HospitalInspections.org

Based on record review, video review, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient's rights as evidenced by:

1) failure to provide nursing assessments per hospital policy of a patient who was found deceased in restraints which resulted in an Immediate Jeopardy.

On 01/29/2025 at 4:30 PM, S3RM and S5CVP were notified of the Immediate Jeopardy . On 01/30/2025 at 9:35 AM, S5CVP presented the plan for lifting the immediacy of the IJ situation and the plan included the following:
- 1. All nursing staff including PCT's will be educated prior to starting their next shift starting from 01/29/2025 until all nurses have received training or no later than 02/14/2025, when they will be removed from the schedule and not allowed to work until training has occurred.
- 2. The entity's removal plan must: Identify those who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Individuals in restraints.
Immediately reviewed all current patients in restraints house-wide via observation and documentation audits and addressed any and all patient needs and ensured appropriate documentation. Immediately a plan was developed by Nursing Leadership and Quality/Patient Safety Leadership on 01/29/2025 to retrain all nursing staff including PCTs prior to starting their next shift. The nursing education and nursing informatics leaders overseen by the CNO provided the training on restraints and assessing, monitoring, and documenting every 2 hours including the assessment points as described in LCMC Health policy Nursing 002 Restraints and following physician's orders. The Nursing Leadership team is responsible for implementing the training. Nursing leadership will monitor the training daily. A report from the EHR will be run to identify all patients in restraints. Once a shift the charge nurse will conduct observational/face to face audits to ensure restraint compliance and patient safety. A review of the required documentation per hospital policy will occur and feedback will be delivered to the nursing staff timely. If noncompliance is found, the disciplinary policy LCMC Health Human Resources titled HR 404 Code of Conduct will be followed. Investigating if EHR automation and reminders are feasible.
- 3. Process/System involved: Maintain a safe environment by consistent application of the restraint policy including proper monitoring of patients in restraints and per physician orders and auditing of compliance.
- 4. Action(s) Taken/Planned to be Taken: See above action plan above. The nurse caring for Patient #1 has been immediately placed on leave and will be terminated and reported to the State Board of Nursing.
- 5. Date Action(s) Taken/Planned to be Taken: Initiated at 7:00 PM 01/29/2025-02/14/2025; Nurses who have not completed the training as of this date will be removed from the schedule until training obtained.
- 6. Staff Education Plan: Nursing staff including PCTs will be trained in person during daily shift huddle by nursing leaders on restraints including patient assessment, monitoring, and documentation AND on implementing physician orders. Nursing staff will be retrained on the restraint module in the electronic education system and this will be completed by 02/14/2025.
- 7. Who: Nursing Leaders and Educators. When: IJ received at 4:30 PM; Training started at 7:00 PM What: In person - (Red) Huddle format to train on policy, procedure, documentation and auditing of compliance of restraints and physician orders with signatures of the staff who were educated.
- 8. Mode of Education: Daily huddle and CBL
- 9. Monitoring of Implemented Action(s): Monitoring daily of restraint monitoring and documentation compliance and the education which includes daily monitoring of in person huddle and weekly of completion of CBL training.
- 10. What will be monitored: Restraint documentation and compliance of following physician orders for vital signs; Once a shift the charge nurse will conduct observational/face to face audits to ensure restraint compliance and patient safety.
- 11. How long will it be monitored: For three months at 100% compliance and monthly thereafter.
- 12. Who/What Committee will receive reports: Patient Safety and Quality Committee and the Quality sub-committee of the UMC board who will then report it to the full UMC board.
- 13. What is the plan if the action does not meet expectations: If noncompliance is found, the disciplinary policy LCMC Health Human Resources will be followed titled HR 404 Code of Conduct.

The Immediacy was lifted on 01/30/2025 at 11:50 AM by the survey team. Noncompliance remains at the Condition Level. (See findings in A0144); and

2) failure to document patients were informed of their rights in 2 (#1, #3) of 3 (#1- #3) records reviewed for notification of patient rights (See findings in A0117); and

3) failure of the hospital to ensure a translator or interpreter was used to facilitate communication with hearing impaired patients in 1(#1) of 1 (#1) reviewed patients with a hearing impairment (See findings in A0131); and

4) failure of the hospital to witness Patient #1's signature on a Formal Voluntary Admission form per hospital policy (See findings in A0131); and

5) failure to have documented evidence that a translator or interpreter was utilized to inform Patient #1, who was hearing impaired, of the reasons for the use of restraint/seclusion and to confirm his understanding before he was placed in restraints (See findings in A0154).

Based on record review and interview, the hospital failed to ensure each patient was notified of their rights. This deficient practice is evidenced by failing to document patients were informed of their rights in 2 (#1, #3) of 3 (#1- #3) records reviewed for notification of patient rights.
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. 2. You have the right to receive care in a safe setting or environment free from all forms of abuse, neglect, harassment, or mistreatment. 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. 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. 14. You have the right to communication that you can understand. The hospital will provide sign language and foreign language interpreters as needed as soon as possible and at no cost to you. Information given will be appropriate to your age, understanding, and language. If you have vision, speech, hearing, and/or other impairments, you will receive additional aids to ensure your care needs are met. 22. You have the right, if applicable and requested, to a statement of your legal rights and responsibilities under the Louisiana Mental Health Law and information about available advocacy services at the time that the Order of Authorization for Temporary Admission."

A review of policy # 0121, titled "Interpreter Services and Communication Services for Hearing-Impaired Patients or Their Companions," last reviewed 03/2021, revealed in part: "Policy Statement: Provide appropriate communication assistance free of charge to assure that patients' needs are met effectively. Ensure that all patients and companions are able to understand medical conditions and treatment options and to provide quality patient care through effective communication to and with its patients and companions. Provide appropriate auxiliary aids and services, including qualified interpreters, where such aids and services are necessary to ensure effective communication with patients and companions who are deaf or hard-of-hearing. Provide deaf and hard-of-hearing patients and companions with the full and equal enjoyment of the services, privileges, facilities, advantages, and accommodations of the hospital as required by the Americans with Disabilities Act (ADA). Definitions: Auxiliary Aids and Services: may include, but not be limited to the following: Qualified interpreters provided either on-site or through video remote interpreting services, Note takers, Real-time computer-aided transcription services, Written materials, Exchange of written notes, Telephone handset amplifiers, Assistive listening devices, Assistive listening systems, Telephones compatible with hearing aids, Closed caption decoders, Open and closed captioning, Video text displays, and Accessible electronic and information technology or other effective methods of making aurally delivered information available to individuals who are deaf or hard-of-hearing. Deaf- refers to persons who are deaf, late-deafened, or hard-of-hearing. The term "hard-of-hearing" includes persons who have a hearing deficit and who may or may not primarily use visual aids for communication and may or may not use auxiliary aides. Qualified Interpreter- means an interpreter who via VRI service or on-site, is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary. Qualified interpreters include, for example, sign language interpreters, oral translators, and cued-language translators. Procedure: UMCNO will provide to deaf or hard-of hearing patients and companions any appropriate auxiliary aids and services that are necessary for effective communication. Appropriate auxiliary aids and services will be provided as soon as practicable and reasonable without compromising patient care. UMCNO will advise patients and companions who require auxiliary aids or services that these will be made available as required by ADA. Hospital personnel are responsible for assessing/determining whether and what type(s) auxiliary aids should be used to effect effective communication with deaf patients and/or their companions. Obtaining A Sign Language Interpreter: Designated computers with "face time" capability are available via the Department of Communications. An in-person sign language interpreter is available 24 hours a day, seven (7) days a week. It is the responsibility of the Hospital personnel coordinating the use of the sign language interpreter to document the use of the sign language interpreter within the patient's medical record.

Patient #1
A review of Patient #1's medical record revealed an admission date of 12/28/2024 with a diagnosis of trauma with an open fracture of the right side of the mandibular body. Patient #1's medical record also revealed patient was developmentally disabled with a hearing impairment and did not have documentation of a Medical Power of Attorney. Further review of Patient #1's medical record failed to reveal that the patient was informed of their patient rights.

In an interview on 01/16/2025 at 2:25 PM, S3RM and S5CVP confirmed that there was no documented evidence that Patient #1 was notified of their patient rights. S3RM and S5CVP also confirmed that Patient #1 did not have documentation of a Medical Power of Attorney in their medical record.

Patient #3
A review of Patient #3's medical record revealed an admission date of 12/31/2024 with a diagnosis of penetrating trauma and suicidal attempt. Patient #3's medical record also revealed that Patient #3 had a Medical Power of Attorney scanned into the chart on 01/01/2025. Further review of Patient #3's medical record failed to reveal that Patient #3 and/or their Medical Power of Attorney were informed of their patient rights.

In an interview on 01/28/2025 at 2:43 PM, S3RM and S5CVP confirmed that there was no documented evidence Patient #3 and/or their Medical Power of Attorney were notified of their patient rights.

Based on record review and interview, the hospital failed to ensure patients/representatives had the right to make informed decisions regarding care. This is evidenced by:
1) failure of the hospital to witness Patient #1's signature on a Formal Voluntary Admission form per hospital policy; and
2) failure of the hospital to ensure a translator or interpreter was used to facilitate communication with hearing impaired patients in 1(#1) of 3 (#1- #3) reviewed patients with a hearing impairment.
Findings:

Review of policy # 5016, titled "Informed Consent," last revised 04/2024, revealed in part: Definitions: Decision-Making Capacity- The ability to understand and appreciate the nature and consequences of a decision regarding medical treatment and the ability to reach and communicate and informed decision in the matter. Disclosure- In the context of Informed Consent, means communicating the risk, benefits, and alternatives to medical treatment. The act of making someone known. Informed Consent- The permission given by a patient or surrogate decision-maker, to perform a medical treatment or surgical procedure after he/she has been advised of and fully understands the risks, benefits and alternatives or hazards that could influence a reasonable person in deciding whether or not to consent, the patient or surrogate decision-maker needs information from the provider about the treatment or procedure, including risks, benefits, and alternatives, in a language or means of communication he/she understands. Procedure: 2. What is the Method for Documenting Informed Consent? e. Witness Requirement of Patient's Signature: i. It is mandatory to have the signature of a witness who observed the patient sign the Informed Consent. ii. The signature of the witness attests to the validity of the signature of the patient (or Surrogate Decision Maker) and not to the quality, relevance, or thoroughness of the discussion that led to the consent. Witnessing a consent does not indicate or imply responsibility for the Informed Consent. iii. The Witness should sign, date and time in the presence of the patient, immediately after the patient (or Surrogate Decision Maker) signs the Informed Consent form. 8. What if there is an Issue Regarding Communication (ESL, hearing or sight impairment, or difficulty reading)? b. Obtaining consent from a patient (or Surrogate Decision Maker) who is hearing impaired shall be secured per Policy 0121 - Interpreter Services and Communication Services for Hearing-Impaired Patients or their companions.

A review of policy # 0121, titled "Interpreter Services and Communication Services for Hearing-Impaired Patients or Their Companions," last reviewed 03/2021, revealed in part: "Policy Statement: Provide appropriate communication assistance free of charge to assure that patients' needs are met effectively. Ensure that all patients and companions are able to understand medical conditions and treatment options and to provide quality patient care through effective communication to and with its patients and companions. Provide appropriate auxiliary aids and services, including qualified interpreters, where such aids and services are necessary to ensure effective communication with patients and companions who are deaf or hard-of-hearing. Provide deaf and hard-of-hearing patients and companions with the full and equal enjoyment of the services, privileges, facilities, advantages, and accommodations of the hospital as required by the Americans with Disabilities Act (ADA). Definitions: Auxiliary Aids and Services: may include, but not be limited to the following: Qualified interpreters provided either on-site or through video remote interpreting services, Note takers, Real-time computer-aided transcription services, Written materials, Exchange of written notes, Telephone handset amplifiers, Assistive listening devices, Assistive listening systems, Telephones compatible with hearing aids, Closed caption decoders, Open and closed captioning, Video text displays, and Accessible electronic and information technology or other effective methods of making aurally delivered information available to individuals who are deaf or hard-of-hearing. Deaf- refers to persons who are deaf, late-deafened, or hard-of-hearing. The term "hard-of-hearing" includes persons who have a hearing deficit and who may or may not primarily use visual aids for communication and may or may not use auxiliary aides. Qualified Interpreter- means an interpreter who via VRI service or on-site, is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary. Qualified interpreters include, for example, sign language interpreters, oral translators, and cued-language translators. Procedure: UMCNO will provide to deaf or hard-of hearing patients and companions any appropriate auxiliary aids and services that are necessary for effective communication. Appropriate auxiliary aids and services will be provided as soon as practicable and reasonable without compromising patient care. UMCNO will advise patients and companions who require auxiliary aids or services that these will be made available as required by ADA. Hospital personnel are responsible for assessing/determining whether and what type(s) auxiliary aids should be used to effect effective communication with deaf patients and/or their companions. Obtaining A Sign Language Interpreter: Designated computers with "face time" capability are available via the Department of Communications. An in-person sign language interpreter is available 24 hours a day, seven (7) days a week. It is the responsibility of the Hospital personnel coordinating the use of the sign language interpreter to document the use of the sign language interpreter within the patient's medical record.

1) Failure of the hospital to witness Patient #1's signature on a Formal Voluntary Admission form per hospital policy.

A review of Patient #1's medical record revealed a Formal Voluntary Admission (FVA) form signed on 01/03/2025 at 2:27 PM by the patient and physician, and signed by S7RN as a witness to the FVA.

In an interview on 01/16/2025 at 3:20 PM, S7RN confirmed that she was the witness for the Formal Voluntary Admission (FVA) form signed by Patient #1. When S7RN was asked if Patient #1 understood what the FVA was when he signed it, S7RN stated she assumed Patient #1 was able to understand it since he signed it. S7RN then stated she was not present in the room when the physician had Patient #1 sign the FVA form, stating she was standing outside the room. S7RN further confirmed that she did not visualized the patient sign the form.

In an interview on 01/16/2025 at 2:45 PM, S3RM and S8ND verified that S7RN stated she was not present in Patient #1's room when he signed his FVA form. S3RM and S8ND also confirmed that S7RN stated she signed her name as a witness on the form although she did not witness Patient #1's signature.

In an interview on 01/27/2025 at 3:14 PM, S3RM and S5CVP confirmed that the only time an interpreter service was used to assist Patient #1 was on 01/02/2025 at 6:37 PM. S3RM and S5CVP further confirmed that there is no further documentation by hospital staff that an interpreter was provided to Patient #1.

2) Failure of the hospital to ensure a translator or interpreter was used to facilitate communication with hearing impaired patients in 1(#1) of 3 (#1- #3) reviewed patients with a hearing impairment.

A review of Patient #1's medical record revealed an admission date of 12/28/2024 with a diagnosis of Facial Trauma with an Open Fracture of the right side of the Mandibular Body.

A review of Psychiatry Consult note dated 12/31/2024 revealed Patient #1 had a past history of Intellectual Disability. Describes Patient #1's speech as difficult to understand due to facial swelling and patient's difficulty hearing/understanding questioning. Collateral obtained revealing Patient #1 wears a hearing aid, which has been lost and he knows sign language and how to read lips. Social History: Source of Income: on disability. Special Ed: yes. Assessment: Intellectual Disability. Patient with history of "bipolar schizophrenia" however, suspect intellectual disability to be the main driver in patient's similar presentations.

A review of Psychiatry Progress note dated 01/03/2025 at 7:48 AM revealed Interval events: Per nursing note, patient unable to be redirected last night despite attempts at verbal de-escalation. Soft restraints ordered for 1 day. Patient #1 is hard of hearing and has trouble communicating. Further review of the plan for Patient #1 revealed -Please allow patient to have dry erase board and marker in his room to assist with communication.

Further review of Patient #1's medical record failed to reveal documentation that the hospital used an interpreter/translator to assist with Patient #1's understanding and agreement of his patient care during his admission.

In an interview on 01/16/2025 at 3:20 PM, S7RN confirmed that she was the primary nurse for Patient #1 on day shift on 01/02/2025 and 01/03/2025. S7RN stated Patient #1 was confused at times and had a developmental delay. S7RN stated the patient knew some sign language. S7RN confirmed that staff would yell in Patient #1's ear to communicate and that the patient could read lips. S7RN stated that she attempted to use the interpreter ipad once to communicate with Patient #1. S7RN confirmed that she did not document the use of the ipad because the interpreter would say Patient #1 wasn't making sense, and that he wasn't using proper ASL. S7RN confirmed this was the only time she attempted to use an interpreter service while providing care for Patient #1.

In an interview on 01/16/2025 at 2:17 PM, S3RM and S5CVP confirmed the use of an interpreter service was not documented as being used on Patient #1 by a provider.

Based on record review, video review, and interview the hospital failed to ensure the patients received care in a safe setting. This deficient practice is evidenced by failing to provide nursing assessment of 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: 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: 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. 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)."

Review of policy #5015, titled "Patient Screening, Assessment, Reassessment and Plan of Care," last revised 07/2024, revealed in part: "Definitions: Assessment: an objective evaluation of appraisal of an individual's health status, including acute and chronic conditions. The assessment gathers information through collection of data, observation, and physical examination. Reassessment: Ongoing data collection, which begins on initial assessment, comparing the most recent data with the data collected at earlier assessments. Procedure: 1. Initial Screening and/or Assessment: b. The extent of the screening, assessment, and reassessment is based on the patient's current condition, age, and treatment setting. 2. Reassessments 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 clinically relevant. i. Reassessment may also be based on the patient's diagnosis; desire for care, treatment, and services; response to previous care, treatment, and services; discharge planning needs; and/or setting requirements. b. Specific assessments related to patient diagnosis or procedure are completed per licensed practitioner order or as clinically relevant. c. Reconciliation of lines, drains, and airways is performed by tracing lines, drains, and airways from the patient to the point of origin at the following times: i. Every change in caregiver. ii. Change in care setting. iii. Change in level of care. iv. Before connecting to or reconnecting any device or infusion. d. .Ongoing assessment is the responsibility of direct caregivers and consultants and may include: i. Current physical, social, and psychological status of the patient. ii. Evaluation of diagnoses considering input from patient/family, consultants, and results of diagnostic testing. iii. Patient reports and physiologic responses related to medical, nursing, and other interventions."

A review of Patient #1's medical record revealed an admission date of 12/28/2024 with a diagnosis of trauma with an open fracture of the right side of the mandibular body. Patient #1's medical record also revealed the patient was developmentally disabled and had a hearing impairment. On 12/29/2024 at 5:38 AM Patient #1 was placed in wrist restraints and a 1:1 sitter was ordered to bedside to monitor the patient.

On 01/03/2025 Patient #1 was taken to surgery and an open reduction with internal fixation of the mandibular fracture and extraction of tooth #30 was performed. Vital signs were obtained prior to leaving Post Anesthesia Care Unit [PACU] at 8:57 PM on 01/03/2025 and returning to the floor. The next set of vital signs were documented at 11:00 PM on 01/03/2025. Further review of Patient #1's medical record failed to reveal documented vital signs after 11:00 PM on 01/03/2025.

Nursing documentation revealed the following nursing notes:
On 01/03/2025 at 9:45 PM - S11RN documented she attempted to take Patient #1 out of restraints and patient started pulling at dressing on his face/head and we were not able to redirect.
On 01/03/2025 at 10:10 PM - S11RN called provider to obtain order to resume oral medications.
01/03/2025 at 11:00 PM - S11RN documented restraint monitoring/assessment performed. 01/03/2025 at 11:09 PM - S11RN administered Oxycodone (Roxicodone) 10mg oral solution for pain to Patient #1.
01/03/2025 at 11:54 PM - S11RN administered Olanzapine (Zyprexa) 10mg IM for agitation to Patient #1.
01/04/2025 at 1:00 AM - S11RN documented restraint monitoring/assessment performed.
01/04/2025 at 3:00 AM - S11RN documented restraint monitoring/assessment performed.
01/04/2025 at 5:00 AM - S11RN documented restraint monitoring/assessment performed.
01/04/2025 at 5:51 AM - S11RN documented a nurse note stating phlebotomist in patient's room drawing labs and when S11RN approached the patient to hang his antibiotic, noticed that patient was not breathing. Immediately chest compressions were initiated and a code blue was called.
01/04/2025 at 6:17 AM - TOD [time of death] called by physician.

On 01/29/2025 from 11:30 AM - 2:30 PM, a review of video footage navigated by S2DPS, S3RM, and S5CVP of hallway outside room a on 01/03/2025 at 11:56 PM through 01/04/2025 at 5:57 AM revealed the following:
01/03/2024
11:58 PM - S11RN enters room a.
11:59 PM - S11RN exits room a.
01/04/2025
12:28 AM - S11RN enters room a.
12:29 AM - S11RN exits room a.
1:04 AM - S12PS enters room a, and relieves previous sitter at bedside.
2:29 AM - PCT enters room a.
3:30 AM - PCT exits room a.
3:41 AM - PCT enters, then exits room a.
4:10 AM - S12PS exits room a, and goes back in room a.
4:34 AM - S11RN enters room a.
4:35 AM - S11RN exits room a.
5:39 AM - PCT enters room a.
5:43 AM - S17PHL enters room a.
5:46 AM - PCT exits room a with soiled linen bag and trash bag.
5:50 AM - S11RN enters room a.
5:51:43 AM - S12PS exits room a to get Phillips vital sign machine and goes back in room.
5:53 AM - S11RN exits room a and activates code.
5:54 AM - S11RN brings crash cart to room a. Code team arriving room a.
5:57 AM - Video footage ends.

Review of video failed to reveal entry into the room a by S11RN for the assessments, as required by hospital policy and documented in her notes, between 12:29 AM and 4:34 AM. Further review of video failed to reveal a PCT or nurse entering room a to obtain vital signs on 01/04/2025 between 12:29 AM and 4:34 AM per provider order.

In an interview on 01/28/2025 at 12:26 PM, S3RM and S5CVP confirmed that there was no documented re-evaluations of the effectiveness of the medications administered by S11RN on 01/03/2025 at 11:09 PM and 11:53 PM.

In an interview on 01/29/2025 at 2:30 PM, S3RM confirmed that the documented monitoring and assessment of restraints by S11RN in the medical record at 1:00AM, 3:00 AM and 5:00 AM did not match the video evidence.

In an interview on 01/29/2025 at 2:34 PM, S2DPS and S3RM confirmed that S11RN did not perform restraint monitoring and assessment every 2 hours per hospital policy. At this time S2DPS, S3RM, and S5CVP also confirmed that based on the video review, S11RN was in Patient #1's room a total of 3 minutes from 01/03/2025 at 11:58 PM until finding the patient unresponsive and initiating a code on 01/04/2025 at 5:53 AM.

In an interview on 01/30/2025 at 11:25 AM, S11RN confirmed that she was the primary nurse for Patient #1 on the night of 01/03/2025 through the morning of 01/04/2025. Per S11RN around midnight, Patient #1 started settling down. S11RN stated at this time she attempted to release the restraint but Patient #1 immediately attempted to pull at facial dressings. S11RN stated she could hear the patient talking at the nurse station which was located directly across the hallway from room a. S11RN stated she would ask the sitter from the nurse station what the patient was doing and was told the patient was talking in his sleep. S11RN stated that the PCT told her around 4:00 AM that they would get vital signs on Patient #1 in a little while when they change the patient linens since he was sleeping. S11RN also stated when she went in Patient #1's room around 4:00 AM (4:34 AM per the video) to check on the patient, she put her hand on his chest to count his respirations and the patient startled when she touched him. When asked why she documented performing assessments during times the video revealed she did not go into the room, S11RN explained she entered her documentation at the end of the shift and, she was so busy on the unit as charge nurse, that she thought she had been in the room at the times she was supposed to check on Patient #1.

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 have documented evidence that a translator or interpreter was utilized to inform Patient #1, who was hearing impaired, of the reasons for the use of restraint/seclusion and to confirm his understanding before he was placed in restraints.
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. 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. 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. 14. You have the right to communication that you can understand. The hospital will provide sign language and foreign language interpreters as needed as soon as possible and at no cost to you. Information given will be appropriate to your age, understanding, and language. If you have vision, speech, hearing, and/or other impairments, you will receive additional aids to ensure your care needs are met."

Review of hospital policy # Nursing 002, titled "Restraints and Seclusion," effective date: 08/01/2024, revealed in part: "Policy Statement: A. Restraints and/or seclusion are only used when they are clinically justified, when less restrictive interventions are ineffective, and with the least restrictive means of restraint or seclusion to ensure patient safety. B. When restraints and/or seclusion are used, the patient's rights, dignity, and well-being shall be preserved. Restraints and seclusion are not to be used as a means of coercion, discipline, corporal punishment, convenience, or retaliation. Discontinuation of restraint and seclusion must occur as soon as possible, based on an individualized patient assessment and reevaluation, regardless of the scheduled expiration of the order. D. Documentation in the EMR must justify each type of restraint or seclusion used, the patient's response, plan of care, observation, and assessment. Responsibility: C. Nurses shall: 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. Procedure: 2. Initiation or Restraint and/or Seclusion: c. Restraint Application: i. Explain to the patient the reason for restraint, the criteria for discontinuation, and the process for frequent reassessments to assure safety and discontinuation of restraints as soon as possible. 4. Monitoring and Interventions: b. A means of communication with staff should always be provided to the patient. 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)."

Patient #1
A review of Patient #1's medical record revealed an admission date of 12/28/2024 with a diagnosis of trauma with an open fracture of the right side of the mandibular body. Patient #1's medical record also revealed patient was developmentally disabled and had a hearing impairment.

On 12/29/2024 at 5:38 AM, Patient #1 was placed in 2 point soft wrist restraints. Nursing documentation describes Patient #1 at this time as restless, agitated, and confused. Education documented as complete with a note stating the following: Yes - patient with AMS, sedated, and/or no family present. Patient #1's response to the restraint education stated no evidence of learning. Discontinuation criteria for restraints was documented as absence of behavior that requires the restraint.

Patient #1 remained in wrist restraints from 12/29/2024 at 5:38 AM until the restraints were discontinued on 01/02/2025 at 12:00 PM with a RN Assessment/Clinical Justification stating the patient no longer meets criteria - restraints removed.

On 01/02/2025 at 11:43 PM Patient #1 was placed back in restraints. Nursing documentation describes Patient #1 at this time as restless and agitated. Education documented as complete with a note stating the following: Yes - patient with AMS, sedated, and/or no family present. Patient #1's response to the restraint education stated no evidence of learning and needs reinforcement. Discontinuation criteria for restraints was documented as absence of behavior that requires the restraint.

Review of Patient #1's medical record revealed that the patient remained in restraints from 01/02/2025 at 11:43 PM until the patient was found without a pulse on 01/04/2025 at 5:53 AM and CPR was initiated.

Patient #1's medical record failed to reveal documentation that a translator or interpreter was used to inform Patient #1 about the reasons for the use of the restraints or that he expressed understanding prior to restraint placement.

In an interview on 01/27/2025 at 3:14 PM, S3RM and S5CVP confirmed that the only time an interpreter service was used on Patient #1 was on 01/02/2025 at 6:37 PM. S3RM and S5CVP confirmed at this time that there is no documentation by hospital staff that an interpreter was provided to Patient #1 prior to restraint application.

In an interview on 01/27/2025 at 3:40 PM, S3RM and S5CVP were unable to confirm if Patient #1 expressed understanding of why the restraints were being used.

Based on record reviews and interview, the hospital failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by failing to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. This deficient practice is evidenced by failure to accurately document, fully investigate and identify neglect in the death of Patient #1 who was found deceased while in restraints (See findings in A0286).

Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to accurately document, fully investigate and identify neglect in the death of Patient #1 who was found deceased while in restraints.
Findings:

Review of the Hospital / Licensed Provider Abuse/ Neglect Initial Report submitted on 01/05/2025 and finalized on 01/10/2025 revealed an anonymous report involving a patient death that occurred on 01/04/2025 at 5:51 AM. The document revealed the following:
Patient #1, identified as the victim, was in restraints following an open reduction internal fixation mandibular fracture surgery and extraction of tooth 01/03/2025.
The report indicated Patient #1 was placed under an FVA on 01/03/2025 at 2:27 PM and one-to-one sitter was at the bedside.
Placed in restraints due to agitation and pulling at lines at10:44 PM.
Spiked a temperature of 100.4 at 11:00 PM.
Administered oxycodone 5mg/5ml orally at 11:09 PM.
Administered Zyprexa 10mg IM at 11:54 PM.
CT scan was ordered to assess for reduction and cancelled by S11RN because the patient was in restraints, and would need to be accompanied to CT.
CT was not completed after medication administration and Patient #1 was calm.
S11RN discovered Patient #1 unresponsive at 5:51 AM on 01/04/2025, while hanging antibiotics, called Code Blue, initiated ACLS.
Time of death was called at 6:17 AM by S18MD.

Continued review of the Hospital / Licensed Provider Abuse/ Neglect Initial Report submitted finalized on 01/10/2025 revealed the following documentation:

Video Review information documented on report included:

No Video surveillance at incident site. No video in patient rooms.
What was revealed on video? Answer: N/A
Names/titles/positions of ALL video reviewers: N/A

Incident details included the following:

Name of the first employee aware of allegation and how they became aware of allegation:-Answer: The alleged allegation was submitted anonymously.

Comments-Answer:

A full investigation had been completed and included interviews and statements from staff involved.
Patient #1 arrived to the ED on 12/28/2024 as a trauma activation due to blunt force trauma to the face with altered mental status. OMFS was consulted due to initial findings of multiple facial fractures.
Investigation revealed Patient #1 was placed in non-violent restraints for safety measures in the ED, with a sitter at the bedside, due to altered mental status and attempting to pull at lines and dressings.
Inpatient consult to psychiatry was ordered for evaluation of mental status on 12/31/24.
It was noted throughout his admission that re-direction was unsuccessful due to Patient #1's continued confusion and lack of safety awareness.
On 01/03/24 at 6:57 PM, following an open reduction internal fixation mandibular fracture and dental extraction, Patient #1 met criteria for discharge from the PACU. Discharge criteria included stable vital signs and Aldrete score between 8-10.
Patient #1 had arch bars in place and was not wired shut.
On 01/03/25 at 9:45 PM, S11RN attempted to take the patient out of restraints; however, patient started pulling at the dressing on his face/head and was not able to be redirected.
At 11:00 PM, it was noted the head of the bed was elevated to 45 degrees.
S11RN documented restraint monitoring every two hours, per protocol, including visual check, circulation, range of motion, fluids, food/meal, elimination, respiration and clinical justification for continued restraints until 5:00 AM on 01/04/25.
At 1:00 AM and 3:00 AM, it was noted by S11RN the patient continued to pull at lines and dressing with altered mental status with no signs of injury and normal respirations with circulation throughout the shift.
A sitter remained at bedside for safety observation with documentation at least every 30 minutes, including the patient location, activity and behavior.
At 5:51 AM, per S11RN, S17PHL was in Patient #1's room to draw routine lab orders.
S11RN approached the patient to start his IV antibiotics.
Patient #1 was noted to be unresponsive.
S11RN stated she immediately started chest compressions and called a "Code Blue."
The "Code Blue" team arrived and ACLS continued until the time of death called at 6:17 AM. Per the anesthesiology note, the intubation during the Code Blue was successful and only one attempt was necessary, with no other remarkable findings.
After thorough review of Patient #1's medical record, including physician orders, nursing assessments and documentation, including sitter observations, the hospital did not substantiate the allegation of neglect.
The hospital stated on the report that this was the final report and the allegation was not substantiated.

The report failed to reveal Patient #1 was diagnosed with Intellectual Disability and hearing impairment requiring the use of hearing aid and sign language as stated in Psychiatric Consult dated 12/31/2024 and Psychiatric Progress notes dated 01/01/2025, 1/02/2025, and 01/03/2024.

The report failed to reveal the results of the available video surveillance in the hallway outside of room a. ("No Video surveillance at incident site. No video in patient rooms").
Review of video showing the hallway outside of room a failed to reveal entry into the room a by S11RN for the assessments, as required by hospital policy and documented in her notes, between 12:29 AM and 4:34 AM. Further review of video failed to reveal a PCT or nurse entering room 'a' to obtain vital signs on 01/04/2025 between 12:29 AM and 4:34 AM per provider order.

In an interview on 01/29/2025 at 2:34 PM, S2DPS and S3RM confirmed that S11RN did not perform restraint monitoring and assessment every 2 hours per hospital policy. At this time S2DPS, S3RM, and S5CVP also confirmed that based on the video review, S11RN was in Patient #1's room a total of 3 minutes from 01/03/2025 at 11:58 PM until finding the patient unresponsive and initiating a code on 01/04/2025 at 5:53 AM.

In an interview on 01/29/2025 at 2:30 PM, S3RM confirmed that the documented monitoring and assessment of restraints by S11RN in the medical record at 1:00AM, 3:00 AM and 5:00 AM did not match the video evidence.

The report failed to reveal S11RN did not documented requisite re-evaluations of the effectiveness of the medications administered on 01/03/2025 at 11:09 PM and 11:53 PM.

In an interview on 01/28/2025 at 12:26 PM, S3RM and S5CVP confirmed that there was no documented re-evaluations of the effectiveness of the medications administered by S11RN on 01/03/2025 at 11:09 PM and 11:53 PM.

The report failed to reveal that S17PHL began chest compressions. The report stated S11RN "immediately started chest compressions".

In an interview on 01/30/2025 at 12:35 PM, S17PHL confirmed she went into Patient #1's room on 01/04/2025 between 5:00 AM and 6:00 AM to draw labs. S17PHL stated Patient #1 was on his back in restraints and did not respond to his name when called. S17PHL proceeded to draw assuming he was asleep. While she was drawing the 2nd tube, S11RN walked in and turned the lights on, called Patient #1's name and he did not respond. S11RN asked S17PHL if Patient #1 was breathing and S17PHL touched his chest and put her hand over his nose and said "I don't think so". S11RN instructed S17PHL to start compressions while S11RN left to get the code cart.

The report failed to reveal the CT order was written as a STAT order. Furthermore, the report did not include evidence that the STAT CT had been rescheduled or discontinued.

In an interview on 01/30/2025 at 11:52 AM, S3RM confirmed that the stat CT order was never modified or discontinued from the original order placed on 01/03/2025 at 7:00 PM until it was automatically discontinued upon discharge from the system.











50453

Based on record review and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:
1) failure of the staff to document 1:1 continuous visual observations for 1 (#1) of 3 (#1-#3) patient medical records reviewed;
2) failure of the nursing staff to document vital signs as ordered by the physician for 1 (#1) of 3 (#1-#3) patient medical records reviewed; and
3) failure of the nursing staff to complete a stat CT as ordered by the physician for 1 (#1) of 3 (#1-#3) patient medical records reviewed.
Findings:

Review of hospital policy #5003, titled "Patient Care Technician Safety Assistant Policy," last revised 02/2022, revealed in part: "The assigned Patient Care Technician Safety Assistant (PCTSA) will always maintain visual contact of the patient to prevent harm with unpredictable behavior and intervene immediately when necessary. Documentation: The PCTSA will document patient observations (location, activity, behavior) in the "Daily Cares" section in the electronic medical record (EMR). i. Documentation will be determined by the patient's physician and/or the Registered Nurse. ii. The registered nurse will document patient observations every 2 hours in the EMR (Daily Cares, Observation Monitoring and/or Shift Assessment). a. Document initiation, changes and stopping of observation. b. In Daily Cares, document Safe Environment, Communication Need, Comfort and Environment Interventions and Entertainment/Diversion activities. c. Note the patient's behavior, mental status, appetite, energy levels and sleep patterns. d. Document refusal to accept treatments which are life sustaining or for which refusal may cause danger to health status or recovery. e. Describe progress or lack of progress in resolving problems identified in the plan of care. f. Document and report attempts by the patient to harm him/herself or others."

1) Failure of the staff to document 1:1 continuous visual observations for 1 (#1) of 3 (#1-#3) patient medical records reviewed.

A review of Patient #1's medical record revealed an admission date of 12/28/2024. On 12/29/2024 Patient #1 was placed in 2 point soft wrist restraints and had a 1:1 sitter ordered for bedside.

Further review of Patient #1's medical record failed to reveal continuous visual observation documentation by a sitter or staff member on 01/01/2025 from 2:30 PM to 7:00 PM.

In an interview on 01/27/2025 at 11:58 AM, S8ND confirmed that a patient with an order for 1:1 sitter for continuous observations are documented on every 30 minutes in the medical record. S8ND also confirmed that the 1:1 sitter documentation includes the location, activity, and behavior of the patient being observed.

In an interview on 01/28/2025 at 11:00 AM, S3RM and S5CVP confirmed that Patient #1 did not have continuous visual observations documented on 01/01/2025 from 2:30 PM to 7:00 PM. S3RM and S5CVP also confirmed that during this time, Patient #1 had orders for a sitter at bedside.

2) Failure of the nursing staff to document vital signs as ordered by the physician for 1 (#1) of 3 (#1-#3) patient medical records reviewed.

A review of Patient #1's medical record revealed an order for vital signs every 4 hours. A review of Patient #1's documented vital signs revealed the following:
On 01/02/2025 vital signs were obtained at the following times: 4:00 AM, 1:00 PM, and 7:32 PM. At 11:00 PM on 01/02/2025 the vital signs were documented as patient refused. The next set of vital signs were obtained on 01/03/2025 at 4:30 AM.

On 01/03/2025 Patient #1 went to the operating room for an Open Reduction Internal Fixation Mandibular Fracture and Extraction of Tooth #30. Vital signs were obtained prior to leaving PACU at 8:57 PM on 01/03/2025. The next set of vital signs were documented at 11:00 PM on 01/03/2025. Further review of Patient #1's medical record failed to reveal documented vital signs after 11:00 PM on 01/03/2025.

Patient #1's medical record failed to reveal documentation for not completing the order for vital signs every 4 hours. There was also no order from the provider to discontinue obtaining vital signs every 4 hours. Further review failed to reveal that vital signs were obtained every 4 hours as per provider order.

In an interview on 01/27/2025 at 1:03 PM, S3RM and S8ND confirmed that vital signs were not obtained on Patient #1 as per provider order. S3RM and S8ND also confirmed there was no provider notification about why the vital signs were not obtained as per provider order.

In an interview on 01/29/2025 at 11:23 AM, S5CVP confirmed there is no documentation from the nurse for Patient #1 regarding not obtaining vital signs at 3:00 AM on 01/04/2025. S5CVP also stated that the nurse told her she used her judgement since the patient had previously been agitated.

3) Failure of the nursing staff to complete a stat CT as ordered by the physician for 1 (#1) of 3 (#1-#3) patient medical records reviewed.

A review of Patient #1's medical record revealed that on 01/03/2025 an Open Reduction Internal Fixation Mandibular Fracture and Extraction of Tooth #30 was performed in the operating room.
On 01/03/2025 at 7:00 PM a one-time order for a CT Maxillofacial without Contrast was entered with a priority level of stat. The order was entered by the surgeon post-op to assess the reduction of the procedure.

On 01/03/2025 at 9:59 PM, an additional note was entered in Patient #1's medical record by the radiology tech stating the following: Per patient nurse, patient is in restraints and will not follow commands. Patient will have to come out of restraints to have scan done. Someone will have to come to CT with patient and remove restraints for patient to have CT done tonight.

On 01/03/2025 at 10:10 PM, an additional note was entered in Patient #1's medical record by S11RN stating the following: Informed radiology tech that patient was being very combative and in 2 patient restraints and we will not be able to take the patient out of restraints for the test. Doctor notified patient not able to go for the CT.

Review of Patient #1's medical record failed to reveal that the order for the stat CT was changed or discontinued. Further review of the medical record failed to reveal that the stat CT order was completed as ordered. Patient #1's medical record also failed to reveal a documentation by S11RN from the physician in response to not completing the stat CT order.

In an interview on 01/30/2025 at 11:25 AM, S11RN confirmed that she was the primary nurse for Patient #1 on the night of 01/03/2025 through the morning of 01/04/2025. S11RN stated that the radiology tech called her about getting Patient #1 for the stat CT that was ordered and at the time the patient was uncooperative. Per S11RN, the radiology tech told her that they couldn't take the patient because he was in restraints. S11RN was asked if she made an additional attempt to get the patient to CT to complete the stat order. S11RN also stated that no one ever called about the CT being done or not, and stated OMFS didn't ask for it, so the patient probably would have just gone in the morning when they had time.

In an interview on 01/27/2025 at 12:55 PM, S3RM and S8ND confirmed that there is no documentation about the response from the physician regarding completing the stat CT order. At this time S3RM and S8ND verified that the stat CT order was never completed.

In an interview on 01/30/2025 at 11:38 AM, S5CVP confirmed that there is no hospital policy that states a patient cannot have a CT if they are in restraints.

In an interview on 01/30/2025 at 11:52 AM, S3RM confirmed that the stat CT order was never modified or discontinued from the original order placed on 01/03/2025 at 7:00 PM until it was automatically discontinued upon discharge from the system.

Based on record review and interview, the hospital nursing staff failed to follow hospital policy and standard of care for medication administration. This deficient practice is evidenced by failure of the nursing staff to monitor the therapeutic effectiveness of pain medications in 1 (#1) of 3 (#1-#3) patients reviewed.
Findings:

Review of hospital policy #5052 titled, "Pain Management," last revised 11/2024, revealed in part: "P. Pain management interventions should be evaluated for effectiveness. a. reassessment should occur within 90 minutes after an IV pain medication has been administered. b. Within 90 minutes after oral pain medication administration. c. Within 90 minutes of any reporting of pain and use of non-pharmacological pain intervention. Q. Assessment and Reassessment of pain management effectiveness must be documented within the patient's medical record."

Patient #1
Review of Patient #1's medication administration record revealed the following pain medications were administered:
01/02/2025 at 12:10 AM - Acetaminophen, 650 mg/20.3ml oral solution, Dose: 650 mg, every 6 hours for pain.
01/02/2025 at 5:44 AM - Acetaminophen, 650 mg/20.3ml oral solution, Dose: 650 mg, every 6 hours for pain.
01/03/2025 at 7:59 PM - Hydromorphone, 0.5mg IV, every 3 minutes, PRN for pain.
01/03/2025 at 11:09 PM - Oxycodone, 5mg/5ml oral solution, Dose: 5 mg, every 4 hours PRN for pain.

Further review of Patient #1's medical record and medication administration record failed to reveal a re-evaluation of the effectiveness of the medications listed above.

In an interview on 01/28/2025 at 12:26 PM, S3RM and S5CVP confirmed the above mentioned findings and verified that there were no documented re-evaluations of the effectiveness of the pain medications listed above.