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Based on interview and record review, the facility failed to provide a comfortable and safe environment for one patient (Patient 1) when Patient 1's urinary retention (UR - unable to empty the bladder completely) was not attended to.

This failure had the potential to affect Patient 1's health, comfort, and well-being.

Findings:

Patient 1 was admitted to the facility on 8/20/25 with diagnoses of osteoarthritis (joint disorder that causes pain), per the admission record.

A concurrent interview and record review was conducted with Clinical Nurse Educator (CNE) 1 on 8/28/25 at 3 P.M. Patient 1's nursing genitourinary assessment (NGUA -nursing evaluation of a patient's urine status) dated 8/27/25 at 12:42 P.M. and 4 P.M., indicated that Patient 1 had not voided (urinated) and had UR. CNE 1 stated that there was no indication in Patient 1's medical record that Patient 1 refused care, and Patient 1 was not reassessed until 8/28/25 at 8 A.M. CNE 1 stated that a bladder scan (non-invasive procedure to measure the urine in the bladder) should had been completed on Patient 1 to identify how much urine Patient 1 had in the bladder. CNE 1 further stated that the nurse should have called the physician to obtain an order for urinary catheterization (tube inserted to drain urine) to help alleviate Patient 1's UR and/or discomfort.

The facility's policy titled, Patient Care Services, dated 5/2024 indicated, "V ...System Review ...1. GU: b. Assess for urine color and clarity, frequency and voiding difficulty. 3. Use bladder scanner to assess for urinary retention. "

Based on interview and record review, the facility failed to ensure patient monitoring for restraint was completed per physician order and hospital policy for 1 of 30 patients (Patient 24). This failure had the potential to affect Patient 24's safety and well-being.

Findings:

Patient 24 was admitted to the facility on 8/27/25 with diagnoses which included subdural hematoma (bleeding near the brain) status post (after) unwitnessed fall and delirium (a change in mental abilities), per the History and Physical (H & P) dated 8/27/25.

A review of Patient 24's physician's orders dated August 2025 was reviewed.

An order dated 8/27/25 at 7 P.M. indicated, Restraint Monitoring Non-Violent: Frequency: 12 times per day ... Restraint Location: RUE/LUE (right upper extremity/left upper extremity)."

An order dated 8/27/25 at 9:57 P.M. indicated, "Restraint Monitoring Non-Violent: Frequency: 12 times per day ... Restraint Location: posey vest."

A review of Patient 24's restraint information indicated that restraint on the torso (central part of the body that includes the chest, abdomen, and back) was initiated (applied) on 8/27/25 at 6 P.M., and the restraint on the bilateral upper extremity was initiated on 8/27/25 at 8:30 P.M.

A review of Patient 24's restraint information, dated 8/29/25 was conducted. There was no documentation of restraint monitoring between 5 A.M. to 8:04 A.M.

A concurrent interview and record review was conducted on 8/29/25 at 2:45 P.M. with the Director of Regulatory (DR). The DR stated that per Patient 24's physician's order, restraint monitoring was (supposed to be) 12 times per day and approximately every 2 hours. However, on 8/29/25, Patient 24's torso and bilateral upper extremity were not monitored between 5 A.M. to 8:04 A.M.

Further review of Patient 24's record titled Restraint Information, dated 8/29/25 was conducted and indicated that restraint monitoring was monitored nine (9) times and not 12 times per physician order.

A review of the hospital's policy and procedure titled, Restraint Used for Non-Violent/Non-Self-Destructive Behavior last revised 8/2019 I indicated, "F. Orders: 1. Restraint is used upon the order of a physician/AHP. H. Ongoing Monitoring and Documentation ... 4. Assessment and Reassessment. A. The RN shall reassess patients in restraint approximately every 2 hours or more frequently if necessary ..."