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Based on interview and record review, the hospital failed to obtain an order for the use and discontinuation of the use of restraints (any manual method or device that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) for three of six patients when:

1. Patient 2 was placed in bilateral (both sides) wrist restraints without a physician order,

2. Patient 16 was kept and continued to be in an enclosure bed restraint (a hospital bed with a tent-like structure creating an enclosed space) with a 1:1 sitter (constant, one-to-one supervision by staff), and

3. Patient 18's ankle restraints was not discontinued when no longer needed.

These failures had the potential to result in an inappropriate/unnecessary and prolonged use of restraints.

Findings:

1. Review of Patient 2's medical record indicated she was admitted to the hospital on 10/31/25 for pneumonia (an infection in one or both lungs).

Review of Patient 2's restraint flowsheet, dated 11/2/25 at 12:00 a.m., indicated wrist restraints was initiated.

Review of Patient 2's physician order indicated the wrist restraint verbal order (instruction or command spoken aloud in person or by telephone by a provider) was placed on 11/2/25 at 4:11 a.m.

During a concurrent interview and record review with the Intensive Care Unit Director (ICUD), on 11/12/25 at 10:42 a.m., the ICUD stated the verbal order should have been placed in the medical record prior to administration of restraint. The ICUD confirmed that the time and date of the actual application of the restraints was not accurate.

2. Review of Patient 16's medical record indicated he was admitted to the hospital on 10/23/25 for dementia (a decline in mental abilities, severe enough to interfere with daily life).

Review of Patient 16's medical record indicated an enclosure bed restraint was ordered on 11/3/25 at 9:48 a.m. and discontinued at 11:59 p.m. on 11/4/25. A 1:1 sitter order was placed on 11/4/25 at 1:57 p.m. and discontinued on 11/8/25 at 4:10 p.m.

During a concurrent interview and record review with the Assistant Director of Terrace West (ADTW), on 11/13/25 at 11:58 a.m., the restraint flowsheet from 11/4/25 at 4 p.m. until 11/5/25, indicated the enclosure bed restraint was open with 1:1 sitter. The ADTW stated that the restraint should have been discontinued if the enclosure bed restraint was open. The ADTW also stated the restraint was not in place if the enclosure bed was open and it should be discontinued. The ADTW further stated it was not documented that the restraint was discontinued.

3. Review of Patient 18's medical record indicated he was admitted to the hospital on 10/7/25 for altered mental status (unusual changes in a person's emotional response, thinking or behavior).

During a concurrent interview and record review with the Clinical Analyst (CA) on 11/14/25 at 9:13 a.m., ankle restraints was used on Patient 18 from 10/17/25 at 8 a.m. until 10/18/25 at 4 p.m. without a physician order. The CA confirmed there was no physician order for the ankle restraints.

During an interview with the Telemetry Services Director (TSD) on 11/14/25 at 9:37 a.m., the TSD stated she did not see the order for the ankle restraints.

Review of the hospital's policy and procedures (P&P), titled "Patient Restraint", dated 2025, indicated "Restraints are applied according to an individualized, time-limited order, initiated by licensed practitioner ...Restraints are implemented in a manner that is least restrictive to the patient and are removed as soon as discontinuation criteria is met ...Verbal orders are allowed in certain situation, and the RN must enter the order promptly."

Review of the hospital's P&P, titled "Using an Enclosure Bed", dated 2025, indicated "Documentation ...date/time enclosure bed was initiated/discontinued ..."

Based on interview and record review, the hospital failed to ensure the registered nurse evaluated the nursing care for seven of 30 patients when pain assessment and/or reassessment were not done for Patients 12, 11, 10, 17, 13, 21 and 15.

This failure had the potential for patients to have continued pain and discomfort.

Findings:

Patient 12 was admitted to the hospital on 11/5/25 for hip fracture (a break in the thigh bone near the hip joint).

During a concurrent interview and record review with the Director of Med-Surge Nursing (DMSN) on 11/13/25 at 9:55 a.m., Patient 12's pain was assessed on 11/7/25 at 6:25 a.m., 11/9/25 at 9:42 p.m., and 11/11/25 at 10:43 p.m. prior to administration of Oxycodone (a narcotic used to treat moderate to severe pain). The DMSN confirmed there was no pain reassessment done within one hour after administration of pain medication.

Patient 12's pain was not assessed on 11/8/25 at 2:02 p.m. prior to administration of Oxycodone. The DMSN confirmed there was no pain assessment done prior to administration of pain medication.

Patient 11 was admitted to the hospital on 11/6/25 for decompressive laminectomy (removal of a portion of the lower spine).

During a concurrent interview and record review with the DMSN on 11/13/25 at 10:07 a.m., Patient 11's pain was assessed on 11/8/25 at 1:21 p.m. and on 11/9/25 at 9:43 p.m. prior to administration of Hydrocodone-Acetaminophen (Norco, a controlled medication to treat moderate to severe pain). The DMSN confirmed there was no pain reassessment done within one hour after administration of pain medication to determine its effectiveness.

Patient 11's pain was not assessed on 11/10/25 at 1:58 p.m. prior to administration of Norco. The DMSN confirmed there was no pain assessment done prior to the administration of pain medication.

Patient 10 was admitted to the hospital on 11/4/25 for lower extremity weakness (loss of muscle strength in the leg).

During a concurrent interview and record review with the DMSN on 11/13/25 at 10:14 a.m., Patient 10's pain was assessed on 11/4/25 at 8:55 p.m., 11/6/25 at 7:53 a.m., and on 11/6/25 at 3:25 p.m. prior to administration of Tramadol (Ultram, a narcotic used to treat moderate to severe pain). The DMSN confirmed there was no pain reassessment done within one hour after administration of pain medication.

Patient 17 was admitted to the hospital on 9/29/25 for hip fracture (a break in the thigh bone near the hip joint).

During a concurrent interview and record review on 11/13/25 at 2:22 p.m., with the Clinical Analyst (CA), Patient 17's pain was not assessed on 10/7/25 at 12:31 a.m. prior to administration of Oxycodone. The CA confirmed there was no pain assessment done.

Patient 13 was admitted to the hospital on 10/29/25 for pleural effusion (buildup of fluid between the lungs and chest).

During a concurrent interview and record review with the DMSN on 11/13/25 at 2:31 p.m., Patient 13's pain was assessed on 10/31/25 at 9:52 p.m. and 11/4/25 at 4:23 p.m. prior to administration of Acetaminophen (Tylenol, used to relieve mild to moderate pain). The DMSN confirmed there was no pain reassessment done within one hour after administration of pain medication.

Patient 21 was admitted to the hospital on 11/8/25 for intractable pain (severe and often constant pain that is difficult to manage or relieve).

During a concurrent interview and record review on 11/14/25 at 9:56 a.m., with the CA, Patient 21's pain was assessed on 11/8/25 at 9:02 p.m. prior to administration of Hydromorphone (Dilaudid, used to treat moderate to severe pain). The CA confirmed there was no pain reassessment within one hour after administration of pain medication.

Patient 21's pain was not assessed on 11/8/25 at 10:29 p.m. and on 11/8/25 at 11:43 p.m. prior to administration of pain medication. The CA confirmed there was no pain assessment done.

Patient 21's pain was assessed on 11/11/25 at 5:05 a.m. prior to administration of Morphine (used to treat moderate to severe pain). The CA confirmed there was no pain reassessment done within one hour after administration of pain medication.

Patient 15 was admitted to the hospital on 11/4/25 for small bowel obstruction (blockage in the small intestine that prevents food, fluids and gas from passing through).

During a concurrent interview and record review with the DMSN on 11/13/25 at 3:24 p.m., Patient 15's pain was assessed on 11/5/25 at 8:43 a.m. prior to administration of Acetaminophen. The DMSN confirmed there was no pain reassessment done within one hour after administration of pain medication.

Patient 15's pain was not assessed on 11/5/25 at 9:59 p.m., 11/6/25 at 10:32 a.m., 11/6/25 at 8:26 p.m., 11/7/25 at 9:12 a.m., 11/8/25 at 8:19 p.m., 11/9/25 at 10:01 a.m., and 11/9/25 at 8:58 p.m. prior to the administration of Acetaminophen. The DMSN confirmed there was no pain assessment done prior to administration of pain medication.

Patient 15's pain was not assessed prior to administration of Acetaminophen on 11/9/25 at 8:58 p.m., and no pain reassessment was conducted within one hour after administration of pain medication. The DMSN confirmed there was no pain assessment and reassessment done.

During an interview on 11/14/25 at 1:31 p.m., with the Interim Accreditation Consultant (IAC), the IAC stated pain assessment prior to pain medication administration and reassessment for the effectiveness of the pain medication administered should be documented in the pain assessment flowsheet and not in the purposeful rounding flowsheet.

Review of the hospital's Policy and Procedure (P&P), titled "Pain Management", dated 2025, indicated "A. Documentation Requirements: 1. Flowsheet - Pain Assessment (all patients) ...B. Pain Screening, Assessment, Treatment and Reassessment ...2. If pain is reported, an assessment is performed ...4. Pharmacologic interventions are reassessed to determine if the intervention was effective ...b. Pain assessment occurs 60 minutes for needed medications."

Based on interview and record review, the hospital failed to provide nursing services according to their policy and procedures for three of seven patients (Patient 2, 14 and 29) when temperature was not checked one hour post blood transfusion and no stop date/time when transfusion was completed.

This failure had the potential to affect the patients' health and safety.

Findings:

Review of Patient 2's medical record indicated she was admitted to the hospital on 10/31/25 for pneumonia (an infection in one or both lungs).

Review of the vital signs for transfusion order, dated 11/5/25, indicated "check the patient's vital signs ...1-hour post-transfusion."

During a concurrent interview and record review with the Intensive Care Unit Director (ICUD), on 11/12/25 at 10:29 a.m., the ICUD confirmed the temperature in the vital signs was missing one hour after blood transfusion. The ICUD further stated it should have been done.

Review of Patient 14's medical record indicated she was admitted to the hospital on 11/8/25 for acute blood loss anemia (body does not have enough healthy red blood cells because of excessive bleeding).

Review of Patient 14's flowsheet indicated blood transfusion was started on 11/9/25 at 8:59 a.m. and at 12:16 p.m.

During a concurrent interview and record review with the Director of Med-Surge Nursing (DMSN), on 11/13/25 at 2:41 p.m., the DMSN confirmed there was no stop time documented in the flowsheet. The DMSN stated there should be a stop time documented when the blood transfusion was completed.

Review of Patient 29's medical record indicated she was admitted on 10/11/25 for abdominal pain (discomfort between the chest and groin area).

During a concurrent interview and record review with the Telemetry Services Director (TSD), on 11/14/25 at 1:53 p.m., blood transfusion was started on 10/12/25 at 8:43 a.m. and stopped at 3:30 p.m. on 10/12/25. The TSD stated the nurse forgot to chart. The TSD further stated there was a delay in the documentation.

Review of the hospital's policy and procedure (P&P), titled "Blood Product Administration", dated 2023, indicated "D. Clinical Record 1. Document in blood flowsheet: d. Vital signs."