition."

Based on interview and record review, the facility failed to ensure its physician performed a complete face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) on one of 64 sampled patients (Patient 13), in accordance with the facility's policy and procedure regarding restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) and seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving), when the emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) physician did not indicate whether restraint should be continued or removed at the end of a face-to-face assessment on 7/28/2025.

This deficient practice had the potential to result in prolonged or unnecessary restraint use for Patient 13.

Findings:

During a review of Patient 13's "Emergency Department Note - Physician (ED note, medical notes completed by ED physician)," dated 7/28/2025, the ED note indicated Patient 13 presented to the facility's ED for agitation (being upset, annoyed, angry, and physically disturbed) and bizarre (strange, unusual) behavior. The ED note also indicated Patient 13 exhibited signs of severe psychiatric distress (a state of emotional suffering characterized by symptoms of anxiety [characterized by excessive and persistent worry, fear, and unease] and depression [a serious mood disorder that can affect how you think, feel, and behave]) and agitated delirium (a sudden, temporary state of confusion) representing an immediate physical danger to self and others.

During a review of Patient 13's physician order dated 7/28/2025, the physician order indicated Patient was placed on keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure) restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) for danger to others.

During a review of Patient 13's "Restraint Initiation (nursing document relating to application of restraint)," dated 7/28/2025, the "Restraint Initiation" form indicated, Patient 13 was placed on keyed polyurethane restraint to both upper and lower extremities on 7/28/2025 at 6:40 p.m.

During a concurrent interview and record review on 7/29/2025 at 2:51 p.m. with the Director (DIR 1) of Medical-Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery)/Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) Unit, Patient 13's "Emergency Department Note - Physician (ED note)," dated 7/28/2025, was reviewed. The ED note indicated, "I performed a face-to-face assessment within one hour of the restraint/seclusion at [time] ... restraints were [removed/continued]." DIR 1 stated the ED physician did not clarify if restraints were removed or continued at the end of face-to-face assessment.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and Restraint," dated 7/2025, the P&P indicated, "Restraints will be used for clinically appropriate and adequately justified situations based on individually assessed patient need and behavioral risk factors ... Monitoring a. Restraints i. A Physician, their designee, or a qualified Registered Nurse must see (face to face) and evaluate the need for seclusion and restraints within one (1) hour after the initiation of this intervention. The evaluation must be documented in the patient medical record and the physician /their designee must be notified of the evaluation if performed by RN."

Based on interview and record review, the facility's Quality Assessment and Performance Improvement program (QAPI, a structured, ongoing process where the hospital collects and analyzes data to identify problems, monitor performance, and implement solutions to improve patient care and safety) failed to ensure that effective monitoring systems were in place to identify and correct missed patient safety rounding in the Behavioral Health Unit (BHU, a hospital unit for patients with mental health conditions requiring inpatient care).

The facility's "rounding, Observation and Monitoring of Patients," policy required q (every) 15-minute rounding (a mandated patient safety protocol where staff members, often mental health technicians or nurses, visually observe patients at least every 15 minutes with the primary goal is to ensure the safety and well-being of patients in a high-risk environment) for all patients in the BHU. For 31 of 64 sampled patients (Patients 10, 11,12, 15, 17, 18, 19, 39, 42, 43, 44, 45, 46, 47,48, 49, 50, 51, 52, 53, 54, 55, 56,57, 58, 59, 60, 61, 62, 63, and 64), q 15-minute rounding was not completed as required.

This deficient practice had the potential to leave patients, including those at high risk for self-harm or aggression (behavior aimed at harming others), without required safety checks, thus increasing the risk of serious injury or death. This deficient practice also had the potential to render the facility's QAPI program ineffective in its ability to promptly detect, address, and prevent recurrence of patient safety risks.

Findings:

During a concurrent interview and record review on 7/30/2025 at 9:55 a.m. with the Lead Security Officer (LSO) and the Nurse Manager (NM) 1, the ABC unit in Campus 1's video surveillance, dated 7/4/2025 and 7/25/2025 from 4 a.m. through 5 a.m., were reviewed. The videos showed the following:

Video reviewed dated 7/4/2025:
- At 4:08 a.m., Mental Health Worker (MHW) 4 walked down the hallway of unit ABC but only opened the doors of 3 to 4 rooms to look inside. During the same interview on 7/30/2025 at 10:02 a.m., Lead Security Officer (LSO) confirmed that MHW 4 did not open the doors to all patient rooms.
-At 4:24 a.m., MHW 4 was scheduled to complete the next 15-minute rounding but did not perform the rounding. Instead, MHW 4 entered information into the tablet at 4:32 a.m. During the same interview at on 7/30/2025 10:54 a.m. NM 1 confirmed that there was a missed rounding at 4:24 a.m.
-At 4:48 a.m., rounding was delayed by 24 minutes, and not all room doors were opened.
-At 5:00 a.m., rounding was completed but still without opening all patient room doors.

During the same interview on 7/30/2025 at 10:40 a.m., NM1 confirmed that MHW 4 did not open the doors to all patient rooms during rounding, and NM1 stated that opening all patient room doors was required to visually confirm patient safety.

Video reviewed date 7/25/2025:
-At 4:15 a.m., the scheduled 15- minute rounding was not completed.
-At 4:30 a.m., MHW 10 completed q 15-minutes rounding.
-At 4:45 a.m., the scheduled 15- minute rounding was not completed.

During the same interview on 7/30/2025 at 10:54 a.m., NM1 confirmed that on 7/25/2025 at 4:15 a.m., and at 4:45 a.m., there was a missed rounding, and at 4:08 a.m., MHW 10 walked down hallway but did not enter all rooms. NM 1stated it was expected for staff to check on all patients, including the patient in the isolation room (a specially designed room used to separate patients with infectious diseases from other patients and healthcare staff).

During a review of the facility's "Current Census Detail (the number of patients receiving care at a healthcare facility unit at a given time)," report for Unit ABC dated 7/4/2025 (date surveillance video was reviewed during survey), the report indicated that Patients 11, 15, 48, 51, 52, 53, 54, 55, 56,57, 58, 59, 60, 61, 62, 63, and 64, were roomed on Unit ABC on 7/4/2025.

During a review of Patients 11, 15, 48, 51, 52, 53, 54, 55, 56,57, 58, 59, 60, 61, 62, 63, and 64's medical record titled, "Rounding reports," dated 7/4/2025, indicated that rounding was completed at 4:30 a.m. or 4:31 a.m. and 4:47 a.m., which did not reflect the video surveillance reviewed.
During a review of the facility's "Current Census Detail (the number of patients receiving care at a healthcare facility unit at a given time)," report for Unit ABC dated 7/25/2025 (date surveillance video was reviewed during survey), the report indicated that Patients 10, 11,12,15,17,19, 39, 42, 43, 44, 45, 46, 47,48, 49,50, and 51, were roomed on Unit ABC on 7/25/2025.

During a review of Patients 10, 11,12,15,17,19, 39, 42, 43, 44, 45, 46, 47,48, 49,50, and 51's medical record titled, "Rounding reports," dated 7/25/2025, indicated that rounding was completed at 4:15 a.m. and 4:47 a.m., which did not reflect the video surveillance reviewed.

During an interview on 7/29/2025 at 4:00 p.m. with the Director of Performance Improvement/Quality Management (DQM, the facility leader responsible for ensuring that QAPI functions effectively), DQM stated that the facility was aware of the missed rounding and had developed a plan to install a monitor in the DQM's office to track rounding. However, the DQM confirmed that this surveillance-based auditing plan would not be conducted on a scheduled basis, and it had not yet been implemented.

During the same interview on 7/29/2025 at 4:00 p.m. with the DQM, the DQM stated that there were no other systems in place, aside from reviewing security surveillance videos, to verify whether staff rounding actually occurred as documented in the medical record (the legal record of a patient's care). The DQM confirmed that reviewing surveillance videos for auditing was neither a scheduled nor routine monitoring practice.

During a review of the facility's policy and procedure (P&P) titled, "Rounding, Observation and Monitoring of Patients," dated June 2025, the P&P indicated, that patients rounds must be performed on all patients at least every 15 minutes, in a manner that allows visual confirmation of patient safety. Standard observations may not be completed by standing in a doorway or at a distance; staff are expected to look directly into the room, particularly for patients who may be sleeping.

During a review of the facility's "Organizational Performance Improvement Plan (a structured, systematic approach designed to enhance the quality and efficiency of healthcare services within a hospital)" dated April 2025, the plan indicated, "The purpose of the Organizational Performance Improvement Plan at (name of the facility) is to ensure that the Governing Board, medical staff and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk ... Assure that the improvement process is organization-wide, monitoring, assessing and evaluating the quality and appropriateness of patient care, patient safety practices and clinical performance to resolve identified problems and improve performance... The status of identified problems and action plans is tracked to assure improvement or problem resolution at the department and organization levels ... Important key aspects of care to the health and safety of patients are identified. Included are those that occur frequently or affect large numbers of patients; place patients at risk of serious consequences of deprivation of substantial benefit if care is not provided correctly or not provided when indicated; or care provided is not indicated, or those tending to produce problems for patients, their families or staff ..."