Alvarado Parkway Institute Behavioral Health Syste

“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: 39474 Based on observation, interview, and record review, the facility failed to ensure 1 of 7 sampled patients (Patient 1) received care in a safe setting when facility staff failed to provide adequate supervision and maintain effective security measures to prevent Patient 1, who was detained under an involuntary psychiatric hold, from leaving the secured psychiatric facility without authorization. Patient 1 scaled a 9-foot high-security anti-climb metal perimeter fence and eloped from the facility. This failure resulted in Patient 1 leaving the secured hospital environment without authorization or staff supervision while Patient 1 was under an involuntary psychiatric hold for continued psychiatric treatment. Patient 1 was not returned to the facility following the elopement for 4 consecutive days. The elopement placed Patient 1 at risk for injury, self-harm, harm to others, exposure to environmental hazards, and interruption of necessary psychiatric treatment. Findings: During an observation on 8/10/26 at 12:34 p.m. in the facility’s south patio, a 9-foot-high security anti-climb metal perimeter fence was observed surrounding the patio. A gap existed in the anti-climb portion of the perimeter fence and just below with gap, was a raised planter. Because the planter was positioned under the portion of the fence where the gap existed, it elevated the standing surface creating the potential for an individual to reach that portion of the fence and pull themselves up. During a review of the facility’s security surveillance video dated 7/20/26 with the Manager of Performance Improvement and Patient Safety (MPS) on 8/10/26 at 2:01 p.m., the video showed Patient 1 scale the 9-foot high-security anti-climb metal perimeter fence using a raised planter and reaching the area where a gap existed in the anti-climb portion of the perimeter fence at approximately 6:51 p.m. Patient 1 was able to climb over the fence and eloped from the facility property without authorization. During an interview on 8/10/26 at 2:01 p.m., the MPS acknowledged the security surveillance video showed Patient 1 scale the 9-foot high-security anti-climb metal perimeter fence and eloped from the facility property without authorization on 7/20/26 at approximately 6:51 p.m. During an interview on 8/10/26 at 3:54 p.m., Registered Nurse 1 (RN1) acknowledged Patient 1 scaled the 9-foot high-security anti-climb metal perimeter fence and eloped from the facility. RN1 stated Patient 1 should not have been able to elope from the facility while detained under an involuntary psychiatric hold. During an interview on 8/11/26 at 2:20 p.m., the Director of Nursing (DON) acknowledged Patient 1 scaled the 9-foot high-security anti-climb metal perimeter fence and eloped from the facility. The DON stated Patient 1 should not have been able to elope from the facility while detained under an involuntary psychiatric hold. A review of Patient 1’s demographic information and history and physical indicated Patient 1 was admitted to the facility on 7/9/26 with diagnoses which included grave disability, schizoaffective disorder (a chronic mental health disorder characterized by symptoms of schizophrenia, such as hallucinations or delusions, together with symptoms of a mood disorder), bipolar disorder with psychotic features (a mental health disorder characterized by significant changes in mood and energy accompanied by symptoms such as hallucinations or delusions), and multiple illicit drug dependence. A review of Patient 1’s Application for 72-Hour Detention for Evaluation and Treatment (a legal document authorizing the involuntary detention of an individual for psychiatric evaluation and treatment, commonly referred to as a 5150 hold), dated 7/11/26, indicated Patient 1 was detained for grave disability. A review of Patient 1’s Notice of Certification for Intensive Treatment (a legal document authorizing up to 14 additional days of involuntary psychiatric treatment pursuant to California Welfare and Institutions Code section 5250), dated 7/14/26, indicated Patient 1 required continued involuntary psychiatric treatment due to grave disability. A review of the facility’s licensed nursing discharge progress note, dated 7/20/26 at 7:30 p.m., indicated, at approximately 6:45 p.m., staff prepared patients for a scheduled patio break. At approximately 6:47 p.m., Patient 1 was first in a line of patients being escorted to the south patio. At approximately 6:50 p.m., one staff member escorted the patients down the ramp toward the patio while a second staff member remained at the patio entrance holding the door for the remaining patients. The progress notes further indicated, Patient 1 rapidly changed direction and fled the area. Staff recognized Patient 1 had eloped and called for assistance. Patient 1 was not immediately recovered and did not return to the facility following the elopement for four consecutive days. A review of the facility’s policy and procedure titled “Elopements - Prevention and Response Guidelines”, dated 9/2021, indicated the facility’s policy was to implement appropriate precautions for patients who presented or became at risk for elopement. The policy identified its purpose as minimizing the potential for elopement through prompt identification and intervention for patients at risk and protecting patient safety.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 22383 Based on interview and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by: The hospital failed to ensure patient’s restraints were removed at the earliest opportunity for 5 of 10 sampled patients (refer to A-0154). The hospital failed to ensure the restraint and seclusion policy was followed to ensure safe and appropriate use of restraints for 8 of 10 sampled patients (refer to A-0167). The hospital failed to ensure there was a physician’s order for each incident of restraint and every 4 hours during restraint for 1 of 10 sampled patients (refer to A-0168). The hospital failed to ensure 1 of 10 sampled patients was seen and assessed by a Registered Nurse face to face within the hour after the initiation of restraints (refer to A-0178). The hospital failed to ensure the Registered Nurse consulted the Physician as soon as possible for 1 of 10 sampled patients after the completion of the hourly face to face assessment (refer to A-0182). The hospital failed to ensure 2 of 6 employee files sample included the required restraint procedure training every 2 years (refer to A-0196). The hospital failed to ensure patients received the required circulation checks every 15 minutes, hourly vital signs were taken, patients were offered fluids hourly, patients were offered toileting hourly, every 2 hours patient’s position was changed, every 2 hours patients restrained limbs were released and ROM (range of motion) was done, for 7 of 10 sampled patients (refer to A-0205). The hospital failed to report death associated with/within 24 hours after 1 of 10 sampled patients (Patient 1) had hard/leather four-point restraints on at the time of Patient 1’s death (refer to A-0213). The cumulative effect of these systemic problems resulted in the hospital’s inability to provide care in a safe setting.”

“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: 43674 The hospital failed to ensure patient’s restraints were removed at the earliest opportunity for 4 of 10 sampled patients (6, 8, 9, 10). As a result, these patients were kept in restraints longer than necessary. Findings: a. Patient 1 was admitted to the hospital on 1/17/23, per the hospital’s Admission/Discharge Record. A concurrent interview and record review were conducted on 4/10/24 at 9:30 A.M., with the Director of Nursing (DON). Patient 1’s medical records including 13 restraint episodes were reviewed from 1/20/24 to 3/8/24 and indicated: 1. Patient 1 was in “Twice as Tough TAT” four-point (on both wrists and both ankles) restraints on 1/20/24 at 5:50 P.M. to 9:40 P.M. Patient 1’s Special Treatment Procedure indicated “Resting” with no behavioral symptoms from 5:45 to 6:30 P.M. There was no evidence that alternatives, less restrictive interventions, and any of the restraints was discontinued, and Patient 1 remained in restraints for an additional 45 minutes. 2. Patient 1 was in “Twice as Tough TAT” four-point (on both wrists and both ankles) restraints from 2/6/24 at 12:30 P.M. to 6:30 P.M. Patient 1’s Special Treatment Procedure indicated “Resting” with no behavioral symptoms from 5:45 to 6:30 P.M. There was no evidence that alternatives, less restrictive interventions, and any of the restraints was discontinued, and Patient 1 remained in restraints for an additional 45 minutes. 3. Patient 1 was in “Twice as Tough TAT” four-point (on both wrists and both ankles) restraints from 3/4/24 at 12 A.M. to 4:43 A.M. Patient 1’s Special Treatment Procedure indicated “Resting” with no behavioral symptoms from 3:30 A.M. to 4:43 P.M. There was no evidence that alternatives, less restrictive interventions, and any of the restraints was discontinued, and Patient 1 remained in restraints for an additional 1 hour and 15 minutes. 22383 b. Patient 6 was admitted to the hospital on 3/3/24, per the hospitals Admission/Discharge Record. Patient 6 was in “Twice as Tough TAT” four-point (on both wrists and both ankles) restraints on 3/3/24 at 8:35 P.M. Patient 6’s Special Treatment Procedure record documented at 8:30 P.M., indicated that Patient 6 was agitated/restless, uncooperative with direction, verbalizing anger, and disoriented/confused. According to documentation at 8:45 P.M., Patient 6 was no longer having any of those behaviors, and was resting. Per this record, Patient 6 was resting with no other behaviors until 10:00 P.M. Patient 6 was still in Twice as Tough TAT four-point restraints until 9:15 P.M., when the four point restraints were decreased to 2 restraints, and were not entirely removed until 10:15 P.M. Patient 6 was restraints for one and a half hours longer than necessary. c. Patient 8 was admitted to the facility on 2/13/24, per the hospitals Admission/Discharge Record. Patient 8 was in “Twice as Tough TAT” four-point (on both wrists and both ankles) restraints on 2/13/24 at 1:15 A.M. Patient 8’s Special Treatment Procedure record documented at 1:15 A.M., indicated that Patient 8 was agitated/restless, uncooperative with direction and verbalizing anger. At 1:30 A.M., staff documented that Patient 8 was resting, yet no changes were made to the restraints. According to the documentation, Patient 8 was resting at 2:15 A.M., when the restraints were decreased to three limbs, and at 3 A.M., restraints were decreased to two limbs, but were not removed. At 4 A.M., while remaining in restraints, Patient 8 began having behaviors, and at 5:30 A.M., staff increased the restraints back to all four limbs. Patient 8 stopped the behaviors and was resting at 5:45 A.M., until 7:15 A.M., however, remained in restraints on all four limbs. There was no documentation that explained why Patient 8 remained in restraints during the periods when Patient 8 was resting and should have been released. Patient 8 remained in restraints for 7 and 1/2 hours. Restraints were not removed when Resident 8 was no longer having behaviors and was resting for 2 hours at 5:45 A.M. d. Patient 9 was admitted to the hospital on 1/29/24, per the hospitals Admission/Discharge Record. Patient 9 was in “Twice as Tough TAT” four-point (on both wrists and both ankles) restraints on 1/29/24 at 11:58 P.M., Patient 9’s Special Treatment Procedure record documented at 12 A.M., indicated that Patient 9 was agitated/restless, uncooperative with direction, verbalizing anger, disoriented/confused, having delusions, and was resistant to taking medications. According to documentation at 2:45 A.M., Patient 9 was no longer having any of those behaviors, and was resting with no other behaviors until 3:55 A.M. Patient 9 remained in restraints on all four limbs during the remaining one hour and 10 minutes while he was resting. e. Patient 10 was admitted to the hospital on 1/31/24, per the hospitals Admission/Discharge Record. Patient 10 was in “Twice as Tough TAT” four-point (on both wrists and both ankles) restraints on 2/3/24 at 4:15 P.M., Patient 10’s Special Treatment Procedure patient record documented at 12 A.M., indicated that Patient 10 was agitated/restless, having hallucinations, uncooperative with direction, verbalizing homicidal ideation, disoriented/confused and was resistant to taking medications. Per the same documentation at 4:45 P.M., Patient 10 was no longer having any of those behaviors and was resting until 5:15 P.M., when the four point restraints were entirely removed. Patient 10 was in restraints for 45 minutes longer than necessary. An interview was conducted on 4/10/24 at 2:15 P.M., with the DON. The DON stated staff should have implemented less restrictive interventions while Patient 10 was resting. The DON further stated, the restraint should have been discontinued at the earliest time possible when the patient was resting and did not show any aggressive behaviors. A review of hospital’s Policy and Procedure titled, Restraint last revised 3/2020 indicated, “ ...IMPLEMENTATION AND DOCUMENTATION OF RESTRAINT ... 15. The Charge Nurse/designee will assess the patient every hour for appropriateness of behavior and level of safety to ensure release at the earliest possible time ...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 43674 Based on interview and record review the hospital failed to ensure staff followed the restraint and seclusion policy to ensure safe and appropriate use of restraints for 8 of 10 sampled patients (1,2,4,5,6,8,9,10) when the hospital: - did not discontinue restraints at the earliest opportunity. - did not obtain physicians orders within the first hour of restraint or every four hours thereafter, and did not ensure the physicians order was signed within 24 hours. - did not ensure the patient was assessed by a (Physician or Licensed Practitioner) or Registered Nurse (RN) face to face within the hour after the initiation/application of restraints. - did not consult the Physician as soon as possible. - did not ensure all staff were trained for restraint/seclusion. - did not complete the required circulation checks every 15 minutes, hourly vital signs were not completed, patients were not offered fluids hourly, patients were not offered toileting hourly, every two hours patients’ position was not changed, every two hours patients restrained limbs were not released and ROM (range of motion) was not done. - did not complete the physician’s post seclusion restraint assessment. -failed to report death associated with restraints. As a result, the hospital did not provide safe and appropriate use of restraints. Findings: According to the hospital’s Policy and Procedure titled, Restraint last revised 3/2020, “IMPLEMENTATION AND DOCUMENTATION OF RESTRAINT ...4. In an emergency, the Charge Nurse or Nursing Supervisor has the authority to make the decision to use restraint as a protective measure ... A. A Physician’s order must be obtained within one hour of initiation of the restraint ...12. A Physician...or trained RN must conduct an in-person assessment of the patient within one hour after the initiation of restraint ...13. When the in-person evaluation is performed by a trained RN, he/she consults with the physician responsible for the patient’s care as soon as possible after the evaluation... 14. Nursing staff assesses, monitors, and reevaluates the patient’s well-being... 15. The Charge Nurse/designee will assess the patient every hour for appropriateness of behavior and level of safety to ensure release at the earliest possible time... 16. Fluids will be offered to the patient every hour. 17. Nursing staff will offer the patient a bedpan or urinal every 2 hours. 18. Range of motion exercises will be done to each extremity every 2 hours ...29. Within 24 hours of the restraint episode, the attending physician shall: A. Authenticate any telephone order ... B. Assess the patient and document a Physician Post Seclusion/Restraint Progress Note regarding the restraint episode...REPORTING REQUIREMENTS ... the hospital will report to CMS: A. Any death that occurs while the patient is trained or in seclusion or where it is reasonable to assume that a patient that is a result of brain or seclusion ...D. The report will be made electronically by completing the electronic form CMS-1045 five no later than the close of the next business day following knowledge of the patient’s death ...” 1. Patient 1 was admitted to the hospital on 1/17/23, per the hospital Admission/Discharge Record. A concurrent interview and record review were conducted on 4/10/2024 at 9:30 A.M. with the Director of Nursing (DON). Patient 1’s restraint episodes and medical records were reviewed from 1/20/2024 to 3/8/2024 and indicated: a.1. Patient 1 was in “Twice as Tough TAT” four-point (on both wrists and both ankles) restraints on 1/20/24 at 5:50 P.M. to 9:40 P.M. Patient 1’s Special Treatment Procedure indicated “Resting” with no behavioral symptoms from 5:45 to 6:30 P.M. There was no evidence that alternatives, less restrictive interventions, or that any of the restraints was discontinued. Patient 1 remained in restraints for an additional 45 minutes longer than necessary. a.2. Patient 1 was placed in restraint on 1/20/24 at 5:50 P.M. to 9:40 P.M. The Physician Order for restraint was not entered into the documentation system until 1/20/24 at 7:41 P.M. a.3. Patient 1 was placed in restraint on 1/20/24 at 5:50 P.M. to 9:40 P.M., according to the Special Treatment Procedure Patient Record. Patient 1 was only offered fluids three times, and not the four that should have been offered. Patient 1 was offered toileting only three times, and vital signs were only assessed three times. Patient 1 was not offered range of motion while in restraints. a.4. Patient 1 was placed in restraint on 1/20/24 at 5:50 P.M. to 9:40 P.M. Patient 1’s Special Treatment Procedure indicated “Resting” with no behavioral symptoms from 5:45 to 6:30 P.M. There was no evidence of documentation that alternatives, less restrictive interventions, or that restraint was discontinued for Patient 1. a.5. Patient 1 was placed in restraint on 1/20/24 at 5:50 P.M. to 9:40 P.M. There was no documented evidence in Patient 1’s chart that the Physician Post Seclusion/Restraint & Daily Progress Note was completed. b.1. Patient 1 was placed in restraint on 1/24/24 at 6 P.M. to 1/25/24 at 12:15 A.M. The Physician Order for restraint was not entered into the documentation system until 1/24/24 at 6:14 P.M. b.2. Patient 1 was placed in restraint on 1/24/24 at 6 P.M. to 1/25/24 at 12:15 A.M., according to the Special Treatment Procedure Patient Record. Patient 1’s respirations were only documented as vital signs for the entire six hours and 15 minutes while in restraints. Patient 1 was not offered position changes or range of motion. b.3. Patient 1 was placed in restraint on 1/24/24 at 6 P.M. to 1/25/24 at 12:15 A.M. The Physician Post Seclusion/Restraint & Daily Progress Note was completed on 3/10/24 at 11:20 A.M. (46 days after the application of restraint). Per the DON, the document should have been completed within 24-hours. c.1. Patient 1 was placed in restraint on 1/29/24 at 4:45 P.M. to 10:30 P.M., according to the Special Treatment Procedure Patient Record. Patient 1’s vital signs were completed when the restraint was applied, but not completed or monitored again until 8 P.M. Patient 1’s position change and range of motion were completed twice. c.2. Patient 1 was placed in restraint on 1/29/24 at 4:45 P.M. to 10:30 P.M. There was no documented evidence in Patient 1’s chart that the Physician Post Seclusion/Restraint & Daily Progress Note was completed. d.1. Patient 1 was in “Twice as Tough TAT” four-point (on both wrists and both ankles) restraints from 2/6/24 at 12:30 P.M. to 6:30 P.M. Patient 1’s Special Treatment Procedure indicated “Resting” with no behavioral symptoms from 5:45 to 6:30 P.M. There was no evidence that alternatives, less restrictive interventions, or that the restraints was discontinued. Patient 1 remained in restraints for 45 minutes longer than necessary. d.2. Patient 1 was placed in restraint on 2/6/24 at 12:30 P.M. to 6:30 P.M. A Physician Order for the restraint was not entered into the documentation system until 2/6/24 at 3:33 P.M., two hours and three minutes later. Patient 1 remained in restraint longer than the ordered four hours. The additional order was required at 4:30 P.M., but was not entered until 8:49 P.M., two hours and 19 minutes after the restraints were removed. In addition, the type of restraint used was not specified. d.3. Patient 1 was in restraint on 2/6/24 at 12:30 P.M. to 6:30 P.M., according to the Special Treatment Procedure Patient Record. Patient 1 was offered toileting five times, and not the six that should have been offered. Patient 1’s vital signs were assessed when the restraint was applied and hourly, but only respiration and temperature were documented. Patient 1’s blood pressure was not checked/monitored until the restraints were removed. Patient 1’s position was changed once, and range of motion was only completed once. d.4.Patient 1 was placed in restraint on 2/6/24 at 12:30 P.M. to 6:30 P.M. Patient 1’s Special Treatment Procedure indicated “Resting” with no behavioral symptoms from 5:45 to 6:30 P.M. There was no documented evidence that alternatives, less restrictive interventions were implemented at the earliest possible time for Patient 1. d.5. Patient 1 was placed in restraint on 2/6/24 at 12:30 P.M. to 6:30 P.M. There was no documented evidence in Patient 1’s chart that the Physician Post Seclusion/Restraint & Daily Progress Note was completed. e.1. Patient 1 was placed in restraint on 2/8/24 at 9:45 P.M. to 2/9/24 at 12:40 A.M. The Physician Orders for restraint was not entered into the documentation system until 2/8/24 at 10:23 P.M. e.2. Patient 1 was placed in restraint on 2/8/24 at 9:45 P.M. to 2/9/24 at 12:40 A.M., according to the Special Treatment Procedure Patient Record. Patient 1’s position was not changed, and range of motion was not provided. f.1. Patient 1 was placed in restraint on 2/11/24 at 9 P.M. to 12:42 A.M. on 2/12/24. The Physician Order for restraint was not entered into the documentation system until 2/11/24 at 9:59 P.M.. Further, the type of restraint used was not specified. f.2. Patient 1 was placed in restraint on 2/11/24 at 9 P.M. to 2/12/24 at 12:42 A.M. The Physician Orders for restraint was not entered into the documentation system until 2/11/24 at 9:59 P.M. In addition, the type of restraint used was not specified. f.3. Patient 1 was placed in restraint on 2/11/24 at 9:40 P.M. to 2/12/24 at 12:42 A.M., according to the Special Treatment Procedure Patient Record. Patient 1 was offered fluids and toileting twice. Patient 1’s position changes and range of motion were completed one time. f.4. Patient 1 was placed in restraint on 2/11/24 at 9 P.M. to 2/12/24 at 12:42 A.M. The Physician Post Seclusion/Restraint & Daily Progress Note was completed on 2/13/24 at 11:20 A.M. (two days after the application of the restraint). Per the DON, the document should have been completed within 24-hours. f.5. Patient 1 was placed in restraint on 2/11/24 at 9:40 P.M., to 2/12/24 at 12:42 A.M. RN 1 completed an in-person assessment on 2/11/24 at 10:30 P.M., but RN 1 did not consult with Physician 1 until 2/12/24 at 8:40 A.M., 11 hours and 40 minutes after the restraint was applied. g.1. Patient 1 was placed in restraint on 2/13/24 at 8:55 P.M. to 11:53 P.M. RN 2 completed an in-person assessment on 2/13/24 at 8:50 P.M. There was no documented evidence that RN 2 had consulted with the Physician or Licensed Practitioner (LP). g.2. Patient 1 was placed in restraint on 2/13/24 at 8:55 P.M. to 11:58 P.M., according to the Special Treatment Procedure Patient Record. Patient 1 was offered fluids every 15 minutes, however was not offered toileting, position changes or range of motion. g.3. Patient 1 was placed in restraint on 2/13/24 at 8:55 P.M. to 11:58 P.M. The Physician Post Seclusion/Restraint & Daily Progress Note was completed on 3/10/24 at 10:50 A.M. (24 days after the application of restraint). Per the DON, the document should have been completed within 24-hours. h.1. Patient 1 was placed in restraint on 2/17/24 at 6:50 P.M. to 2/18/24 at 12:15 A.M. The Physician Orders for restraint was not entered into the documentation system until 2/17/24 at 7:24 P.M. h.2. Patient 1 was placed in restraint on 2/17/24 at 6:50 P.M. to 2/18/24 at 12:15 A.M., according to the Special Treatment Procedure Patient Record. Patient 1’s vital signs were documented as respirations initially, and Patient 1’s vital signs were not assessed again until 10 P.M., three hours later. Position changes and range of motion were completed only twice. h.3. Patient 1 was placed in restraint on 2/17/24 at 6:50 P.M. to 2/18/24 at 12:15 A.M. The Physician Post Seclusion/Restraint & Daily Progress Note was completed on 3/10/24 at 11:00 A.M. (22 days after the application of restraint). Per the DON, the document should have been completed within 24-hours. i.1. Patient 1 was placed in restraint on 2/22/24 at 1:20 A.M. to 6:20 A.M. The Physician Order for restraint was not entered into the documentation system until 2/22/24 at 2:27 A.M. i.2. Patient 1 was placed in restraint on 2/22/24 at 1:20 A.M. until 6:20 A.M. There was no documented evidence that Patient 1 received a face-to-face assessment after the restraint initiation/application and every four hours thereafter while in restraints. The DON stated she could not find either the first or additional “In-Person Assessment” in Patient 1’s medical record. i.3. Patient 1 was placed in restraint on 2/22/24 at 1:20 A.M. to 6:20 A.M., according to the Special Treatment Procedure Patient Record. Patient 1’s range of motion was only provided once. i.4. Patient 1 was placed in restraint on 2/22/24 at 1:20 A.M. to 6:20 A.M. The Physician Post Seclusion/Restraint & Daily Progress Note was completed on 3/10/24 at 11:15 A.M. (17 days after the application of restraint). Per the DON the document should have been completed within 24-hours. j.1. Patient 1 was placed in restraint on 2/27/24 at 6:10 P.M. to 2:05 A.M. 2/28/24. The Physician Order for restraint was not entered into the documentation system until 2/27/24 at 10:01 P.M. j.2. Patient 1 was placed in restraint on 2/27/24 at 6:10 P.M. to 2/28/24 at 2:05 A.M., according to the Special Treatment Procedure Patient Record. Patient 1’s vital signs were assessed at the initiation/application of restraints, and not again until 10 P.M.. Patient 1’s position was changed twice, and range of motion was only offered twice. j.3. Patient 1 was placed in restraint on 2/27/24 at 6:10 P.M. to 2/28/24 at 2:05 A.M. The Physician Post Seclusion/Restraint & Daily Progress Note was completed on 3/4/24 at 8:45 A.M. (7 days after the application of restraint). Per the DON, the document should have been completed within 24-hours. k.1. Patient 1 was placed in restraint on 2/28/24 at 10:00 A.M. to 17:30 A.M. The Physician Orders for restraint was not entered into the documentation system until 2/28/24 at 2:21 P.M. k.2. Patient 1 was placed in restraint on 2/28/24 at 10:00 A.M. to 17:30 A.M., according to the Special Treatment Procedure Patient Record. Patient 1’s vital signs were assessed on initiation/application of the restraints, and for the next four hours, but were not monitored/checked during the last three hours while in restraints. Patient 1 was not offered position changes or range of motion. In addition, there was no documented evidence of the RN’s hourly patient response to interventions on 2/28/24 from 3 P.M. to 5:30 P.M. k.3. Patient 1 was placed in restraint on 2/28/24 at 10:00 A.M. to 17:30 A.M. There was no documented evidence in Patient 1’s chart that the Physician Post Seclusion/Restraint & Daily Progress Note was completed. l.1. Patient 1 was placed in “Twice as Tough TAT” four-point (on both wrists and both ankles) restraints on 3/4/24 at 12 A.M. to 4:43 A.M. Patient 1’s Special Treatment Procedure indicated “Resting” with no behavioral symptoms from 3:30 A.M. to 4:43 P.M. There was no evidence that alternatives, less restrictive interventions, or that any of the restraints was discontinued. Patient 1 remained in restraints for an additional 1 hour and 15 minutes longer than necessary. The DON was interviewed on 4/10/24 at 2:15 P.M. The DON stated that Patient 1 should have been provided with less restrictive intervention and possible termination of restraint at the earliest possible time when the criteria for release of restraint was met. The DON also stated that the restraints should have been discontinued when the patient was resting and/or did not show any aggressive behaviors. The DON acknowledged these interventions were not completed for Patient 1. l.2. Patient 1 was placed in restraint on 3/4/24 at 12 A.M. to 4:43 A.M.. The Physician Orders for restraint was not entered into the documentation system until 3/4/24 at 12:11 A.M. Further, the type of restraint used was not specified. Patient 1 remained in restraint longer than the ordered four hours, and the additional order was entered at 3/4/24 at 3 A.M., but was not authenticated by the Physician until 3/12/24 at 10:10 A.M., eight days later. l.3. Patient 1 was placed in restraint on 3/4/24 at 12 A.M. to 4:43 A.M., according to the Special Treatment Procedure Patient Record. Patient 1’s position was changed once and range of motion was only provided twice. The DON was interviewed on 4/10/24 at 2:15 P.M. The DON stated that nurses should have assessed Patient 1’s vital signs, and offered fluids and toileting every hour. The DON stated that nurses should have provided position changes and range of motion every two hours. The DON stated these interventions were very important for safety. The DON acknowledged these interventions were not completed and/or offered consistently for Patient 1. l.4. Patient 1 was placed in restraint on 3/4/24 at 12 A.M. to 4:43 A.M. Patient 1’s Special Treatment Procedure indicated “Resting” with no behavioral symptoms from 3:30 A.M. to 4:43 P.M. There was no documented evidence that alternatives or less restrictive interventions were implemented at the earliest possible time for Patient 1. l.5. Patient 1 was placed in restraint on 3/4/24 at 12 A.M. to 4:43 A.M. RN 1 completed an in-person assessment on 3/4/24 at 12:15 A.M. RN 1 did not consult with Physician 1 until 3/4/24 at 3 A.M., three hours after the restraint was initiated/applied. m.1. Patient 1 was placed in restraint on 3/7/24 at 10:10 P.M. to 3/8/24 at 11:20 A.M. Patient 1 remained in restraint longer than the ordered four hours, and the additional Physician Orders for restraint was not entered into the documentation system until 3/8/24 at 3:33 A.M. Patient 1 remained in restraints longer than the ordered four hours, and the additional order was entered into the documentation system on 3/8/24 at 6:45 A.M. Patient 1 remained in restraints longer than the ordered four hours, and the additional order was entered into the documentation system on 3/8/24 at 7:19 P.M., 11 hours and 9 minutes late. Further, the order did not specify the type of restraint used. There was no active order for restraint and seclusion from 10:10 A.M. until the restraints were removed when Patient 1 became unresponsive, and a code was called at 11:20 A.M. m.2. Patient 1 was placed in restraint on 3/7/24 at 10:10 P.M., to 3/8/24 at 11:20 A.M. There was no documented evidence of Patient 1’s face to face assessment at 2:10 A.M. The documentation of Patient 1’s face to face assessment due at 6:10 A.M. was completed two hours and 50 minutes late, at 9 A.M. The 9 A.M. and 10:10 A.M. face to face assessments were not reviewed with the physician. The DON stated that the form should have been completed timely. m.3. Patient 1 was placed in restraint on 3/7/24 at 10:10 P.M. to 3/8/24 at 11:20 A.M., according to the Special Treatment Procedure Patient Record. Patient 1’s vital signs were assessed when the restraints were applied, and documented as Blood Pressure (BP) 174/142, pulse 174, respirations 24, temperature 100°F (Normal vital sign ranges were: BP between 90/60 and 120/80, Pulse 60 to 100, respirations between 12 to 18 breaths per minute, Temperature: 97.8°F to 99.1°F ). Patient 1’s vital signs were abnormal (not within normal range), and were not taken again during the 13 hours while in restraints. Patient 1 started vomiting on 3/8/24 at 2:30 A.M. The mental health aid documented, “patient is now forcing himself to vomit and spit out to the room and staff.” At 4:30 A.M., the vomit was described as a “brown substance.” At 6:30 A.M. RN 3 documented that Patient 1 was “self-inducing vomit and spitting vomit towards walls and doors.” Patient 1 continued to vomit until 10:50 A.M. There was no documentation in the nurses assessment or the physicians progress note that Patient 1’s vomiting was considered a medical issue, and not a behavioral issue. Patient 1’s required 15-minute circulation checks were not documented as completed from 4 A.M. until 7 A.M. In addition, there was no documented evidence of RN hourly patient response to intervention on 3/7/24 at 11 P.M., and 3/8/24 at 2:30 A.M. and 9:30 A.M. The mental health aid was interviewed on 4/10/24 at 9:53 A.M. The mental health aid stated he documented position changes and range of motion every 15 minutes because the patient was constantly moving and changing position, and constantly moving both of his arms and legs, thereby meeting that requirement. The mental health aid stated he did not assist Patient 1 to change position, and he did not remove any of the restraints to provide a position change or range of motion. m.4. Patient 1 was placed in restraint on 3/7/24 at 10:10 P.M. to 3/8/24 at 11:20 A.M. The Physician Post Seclusion/Restraint & Daily Progress Note was completed on 10/7/24 at 12:00 P.M. (future date). Per the DON, the document should have been completed within 24-hours. m.5. Patient 1 was placed in restraint on 3/7/24 at 10:10 P.M. to 3/8/24 at 11:20 A.M. RN 3 completed Patient 1’s in-person assessments on 3/8/24 at 9 A.M., and 10:30 A.M. There was no documentation that RN 3 consulted with a Physician or Licensed Practitioner (LP) for either assessment. m.6. According to the documentation, Patient 1 was placed in seclusion/restraint at 10:10 P.M., on 3/7/24 and remained in seclusion/restraint until 11:20 A.M. on 3/8/24, when the restraints were removed due to Patient 1 becomimg unresponsive. A Code Blue (someone has gone into cardiac or respiratory arrest) was called and CPR (cardiopulmonary resuscitation) was started. Patient 1 was taken by ambulance to a local General Acute Care Hospital where he was pronounced dead. The hospital was informed of Patient 1’s death on 3/8/24 at 2 P.M. The Director of Quality was interviewed on 4/5/24 at 10:28 A.M. The Director of Quality stated the hospital was unaware of the reporting requirement until 10 days later when they were reviewing the seclusion restraint policy. The hospital informed CMS of Patient 1’s death on 3/22/24, 14 days after they were aware of the death. 22383 2. Patient 2 was admitted to the hospital on 9/28/23, per the hospital Admission/Discharge Record. a. Patient 2 was placed in restraints on 1/10/24, from 8:37 P.M. until 10 P.M., according to the documentation on the Special Treatment Procedure Patient Record. Patient 2 was not offered something to drink or offered to use the bathroom. b. Patient 2 was placed in restraints on 1/12/24, from 5:05 P.M. until 7:05 P.M., according to the documentation on the Special Treatment Procedure Patient Record. Patient 2 was not offered something to drink or offered to use the bathroom. 3. Patient 4 was admitted to the hospital on 8/4/23, per the hospital Admission/Discharge Record. Patient 4 was placed in restraints on 3/9/24, from 9:43 P.M. until 10:58 P.M., according to the documentation on the Special Treatment Procedure Patient Record. Patient 4 was not offered something to drink or offered to use the bathroom. 4. Patient 5 was admitted to the hospital on 3/14/24, per the hospital Admission/Discharge Record. Patient 5 was placed in restraints on 3/20/24, from 7:22 P.M. until 8:37 P.M., according to the documentation on the Special Treatment Procedure Patient Record. Patient 5’s vital signs were checked one time. Patient 5 was not offered something to drink or offered to use the bathroom. 5. Patient 6 was admitted to the hospital on 3/3/24, per the hospital Admission/Discharge Record. Patient 6 was in “Twice as Tough TAT” four-point (on both wrists and both ankles) restraints on 3/3/24 at 8:35 P.M. The Special Treatment Procedure patient record documented at 8:30 P.M. indicated that Patient 6 was agitated/restless, uncooperative with direction, verbalizing anger, and disoriented/confused. According to the 8:45 P.M. documentation, Patient 6 was no longer having any of those behaviors, and was resting with no other behaviors until 10:00 P.M. Documentation indicated that at 9:15 P.M., the four point restraints were decreased to two restraints, and were not entirely removed until 10:15 P.M. Patient 6 was in restraints for one and a half hours longer than necessary. 6. Patient 8 was admitted to the facility on 2/13/24, per the hospital Admission/Discharge Record. a.1. Patient 8 was in “Twice as Tough TAT” four-point (on both wrists and both ankles) restraints on 2/13/24 at 1:15 A.M. Patient 8’s Special Treatment Procedure patient record documented at 1:15 A.M. indicated that Patient 8 was agitated/restless, uncooperative with direction, and was verbalizing anger. At 1:30 A.M., staff documented that Patient 8 was resting, yet no changes were made to the restraints. a.2. According to the documentation, Patient 8 was resting at 2:15 A.M., when the restraints were decreased to three limbs. Patient 8 was resting at 3 A.M., when the restraints were decreased to two limbs. Staff increased the restraints back to all four limbs at 4 A.M. when Patient 8 began having behaviors. However, documentation indicated that Patient 8 was resting at 5:45 A.M. until 7:15 A.M. There was no documented explanation on why Patient 8 remained in restraints during periods when Patient 8 was resting and when the restraints should have been released. a.3. Patient 8 was placed in restraints on 2/13/24, from 1:15 A.M. until 8:45 A.M., according to the documentation on the Special Treatment Procedure Patient Record. Patient 8 was not assessed for the required 15 minute circulation checks for 22 time increments. Further, Patient 8’s vital signs were not checked during three required times. Patient 8 was not offered a drink hourly, and was not offered to use the bathroom during four of the 7 1/2 hours in restraints. Patient 8 was repositioned twice, and was not offered ROM (range of motion) during the 7 1/2 hours in restraints. 7. Patient 9 was admitted to the hospital on 1/29/24, per the hospital Admission/Discharge Record. a.1. Patient 9 was in “Twice as Tough TAT” four-point (on both wrists and both ankles) restraints on 1/29/24 at 11:58 P.M. Patient 9’s Special Treatment Procedure patient record documented at 12 A.M. (midnight) indicated that Patient 9 was having delusions, agitated/restless, uncooperative with direction, verbalizing anger, disoriented/confused was resistant to taking medications. According to documentation at 2:45 A.M., Patient 9 was no longer having any of those behaviors, and was resting. The documentation indicated that Patient 9 was resting with no other behaviors until 3:55 A.M., when the four-point restraints were entirely removed. Patient 9 was in restraints for one hour and 10 minutes longer than necessary. a.2. Patient 9 was placed in restraints on 1/29/24, from 11:58 P.M. until 3:55 A.M., according to documentation on the Special Treatment Procedure Patient Record. Patient 9 was not offered fluids or to use the bathroom for the last one hour and 55 minutes, and was only repositioned once. 8. Patient 10 was admitted to the hospital on 1/31/24, per the hospital Admission/Discharge Record. a.1. Patient 10 was in “Twice as Tough TAT” four-point (on both wrists and both ankles) restraints on 2/3/24 at 4:15 P.M. Patient 10’s Special Treatment Procedure patient record documented at 12 A.M. (midnight) indicated that Patient 10 was agitated/restless, uncooperative with direction, verbalizing homicidal ideation, disoriented/confused, having hallucinations, and was resistant to taking medications. According to the 4:45 P.M. documentation, Patient 10 was no longer having any of those behaviors, and was resting. The four-point restraints were not entirely removed until 5:15 P.M. Patient 10 was in restraints 45 minutes longer than necessary. a.2. Patient 10 was placed in restraints on 2/3/24 from 4:05 P.M. until 5:30 P.M., according to the documentation on the Special Treatment Procedure Patient Record Patient. Patient 10’s vital signs were taken once during the one hour and 25 minutes of being in restraints. 9.a. RN 10’s personal file was reviewed on 4/5/24. The hospital required a three-day restraint training to be completed every two years. RN 10 last completed the required restraint training on 1/13/22, and the training was due to be completed again in January 2024. According to the DON, the training was not completed in January 2024. Per the DON, RN 10 was scheduled to complete the training in April 2024, due to staffing needs. 9.b. LVN 10’s personal file was reviewed on 4/5/24. The hospital required a three-day restraint training be completed every two years. LVN 10 last completed the required restraint training on 3/16/22, and the training was due to be completed again in March 2024. According to the DON, the training was not completed in March 2024. Per the DON, LVN 10 was scheduled to complete the training in April 2024. An interview was conducted on 4/10/24 at 2:15 P.M., with the DON. The DON stated that staff should have implemented less restrictive interventions while a patient was resting. The DON further stated that the restraints should have been discontinued at the earliest time possible when the patient was resting and/or when the patient no longer had aggressive behaviors. The DON acknowledged the discrepancy on the start date and time of the restraint orders. Per the DON, staff should have documented and entered the physician order as soon as the order was received. The DON stated it was important to ensure that entered physician orders were reflected correctly in the Electronic Medical Record (EMR). The DON stated that the RN who conducted the in-person face-to-face assessment should have consulted with the physician on the result of the assessment. The DON further stated it was important to review and consult the patient’s assessment with the physician to ensure that the physician was aware of the patient situation and that the intervention in place was safe and appropriate. The DON acknowledged the inconsistent monitoring, interventions, and documentation on the assessment of vital signs, offering of fluids and toileting, position changes and range of motion of the patient. Further, the DON stated it was very important to ensure that vital signs were taken hourly for patient safety. The DON stated the face-to-face assessment form should have been completed timely for patient safety. The DON acknowledged that the “Physician Post Seclusion/Restraint & Daily Progress Notes” were not completed timely and accurately. Per the DON, the physician should have completed the document within 24 hours after the initiation of restraint. The DON was interviewed on 4/10/24 at 2:15 P.M. The DON stated nurses should have assessed Patient 1’s vital signs, and offered fluids and toileting every hour. The DON stated that nurses should have provided position changes and range of motion every two hours. The DON stated these interventions were very important for the patient’s safety. The DON acknowledged these interventions were not consistently completed for the patient’s who were in restraints.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 43674 Based on interview and record review the hospital failed to ensure that there was a physician’s order obtained within 1 hour for each incident of restraint and every 4 hours during restraint for 1 of 10 sampled patients (1). As a result, there was the potential the physician may not have ordered the use of restraint. Findings: Patient 1 was admitted to the hospital on 1/17/23, per the hospital’s Admission/Discharge Record. A concurrent interview and record review were conducted on 4/10/24 at 9:30 A.M., with the Director of Nursing (DON). Patient 1’s Restraint episodes and Physician Orders for Restraints were reviewed from 1/20/24 to 3/8/24 and indicated: 1. Patient 1 was placed in restraint on 1/20/24 at 5:50 P.M. to 9:40 P.M. A Physician Order for restraint was not entered into the documentation system until 1/20/24 at 7:41 P.M. (51 minutes later). 2. Patient 1 was placed in restraint on 2/6/24 at 12:30 P.M. to 6:30 P.M. A Physician Order for the restraint was not entered into the documentation system until 2/6/24 at 3:33 P.M., two hours and three minutes later. Patient 1 remained in restraint longer than the ordered 4 hours, and the additional order was required at 4:30 P.M., but was not entered until 8:49 P.M., two hours and 19 minutes after the restraints were removed. In addition, the type of restraint used was not specified. 3. Patient 1 was placed in restraint on 2/11/24 at 9 P.M. to 12:42 A.M. on 2/12/24. A Physician Order for restraint was not entered into the documentation system until 2/11/24 at 9:59 P.M. In addition, the type of restraint used was not specified. 4. Patient 1 was placed in restraint on 2/22/24 at 1:20 A.M. to 6:20 A.M. A Physician Order for restraint was not entered into the documentation system until 2/22/24 at 2:27 A.M. 5. Patient 1 was placed in restraint on 2/27/24 at 6:10 P.M. to 2:05 A.M. on 2/28/24. A Physician Order for restraint was not entered into the documentation system until 2/27/24 at 10:01 P.M. 6. Patient 1 was placed in restraint on 2/28/24 at 10:00 A.M. to 5:30 P.M. A Physician Orders for restraint was not entered into the documentation system until 2/28/24 at 2:21 P.M. 7. Patient 1 was placed in restraint on 3/4/24 at 12 A.M. to 4:43 A.M. A Physician Orders for restraint was not entered into the documentation system until 3/4/24 at 12:11 A.M. In addition, the type of restraint used was not specified. Patient 1 remained in restraint longer than the ordered four hours, and the additional order was entered on 3/4/24 at 3 A.M., but was not authenticated by the Physician until 3/12/24 at 10:10 A.M., eight days later. 8. Patient 1 was placed in restraint on 3/7/24 at 10:10 P.M. to 3/8/24 at 11:20 A.M. Patient 1 remained in restraint longer than the ordered four hours, and the additional Physician Orders for restraint was not entered into the documentation system until 3/8/24 at 3:33 A.M. Patient 1 remained in restraint longer than the ordered four hours, and the additional order was not entered into the system until 3/8/24 at 6:45 A.M. Patient 1 remained in restraint longer than the ordered four hours, and the additional order was entered into the system on 3/8/24 at 7:19 P.M., 11 hours and nine minutes late. In addition, the order did not specify the type of restraint used. There was no active order for restraint and seclusion from 10:10 A.M. until the restraints were removed at 11:20 A.M., when Patient 1 became unresponsive and a code was called. The DON acknowledged the discrepancy on the start date and time of the Restraint Orders. Per the DON, staff should have documented and entered the physician order as soon as the order was received via telephone order. The DON stated it was important to ensure that entered physician orders were correctly reflected in the Electronic Medical Record (EMR; documentation system). A review of hospital’s Policy and Procedure titled Restraint last revised 3/2020 indicated, “ ...IMPLEMENTATION AND DOCUMENTATION OF RESTRAINT ... 4. In an emergency, the Charge Nurse or Nursing Supervisor has the authority to make the decision to use restraint as a protective measure ... A. A Physician’s order must be obtained within one hour of initiation of the restraint.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 43674 Based on interview and record review the hospital failed to ensure 1 of 10 sampled patients (1) was seen and assessed by a Physician, Licensed Practitioner, or Registered Nurse (RN) face-to-face within the hour after the initiation (application) of restraints. As a result, there was the potential for a patient to be inappropriately restrained. Findings: Patient 1 was admitted to the hospital on 1/17/23, per the hospital Admission/Discharge Record. A concurrent interview and record review was conducted on 4/10/24 at 9:30 A.M., with the Director of Nursing (DON). Patient 1’s medical record indicated: 1. Patient 1 was placed in restraint on 2/22/24 at 1:20 A.M. until 6:20 A.M. There was no documented evidence that Patient 1 received a face-to-face assessment after the restraint initiation and/or every four hours thereafter, while in restraint. The DON stated she could not find either the first or additional “In-Person Assessment” in Patient 1’s medical record. 2. Patient 1 was placed in restraint on 3/7/24 at 10:10 P.M. to 3/8/24 at 11:20 A.M. There was no documented evidence of Patient 1’s face-to-face assessment that was due at 2:10 A.M. In addition, the documentation of Patient 1’s face-to-face assessment that was due at 6:10 A.M. was completed two hours and 50 minutes later, at 9 A.M. Further, the 9 A.M. and 10:10 A.M., face-to-face assessments were not reviewed with the physician. The DON stated that the form should have been completed timely and consistently. The DON stated that the RN who conducted the in-person face-to-face assessment should had consulted with the physician about the result of the assessment. The DON stated it was important to review and consult with the physician to ensure that that physician was aware of the patient’s situation, and that the interventions in place were safe and appropriate. The DON further stated it was important to complete the face-to-face assessment for patient safety. A review of the hospital’s Policy and Procedure titled Restraint last revised 3/2020 indicated, “ ...IMPLEMENTATION AND DOCUMENTATION OF RESTRAINT ... 12. A physician, licensed independent practitioner, or trained RN must conduct an in-person assessment of the patient within one hour after the initiation of restraint ...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(14) If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. This Standard is not met as evidenced by: 43674 Based on interview and record review the hospital failed to ensure the Registered Nurse (RN) consulted the Physician as soon as possible for 1 of 10 sampled patients (1) after the completion of the hourly face-to-face assessment. As a result, there was a potential that the physician may not have agreed with the use of restraints. Findings: Patient 1 was admitted to the hospital on 1/17/23, per the hospital Admission/Discharge Record. A concurrent interview and record review was conducted on 4/10/24 at 9:30 A.M., with the Director of Nursing (DON). Patient 1’s medical record indicated: 1. Patient 1 was placed in restraint on 2/11/24 at 9:40 P.M., to 2/12/24 at 12:42 A.M. RN 1 completed an in-person assessment on 2/11/24 at 10:30 P.M., but RN 1 did not consult with Physician 1 until 2/12/24 at 8:40 A.M., 11 hours and 40 minutes after the restraint was initiated (applied). 2. Patient 1 was placed in restraint on 2/13/24 at 8:55 P.M. to 11:53 P.M. RN 2 completed an in-person assessment on 2/13/24 at 8:50 P.M. There was no documented evidence that RN 2 had consulted with the Physician or Licensed Practitioner (LP). 3. Patient 1 was placed in restraint on 3/4/24 at 12 A.M. to 4:43 A.M. RN 1 completed an in-person assessment on 3/4/24 at 12:15 A.M. RN 1 did not consult with Physician 1 until 3/4/24 at 3 A.M., three hours after the restraint was initiated. 4. Patient 1 was placed in restraint on 3/7/24 at 10:10 P.M. to 3/8/24 at 11:20 A.M. RN 3 completed Patient 1’s in-person assessments on 3/8/24 at 9 A.M. and 10:30 A.M. There was no documentation that RN 3 consulted with the Physician or Licensed Practitioner (LP) for either assessment. The DON stated that the RN who conducted the in-person face-to-face assessment(s) should have consulted with the physician about the results of the assessment(s). The DON stated it was important to review and consult with the physician to ensure that the physician was aware of the patient situation, and that the interventions in place were safe and appropriate. The DON further stated it was important to complete the face-to-face assessment(s) for patient safety. A review of hospital’s Policy and Procedure titled Restraint last revised 3/2020 indicated, “ ...IMPLEMENTATION AND DOCUMENTATION OF RESTRAINT ... 13. When the in-person evaluation is performed by a trained RN, he/she consults with the physician responsible for the patient’s care as soon as possible after the evaluation.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(1) Training intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion- (i) Before performing any of the actions specified in this paragraph; (ii) As part of orientation; and (iii) Subsequently on a periodic basis consistent with hospital policy. This Standard is not met as evidenced by: 22383 Based on interview and record review, the hospital failed to ensure 2 of 6 employee file samples had the mandatory Pro-CARE (Professional Communication Assessment and Response Education) training which included the restraint/seclusion training, every two years. As a result, staff may not have followed the hospital policy when using restraints and seclusion. Findings: a. RN 10’s personal file was reviewed on 4/5/24. The hospital required a three-day restraint training to be completed every two years. RN 10 last completed the required restraint training on 1/13/22, and the training was due to be completed in January 2024. There was no documented evidence that the training was completed in January 2024. Per the Director of Nursing (DON), RN 10 was scheduled to complete the training in April 2024. b. LVN 10’s personal file was reviewed 4/5/24. The hospital required a three-day restraint training to be completed every two years. LVN 10 last completed the required restraint training on 3/16/22, and the training was due to be completed in March 2024. There was no documented evidence that the training was completed in March 2024. Per the Director of Nursing (DON), LVN 10 was scheduled to complete the training in April 2024. A review of hospital’s Policy and Procedure titled Restraint last revised 3/2020 indicated “ ...PROCEDURE ... 1. All staff who have direct patient contact will have mandatory Pro-CARE (Professional Communication Assessment and Response Education) training upon hire and mandatory training every 2 years.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(vi) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (vi) Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1-hour face-to-face evaluation. This Standard is not met as evidenced by: 43674 Based on interview and record review, the facility failed to ensure patients received the required circulation checks every 15 minutes, hourly vital signs were taken, patients were offered fluids hourly, patients were offered toileting hourly, patient’s position were changed every two hours, patients restrained limbs were released every two hours, and ROM (range of motion) was provided, for 7 of 10 sampled patients (1, 2, 4, 5, 8, 9, 10). As a result, there was a potential for restrained patients to have an unidentified complication. Findings: a. Patient 1 was admitted to the hospital on 1/17/23, per the hospital Admission/Discharge Record. A review of Patient 1’s Medical Record was conducted, which indicated Patient 1 was placed in restraints on the following dates: 1/20, 1/24, 1/29, 2/6, 2/8, 2/11, 2/13, 2/17, 2/22, 2/27, 2/28, 3/4, and 3/7/24. A review of Patient 1’s medical record titled, Special Treatment Procedure Restraints Monitoring was reviewed. This record indicated the following: 1. Patient 1 was placed in restraint on 1/20/24 at 5:50 P.M. to 9:40 P.M. according to the Special Treatment Procedure Patient Record. Patient 1 was only offered fluids three times, and not the four that he should have been offered. Patient 1 was offered toileting three times, and vital signs were only assessed three times. Patient 1 was never offered/provided range of motion. 2. Patient 1 was placed in restraint on 1/24/24 at 6 P.M. to 1/25/24 at 12:15 A.M., according to the Special Treatment Procedure Patient Record. Patient 1’s respirations were documented as vital signs for the six hours and 15 minutes while in restraints. Patient 1 was not offered position changes or range of motion. 3. Patient 1 was placed in restraint on 1/29/24 at 4:45 P.M. to 10:30 P.M., according to the Special Treatment Procedure Patient Record. Patient 1’s vital signs were completed when the restraint was applied, however the vital signs were not monitored again until 8 P.M. Patient 1’s position was changed twice, and range of motion were completed twice. 4. Patient 1 was placed in restraint on 2/6/24 at 12:30 P.M. to 6:30 P.M., according to the Special Treatment Procedure Patient Record. Patient 1 was offered toileting five times, and not the six that he should have been offered. Patient 1’s vital signs were assessed when the restraint was applied, and hourly, but only Patient 1’s respiration and temperature were documented. Patient 1’s blood pressure was not monitored until the restraints were removed. Further, Patient 1’s position was changed once, and range of motion was completed once. 5. Patient 1 was placed in restraint on 2/8/24 at 9:45 P.M. to 2/9/24 at 12:40 A.M., according to the Special Treatment Procedure Patient Record. Patient 1 did not have any position changes or range of motion. 6. Patient 1 was placed in restraint on 2/11/24 at 9:40 P.M. to 2/12/24 at 12:42 A.M., according to the Special Treatment Procedure Patient Record. Patient 1 was only offered fluids and toileting twice. Patient 1’s position changes and range of motion were completed one time. 7. Patient 1 was placed in restraint on 2/13/24 at 8:55 P.M. to 11:58 P.M., according to the Special Treatment Procedure Patient Record. Patient 1 was offered fluids every 15 minutes, however was not offered toileting, position changes or range of motion. 8. Patient 1 was placed in restraint on 2/17/24 at 6:50 P.M. to 2/18/24 at 12:15 A.M., according to the Special Treatment Procedure Patient Record. Patient 1’s vital signs were only documented as respirations initially, and Patient 1’s vital signs were not assessed again until 10 P.M., 3 hours later. Position changes and range of motion were completed only twice. 9. Patient 1 was placed in restraint on 2/22/24 at 1:20 A.M. to 6:20 A.M., according to the Special Treatment Procedure Patient Record. Patient 1’s range of motion was only provided once. 10. Patient 1 was placed in restraint on 2/27/24 at 6:10 P.M. to 2/28/24 at 2:05 A.M., according to the Special Treatment Procedure Patient Record. Patient 1’s vital signs were assessed when the restraints were applied, and not again until 10 P.M. Patient 1’s position was changed twice, and range of motion were only offered twice. 11. Patient 1 was placed in restraint on 2/28/24 at 10:00 A.M. to 17:30 A.M., according to the Special Treatment Procedure Patient Record. Patient 1’s vital signs were assessed when the restraints were applied, however were not monitored during the next four hours. Further, Patient 1’s vital signs were not monitored during the final three hours that Patient 1 was in restraints. Patient 1 was not offered a position change or range of motion. In addition, there was no documented evidence of the RN’s hourly note of patient response to interventions on 2/28/24 from 3 P.M. to 5:30 P.M. 12. Patient 1 was placed in restraint on 3/4/24 at 12 A.M. to 4:43 A.M., according to the Special Treatment Procedure Patient Record. Patient 1’s position was changed once and was provided range of motion twice. 13. Patient 1 was placed in restraint on 3/7/24 at 10:10 P.M. to 3/8/24 at 11:20 A.M., according to the Special Treatment Procedure Patient Record. Patient 1’s vital signs were assessed when the restraints were applied, and documented as Blood Pressure (BP) 174/142, pulse 174, respirations 24, temperature 100°F (normal vital sign ranges were: BP between 90/60 and 120/80, Pulse 60 to 100, respirations between 12 to 18 breaths per minute, Temperature: 97.8°F to 99.1°F ). Patient 1’s (abnormal) vital signs were not monitored and taken again throughout the 13 hours while in restraints. Patient 1 started vomiting on 3/8/24 at 2:30 A.M. The mental health aid documented “patient is now forcing himself to vomit and spit out to the room and staff.” At 4:30 A.M., the vomit was described as a “brown substance.” At 6:30 A.M. RN 3 documented that Patient 1 was “self inducing vomit and spitting vomit towards walls and doors.” Patient 1 continued to vomit until 10:50 A.M. There was no documentation in the nurse’s assessment or the physicans progress note, that Patient 1’s vomiting was considered as a medical issue, and not a behavioral issue. Patient 1’s required 15 minute circulation checks were not documented from 4 A.M. until 7 A.M., and position changes and range of motion were only documented as completed every 15 minutes from 8 A.M. until 10:45 A.M. In addition, there was no documented evidence of RN hourly patient response to interventions on 3/7/24 at 11 P.M., and 3/8/24 at 2:30 A.M. and 9:30 A.M. The mental health aid was interviewed on 4/10/24 at 9:53 A.M. The mental health aid stated he documented position changes and range of motion every 15 minutes because the patient was constantly moving and changing position, and constantly moving both of his arms and legs, thereby meeting that requirement. The mental health aid stated that he did not assist Patient 1 to change Patient 1’s position, or removed any of the restraints to provide a position change or range of motion. The DON was interviewed on 4/10/24 at 2:15 P.M. The DON stated that nurses should have assessed Patient 1’s vital signs, and offered fluids and toileting every hour. The DON stated that nurses should have provided position changes and range of motion every two hours. The DON stated that these interventions were important for the patient’s safety. The DON acknowledged these interventions were not completed and provided consistently for Patient 1. 22383 b. Patient 2 was admitted to the hospital on 9/28/23, per the hospital Admission/Discharge Record. Patient 2 was placed in restraints on 1/10/24, from 8:37 P.M., until 10 P.M., according to the documentation on the Special Treatment Procedure Patient Record. Patient 2 was not offered something to drink or offered to use the bathroom. Patient 2 was placed in restraints on 1/12/24, from 5:05 P.M., until 7:05 P.M., according to the documentation on the Special Treatment Procedure Patient Record. Patient 2 was not offered something to drink or offered to use the use bathroom. c. Patient 4 was admitted to the hospital on 8/4/23, per the hospital Admission/Discharge Record. Patient 4 was placed in restraints on 3/9/24, from 9:43 P.M., until 10:58 P.M., according to the documentation on the Special Treatment Procedure Patient Record. Patient 4 was not offered something to drink or offered to use the bathroom. d. Patient 5 was admitted to the hospital on 3/14/24, per the hospital Admission/Discharge Record. Patient 5 was placed in restraints on 3/20/24, from 7:22 P.M., until 8:37 P.M., according to the documentation on the Special Treatment Procedure Patient Record. Patient 5’s vital signs were monitored/taken once. Patient 5 was not offered something to drink or offered to use the bathroom. e. Patient 8 was admitted to the facility on 2/13/24, per the hospital Admission/Discharge Record. Patient 8 was placed in restraints on 2/13/24, from 1:15 A.M. until 8:45 A.M., according to the documentation on the Special Treatment Procedure Patient Record. Patient 8’s vital signs were not monitored and recorded during the three required times. In addition, circulation checks that were required to be completed every 15 minutes, were not completed during 22 required 15-minute interval times. Patient 8 was not offered a drink hourly, and was not offered use of the bathroom during four of the 7 1/2 hours while in restraints. Patient 8 was only repositioned twice, and was not offered or provided ROM (range of motion) during the 7 1/2 hours in restraints. f. Patient 9 was admitted to the hospital on 1/29/24, per the hospital Admission/Discharge Record. Patient 9 was placed in restraints on 1/29/24, from 11:58 P.M. until 3:55 A.M., according to the documentation on the Special Treatment Procedure Patient Record. Patient 9 was not offered fluids or use of the bathroom for the last one hour and 55 minutes, and was only repositioned once while in restraints. g. Patient 10 was admitted to the hospital on 1/31/24, per the hospital Admission/Discharge Record. Patient 10 was placed in restraints on 2/3/24 from 4:05 P.M. until 5:30 P.M., according to the documentation on the Special Treatment Procedure Patient Record. Patient 10’s vital signs were taken once during the one hour and 25 minutes while in restraints. A review of hospital’s Policy and Procedure titled Restraint last revised 3/2020 indicated, “ ...IMPLEMENTATION AND DOCUMENTATION OF RESTRAINT ... 14. Nursing staff assesses, monitors, and reevaluates the patient’s well-being. 15. The charge nurse/designee will assess the patient every hour for appropriateness of behavior and level of safety to ensure release at the earliest possible time, adequate circulation, and condition of skin and document findings. 16. Fluids will be offered to the patient every hour. 17. Nursing staff will offer the patient a bedpan or urinal every 2 hours. 18. Range of motion exercises will be done to each extremity ever 2 hours.””

“PATIENT RIGHTS:RESTRAINT/SECLUSION DEATH RPT CFR(s): 482.13(g)(1) & (3)(i) [Death Reporting Requirements: Hospitals must report deaths associated with the use of seclusion or restraint.] (1) With the exception of deaths described under paragraph (g)(2) of this section, the hospital must report the following information to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient’s death: (i) Each death that occurs while a patient is in restraint or seclusion. (ii) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion. (iii) Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death, regardless of the type(s) of restraint used on the patient during this time.”Reasonable to assume” in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation.... (3) The staff must document in the patient’s medical record the date and time the death was: (i) Reported to CMS for deaths described in paragraph (g)(1) of this section; or .... This Standard is not met as evidenced by: 22383 Based on interview and record review, the hospital failed to report death associated with restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) within 24 hours after 1 of 10 sampled patients (1) had Twice as Tough (TAT) four-point (on both wrists and both ankles) restraints on at the time of Patient 1’s death. This deficient practice resulted in the hospital not complying with the regulatory reporting requirement, and had the potential to delay an investigation which may have resulted in harm to other patients who were placed in restraints. Findings: Patient 1 was admitted to the hospital on 1/17/24, per the hospital Admission/Discharge Record. Patient 1’s clinical record was reviewed on 4/5/24. The documentation for the use of seclusion/restraint on 3/7/24 and 3/8/24 was reviewed. According to the documentation, Patient 1 was placed in seclusion/restraint at 10:10 P.M., on 3/7/24 and remained in seclusion/restraint until 11:20 A.M. on 3/8/24. The restraints were removed on 3/8/24 at 11:20 A.M. when Patient 1 became unresponsive, and a Code Blue (someone has gone into cardiac or respiratory arrest) was called and CPR (cardiopulmonary resuscitation) was started. Patient 1 was taken by ambulance to a local General Acute Care Hospital where he was pronounced dead. The hospital was informed of Patient 1’s death on 3/8/24 at 2 P.M. The Director of Quality was interviewed on 4/5/24 at 10:28 A.M. The Director of Quality stated the hospital was unaware of the reporting requirement until 10 days later when they were reviewing the seclusion restraint policy. The hospital informed CMS of Patient 1’s death on 3/22/24, 14 days after they were aware of Patient 1’s death. The hospitals policy and procedure (P&P) titled, “Restraints: Violent Behavior or Seclusion (involuntary confinement),” dated 8/15/2023, the P&P indicated, “The hospital must report the following information to [federal agency]: Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion.””