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Based on record review and interview the hospital failed to ensure each patient or patient representative consented to treatment and was informed of his or her patient rights. This deficient practice is evidenced by failure to obtain signed consent for treatment or signed patient rights information form for 1 (#2) of 3 (#1-#3) records reviewed.
Findings:

Review of hospital policy # 04.01.010, titled "Patient Rights and Responsibilities," effective date: 12/01/2024, revealed in part: "Purpose: To educate patients about their rights and responsibilities in their health care to engage them in the process and better meet their needs. Policy Statement: Whenever possible, this notice must be provided before providing or stopping care. All patients, inpatient or outpatient, must be informed of their rights as hospital patients. The patient's rights should be provided and explained in a language or manner that the patient (or the patient's representative) can understand. Definition: Patient Rights- 1. You have the right to receive considerate, respectful, and compassionate care in a safe setting regardless of your age, gender, race, national origin, religion, sexual orientation, gender identity, disabilities, handicap, diagnosis, or ability to pay or source of payment. 7. You have the right to be told by your doctor about your health status, diagnosis and possible prognosis, the benefits and risks of treatment, and the expected outcome of treatment, including unexpected outcomes. You or your representative (as allowed by state law) have the right to give written informed consent before any non-emergency procedures begins. 11. You, your family, and friends with your permission, have the right to participate in decisions about your care, your plan of care including its development and implementation, your treatment, and services provided, including the right to refuse treatment to the extent permitted by law."

Review of Patient #2's medical record revealed Patient #2 was admitted from the ED on 07/01/2025 with a diagnosis of Encephalopathy. Further review of Patient #2's medical record failed to reveal evidence that consents for patient rights or treatment were obtained prior to discharge from the hospital on 07/03/2025.

In an interview on 07/08/2025 at 9:51 AM, S1RM confirmed there was no documented evidence that Patient #2 was notified of their patient rights or that a consent for treatment was obtained prior to discharge from the hospital.

Based on record reviews and interview, the hospital failed to ensure patients in the hospital were informed of their right to be free from physical or mental abuse, and corporal punishment and to be free from restraint or seclusion of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff. This deficient practice is evidenced by failing to provide nursing assessment and clinical justification for a patient in restraints per hospital policy.
Findings:

Review of hospital policy # 04.01.010, titled "Patient Rights and Responsibilities," effective 12/01/2024, revealed in part: " Definition: Patient Rights- 1. You have the right to receive considerate, respectful, and compassionate care in a safe setting regardless of your age, gender, race, national origin, religion, sexual orientation, gender identity, disabilities, handicap, diagnosis, or ability to pay or source of payment. 2. You have the right to receive care in a safe setting or environment free from all forms of abuse, neglect, harassment, or mistreatment. 9. You have the right to be free from restraints and seclusion in any form that is not medically required or that is used as a means of coercion, discipline, convenience, or retaliation by staff. In addition, any restrictions on your freedom must be kept to the minimum necessary to protect yourself or other people."

Review of hospital policy # Nursing 002, titled "Restraints and Seclusion," effective 08/01/2024, revealed in part: "Definitions: Non-violent, Non-Self-Destructive, or Least Restrictive Restraint: A restraint that meets the safety needs of the patient, reduces the risk for dislodgment of tubes, lines, and catheters, and permits maximum freedom of movement. The use of non-violent restraints directly supports the medical healing of the patient and can be used in any unit of the hospital. Designated Staff: Describes staff roles involved in the application or monitoring or restraint or seclusion other than registered nurse (RN) but not limited to licensed practical nurse, certified nurse assistant, clinical nurse extern, clinical technician, public safety officer. Designated Staff are trained in de-escalation techniques, CPR/first aid, and restraint safety and may aid in the monitoring of patients placed in restraint or seclusion including providing fluids, nutrition, oral care, skin care, toileting, positioning, and range of motion. Responsibility: C. Nurses shall: 2. Initiate and discontinue restraint or seclusion based on the assessment of a patient's need for restraint or seclusion with demonstrated and documented competency. 7. Perform ongoing assessments including: i. Need for the continuation of restraint or seclusion. ii. Re-evaluation of the patient's response to the restraint or seclusion episode. 8. Educate the patient, as applicable, about behaviors leading to the initiation and discontinuation of restraint or seclusion. 9. Remove restraint or seclusion and discontinue the order as soon as safely possible, which may be before the time-limited order expires, if clinical justifications for restraint or seclusion are no longer met. Procedure: 4. Monitoring and Interventions: d. Non-Violent/Non-self-destructive Restraints will be assessed, monitored, and documented in the EMR every two (2) hours: i. The nurse's assessment must include, but is not limited to: 1. Level of distress/Patient behavior/Visual check 2. Circulation 3. Range of motion 4. Fluids 5. Food/meal 6. Elimination 7. Respirations 8. Assessment and clinical justification for continued use of restraints ii. Vital signs per physician order. 5. Documentation: a. All required documentation is to be completed and documented in the EMR immediately following patient stabilization. b. Rationale for ongoing restraint usage must be documented. 7. Discontinuation of Restraint or Seclusion: a. The need for restraint or seclusion must be evaluated with every assessment/reassessment. b. Restraint or seclusion are discontinued as soon as safely possible and when the reason for implementation is resolved (i.e. when the patient's behavior no longer threatens the physical safety of the patient, staff, or others)."

A review of Patient #1's medical record revealed Patient #1 to the ED on 05/07/2025 and was admitted to the hospital with a diagnosis of encephalopathy. On 05/20/2025 at 10:00 PM Patient #1 was placed in 4 point restraints after the patient became combative with staff.

A review of Patient #1's restraint documentation revealed in part the following:
05/20/2025 10:00 PM: 4 point soft restraints initiated, Patient agitated/restless, and circulation intact. Discontinuation Criteria: Absence of behavior that requires restraint, patient verbalized understanding and daughter notified.
05/21/2025 12:00 AM: "Patient Asleep" documented for the following: Visual Check, Range of Motion, Fluids, Food/Meal, and Elimination. Circulation intact. 4 point soft restraints continued.
05/21/2025 2:00 AM: "Patient Asleep" documented for the following: Visual Check, Range of Motion, Fluids, Food/Meal, and Elimination. Circulation intact. 4 point soft restraints continued.
05/21/2025 4:00 AM: "Patient Asleep" documented for the following: Visual Check, Range of Motion, Fluids, Food/Meal, and Elimination. Circulation intact. 4 point soft restraints continued.
05/21/2025 6:00 AM: "Patient Asleep" documented for the following: Visual Check, Range of Motion, Fluids, Food/Meal, and Elimination. Circulation intact. 4 point soft restraints continued.
05/21/2025 8:00 AM: Circulation: intact; Range of Motion: Performed; Fluids: Patient Accepted; Food/Meal: Patient Declined; Elimination: Incontinent/diapered/patient changed; RN Assessment Clinical Justification: Prevention of self-harm/Patient Safety. 4 point soft restraints continued.

Review of Patient #1's restraint documentation failed to reveal documentation by the nurse of an RN Assessment and clinical justification for continued use of 4 point restraints on 05/21/2025 at 12:00 AM, 2:00 AM, 4:00 AM, or 6:00 AM. Further review of Patient #1's medical record revealed that Patient #1 remained in restraints until the patient was discharged home with family on 05/30/2025.

In an interview on 07/07/2025 at 3:21 PM, S1RM and S4RN confirmed the above mentioned findings. S1RM also confirmed that S6RN did not perform restraint monitoring and assessment on Patient #1 every 2 hours per hospital policy.

Based on record review, policy review and interview, the hospital failed to ensure the nursing plan of care for each patient was kept current and reflected the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice is evidenced by failure of the nursing staff to include existing and potential problems in the plan of care for 1 (#3) of 3 (#1-#3) patients reviewed.
Findings:

Review of hospital policy #5015, titled "Patient Screening, Assessment, Reassessment and Plan of Care," last revised 07/2024, revealed in part: "Procedure: 2. Reassessment for Inpatients: a. Each patient is reassessed as necessary based on their identified problems, plan for care, changes in condition, changes in care setting, or as relevant. 3. Plan of Care for Inpatients: a. The patient's plan of care is initiated within 24 hours of admission. b. Existing and potential problems, goals, and interventions are evaluated once in 24 hours and updated as clinically relevant."

Review of Patient #3's medical record revealed Patient #3 was an 83 year old female who was admitted on 07/01/2025 for dysphagia. On 07/02/2025 Patient #3 had an EGD performed. Patient #3 was discharged home on 07/04/2025.

Review of the Patient #3's history and physical revealed in part the following Assessment/Plan: Dysphagia, Schatzki Ring, Abdominal Pain (GI consulted, EGD tomorrow), COPD, Anxiety (0.5mg Ativan IV once), Rheumatoid Arthritis, Hypertension, and Hyperlipidemia.

Review of Patient #3's nursing plan of care revealed in part: Problem: Gastrointestinal, Goals: Minimal or absence of nausea and vomiting, Maintains or returns to baseline bowel function, Maintains adequate nutritional intake, and establish and maintain optimal ostomy function.

Further review of nursing plan of care failed to reveal the following existing problems: Dysphagia, Abdominal Pain, COPD, Anxiety, Rheumatoid Arthritis, Hypertension, or Hyperlipidemia. Further review failed to reveal that the nursing plan of care was updated after the EGD was performed.

In an interview on 07/08/2025 at 10:40 AM, S1RM confirmed the above mentioned findings and verified the plan of care did not include all of Patient #3's existing and potential problems.