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Based on policy review, medical record review, observation, and staff interviews, it was determined the facility failed to ensure the patient was free from restraints for one (1) out of ten (10) patients, patient 1. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A policy was reviewed titled, "Patient Restraints," last revised 02/25. The policy states in part, "...II Purpose: A. To protect each patient's rights of freedom from physical restraints or seclusion- except when determined to be clinically justified or warranted by patient behavior that threatens the physical safety of the patient, staff or others. Restraint and seclusion will only be used when less restrictive interventions have been determined to be ineffective to protect the patient, staff member, or others from harm. Restraints or seclusion shall not be used for the purpose of discipline, staff convenience, coercion, retaliation, or due to a history of dangerous behavior. B. To promote an environment that minimizes circumstances requiring use of restraints and maximizes patient safety ...IV. ASSESSMENT AND MONITORING A. A LP or registered nurse (RN) shall assess patient behavior and need for restraints. Trained, unlicensed staff may perform components of monitoring (e.g., checking vital signs, level of distress and agitation, circulation and range of motion, skin integrity) and may provide for general care needs (e.g., eating, hydration, toileting). The comprehensive assessment shall include signs of confusion or disorientation and identification of medical problems that may be the causative factor ...V. ORDERS A. The physician or other LP responsible for the care of the patient shall order restraint or seclusion prior to the application of restraint or seclusion. Emergent application of a restraint prior to obtaining an order from a LP responsible for the care of the patient may be done at the discretion of a RN following an assessment of the patient. The RN shall notify the LP of restraint initiation and obtain a restraint order either during the emergency application of the restraint or as soon as possible immediately (within 60 minutes), after the restraint has been applied. B. If the attending physician is not the LP ordering restraints, he/she shall be notified as soon as possible, within 60 minutes of restraint use ...C. PRN orders for restraint are not permitted ...VI. DISCONTINUATION OF RESTRAINT OR SECLUSION: A. Patients shall be released from restraints at the earliest possible time as determined by patient behavior or per LP order. A RN or LP may discontinue the use of restraint or seclusion. When a restraint is discontinued by the RN, the LP responsible for the patient shall be notified of the discontinuation as soon as possible, no later than one hour ...VII. DOCUMENTATION:...B. Each episode of restraint use shall be documented in the patient's medical record, and shall include but not limited to: 1. A description of the patient's condition or symptom(s) that warranted the use of restraint or seclusion 2. A description of the patient's behavior, symptoms, or condition necessitating on-going restraint or seclusion. 3. Alternatives or other less restrictive interventions attempted. 4. Type of intervention used - restraint (violent or non-violent), seclusion, and chemical. 5. Results of assessment and monitoring. 6. Revisions to the care plan 7. The patient's response to the intervention used, including rationale for continued use. 8. Any significant change in condition or injuries ...VIII. RESTRAINT ALTERNATIVES: A. Restraint alternatives are the actions taken, including verbal de-escalation, by staff to negate the need for restraint. This assessment shall include collaboration with the patient (if possible), family members, patient representative, and/or other healthcare professionals. B. Documentation must include the alternative measures taken. C. If all attempts for alternative measures have failed, or the patient status has changed and imminent risk is present, and restraints are deemed necessary, least restrictive restraint methods should be attempted first. IX. LEAST RESTRICTIVE MEASURES: A. The hospital uses restraint and seclusion only when it can be clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff, or others AND when less restrictive interventions have been ineffective. B. Least restrictive measures provide the maximum amount of safety, providing protection of patient, staff, and others while employing the least amount of force ..."

A medical record review was conducted for patient 1. The patient expired on 10/19/25. A "Progress Note-Nurse" on 10/20/25 at 10:29 a.m. by staff 2 states, "Patient expired within 24 [twenty four] hours of being in bilateral soft wrist restraint. Death logged in internal hospital seclusion/restraint log." May it be noted, in the medical record, there was no nursing documentation and no physician orders related to restraints.

An observation was conducted of a picture provided to this surveyor by ME (Medical Examiner) 1. The picture shows patient 1, with burns to the left side and arm. A soft limb restraint string is seen in the picture draped across the patient.

An interview was conducted with staff 5 on 10/21/25 at 12:00 p.m. Regarding the incident with patient 1, staff 5 states in part, "The patient had wrist restraints on, but when the patient coded we removed the wrist restraint."

An interview was conducted with staff 6 on 10/21/25 at 12:28 p.m. Regarding the incident with patient 1, staff 6 states in part, "The patient did not have restraints, not that I remember. We usually don't restrain the patient until after they are on the ventilator. We do keep a pair in every room; it's part of the intubation protocol."

A telephone interview was conducted with staff 8 on 10/21/25 at 1:49 p.m. Regarding the incident with patient 1, staff 8 states in part, "The patient was not in restraints, [he/she] was relaxed and there was no need to restrain the patient. The patient was initially thrashing around and pulling at things, but the minute [he/she] was sedated there was no need for any restraints. I didn't see restraints, and I don't remember that we had to restrain [him/her] prior to [him/her] arriving in the unit. [He/she] was sedated at the time, was intubated, and did not need restraints."

A telephone interview was conducted with staff 9 on 10/21/25 at 2:04 p.m. Regarding the incident with patient 1, staff 9 states in part, " The patient was not in restraints at the time that this happened. Restraints were never ordered. I did not know if the patient had restraints prior to coming to the ICU [Intensive Care Unit]. I remember [he/she] was fighting the staff on the other unit and pulling things, but I never put in an order for restraints."

An interview was conducted with staff 10 on 10/21/25 at 2:30 p.m. Regarding the incident with patient 1, staff 10 states in part, "I was told the patient had both wrist restraints on the patients but they were not connected to the bed. We don't have to have an order unless the restraints are actually connected to the bed, as in the patient was actually restrained ...There's no restraints located in the patient rooms. We keep them in the stock room or the store room. There's no documentation from our staff that the patient was ever restrained. If the arm restraints were on and weren't attached there would not be any documentation as the patient was not restrained."

A telephone interview was conducted with ME 1 on 10/21/25 at 3:34 p.m. Regarding the incident with patient 1, ME 1 states in part, "The patient was restrained to the bed ... The patient's right leg was still tied to the bed. The patient had soft restraints on all four limbs. The right leg was the only one tied to the bed ..."

A telephone interview was conducted with the Fire Marshall 1 on 10/21/25 at 3:49 p.m. Regarding the incident with patient 1, the Fire Marshall 1 states in part, "I remember that the ME 1 found two (2) arm restraints, one (1) under the patient's gown and one (1) under the blanket. I do not believe [his/her] legs were restrained. We pulled the blanket back to check [his/her] lower extremities and [his/her] legs were not restrained ..."

A telephone interview was conducted with staff 14 on 10/22/25 at 11:02 a.m. Regarding the incident with patient 1, staff 14 states in part, "I remember we placed soft wrist restraints around the patient's wrist, but I don't think we ever clicked them onto the bed ...I know that I didn't lock the restraints to the bed. I know the patient had wrist restraints on the wrist, but I don't know if they were attached. Without clicking onto the bed, they don't restrain anything ..."

Staff 18 provided the following written statement on 10/23/25, which states in part: "During this time, restraints were attached to lower bed (do not recall by who), were not attached to pt. as pt. was already sedated due to intubation (only attached to bed) as I recall ..."

An interview was conducted with staff 2 on 10/23/25 at 10:26 a.m. Regarding restraint documentation for patient 1, staff 2 confirmed there was no documentation in the medical record, and no physician order.

Based on document review, observation, and staff interview, it was determined the facility failed to ensure proper defibrillator pad placement while conducting a code blue response for one (1) out of ten (10) patients, patient 1. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

The "Zoll R Series ALS [advanced life support] Operator's Guide" was reviewed. The issue date for the R Series Operator's Guide ALS (REF 9650-0912-01 Rev. Y) is August, 2020. The guide states in part, "...Warnings. General:...Proper operation of the unit and correct electrode placement is critical to obtaining optimal results. Operators must be thoroughly familiar with proper device operation ...Emergency Defibrillation Procedure with Hands-Free Therapy Electrodes:...Prepare Patient: Remove all clothing covering the patient's chest. Dry chest if necessary. If the patient has excessive chest hair, clip or shave it to ensure proper adhesion of the electrodes. Attach hands-free therapy electrodes according to instructions on the electrode packaging. Ensure that the therapy electrodes are making good contact with the patient's skin and are not covering any part of the ECG electrodes. Connect the hands-free therapy electrodes to the OneStep cable if not preconnected ...WARNING! Poor adherence and/or air under the therapy electrodes can lead to the possibility of arcing and skin burns ...1. Apply one edge of the pad securely to the patient. 2. Roll the pad smoothly from the applied edge to the other, being careful not to trap any air pockets between the gel and skin ...Deliver Shock: WARNING! Warn all persons in attendance of the patient to STAND CLEAR prior to defibrillator discharge. Do not touch the bed, patient, or any equipment connected to the patient during defibrillation. A severe shock can result. Do not allow exposed portions of the patient's body to come into contact with metal objects, such as a bed frame, as unwanted pathways for defibrillation current may result ..."

The "Patient Safety Event Review Form" was reviewed, dated 10/20/25. The review states in part, "...Environmental Issues: The high flow nasal cannula was connected to the wall oxygen and placed on the patient bed on the left side. Wall oxygen was still on at the time of the event. The defib.[defibrillator] pads that were on the patient were not removed so they went with the patient to the coroner in Charleson. Unable to determine if there were any issues with placement etc ..."

An observation was conducted of a picture provided to this surveyor by ME 1. The picture shows patient 1, with burns to the left side and arm. A burnt impression of a cardiac monitor lead is on the patient's left side. The remaining defibrillator pad is positioned across the patient's center lower chest, with the top of the pad over a cardiac monitoring sticker, and the left side of the pad over a portion of an electrocardiogram sticker. The pad is lifted off the patient's chest at the bottom.

A telephone interview was conducted with the ME 1 on 10/21/25 at 3:34 p.m. Regarding the incident with patient 1, ME 1 states in part, "I did not take any equipment with me. It was only items that were on the patient. The defibrillator pads went with the patient. There was one (1) on the left side that was completely melted and another one (1) was intact. There were also two (2) saline syringes that were melted to the O2 tubing and next to the patient. This was a strange fire, I've never seen this before. I did take one picture. It looked like they had put the defibrillator pad over the heart monitor electrode. You can see a square impression where the patient was burnt ..."

An interview was conducted with staff 19 on 10/23/25 at 8:56 a.m. Regarding defibrillator pad placement, staff 19 states, "There are two (2) pads. First you would make sure the patient is dry as possible. If the patient is very hairy, you can use a razor or due to expediting the situation you can use a set of pads, put them on, take them off to remove the hair and then put a new set of pads on. If the patient has an implantable defibrillator, make sure you don't place the pad over top of it. If they have any medication patches or any stickers, you make sure you remove them. If the patient is already on a heart monitor with leads or stickers, you would not place them on top of them, you place them around. The pads have pictures on where to place them, but it doesn't matter if you place them backwards. You just want to make sure the pads aren't touching. When determining if the patient has a shockable rhythm, you should go by the Rhythm on the defibrillator. If there's no rhythm on the defibrillator screen, or if it's not reading that could be indicative of the pads not properly placed on the patient." Regarding the picture of patient 1, staff 19 states, "The one defibrillator pad remaining in the picture is on top of the heart monitor sticker on one end and an EKG tab sticker on the side. There should not be anything under the pad. It appears there is a complete heart monitor lead and sticker underneath where the other pad was, but I can't be sure since it's no longer there."