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Based on interview and record review, the facility failed to ensure patient rights were honored, for two of 20 sampled patients (Patients 1 and 2), in accordance with the facility's policies and procedures (P&P), when restraint orders were not renewed in a timely manner.

These failures resulted in the misuse of restraints and had the potential for patient harm.

Findings:

1 a. On July 1, 2025, at 1 p.m., a review of Patient 1's medical record was conducted with the Stoke Program Coordinator (SPC). A facility document titled, "Admission H&P [History and physical]," dated February 17, 2025, was reviewed and indicated Patient 1 was admitted to the facility on February 17, 2025, and presented to the emergency room by ambulance for left sided chest pain that began two weeks ago. The document indicated, "...Past medical history includes the set of expressive aphasia [a language disorder where individuals have difficulty producing speech]..."

The facility document titled, "Restraint Initiation Non Violent," dated February 17, 2025, at 2:31 p.m., was reviewed and indicated, "...Priority: Routine, Requested start date and time: 2/17/2025 [February 17, 2025] 14:31 [2:31 p.m.] PST [Pacific Standard Time], Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 [two] Point Extremity [a limb of the body, specifically the arms and legs], Restraint location: Bilateral [both sides] Upper Extremity, Frequency: Once scheduled, Continuous: No..."

The facility document titled, "Restraint Renewal Non Violent," dated February 18, 2025, at 5:18 p.m., was reviewed and indicated, "...Priority: ASAP [as soon as possible], Requested start date and time: 2/18/2025 [February 18, 2025] 17:18 [5:18 p.m.] PST, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No..."

An untitled facility document, dated February 17, 2025, 1 p.m., through February 21, 2025, 1:59 p.m., was reviewed. The document indicated, on February 18, 2025, at 4 p.m., restraints remained on Patient 1 despite not having an active order on February 18, 2025, from 2:31 p.m. to 5:18 p.m.

The facility document titled, "Restraint Renewal Non Violent," dated March 6, 2025, at 10:54 a.m., was reviewed and indicated, "...Priority: Routine, Requested start date and time: 3/6/2025 [March 6, 2025] 10:54 a.m. PST, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No..."

The facility document titled, "Restraint Renewal Non Violent," dated March 7, 2025, at 6:38 p.m., was reviewed and indicated, "...Priority: Routine, Requested start date and time: 3/07/2025 [March 7, 2025] 18:38 [6:28 p.m.] PST, Reason for Restraints: Disconnects/removes therapeutic devices, Criteria for Release: Behavior no longer warrants restraint, Restraints: Hand mittens, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No..."

An untitled facility document, dated February 17, 2025, 1 p.m., through March 8, 2025, 1:59 p.m., was reviewed. The document indicated, from March 6, 2025, at 11 a.m., to March 7, 2025, at 6 p.m., restraints remained on Patient 1 despite not having an active order on March 6, 2025, at 10:54 a.m., to March 7, 2025, at 6:38 p.m.

An interview was conducted on July 1, 2025, at 1:15 p.m., with the SPC. The SPC stated restraints should be renewed within 24 hours. Based on documentation on February 18, 2025, the restraints were not removed or discontinued by the nurse while waiting for the renewal order. The SPC stated the nurse should have discontinued the restraints on February 18, 2025, at 2:31 p.m., when the order expired. There was no active restraint order for Patient 1 for approximately two and a half hours. The SPC further stated based on documentation on March 6, 2025, at 10:54 a.m., the restraints were not discontinued by the nurse while waiting for the renewal order. The SPC stated the nurse should have discontinued the restraints on March 6, 2025, at 10:54 a.m., when the order expired. There was no active order for Patient 1 for approximately eight hours.

1 b. On July 1, 2025, at 1:30 p.m., a review of Patient 2's medical record was conducted with the SPC. A facility document titled, "Admission H&P," dated June 25, 2025, was reviewed and indicated Patient 2 presented to the emergency room after sustaining a fall in the bathtub. Patient 2 was admitted for the diagnosis of Fournier Gangrene (a rare, but life-threatening infection).

The facility document titled, "Restraint Initiation Non Violent," dated June 25, 2025, at 1:21 p.m., was reviewed and indicated, "...Priority: Routine, Requested start date and time: 06/25/2025 [June 25, 2025] 10:00 PDT [Pacific Daylight Time], Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No..."

The facility document titled, "Restraint Renewal Non Violent," dated June 26, 2025, at 12:32 p.m., was reviewed and indicated, "...Priority: Routine, Requested start date and time: 06/26/2025 [June 26, 2025] 12:32 PDT, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No..."

An untitled facility document, dated June 26, 2025, 1:29 a.m., through July 2, 2025, 1:59 p.m., was reviewed. The document indicated, on June 26, 2025, at 10 a.m., restraints remained on Patient 2 despite not having an active order on June 26, 2025, from 10 a.m., to 12:32 p.m.

The facility document titled, "Restraint Renewal Non Violent," dated June 30, 2025, at 11:04 a.m., was reviewed and indicated, "...Priority: Routine, Requested start date and time: 06/30/2025 [June 30, 2025] 11:00 a.m. PDT, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No..."

The facility document titled, "Restraint Renewal Non Violent," dated July 1, 2025, at 3:26 p.m., was reviewed and indicated, "...Priority: Routine, Requested start date and time: 07/01/2025 [July 1, 2025] 15:26 [3:26 p.m.] PDT, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No..."

An untitled facility document, dated June 30, 2025, 12:00 a.m. through July 2, 2025, 12:00 a.m., was reviewed. The document indicated, on July 1, 2025, at 11:04 a.m., restraints remained on Patient 2 despite not having an active order on July 1, 2025, from 11:04 a.m., to 3:26 p.m.

An interview was conducted on July 1, 2025, at 3:20 p.m., with Registered Nurse (RN) 1. RN 1 stated Patient 2 is currently on the unit and wearing restraints. RN 1 further stated the order expired on July 1, 2025, at 11:04 a.m., and should not have been placed at 11:04 a.m. RN 1 further stated there is currently no active order right and Patient 2 should not be in restraints.

An interview was conducted on July 2, 2025, at 1:13 p.m., with the Accreditation and Regulatory Manager (ARM). The ARM stated if the restraint order is not renewed within 24 hours, it is expired and should no longer be on the patient until a new order is placed. Our policy reads order must be renewed "daily", which means within a 24-hour timeframe.

The facility P&P titled, "DES ADM 749 RESTRAINT & SECLUSION," dated January 18, 2024, was reviewed. The P&P indicated, "...to define [name of facility] approach to the use of Restraints and Seclusion for patients in a way that protects the patient's health and safety, and preserves their dignity, rights, and well-being...Restraint: any manual method: physical or mechanical device material, or equipment that immobilizes or reduces the patients ability to move...Authorized staff must never write Restraint orders on an "as needed" basis or as PRN orders or standing orders...Non-violent/Medical Behavior order for restraints based on medical needs/behaviors must be renewed daily..."

The facility P&P titled, "DES ADM 970 PHYSICIAN NOTIFICATION," dated December 20, 2019, was reviewed. The P&P indicated, "...It is the policy of [name of facility] to assure timely physician notification and appropriate physician intervention to treat each patient's needs..."

Based on interview and record review, the facility failed to ensure patient rights were honored, for one of 20 sampled patients (Patient 3), in accordance with the facility's policies and procedures (P&P), when restraint orders were placed on an "as needed" basis.

This failure resulted in the misuse of restraints and had the potential for patient harm.

Findings:

On July 1, 2025, at 1:45 p.m., a review of Patient 3's medical record was conducted with the Stoke Program Coordinator (SPC). A facility document titled, "Admission H&P [History and Physical]," dated June 15, 2025, was reviewed and indicated Patient 3 was admitted to the facility on June 15, 2025, and presented to the emergency room from a skilled nursing facility with shortness of breath. Admitting diagnosis of acute AKI (acute kidney injury- damage to the kidney causing it to not function properly) and hypokalemia (increased levels of potassium in the blood).

The facility document titled, "Restraint Renewal Non Violent," dated June 16, 2025, at 8:03 a.m., was reviewed and indicated, "...Priority: Routine, Requested start date and time: 06/16/2025 [June 16, 2025] 08:03 a.m. [8:03 a.m.] PDT, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 [two] Point Extremity [a limb of the body, specifically the arms and legs], Restraint location: Bilateral [both sides] Upper Extremity, Frequency: Once scheduled, Continuous: No..."

An untitled facility document, dated June 14, 2025, 3:52 a.m. through June 21, 2025, 3:59 p.m., was reviewed. The document indicated, on June 17, 2025, at 7:45 a.m., restraints were discontinued and no longer needed based on RN assessment.

The facility document titled, "Restraint Renewal Non Violent," dated June 18, 2025, at 10:40 a.m., was reviewed and indicated, "...Priority: Routine, Requested start date and time: 06/18/2025 [June 18, 2025] 10:40 a.m. PDT, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No..."

The facility document titled, "Restraint Renewal Non Violent," dated June 19, 2025, at 11:01 a.m., was reviewed and indicated, "...Priority: Routine, Requested start date and time: 06/19/2025 [June 19, 2025] 11:01 a.m. PDT, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No..."

The facility document titled, "Restraint Renewal Non Violent," dated June 21, 2025, at 07:30 [7:30 a.m.], was reviewed and indicated, "...Priority: Routine, Requested start date and time: 06/21/2025 [June 21, 2025] 07:30 a.m. PDT, Reason for Restraints: Interferes with Medical Device, Criteria for Release: Medical device not present, Restraints: Soft limb, Points of Restraint: 2 Point Extremity, Restraint location: Bilateral Upper Extremity, Frequency: Once scheduled, Continuous: No..."

An untitled facility document, dated June 14, 2025, 3:52 a.m. through June 21, 2025, 3:59 p.m., was reviewed. The document indicated the restraints were not needed for Patient 3 on June 18, June 19, or June 21.

An interview was conducted on July 2, 2025, at 1:20 p.m., with Registered Nurse (RN) 2. RN 2 stated the Resident ordered the restraints. However, on June 17, 2025, at 7:45 am, the restraints were discontinued by the nurse because they were no longer deemed necessary based on nursing assessment. The restraints were "pre-ordered" by the resident on June 18, June 19, and June 21.

An interview was conducted on July 2, 2025, at 1:25 p.m., with the ICU Manager (ICU-M). The ICU-M stated sometimes the residents "pre-order" the restraints despite the nurses not needing the order. The ICU-M further stated sometimes the residents think that they can put the order in "just in case" the nurses need them and that is not how it works.

An interview was conducted on July 2, 2025, at 1:13 p.m., with the Accreditation Regulatory Manager (ARM). The ARM stated the Resident who placed the restraint orders on June 18, 2025, June 19, 2025, and June 21, 2025, no longer works here and can't speak to why they were ordered when the patient no longer needed them.

The facility P&P titled, "DES ADM 749 RESTRAINT & SECLUSION," dated January 18, 2024, was reviewed. The P&P indicated, "...to define [name of facility] approach to the use of Restraints and Seclusion for patients in a way that protects the patient's health and safety, and preserves their dignity, rights, and well-being...Restraint: any manual method: physical or mechanical device material, or equipment that immobilizes or reduces the patients ability to move...Authorized staff must never write Restraint orders on an "as needed" basis or as PRN orders or standing orders...Non-violent/Medical Behavior order for restraints based on medical needs/behaviors must be renewed daily..."

The facility P&P titled, "DES ADM 970 PHYSICIAN NOTIFICATION," dated December 20, 2019, was reviewed. The P&P indicated, "...It is the policy of [name of facility] to assure timely physician notification and appropriate physician intervention to treat each patient's needs..."