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Based on interview, record review and policy review, the hospital failed to ensure that the practitioners responsible for the care of the patients authenticated, dated, timed and signed the restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) orders in real time for four current patients (#1, #3, #10, and #15) and one discharged patient (#19) of 10 restraint patients reviewed. (A-0168)
The hospital also failed to ensure that appropriate monitoring and completion of nursing documentation during the use of restraints was completed for six current patients (#1, #10, #15, #24, #25, and #27) and one discharged patients (#19) of 10 restraint patients reviewed. (A-0175)

These failures placed all patients admitted to the hospital with the need for restraints at risk for potential injury, resulting in noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights.

The hospital census was 37.


48359

Based on interview, record review and policy review, the hospital failed to provide adequate oversight and supervision of nursing personnel when staff failed to properly implement and document appropriate wound care treatments and interventions. They failed to maintain an effective wound care prevention program that prevented new or worsening wounds from occurring for five current patients (#4, #16, #25, #29 and #30) and one discharged patient (#19) of six patients with wounds reviewed. (A-0395)

These failed practices created an unsafe environment and had the potential to place all patients
admitted to the hospital at risk, resulting in a systemic failure and noncompliance with 42 CFR
482.23 Condition of Participation: Nursing Services. The hospital census was 37.


48359

Based on interview, record review and policy review, the hospital failed to ensure that the practitioner responsible for the care of the patient authenticated, dated, timed and signed the restraint (any manual method, physical, or mechanical device that limits the ability of free movement of arms, legs, body, or head) orders in real time for four current patients (#1, #3, #10, and #15) and one discharged patient (#19) of 10 restraint patients reviewed. This failure had the potential to cause poor nursing care outcomes for all patients placed in restraints. The hospital census was 37.

Findings included:

Review of the hospital's document titled, "Medical Staff Rules and Regulations," dated 2019, showed practitioners are responsible for the prompt completion and accuracy of the medical record and should ensure that all entries into the medical record are to be authenticated, dated, and timed.

Review of the hospital's policy titled, "Physical Restraints, Violent and Non-Violent Behavior, and Seclusion," dated 06/2023, showed a Registered Nurse (RN) should perform a safety check of restraints immediately, but no later than 30 minutes, after application. Ongoing safety checks and monitoring of the patient, including visual observation, are to be completed at least every two hours by trained staff under the direction of a RN. The restraint episode ends when the criteria for release are met or the restraints are removed. All documentation should be in real time.

Review of the hospital's document titled, "Restraint Care Plan," dated 12/2018, showed that the physician must complete the section titled, "Physician/Licensed Professional/Allied Health Practitioner Assessment/Restraint Order Confirmation," attesting that a comprehensive assessment of the patient had been completed and that the restraints ordered were medically necessary. The signature, date and time were required to authenticate any restraint order.

Review of Patient #1's restraint documentation showed that on 07/20/23 at 1:12 PM, a telephone order for soft wrist restraints to both arms was obtained. The physician never signed or dated the order. Patient #1 was in soft wrist restraints from 07/20/23 at 1:12 PM through 07/21/23 at 12:08 PM, a total of 22 hours and 56 minutes. The order had never been signed.

Review of Patient #3's restraint documentation showed:
- On 07/15/23 at 8:00 AM, an order for soft wrist restraints to both arms was obtained. The provider signed the order, there was no date or time documented for the signature.
- On 07/19/23 at 12:00 AM, an order for soft wrist restraints to both arms was obtained. The order was signed by the physician, but the date and time of his signature had been completed by another individual with a different script and different type of pen.
- On 08/02/23 at 12:00 AM, an order for soft wrist restraints to both arms was obtained. The order was signed by the physician, but the date and time of his signature had been completed by another individual with a different script and different type of pen.

Review of Patient #10's restraint documentation showed that on 07/28/23 at 7:00 PM, an order was obtained for restraint mittens to both hands. The order was signed by the physician, but the date and time of his signature had been completed by another individual with a different script and different type of pen. On 08/02/23 at 12:00 AM, an order was obtained for restraint mittens to both hands. Again, the order was signed by the physician, but the date and time of his signature had been completed by another individual with a different script and different type of pen.

Review of Patient #15's restraint documentation showed:
- On 07/21/23 at 7:40 PM, a telephone order was written for a left soft wrist restraint. The restraint order was signed by the physician on 07/24/23 at 1:00 PM, two days, 17 hours and 20 minutes after the telephone order was written.
- On 07/27/23 at 12:00 AM, a telephone order was written for a left soft wrist restraints. The order was signed by the physician on 07/27/23. The time of the physician signature had been altered to 12:00 AM.
- On 08/02/23 at 12:00 AM, a telephone order was written for a left soft wrist restraint. The order was signed by the physician on 08/02/23 at 12:00 AM.
- On 08/04/23 at 11:50 AM the restraint was removed.
- On 08/05/23 at 12:00 AM, documentation showed the patient was in a left mitten restraint.
- On 08/09/23 at 12:00 AM, a telephone order for a left mitten restraint was written. Patient #15 had been in a left mitten restraint for four days without a physician order.

Review of Patient #19's restraint documentation showed on 07/31/23 at 8:50 PM, a telephone order was obtained for a restraint mitten to her right hand. The order was signed by the physician, dated 07/31/23 at 8:50 PM. The date and time of the physician's signature had been completed by another individual with a different script and different type of pen. On 08/02/23 at 12:00 AM, an order for a restraint mitten to her right hand was documented. The order was signed by the physician, dated 08/02/23 at 12:00 AM. The date and time of the physician's signature had been completed by another individual with a different script and different type of pen. There was no second page of the order with the nursing restraint care plan.

During an interview on 08/15/23 at 2:35 PM, Staff C, Director of Nursing, stated that the physician was not on-site at midnight on 07/27/23 or 08/02/23. Physicians were to sign telephone restraint orders within one calendar day. Physicians should date and time the orders at the time of the physician signature.

During an interview on 08/15/23 at 3:05 PM, Staff A, Director Quality Management, stated that physicians must perform a patient assessment and sign telephone restraint orders within one calendar day. Physicians need to document the actual date and time the telephone order was signed.




48359

Based on interview, record review and policy review the hospital failed to ensure appropriate monitoring and nursing documentation during the use of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) for six current patients (#1, #10, #15, #24, #25, and #27) and one discharged patients (#19) of 10 restraint patients reviewed. This failure created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety. The hospital census was 37.

Findings included:

Review of the hospital's policy titled, "Physical Restraints, Violent and Non-Violent Behavior, and Seclusion," dated 06/2023, showed a Registered Nurse (RN) should perform a safety check of restraints immediately, but no later than 30 minutes, after application. Ongoing safety checks and monitoring of the patient, including visual observation, are to be completed at least every two hours by trained staff under the direction of a RN. All documentation should be in real time.

Review of Patient #1's restraint documentation showed on 07/20/23 at 1:12 PM, a telephone order for soft wrist restraints to both arms was obtained. The RN 30 Minute Post Restraint Application Safety Check documentation was incomplete. No interventions or checks were indicated and no signature was present.

Review of Patient #10's restraint documentation showed:
- On 07/28/23 at 7:00 PM, she had mitten restraints applied to both her right and left hands.
- On 07/30/23 a safety check was performed at 3:25 AM and again at 7:30 AM. She was not observed for safety for four hours and five minutes.
- On 07/31/23 a safety check was performed at 4:10 AM and again at 6:20 AM, two hours and 10 minutes later.

Review of Patient #15's restraint documentation showed:
- On 07/27/23 at 12:00 AM, she was placed in a left soft wrist restraint.
- On 07/30/23 a safety check was performed at 3:43 AM and then again at 7:10 AM. She was not observed for safety for three hours and 27 minutes.
- On 08/01/23 a safety check was performed at 11:00 AM and then again at 2:15 PM. She was not observed for safety for three hours and 15 minutes.
- On 08/09/23 a safety check was performed at 7:00 PM and then again on 08/11/23 at 12:20 AM. She was not observed for safety for 29 hours.
- On 08/12/23 a safety check was performed at 3:39 PM and then again at 7:10 PM. She was not observed for safety for three hours and 31 minutes.

Review of Patient #19's restraint documentation showed:
- On 07/31/23 at 8:50 PM, a telephone order was obtained for a restraint mitten to her right hand. This was restraint day one.
- On 08/01/23 there was no nursing restraint documentation for Patient #19. This was restraint day two.
- On 08/02/23 at 12:00 AM, an order for a restraint mitten to her right hand was documented. There was no nursing signature for the type of restraint applied.
- On 08/02/23 at 12:30 AM, there was no nursing signature on the RN 30 Minutes Post Restraint Application Safety Check.
- On 08/02/23 a safety check was performed at 7:50 AM and then again at 11:55 AM, three hours and five minutes later. This was restraint day three.
- On 08/03/23 a safety check was performed at 12:10 PM and then again at 2:20 PM, two hours and 10 minutes later. This was restraint day four.
- On 08/03/23 a safety check was performed at 4:15 PM and then again at 6:20 PM, two hours and five minutes later.
- On 08/04/23, there was no nursing restraint documentation for Patient #19. This was restraint day five.
- On 08/05/23, Patient #19's restraint was removed at 6:16 PM. This was restraint day six.

Review of Patient #24's restraint documentation showed on 07/25/23 the daily assessment to determine the need for restraint section of the nursing documentation was not completed. On 07/29/23 a safety check was performed at 1:58 PM and then again at 6:00 PM, four hours and two minutes later.

Review of Patient #25's restraint documentation showed:
- On 08/13/23 at 6:08 PM, a telephone order for soft limb restraints were obtained, the location was not indicated on the order.
- On 08/13/23 a safety check was performed at 8:30 PM and again at 11:10 PM. He was not observed for safety for two hours and 40 minutes.
- On 08/14/23 a safety check was performed at 2:15 AM and again at 4:30 AM, two hours and 15 minutes later.
- On 08/14/23 a safety check was completed at 8:30 AM and again at 11:00 AM, two hours and 30 minutes later.
- On 08/14/23 a safety check was completed at 1:00 PM and again at 3:30 PM, two hours and 30 minutes later.
- On 08/14/23 a safety check was completed at 5:15 PM and again at 7:40 PM, two hours and 25 minutes later.
- On 08/14/23 the daily assessment to determine the need for restraint section of the nursing documentation was not completed.
- On 08/15/23 a safety check was completed at 7:08 AM and again at 10:00 AM, two hours and 52 minutes later.
- On 08/15/23 a safety check was completed at 12:00 PM and again at 2:15 PM, two hours and 15 minutes later.
- On 08/15/23 a safety check was completed at 2:15 PM and again at 4:55 PM, two hours and 40 minutes later.

Review of Patient #27's restraint documentation for 08/13/23 showed the daily assessment to determine need for restraints section of the nursing documentation was not signed, dated, or timed by a RN.

During an interview on 08/14/23 at 12:05 PM, Staff G, Registered Nurse (RN), stated that a restraint safety check was performed every two hours.

During an interview on 08/14/23 at 12:55 PM Staff I, RN, stated that a restraint safety check was performed within 30 minutes of restraint application and then every two hours.

During an interview on 08/15/23 at 2:35 PM, Staff C, Director of Nursing (DON), stated that, restraint safety checks were to be performed every two hours.

During an interview on 08/15/23 at 3:05 PM, Staff A, Director Quality Management (DQM),
stated that restraint safety checks were to be performed every two hours.



48359

Based on interview, record review and policy review, the hospital failed to maintain an effective wound care prevention program that prevented new or worsening wounds from occurring for five current patients (#4, #16, #25, #29 and #30) and one discharged patient (#19) of six patients with wounds reviewed. These failures created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety. The combined hospital census was 37.

Findings included:

Review of the hospital's policy titled, "Clinical Guidelines for Pressure Injury," dated 06/2022, showed skin and wound assessments were conducted on admission and each shift per the registered nurse (RN). Standard interventions for all patients include to reposition a minimum of every two hour turns.

Review of the hospital's policy titled, "Skin and Wound Care Program Overview," dated 06/2023, showed skin assessments/inspections would be performed at the time of admission and each shift.

Review of Patient #16's medical record showed:
- On 07/22/23, there was no admission skin/wound assessment.
- On 07/23/23 at 10:15 AM her skin assessment showed her skin was intact.
- On 07/25/23 at 9:21 PM her skin assessment showed her skin was not intact and this was wound related.
- On 07/26/23 at 10:40 AM showed her skin was intact.
- On 07/27/23 at 9:11 AM her skin assessment showed her skin was not intact and this was wound related.
- On 07/28/23 at 3:21 AM showed her skin was intact.
- On 08/09/23 at 11:42 AM, Staff F, Wound Care Nurse (WCN), identified a hospital acquired stage four pressure injury (injury to the skin that extends to the bone and muscle) to her tailbone.
- On 08/12/23 at 2:32 AM, her skin assessment showed her skin was intact.
- On 08/12/23 at 11:42 AM showed her skin was not intact and this was wound related.
- Between the dates of 07/23/24 through 08/14/23, there were ten missing or incomplete skin/wound assessments.

Review of Patient #30's medical record showed, between the dates of 07/24/23 through 08/15/23, there were 45 missing or incomplete skin/wound assessments.

Review of Patient #25's medical record showed, between the dates of 07/31/23 through 08/15/23, there were 13 missing or incomplete skin/wound assessments.

Review of Patient #4's medical record showed on 08/02/23 there was no admission skin/wound assessment. Between the dates of 08/02/23 through 08/13/23, there were nine missing or incomplete skin/wound assessments.

Review of Patient #19's medical record showed there were eight missing or incomplete skin/wound assessments.

During an interview on 08/14/23 at 12:14, Staff G, Outcomes Manager, stated that skin and wound assessments were completed and documented every shift by the RN.

During an interview on 08/15/23 at 10:39 AM, Staff F, WCN, stated that every wound is assessed every shift. If the wound was covered with a dressing the RN was to peel the dressing back and then document the wound assessment every shift, unless there were specific orders not to remove the dressing. Staff F agreed that it is not uncommon for a patient to have missed skin and wound assessments. She has observed inconsistent documentation regarding skin and wound assessments. The wound care program had begun to perform skin and wound care audits, but the inconsistencies in documentation was a problem.

During an interview on 08/16/23 at 2:35 PM, Staff C, Director of Nursing (DON), stated that skin and wound assessments were to be completed and documented every shift by the nurse.

During an interview on 08/15/23 at 3:05 PM, Staff A, Director of Quality Management (DQM), stated that skin and wound assessments were to be performed and documented by the nurse every shift.

Review of Patient #25's medical record showed 21 missed turns with a time span of greater than three hours between turns.

Review of Patient #4's medical record showed, between the dates of 08/02/23 through 08/14/23, there were 16 missed turns with a time span of greater than three hours between turns.

Review of Patient #16's medical record showed, between the dates of 07/22/23 through 08/14/23, there were 12 missed turns with a time span of greater than three hours between turns.

Review of Patient #30's medical record showed, between the dates of 07/29/23 through 08/16/23, there were 11 missed turns with a times span of greater than three hours between turns.

Review of Patient #19's medical record showed, between the dates of 08/01/2023 through 08/10/23, there were 10 missed turns with a time span of greater than three hours between turns.

Review of Patient #29's medical record showed, between the dates of 08/08/23 through 08/16/23, there were eight missed turns with a time span of greater than three hours between turns.

During an interview on 08/15/23 at 10:39 AM, Staff F, WCN, stated that every patient is to be turned at least every two hours. The hospital has eliminated block charting and turns were documented in real time.

During an interview on 08/15/23 at 2:35 PM, Staff C, DON, stated that patients were to be turned a minimum of every two hours.

During an interview on 08/15/23 at 3:05 PM, Staff A, DQM, stated that the population of patients served at Hospital A are at high risk for skin breakdown and were to be turned every two hours.



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