Lac/Rancho Los Amigos National Rehabilitation Ctr

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure the plan of care for one of six sampled patients (Patient 3) was updated to reflect the use of restraints. This failure posed a risk for substandard patient outcomes. Findings: Review of the hospital’s P&P titled Violent and Non-Violent Restraints dated 1/22/25, showed documentation should be done according to the regulatory and agencies standards. Clinical staff must document the following: * Initiate the Risk for Injury Related to Restraint, Interdisciplinary Plan of Care (IPOC) to justify the use of restraint. On 8/6/26 at 1148 hours, medical record review for Patient 3 was initiated with Assistant Nursing Director 1, Assistant Nursing Director 2, and the Clinical Instructor. Patient 3’s medical record showed the patient was admitted to the hospital on 12/23/25, and discharged on 1/16/26. Review of the Inpatient Progress Note dated 1/15/26 at 2310 hours, showed Patient 3 was restrained after becoming increasingly agitated, unable to be redirected, and physically assaultive, including hitting, scratching, and biting staff. Review of Patient 3’s physician order dated 1/15/26 at 2054 hours, showed an order to apply hard restraints to all four extremities due to physical abuse toward others. Review of Patient 3’s medical record showed the restraints were applied on 1/15/26 at 2030 hours, and removed at 2125 hours. However, further review of Patient 3’s medical record did not show Patient 3’s plan of care was updated to reflect the use of restraints. On 8/6/26, Assistant Nursing Director 1, Assistant Nursing Director 2, and the Clinical Instructor verified the findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 39199 Based on interview and record review, the staff failed to assess and monitor one of six sampled patients (Patient 3) while the patient was in restraints. This failure had the potential to result in unsafe care for the patient. Findings: Review of the hospital’s P&P titled Violent and Non-Violent Restraints dated 1/22/25, showed: * A staff member will remain with the patient while on restraints and monitor the patient every 15 minutes for behavioral health patient activity, restraint type, restraint location, signs of injury, and respiratory rate. * Documentation should be done according to the regulatory and agencies standards. Clinical staff must document the following: Patient monitoring. On 8/6/26 at 1148 hours, review of Patient 3’s medical record was conducted with Assistant Nursing Director 1, Assistant Nursing Director 2, and the Clinical Instructor. Patient 3’s medical record showed the patient was admitted to the hospital on 12/23/25, and discharged on 1/16/26. Review of the Inpatient Progress Note dated 1/15/26 at 2310 hours, showed Patient 3 was restrained after becoming increasingly agitated, unable to be redirected, and physically assaultive, including hitting, scratching, and biting staff. Review of Patient 3’s physician order dated 1/15/26 at 2054 hours, showed an order to apply hard restraints to all four extremities due to physical abuse toward others. Review of Patient 3’s medical record showed the restraints were applied on 1/15/26 at 2030 hours, and removed at 2125 hours. However, review of Patient 3’s medical record did not show that staff completed the required assessments and monitoring during the restraint episode. The record contained no documentation showing the patient’s respiratory rate was monitored every 15 minutes. On 8/6/26, during the concurrent interview and record review, Assistant Nursing Director 1, Assistant Nursing Director 2, and the Clinical Instructor verified the findings.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 38660 Based on an interview and record review, the hospital failed to ensure that advance directive information was provided for one of two sampled patients (Patient 1) as requested to formulate the Advance Directive. This had the potential for the patient’s decisions regarding health care and treatment options not being honored. Findings: During a review of the hospital’s P&P titled, “Advance Health Care Directives” dated 1/17/25, the P&P showed * Advance Health Care Directive or Advance Directive means either an individual health care instruction or a power of attorney for health care. * Individual Health Care Instruction or Individual Instruction means a patient’s written or oral direction concerning a health care decision. * Inpatient Admission Procedure: - During the admission process, nurses are required to ask and document in the electronic health record (EHR) if the patient has an advance directive for: adults over the age of 18 or emancipated minors; responsible for adults who were cognitively impaired or mentally incompetent. - If the response is “no,” the staff shall ask the patient if they wish to receive further information on the advance directive. If the patient requests more information: provide a brochure on Advance Health Care Directives and/or advise the patient or relative that information on Advance Health Care Directives is available through closed-circuit television and/or refer to the Social Work Department for further information. * Social Work Procedure: - When requested by the patient, family, or staff, the social worker offers information/assistance with Advance Health Care Directives to patients who did not have Advance Health Care Directives on file. - Refer patients to physicians for information regarding their health care choices as requested. - Document in the Social Work Progress Note of the medical record all actions taken regarding Advance Health Care Directives. During a review of Patient 1’s medical record on 1/28/26, Patient 1’s medical record showed the patient was admitted to the hospital on 10/24/25. During a review of the Admission History Adult in the EHR, the Advance Directives (AD) tab showed Patient 1 did not have an advance directive and wished to receive further information about the advance directive. A referral was made to the social worker. During a review of Patient 1’s medical records, the medical records did not show Patient 1 received any information about the advance directive. During a concurrent interview and record review with the CSW Supervisor and the Clinical Nursing Director on 1/28/26 at 1436 hours, the CSW Supervisor stated that all patients without AD were referred to CSW, who assisted capable patients who wished to complete their AD by explaining and giving them the form to apply for the AD. The CSW Supervisor verified Patient 1 did not receive information about the advance directive.”