Alta Bates Summit Medical Center

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 50146 Based on interview and record review, the hospital failed to ensure patients were free from unnecessary restraints when three of three sampled patients (Patients 10, 11, and 13) did not have appropriate physician-ordered restraints or appropriate monitoring of patients in restraints. This failure placed all patients in the hospital’s Acute Rehab Unit (ARU) at risk of inappropriate restraint use and possible injury and harm, up to and including death. Findings: During a review of the “H&P” for Patient 10, dated 5/29/26, the “H&P” indicated Patient 10 admitted to the hospital in May 2026 with a diagnosis of anoxic brain injury (a medical issue where the brain receives no oxygen, leading to brain cell death.) During a concurrent interview and record review on 6/11/26 at 2:00 p.m. with the Nurse Informaticist (NI), the untitled physician’s orders summary for Patient 10, undated, was reviewed. The summary indicated Patient 10 had orders for all four bed side rails (rails on the side of a bed that can be used to help patients move or as restraints) to be used as restraints from 6/2/26 to 6/6/26 on a continuous basis while Patient 10 was in bed, and to have a wheelchair belt placed on when Patient 10 was out of bed from 6/2/26 to 6/6/26. The summary further indicated Patient 10 did not have a valid order present for restraint usage on 6/3/26 from 12:09 p.m. to 2:09 p.m., and again on 6/5/26 from 2:16 p.m. to 5:06 p.m. During a concurrent interview and record review on 6/11/26 at 2:10p.m. with NI, the restraint monitoring flowsheets for Patient 10 were reviewed. The record indicated Patient 10’s restraints were not assessed and Patient 10 was not monitored during restraint usage on 6/3/26 from 12 a.m. midnight to 8:00 a.m. (four missed occurrences), on 6/4/26 from 12 a.m. midnight to 8:00 a.m. (four missed occurrences), and on 6/5/26 from 12 a.m. midnight to 8:00 a.m. (four missed occurrences.) NI confirmed no documentation was present that Patient 10 was monitored for restraint usage during these time periods. During a review of the “H&P” for Patient 11, dated 6/1/26, the “H&P” indicated Patient 11 admitted to the hospital in June 2026 with diagnoses of Parkinson’s disease and sepsis. During a concurrent interview and record review on 6/12/26 at 1:00 p.m. with the Nurse Informaticist (NI), the untitled physician’s orders summary for Patient 11, undated, was reviewed. The summary indicated Patient 11 had orders for all four bed side rails (rails on the side of a bed that can be used to help patients move or as restraints) to be used as restraints from 6/3/26 to 6/12/26 on a continuous basis while Patient 11 was in bed, and to have a wheelchair belt placed on when Patient 11 was out of bed from 6/3/26 to 6/12/26. During a concurrent interview and record review on 6/12/26 at 1:10 p.m. with NI, the restraint monitoring flowsheets for Patient 11 were reviewed. The record indicated Patient 11’s restraints were not assessed and Patient 11 was not monitored during restraint usage on 6/3/26 from 2:00 p.m. to 6/4/26 at midnight (five missed occurrences), on 6/4/26 from 4:00 p.m. to 6/5/26 at midnight (four missed occurrences), on 6/6/26 at 2:00 p.m. and 6:00 p.m., on 6/7/26 from 6:00 p.m. to 6/8/26 at midnight (three missed occurrences), 6/9/26 from 10:00 a.m. to 10:00 p.m. (seven missed occurrences), and 6/10/26 at 12:00 p.m. noon. NI confirmed no documentation was present that Patient 11 was monitored for restraint usage during these time periods. During a review of the “H&P” for Patient 13, dated 6/2/26, the “H&P” indicated Patient 13 admitted to the hospital in June 2026 with a diagnosis of multiple traumatic body injuries after a fall. During a concurrent interview and record review on 6/12/26 at 1:30 p.m. with NI, the untitled physician’s orders summary for Patient 13, undated, was reviewed. The summary indicated Patient 13 had orders for all four bed side rails to be used as restraints from 6/6/26 to 6/12/26 on a continuous basis while Patient 13 was in bed, and to have a wheelchair belt placed on when Patient 11 was out of bed from 6/6/26 to 6/12/26. The summary further indicated Patient 13 did not have a valid order present for restraint usage on 6/7/26 from 7:57 a.m. to 10:12 a.m., and again on 6/10/26 from 1:59 p.m. to 3:21 p.m. During a concurrent interview and record review on 6/12/26 at 1:40 p.m. with NI, the restraint monitoring flowsheets for Patient 13 were reviewed. The record indicated Patient 13’s restraints were not assessed and Patient 11 was not monitored during restraint usage on 6/9/26 at 10:00 a.m., on 6/10/26 from 8:00 a.m. to 2:00 p.m. (three missed occurrences), and on 6/11/26 from 8:00 a.m. to 12 p.m. noon (two missed occurrences.) NI confirmed no documentation was present that Patient 11 was monitored for restraint usage during these time periods. During an interview on 6/11/26 at 2:49 p.m. with Registered Nurse (RN2), RN2 stated if a patient’s order for restraints expired, the typical practice on the unit was to keep using the restraints, even if there was no order present. During an interview on 6/12/26 at 5:28 p.m. with the Director of Quality and Patient Safety (DQPS), DQPS stated the risks of missing physician’s orders for restraints and missing routine monitoring for restraint usage included violation of patients’ rights to be free of restraints and injury to patients. During a review of the hospital policy and procedure (P&P), titled “Restraints, Management Assessment and Use of”, dated 4/13/13 and last revised 1/20/22, the P&P indicated, “Use of restraint or seclusion must be in accordance with the order of a LP who is responsible for the care of the patient and trained per hospital policy to order restraint or seclusion ...”, “A new order must be obtained every 24 hours ...”, and “Evaluate patient and perform interventions every two (2) hours ...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 50146 Based on interview and record review, the hospital failed to ensure staff members were adequately trained when two of six sampled staff members did not have a completed job orientation packet. This failure placed all patients in the hospital’s Acute Rehab Unit (ARU) at risk of receiving inadequate and improper nursing care. Findings: During a review of the untitled hospital staff roster, undated, the record indicated Certified Nursing Assistant (CNA) 1 began working in the hospital in November 2019, and Registered Nurse (RN) 1 began working in the hospital in January 2026. During a review of the untitled staff training and competency file for CNA 1, undated, the “End User Proficiency Agreement”, undated, and the “[Health System] Department Orientation Checklist”, undated, were reviewed. The record had no documentation that CNA 1 had ever completed the “End User Proficiency Agreement” or the “Department Orientation Checklist.” During a review of the untitled staff training and competency file for RN 1, the “[Health System] Department Orientation Checklist”, undated, was reviewed. The record contained no documentation that RN 1 had ever completed this “Department Orientation Checklist.” During an interview on 6/12/26, at 3:36 p.m. with the Nurse Manager (NM), NM confirmed neither CNA 1 or RN 1 had any documentation present that they ever received job orientation. During an interview on 6/12/26 at 5:28 p.m. with the Director of Quality and Patient Safety (DQPS), DQPS stated the risks of inadequate or missing staff orientation include lack knowledge of how to adequately care for patients in the hospital. During a review of the hospital’s Policy and Procedure (P&P), titled “Orientation of Staff - Inpatient Acute Rehabilitation”, dated 6/16/21 and revised 7/12/24, the P&P indicated, “All new staff shall be given an individually tailored orientation to the Rehabilitation Program, taking into account each person’s experience and clinical skills ...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50146 The Condition of Participation - Patient’s Rights is not met as evidenced by: 1. Based on interview and record review, the facility failed to ensure one of three sampled patients (Patient 16) received care in a safe setting when Patient 16 was left unsupervised and fell out of bed and on to the floor. Patient 16’s bed was not at the lowest possible height and the right-side rail (rails attached to the side of a hospital bed) of the bed was down and was left unlocked. This failure resulted in Patient 16 falling out of bed and sustaining six pelvic fractures, a right-sided pelvic hematoma (a collection of blood pooling in the body outside of the blood vessels, often due to injury or trauma), and suffering from acute blood loss (a rapid and significant loss of blood) as a result of the hematoma. (Refer to Tag A-0144) 2. Based on interview and record review, the facility failed to ensure, for one of three sampled Patients (Patient 16), all visitors enjoyed full and equal visitation privileges consistent with patient preference when Patient 16 was denied visitors for a period of four days without appropriate rationale. This failure placed Patient 16 at risk of psychosocial harm, including isolation and loneliness. (Refer to Tag A-0217) Therefore, the cumulative failure of the hospital to protect and promote each patient’s rights resulted in the hospital’s failure to meet the Condition of Participation for Patient’s Rights.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 50146 The Condition of Participation - Discharge Planning is not met as evidenced by: Based on interview and record review, Facility 1 failed to ensure, for one of three sampled Patients (Patient 16), the discharge plan was consistent with Patient 16’s treatment preferences when Facility 1 discharged Patient 16 home against Patient 16’s family’s preference that Patient 16 be admitted to a Skilled Nursing Facility (SNF, an inpatient rehabilitation and medical treatment center providing 24-hour care from licensed nurses and therapists.) This failure resulted in Patient 16 being unsafely discharged home from Facility 1 and Patient 16 being admitted and hospitalized at a different facility, Facility 2, later that same day. After a one-week admission at Facility 2, Patient 16 was transferred to a SNF to continue receiving rehabilitative care. Therefore, the cumulative failure of these systemic problems resulted in Facility 1’s failure to meet the Condition of Participation for Discharge Planning. Findings: During a review of Facility 1’s document titled “History and Physical” (H&P, a document used to communicate a patient’s previous medical history and current reason for needing medical care), dated 1/22/26, for Patient 16, the “H&P” indicated Patient 16 was admitted to Facility 1 in January 2026 with diagnoses of generalized weakness, acute encephalopathy (a brain disease that alters brain function or structure, manifested by declining ability to reason and concentrate), sepsis (a serious condition in which the body responds improperly to an infection, causing the organs to work poorly), depression (a mood disorder that causes a persistent feeling of sadness), multiple pelvic fractures (broken bones), and acute blood loss anemia (a blood disorder characterized by a lack of red blood cells, which results in the body being unable to oxygenate tissues) due to pelvic fractures. During a review of Facility 1’s document titled “Care Plan Notes” (a type of progress note used to document a patient’s progress in their plan of care), dated 1/23/26, for Patient 16, the “Care Plan Notes” indicated Patient 16’s “Patient Identified Support for discharge planning” was a Family Member (FM). During a review of Facility 1’s document titled “Formal Legal Notice of Active Appeal, Medicare Coverage Confirmation, Unsafe Discharge Risk, and Invocation of Federal Patient Rights Protection”, dated 2/27/26, for Patient 16, the “Formal Legal Notice of Active Appeal, Medicare Coverage Confirmation, Unsafe Discharge Risk, and Invocation of Federal Patient Rights Protection” indicated, “an expedited appeal has been initiated with [Patient 16’s insurance provider] regarding [SNF] placement”, and, “Given [Patient 16’s] ... condition, [Patient 16’s FM] formally request that the hospital coordinate [Patient 16’s] safe transfer to a Skilled Nursing Facility rather than discharge home.” During a concurrent interview and record review on 3/6/26 at 10:35 a.m. with Registered Nurse Case Manager (RNCM), Facility 1’s document titled “Care Plan Notes”, dated 2/28/26 and timed at 7:57 a.m. for Patient 16 were reviewed. The “Care Plan Notes”, indicated, “[Case manager, case management leadership], and upper management received email from [FM] regarding [Patient 16’s] [discharge plan] ... plan is to move forward with [discharge] home with [home health] today ... pickup at 10AM.” RNCM stated Facility 1’s leadership received and were aware of this email, which contained the “Formal Legal Notice of Active Appeal, Medicare Coverage Confirmation, Unsafe Discharge Risk, and Invocation of Federal Patient Rights Protection”, dated 2/27/26. RNCM confirmed Patient 16 was discharged from Facility 1 to FM’s home, and this decision was made by case management leadership despite FM’s documented request to have Patient 16 admitted to a SNF. During an interview on 3/6/26 at 11:00 a.m. with the Case Management Director (CMD), CMD confirmed the case management department received a copy of the “Formal Legal Notice of Active Appeal, Medicare Coverage Confirmation, Unsafe Discharge Risk, and Invocation of Federal Patient Rights Protection”, dated 2/27/26, sent by Patient 16’s FM. CMD stated Patient 16 was discharged back to FM’s home despite Patient 16’s and FM’s treatment preferences. CMD was unable to state why Facility 1 discharged Patient 16 against FM’s stated preference to have Patient 16 admitted to a SNF. During a review of Patient 16’s “H&P”, dated 3/1/26, from Facility 2, the “H&P” indicated, “[Patient 16] ... recent admission at [facility 1] ... was ... sent home yesterday ... re-presented to [Emergency Department] ... here for SNF placement.” During a review of Patient 16’s “Discharge Summary”, dated 3/5/26, from Facility 2, the “Discharge Summary” indicated, “Discharge Disposition: Skilled Nursing Facility ...”, and “Family unable to care for patient at home due to mobility needs. [Physical Therapy/Occupational Therapy] evaluation recommending SNF ...” During a review of Facility 1’s policy and procedure (P&P), titled “Discharge Coordinating”, last reviewed and effective 9/18/24, the P&P indicated the purpose of discharge coordination is to “address the patient’s needs for continuing care, treatment, and services after discharge or transfer ...””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50146 Based on interview and record review, the hospital failed to ensure one of three sampled patients (Patient 16) received care in a safe setting when Patient 16 was left unsupervised and fell out of bed and on to the floor. Patient 16’s bed was not at the lowest possible height and the right-side rail (rails attached to the side of a hospital bed) of the bed was down and was left unlocked. This failure resulted in Patient 16 falling out of bed and sustaining six pelvic fractures (broken bones), a right-sided pelvic hematoma (a collection of blood pooling in the body outside of the blood vessels, often due to injury or trauma), and suffering from acute blood loss (a rapid and significant loss of blood) as a result of the hematoma. Findings: During a review of the hospital’s document titled “History and Physical” (H&P, a document used to describe a patient’s past medical history and current condition) dated 1/16/26, for Patient 16, the “H&P” indicated Patient 16 was admitted to the hospital in January 2026, with diagnoses of right-sided body pain, gout (a condition where the body cannot clear certain acids, resulting in chronic pain), and a history of two prior strokes (a condition where blood flow to the brain is interrupted, causing damage to the brain.) During a review of the hospital’s document titled “Post Fall SBAR” (Situation, Background, Assessment, and Recommendation, a document used to describe a situation and the hospital’s response to it) dated 1/17/26, for Patient 16, the “Post Fall SBAR” indicated, on 1/17/26, “Informed by ... registration clerk that ‘the patient fell.’ Entered patient’s room to find the right-side rail down and the bed not in lowest position. Patient found lying on the ground on ... right side ...” During a review of the hospital’s document titled “ED [(Emergency Department)] Notes” for Patient 16, dated 1/17/26, the “ED Notes” indicated Patient 16’s blood had been drawn on 1/16/26 to rule out potential causes of Patient 16’s pain. The “ED Notes” also indicated Patient 16 had been discharged back to a Skilled Nursing Facility (SNF, a facility which provides 24-hour medical care to patients who have chronic medical conditions) on 1/17/26. During a review of the SNF’s document titled “Admission Record” (a document used to communicate the most pertinent information about a patient) undated, for Patient 16, the “Admission Record” indicated Patient 16 was currently residing there and had been admitted there since January 5, 2026. During a review of the SNF’s document titled “Progress Notes” (a document used to capture a patient’s progress for a set amount of time) for dates 1/16/26-1/19/26, for Patient 16, the “Progress Notes” indicated Patient 16 had no falls or injuries from 1/16/26-1/19/26. During a review of the hospital’s document titled “H&P” dated 1/19/26, for Patient 16, the “H&P” indicated Patient 16 returned to the hospital with diagnoses of increased lethargy (weakness) and a high fever of 102.0 degrees Fahrenheit (a unit of measure). The “H&P” indicated the hospital took a sample of Patient 16’s blood prior to discharge, and then discharged Patient 16 back to the SNF later that day. During a review of the hospital’s document titled “H&P” dated 1/22/26, for Patient 16, the “H&P” indicated Patient 16 returned to the hospital with diagnoses of acute encephalopathy (a brain disease where a person’s brain function becomes altered, often due to infection, toxins, organ failure, or trauma) due to ongoing anemia (a condition where the body does not produce enough healthy red blood cells, which reduces oxygen delivery to all parts of the body), and “exquisite tenderness to touch” of the right knee. During a review of the hospital’s document titled “CT (Computerized tomography, a scan that uses a rotating machine to create 3D images of bones, organs, and body structures) Abdomen Pelvis Without Contrast (Final Result) (a CT scan which focuses on the abdomen and pelvic region and does not use a contrast liquid as part of the scan)”, dated 1/23/26, for Patient 16, the “CT Abdomen Pelvis Without Contrast (Final Result)” indicated a Doctor of Osteopathic Medicine (DO, a type of physician) had ordered a “CT Scan” for Patient 16 on 1/22/26. The “CT Abdomen Pelvis Without Contrast (Final Result)” indicated Patient 16 had “multiple pelvic fractures, involving the right ... pubic ramus (a segment of bone in the pelvis), right ... acetabulum (a part of the pelvis where several bones meet), right sacrum (a bone in the lower back near the middle of the pelvis), bilateral pubis (the portion of the hip bone near the abdomen), and ... left ... pubic ramus ...” and, “large hematoma at the right ...pelvic musculature, extending ...” During an interview on 3/5/26 at 12:23 p.m. with the Medical Doctor (MD), MD stated Patient 16’s fractures appeared to be new and had not healed. MD stated based on the presentation of the CT results and Patient 16’s history, the fractures were “most likely” the result of the fall Patient 16 had during the 1/16/26-1/17/26 ED admission. During a review of the hospital’s document titled “Provider Progress Notes” dated 1/23/26, for Patient 16, the “Provider Progress Notes” indicated Patient 16’s diagnosis had been updated to include “acute blood loss anemia due to pelvic fractures” and “multiple pelvic fractures.” During an interview on 3/6/26 at 9:34 a.m. with the Healthcare Risk Officer (HRO), HRO stated a laboratory staff member had drawn Patient 16’s blood during Patient 16’s 1/16/26-1/17/26 ED admission. HRO stated, as part of the facility’s root case analysis, the hospital determined the laboratory staff member had adjusted the height of Patient 16’s bed to be higher than the lowest possible position and left the right-side rail of Patient 16’s bed down, which led to Patient 16 falling out of bed. During a review of the hospital’s policy and procedure (P&P) titled. “Rights and Responsibilities of Patients”, dated 11/1/91 and reviewed 8/14/24, the P&P indicated, “All ... employees and medical staff are responsible for recognizing and observing the rights and responsibilities of all patients ...””

“PATIENT VISITATION RIGHTS CFR(s): 482.13(h)(3), (h)(4) [A hospital must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation. A hospital must meet the following requirements]: (3) Not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. (4) Ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences. This Standard is not met as evidenced by: 50146 Based on interview and record review, the facility failed to ensure, for one of three sampled Patients (Patient 16), all visitors enjoyed full and equal visitation privileges consistent with patient preference when Patient 16 was denied visitors for a period of three days without appropriate rationale. This failure had the potential to result in psychosocial harm to Patient 16 and placed all patients receiving care in the facility at risk for inappropriate denial of their rights. Findings: During a review of the facility’s document titled “History and Physical” (H&P, a document used to communicate a patient’s previous medical history and current reason for needing medical care), dated 1/22/26, for Patient 16 , the “H&P” indicated Patient 16 was admitted to facility in January 2026, with diagnoses of generalized weakness, acute encephalopathy (a brain disease that alters brain function or structure, manifested by declining ability to reason and concentrate), sepsis (a serious condition in which the body responds improperly to an infection, causing the organs to work poorly), and depression (a mood disorder that causes a persistent feeling of sadness). During a review of the facility’s document titled “Care Plan Notes” (a type of progress note used to document a patient’s progress in their plan of care), dated 2/20/26 for Patient 16, the “Care Plan Notes” indicated, “CM [Case Management] Director and RN [Registered Nurse] Supervisor spoke with [Family Member (FM)1] and FM 2 at [bedside] regarding [discharge plan]. They informed [FM 1] of [skilled nursing facility {SNF, a facility that provides 24-hour-a-day nursing care for patients}] choices and will have 24 hours before the facility will enforce trespassing due to patient 16 being medically stable for [discharge.]” During a review of the facility’s document titled “Care Plan Notes”, dated 2/23/26, for Patient 16, the “Care Plan Notes” indicated, “[Social worker] called [FM 1] to discussed to [discharge] plan ... She summarized the discussion that she and [case management] leadership and assistant nurse manager had yesterday about her having to make a decision on [skilled nursing facility] in 24 hrs as of yesterday’s discussion with Leadership. [FM 1] stated that she was told that family will not have access to premises after that 24 hr period. Her understanding was that if she had made a decision on a SNF, then family would still be able to visit ... [Social worker] met with [patient 16’s] FM 2 at bedside around 12:20PM ... [Social worker] also notified [patient’s] FM 2 that Security will be limiting visitation today starting at 12:30PM. [Patient 16’s] FM 2 proceeded to get his belongings and was ... leaving pt’s [Patient 16’s] room.” During a concurrent interview and record review on 3/3/26 at 11:51 a.m. with the Accreditation, Licensing, and Regulation Director (ARLD), the facility’s document titled “Care Plan Notes”, dated 2/23/26, for Patient 16 were reviewed. ARLD confirmed visitation was restricted for Patient 16 for a period of three days, from 2/23/26 to 2/25/26 (date inclusive.) ARLD stated Patient 16’s family did not have any incidents in which they interfered with care or posed a safety risk to Patient 16, any other patients in the facility, or facility staff. ARLD stated the facility restricted visitation for Patient 16 based on disagreement between the facility and the patient’s family about a discharge plan for Patient 16. ARLD stated visitation should not be restricted based on disagreement over the discharge plan. During an interview on 3/3/26 at 12:11 p.m. with Director of Nursing 2 (DON2), DON2 stated Patient 16’s FM 2 was made to leave the facility abruptly on 2/23/26 due to the visitation restriction. During a review of the facility’s policy and procedure (P&P), titled “[Facility Name] Visitor Policy”, last revised and effective 2/19/25, the P&P), the P&P indicated, “All patients will have the right to receive visitors of their choice during their stay unless visitation: a. Interferes with patient care or safety. b. Impacts the well-being or rights of others. c. Is not medically indicated ...””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 38534 Based on record review and interview, the facility failed to: 1. Complete a pain assessment and reassessment for four of 30 sample selected patients (Patient 13, 11, 4, and 16), when Patients 13, 11, 16, and 4 had pain, were not being assessed, nor were they reassessed for pain based on the facility’s policy and procedure (P&P). 2. Complete the restraint monitoring sheet for one of 15 sample selected patients (Patient 7), when Patient 7 had an order for restraint use and the nurses did not document if they monitored Patient 7 every two hours as required by the facility’s P&P. These failures could have resulted in: 1. Patients 13, 11, 16 and 4 experiencing uncontrolled pain, delayed treatment, increased complications, and reduced satisfaction. 2. Patient 7 being placed at risk for unrecognized circulatory impairment, respiratory compromise, skin injury, or psychological harm due to the lack of timely assessment and intervention. Findings: 1. A review of Patient 13’s “Medicine/ Hospitalist History & Physical (H&P)” undated, indicated Patient 13 was admitted to the facility with multiple diagnosis including left leg and arm pain. During a review of Patient 13’s “Pain and Agitation” record, the “Pain and Agitation” record indicated on 3/2/26, at 09:14 a.m., Patient 13 had pain level “6” and received acetaminophen (pain reliever). At 5:50 p.m., staff checked Patient 13’s pain level again and it was “8”. At 12:03 a.m., Patient 13’s pain level was “7”, and Patient 13 received two milligrams (mg, a unit of measure) of Morphine Sulfate (a narcotic pain reliever). At 6:39 a.m. approximately 6 hours and 36 minutes later, Patient 13’s pain level was rechecked and was “8”. During a review of Patient 11’s “H&P”, the “H&P” indicated Patient 11 was admitted to the facility with multiple diagnosis including chest pain. During a review of Patient 11’s “Pain and Agitation” record, the “Pain and Agitation” record indicated on 3/3/26, at 05:33 a.m., Patient 11 had pain level “7 (severe)”. The “Pain and Agitation” record indicated Patient 11’s pain was not reassessed until 4:10 p.m., which was 10 hours and 37 minutes later. During a review of Patient 4’s “H&P”, the “H&P” indicated Patient 4 was admitted to the facility with multiple diagnosis including seizures. During a review of Patient 4’s “Pain Flowsheet”, the “Pain Flowsheet” indicated on 2/27/26 at 2:11 a.m., Patient 4’s pain level was 8 (severe). Patient 4’s pain was not reassessed until 8:45 a.m., which was 6 hours and 34 minutes later. During a review of Patient 4’s “Medication Administration Record (MAR)”, the “MAR” indicated Patient 4 received 0.5 mg of Hydromorphone (opioid pain reliever) intravenously (IV) (Intravenous) at 2:11am. During a concurrent interview and record review on 3/4/26, at 3:00 p.m., with Registered Nurse (RN) 2, Patient 13, 11, and 4’s “Pain flowsheets”, “Pain and Agitation”, and “H&P” documents were reviewed. RN2 confirmed that the nursing staff did not reassess Patient 13, 11 & 4’s pain level based on the facility’s policy. During an interview on 3/4/26 at 2:15 p.m., with the Director of Nursing (DON), DON stated Patients’ pain level must be checked at least two hours after receiving pain medication per the facility’s P&P. DON stated that not checking a patient’s pain level can cause the patient’s condition to worsen. A review of the facility’s P&P titled “ Pain, Management of; Policy and Procedure “ revised 1/25/21, indicated “ ... Upon admission, patients are asked if they are experiencing pain, or assessed for pain for those who are unable to self-report ...Compare post-intervention pain level to Acceptable Level of Pain to determine intervention effectiveness and/or additional interventions for patients able to provide a self-report 1. Reassessment of pain following treatment occurs within a time frame. a. Sufficient for the treatment to reach effectiveness. b. Should not exceed 2 hours ...” 2. During a review of Patient 7’s “H&P”, the “H&P” indicated Patient 7 was admitted to the facility with multiple diagnosis including ST elevation myocardial infarction (a type of heart attack). During a review of Patient 7’s “Restraints For Non-Violent, Non-Self-Destructive Behaviors - Daily (Order 2315753908)” record, the “Restraints For Non-Violent, Non-Self-Destructive Behaviors - Daily (Order 2315753908)” indicated the physician ordered restraints on 2/28/26 at 9:19 p.m., and canceled the order on 3/1/26 at 8:08 a.m. During a review of Patient 7’s “Restraint Flowsheet” dated from 2/28/26 at 9:00 p.m.-3/1/26 at 2:00 a.m., the “Restraint Flowsheet” was blank and did not include any assessment by the nursing staff. During an interview on 3/6/26 at 9:20 a.m., with RN3, RN3 stated she did not implement the restraint order for Patient 7 because Patient 7 was in a “coma” and did not need a restraint. RN3 stated that she did not document in Patient 7’s EMR because it is not the facility’s standard of practice to document the reason why a restraint is discontinued. A review of the facility’s P&P titled “Restraints, Management Assessment and Use of” revised 1/20/22, indicated “ ...Registered Nurse (RN): Assesses for the need, based on specific patient behaviors, and type of restraint, provides ongoing assessment /interventions and discontinues, the restraints as patient condition warrants ... Assess the patient after application of restraint and document ...Evaluate patient and perform interventions every two (2) hours (or more often, if indicated), per Non-violent Restraint Flowsheet in the medical record ...””