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Based on interview, medical record review, and facility document review, it was determined the facility failed to ensure that patients were informed of their patient right's in advance of furnishing patient care for one (1) (Patient #4) of three (3) patient medical records reviewed.

Findings:

The facility's policy titled "Patient Rights" issued October 1, 2023 states in part: "... Each patient/family admitted to the Hospital will receive a copy of the Patients Right's policy upon admission..."

The four (4) page "Patient Rights and Responsibilities" document that is provided to patients to inform them of their patient right's, contains on the last page; patient signature, time, and date lines to be completed confirming that the patient right's have been "accepted" by the patient or patient representative.

The medical record for Patient #4 contained evidence that Patient #4 was admitted to the facility on January 18, 2024, and the "Patient Rights and Responsibilities" form for Patient #4 was signed and dated five (5) days later on 01/23/2024 at 10:20 a.m. The "Patient Rights and Responsibilities" form for Patient #4 did not contain identifying patient information on any of the four (4) pages of the form.

The above concerns were discussed with Staff Member #1, Staff Member #2, Staff Member #6, and Staff Member #7 at the exit conference on 04/09/2024 at 4:44 p.m.

Based on interview, medical record review, and facility document review, it was determined the facility failed to renew a physician's order for restraints every twenty-four (24) hours and/or failed to implement restraints as per the physician's order for three (3) (Patient #5, Patient #6) of three (3) patient restraint records reviewed.

Findings:

The facility's policy titled "Restraints and Seclusion" last revised 01/01/2024 states in part:
"... Orders for restraints must be renewed on a daily basis..."

The surveyor conducted a review of the restraint documentation for Patient #5, Patient #6, and Patient #7.

Patient #5

There was no order for restraints provided by the facility for Patient #5 for 04/08/2024, but the patient was documented in restraints on 04/08/2024 at 12:00 a.m., 7:54 a.m., 10:00 a.m., 12:00 a.m., 2:00 p.m., 4:00 p.m., 5:55 p.m. 8:00 p.m. 10:00 p.m., and on 04/09/2024 at 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m. A new order was placed on 04/09/2024 at 8:00 a.m. The prior documented physician's order was placed on 04/07/2024 at 4:24 p.m. The policy states that "orders for restraints must be renewed on a daily basis".

The restraint type was not documented in the nursing flow sheet on 04/08/2024 from 10:00 am through 5:55 p.m.

Patient #6

There was no order for restraints for Patient #6 for 04/08/2024 provided by the facility but the patient was documented in restraints on 04/08/2024 from at 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m., 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., 5:56 p.m., 7:34 p.m., 10:00 p.m., 04/04/2024 at 12:00 p.m., 2:00 p.m., and 4:00 p.m. A new order was placed on 04/09/2024 at 6:28 a.m. The prior documented physician's order was placed was on 04/07/2024 at 4:42 p.m. The policy states that "orders for restraints must be renewed on a daily basis".

There was an order on 04/07/2024 at 7:45 a.m. for "Mittens secured/tied". The nursing documentation stated on 04/07/2024 at 8:16 a.m. that the nursing staff started "Mittens Secured/Tied R (right), Mittens Secured/Tied L (left), Mittens Secured/Untied R, Mittens Secured/Untied L" and "Continued - Soft Restraint R Wrist and Soft Restraint L Wrist." There was no order for the right and left "Mittens Secured/Untied" or for the right and left soft wrist restraints.

There was an order on 04/07/2024 at 4:42 p.m. for "Mittens secured/tied". The nursing documentation stated on 04/07/2024 at 5:01 p.m. that the nursing staff "Discontinued - Mittens Secured/Tied R" and started "Mittens Secured/Tied L, Mittens Secured/Untied R, Mittens Secured/Untied L, Soft Restraint R Wrist, Soft Restraint L Wrist." There was no order for the right and left "Mittens Secured/Untied" or for the right and left soft wrist restraints. There was an order for "Mittens Secured/Tied R" which nursing documented as "Discontinued".

Patient #7

There was an order for "Soft wrist restraints" on 04/07/2024 at 2:27 p.m. The nurse documented that the patient was in "Mittens Secured/Tied" right and left on 04/07/2024 at 8:00 p.m. through 04/09/2024 at 12:00 p.m.

The nurse documented "Side Rails Up x 4" from 04/08/2024 at 8:00 p.m. through 04/09/2024 at 4:00 a.m. There was no order for side rails for Patient #7 provided by the facility for this time period.

The above concerns were discussed with Staff Member #1, Staff Member #2, Staff Member #6, and Staff Member #7 at the exit conference on 04/09/2024 at 4:44 p.m.

Based on interview, medical record review, and facility document review, it was determined the facility failed to monitor patients in non-violent restraints every two (2) hours and failed to remove restraints for ten (10) minutes every two (2) hours as per facility policy for two (2) (Patient #5 and Patient #7) of three (3) patient restraint records reviewed.

Findings:

The facility's policy titled "Restraints and Seclusion" last revised 01/01/2024 states in part:

"...removal of restraints at least 10 minutes every 2 hours or more often (observations every two hours for medical restraints and every 15 minutes for behavioral restraints) ..."

Patient #5

A review of the restraint documentation on 04/09/2024 for Patient #5 contained evidence that there was no documentation of monitoring Patient #5 while in restraints every two hours on 04/05/2024 after 8:00 a.m. until 2:05 p.m., then on 04/07/2024 after 2:00 a.m. until 7:39 a.m., and then on 04/08/2024 after 12:00 a.m. until 7:54 a.m.

The staff failed to document that Patient #5 was released from restraints every two (2) hours for at least ten (10) minutes as per the facility's policy for twenty-six (26) out of fifty-six (56) times there was documentation of patient monitoring every two (2) hours, and during the times there was no monitoring documented.

Patient #7

A review of the restraint documentation on 04/09/2024 for Patient #7 contained evidence that there was no documentation of monitoring Patient #7 while in restraints every two hours on 04/06/2024 after 10:00 a.m. until 8:00 p.m., then after 8:00 p.m. until 04/07/2024 at 8:32 a.m., and then after 8:32 a.m. until 8:00 p.m.

The staff failed to document that Patient #7 was released from restraints every two (2) hours for at least ten (10) minutes as per the facility's policy for twenty-six (26) out of forty-three (43) times there was documentation of patient monitoring every two (2) hours, and during the times there was no monitoring documented.

While reviewing restraint records on 04/09/2024, Staff Member #2 confirmed that monitoring documentation for patient's in restraints should occur every two (2) hours.

The surveyors discussed the missing restraint monitoring documentation with Staff Member #1 on 04/09/2024 around 4:15 p.m.

The above concerns were discussed with Staff Member #1, Staff Member #2, Staff Member #6, and Staff Member #7 at the exit conference on 04/09/2024 at 4:44 p.m.

Based on medical record review, and facility document review, it was determined the facility failed to document skin assessments every shift and a comprehensive wound assessment every seven (7) days as per the facility's policy for one (1) of one (1) patient (Patient #2) with wound care documentation reviewed.

Findings:

The facility's policy titled "Wound Assessment" issued 04/01/2023 states in part:

"... Policy: All patients admitted will have a skin assessment within 8 hours of admission, skin will be assessed every shift, and every 7 days during the comprehensive wound assessment...."

The medical record for Patient #2 contained evidence that a wound care assessment, which is part of the skin assessment, was not completed every twelve (12) hour shift on the following days: 01/16/2024, 01/20/2024, 01/22/2024, 01/24/2024, 01/26/2024, 01/27/2024, 01/28/2024, 01/29/2024, 02/28/2024, 02/11/2024, 02/13/2024, 02/14/2024, 02/15/2024, 02/16/2024, 02/17/2024, 02/18/2024, 02/19/2024, 02/20/2024, 02/23/2024, 02/25/2024, 02/26/2024, 02/28/2024, 02/29/2024, 03/01/2024, 03/03/2024, 03/04/2024, 03/05/2024, 03/06/2024, and 03/07/2024; that is twenty-nine (29) out of fifty-three (53) days that a skin assessment was not completed on at least one twelve (12) hour shift each of those days.

The wound assessment/care flow sheet documentation for Patient #2 contained evidence that not all documented wounds were assessed on the following shifts when an assessment was documented: 01/19/2024 at 8:00 p.m., 01/21/2024 at 8:00 a.m., 01/23/2024 at 8:00 p.m., 02/04/2024 at 8:00 p.m., 02/05/2024 at 8:00 a.m., 02/16/2024 at 8:00 a.m., 03/01/2024 at 8:00 p.m., 03/03/2024 at 8:00 a.m., 03/04/2024 at 8:00 p.m., and 03/05/2024 day shift.

The wound assessment/care flow sheet documentation for Patient #2 contained evidence that comprehensive wound assessments were not completed every seven (7) days as per the facility's policy. The comprehensive wound assessments were documented on 01/16/2024, then seven (7) days later on 01/23/2024, then eight (8) days later on 01/31/2024, then nine (9) days later on 02/09/2024, then fourteen (14) days later on 02/23/2024, and then eight (8) days later on 03/31/2024.