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Based on record review, interview and policy review, the facility failed to ensure nurses documented non-violent restraint monitoring every two hours and failed to ensure a physician order was obtained for the implementation of non-violent restraints. The facility's active census was 857.

See A167 and A168.

Based on record review, interview and policy review, the facility failed to ensure patients were turned and repositioned, that endotracheal tubes were repositioned and that arterial lines were assessed. This affected two (Patients #5 and #10) patients. The hospital census was 857.

See A395.

Based on record review, interview and policy review the facility failed to perform restraint checks every two hours. This affected Patient #10.

Findings include:

Review of the medical record of Patient #10 revealed the patient presented to the Emergency Department on 03/11/25 at 5:52 PM with complaints of having tested positive for Influenza A the week prior and was started on Tamiflu. The patient became progressively weak. He then started to have diarrhea which worsened. In the ED, the patient received three liters of IV fluids and was started on antibiotics. The critical care physicians made the decision to admit the patient for septic shock likely related to pneumonia. He was also started on Norepinephrine (a vasopressor typically administered to maintain mean arterial pressure via increased systemic vascular resistance). According to the physician's history and physical, the patient had a history of peripheral vascular disease status post bilateral above the knee amputation, end stage renal disease on home hemodialysis. The decision was made to intubate the patient on 03/12/25 due to worsening metabolic acidosis. The patient remained intubated until 03/19/25.

A physician ordered bilateral soft wrist restraints due to the patient pulling at medical devices. Review of the restraint flowsheet revealed the restraints were initiated on 03/12/25 at 6:45 AM. The restraints continued through 03/13/25. The medical record lacked documentation of a physician order on 03/13/25. Every two hour restraint checks continued until 03/15/25 at 2:00 PM. The medical record lacked documentation of the two hour restraint check until 8:00 PM, six hours later. On 03/16/25 at 4:00 AM, a restraint check was completed, however the next check wasn't completed until 8:00 AM. On 03/20/25 at 2:00 PM, a restraint check was completed, however, the medical record lacked documentation of another check until 10:15 PM. On 03/23/25 a restraint check was completed by a staff nurse at 2:00 PM. The medical record lacked documentation of the next restraint check until 12:00 AM. The medical record also lacked documentation of a physician order for restraints on 04/19/25.

These facts were confirmed during an interview on 05/29/25 at 4:05 PM with Staff A.

The facility policy titled "Premier Nursing Services Non-Violent Restraint Policy", effective 03/27/25, stated restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or reduces the ability to have normal access to his or her body, or does not promote the patient's independent function. A non-violent or non-self-destructive behavior restraint is utilized for a non-violent/non-self-destructive patient to protect the patient who demonstrates impaired safety judgment. A verbal or electronic order is required from the Qualified LIP or LIP's designee who is primarily responsible for the patient's care at the time or immediately (within a few minutes) after the restraint is applied. Authentication of a telephone order/verbal order based upon an examination of the patient by a Qualified LIP is required to be in the electronic medical record within 24 hours of initiation and every 24 hours.

Based on record review, interview and policy review, the facility failed to ensure there was a physician order for non-violent restraints in two patients. This affected two (Patients #5 and #10) patients.

Findings include:

1. Review of the medical record of Patient #5 revealed the patient presented to the Emergency Department on 01/21/25 at 5:11 PM after being being hit by a truck traveling at 30 miles per hour. The patient sustained the following injuries: occipital bone fracture, clivus fracture, left orbital fracture, subdural hematoma, subarachnoid hemorrhage, intraparenchymal hemorrhage, and acute respiratory failure. Upon arrival to the Emergency Department, the patient was hemodynamically stable but the patient had been intubated prior to arrival for a depressed Glasgow Coma Scale. The patient was transported to the facility's Medical Surgical Intensive Care Unit (MSICU) at 6:15 PM. Given the patient's prolonged mechanical ventilation, tracheostomy and percutaneous endoscopic gastrostomy tube placement were performed on 02/01/25. The patient remained hospitalized until 02/24/25 when he was discharged to a long term acute care facility.

Review of the medical record of Patient #5 revealed the patient required non-violent restraints from 01/21/25 to 02/14/25 due to pulling at his medical devices. A physician ordered bilateral soft wrist restraints on 01/22/25. The medical record lacked documentation of a physician order on 01/21/25. Although the patient remained in bilateral soft wrist restraints on 01/23/25 and 01/24/25, the medical record lacked documentation of a physician order. There were also no physician orders for restraints on 01/27/25, 01/30/25, 01/31/25, 02/03/25, 02/06/25, 02/08/25, 02/12/25, and 02/13/25.

2. Review of the medical record of Patient #10 revealed the patient presented to the Emergency Department on 03/11/25 at 5:52 PM with complaints of having tested positive for Influenza A the week prior and was started on Tamiflu. The patient became progressively weak. He then started to have diarrhea which worsened. In the ED, the patient received three liters of IV fluids and was started on antibiotics. The critical care physicians made the decision to admit the patient for septic shock likely related to pneumonia. He was also started on Norepinephrine (a vasopressor typically administered to maintain mean arterial pressure via increased systemic vascular resistance). According to the physician's history and physical, the patient had a history of peripheral vascular disease status post bilateral above the knee amputation, end stage renal disease on home hemodialysis. The decision was made to intubate the patient on 03/12/25 due to worsening metabolic acidosis.

Review of the patient's medical record revealed a physician ordered bilateral soft wrist restraints due to the patient pulling at medical devices. Review of the restraint flowsheet revealed the restraints were initiated on 03/12/25 at 6:45 AM. The restraints continued through 03/13/25. The medical record lacked documentation of a physician order on 03/13/25. Every two hour restraint checks continued until 03/15/25 at 2:00 PM. The medical record lacked documentation of the two hour restraint check until 8:00 PM, six hours later. On 03/16/25 at 4:00 AM, a restraint check was completed, however the next check wasn't completed until 8:00 AM. On 03/20/25 at 2:00 PM, a restraint check was completed, however, the medical record lacked documentation of another check until 10:15 PM. On 03/23/25 a restraint check was completed by a staff nurse at 2:00 PM. The medical record lacked documentation of the next restraint check until 12:00 AM. The medical record also lacked documentation of a physician order for restraints on 04/19/25. The patient experienced cardiac arrest on 04/20/25 and despite resuscitative efforts did not survive and passed away at 9:29 AM.

During an interview on 05/28/25 at 3:30 PM, Staff A confirmed the medical record lacked documentation of a physician orders for restraints for Patients #5 and #10.

The facility policy titled "Premier Nursing Services Non-Violent Restraint Policy", effective 03/27/25, stated a restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or reduces the ability to have normal access to his or her body, or does not promote the patient's independent function. A non-violent or non-self-destructive behavior restraint is utilized for a non-violent/non-self-destructive patient to protect the patient who demonstrates impaired safety judgment. A verbal or electronic order is required from the Qualified LIP or LIP's designee who is primarily responsible for the patient's care at the time or immediately (within a few minutes) after the restraint is applied. Authentication of a telephone order/verbal order based upon an examination of the patient by a Qualified LIP is required to be in the electronic medical record within 24 hours of initiation and every 24 hours.

Based on record review, interview and policy review, the facility failed to ensure patients were turned and repositioned, that endotracheal tubes were repositioned and that arterial lines were assessed. This affected two (Patients #5 and #10) patients. The hospital census was 857.

Findings include:

1. Review of the medical record of Patient #5 revealed the patient presented to the Emergency Department on 01/21/25 at 5:11 PM after being being hit by a truck traveling at 30 miles per hour. The patient sustained the following injuries: occipital bone fracture, clivus fracture, left orbital fracture, subdural hematoma, subarachnoid hemorrhage, intraparenchymal hemorrhage, and acute respiratory failure. Upon arrival to the Emergency Department, the patient was hemodynamically stable but the patient had been intubated prior to arrival for a depressed Glasgow Coma Scale. The patient was transported to the facility's Medical Surgical Intensive Care Unit (MSICU) at 6:15 PM. A skin assessment was performed by a staff nurse on admission on 01/21/25 at 6:10 PM. Although there were no pressure sores noted on the patient, advanced skin protectant in the form of foam dressing was applied to the patient's coccyx. Given the patient's prolonged mechanical ventilation, tracheostomy and percutaneous endoscopic gastrostomy tube placement were performed on 02/01/25.

The activity flow sheet where staff documented turning and repositioning the patient was reviewed. On 01/21/25 at 6:10 PM, the patient was repositioned to a supine position. At 8:00 PM, the patient was turned and repositioned to a supine position. At 4:00 AM on 01/22/25, the patient was repositioned to a supine position and two hours later, at 6:00 AM, the patient was repositioned to a supine position. On 01/28/25 at 2:00 AM, the patient was repositioned to a supine position. Two hours later, at 4:00 AM, the medical record revealed the patient was repositioned to a supine position. At 6:00 AM, the patient was repositioned to a supine position. At 12:00 PM the patient was repositioned from his left side to a supine position. He was not repositioned again for four hours, at 4:00 PM. The medical record revealed the patient was repositioned to a supine position at this time.

A wound nurse's progress note on 02/02/25 at 5:52 PM stated the patient had a deep tissue injury to his sacrum/coccyx. The wound nurse recommended nursing staff turn the patient every two hours.

Review of the activity flow sheet revealed that on 02/03/25 at 6:00 AM, the patient was repositioned from his left side to a supine position. At 8:29 AM, staff repositioned the patient to a supine position. He was repositioned to his left side at 10:00 AM. Two hours later, at 12:00 PM, the patient was repositioned to a supine position. At 2:00 PM, 3:24 PM, and 4:00 PM, each position change was in a supine position. He remained in a supine position until 6:00 PM when he was repositioned to his right side. On 02/05/25 at 6:00 PM, the patient was repositioned from his right side to a supine position. When he was repositioned again two hours later, at 8:00 PM, he was again placed in a supine position where he remained until 10:00 PM. He was repositioned to his left side at this time. Staff continued to reposition the patient until he was discharged on 02/24/25. Numerous times staff repositioned the patient to the same position he was in two hours prior.

During an interview on 05/29/25 at 5:05 PM, Staff O confirmed that patients should be repositioned every two hours to prevent pressure injuries and should be repositioned to a new position.

2. Review of the medical record of Patient #10 revealed the patient presented to the Emergency Department on 03/11/25 at 5:52 PM with complaints of having tested positive for Influenza A the week prior and was started on Tamiflu. The patient became progressively weak. He then started to have diarrhea which worsened. In the ED, the patient received three liters of IV fluids and was started on antibiotics. The critical care physicians made the decision to admit the patient for septic shock likely related to pneumonia. He was also started on Norepinephrine (a vasopressor typically administered to maintain mean arterial pressure via increased systemic vascular resistance). According to the physician's history and physical, the patient had a history of peripheral vascular disease status post bilateral above the knee amputation, end stage renal disease on home hemodialysis. The decision was made to intubate the patient on 03/12/25 due to worsening metabolic acidosis. The patient remained intubated until 03/19/25.

The endotracheal tube was secured with an anchoring device. The flow sheet that identified the tube repositioning was reviewed. On 03/12/25 at 6:55 AM, the tube was positioned in the center with the patient's teeth/gums as landmarks. At 1:45 PM, the tube was repositioned to the center. At 03/12/25 at 8:09 PM, the tube was repositioned to the left side. On 3/13/25 at 12:38 AM, the tube was repositioned to the center. The medical record lacked documentation the tube was repositioned again until 8:21 AM, eight hours later. It was repositioned to the left side. At 12:26 PM, the tube was repositioned to the left side. The medical record lacked documentation the tube was positioned again until 11:55 AM on 03/14/25. It was repositioned to the left side again at this time. Staff continued to reposition the tube every four hours. By 03/18/25 at 4:34 AM, the tube was repositioned to the right side. At 8:36 AM, the tube was repositioned to the right side. The medical record lacked documentation the tube was actually repositioned to a different position until 1:16 PM. It was repositioned to the center at this time. On 03/19/25 at 4:11 AM, the tube was repositioned to the center, however at 7:17 AM, the flow sheet revealed the tube was repositioned to the center again.

A physician's progress note on 03/23/25 stated the tube was secured against the patient's lip causing full thickness necrosis. Given that the patient was a poor surgical candidate, a debridement under light sedation with local sedation was performed on 04/09/25. The operative report revealed that when the necrotic tissue was excised down to the healthy tissue, it was noted to communicate with the patient's oral cavity. There were no immediate postoperative complications.

The Hollister Anchor Fast endotracheal tube fastener instructions for use were reviewed. Under precautions, the instructions stated to minimize the risk of pressure injury, inspect the patient's lips, skin and oral cavity at least every two hours or more frequently if the patient's condition dictates.

A right arterial line was placed in the patient's arm on 03/12/25 at 5:37 AM. The left arm could not be used as a graft for hemodialysis was located in the left arm. Review arterial line flow sheet revealed staff did not assess the arterial line. A physician ordered the arterial line to be removed on 03/15/25 as it was not functioning.

A vascular surgeon progress note on 03/23/25 at 9:22 AM stated the patient's hand was discolored and there was no evidence of full thickness gangrene or ischemia.

During an interview on 06/03/25 at 2:07 PM, Staff Q stated respiratory staff should reposition the endotracheal tube every four hours.

During an interview on 06/05/25 at 9:10 AM, Staff A confirmed that the medical record lacked documentation of the arterial line assessment every four hours.

The facility policy titled "Premier Nursing Services Skin Integrity Maintenance Program and Pressure Ulcer Prevention Program Initiatives", effective 06/24/24, stated staff is instructed to perform the following interventions to prevent pressure injuries:

1. Off-loading of bony prominences
2. Minimization of friction and shear
3. Repositioning as appropriate to redistribute pressure
4. Management of moisture

The facility policy titled "Patient Monitoring and Care" stated nurses are instructed to assess the arterial line immediately after catheter insertion and every four hours.