Lawrence & Memorial Hospital

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 14216 Based on a review of clinical records, hospital documentation, and staff interviews, for 1 of 5 sampled patients reviewed for grievances (Patient #133) the hospital failed to ensure patient concerns were addressed in the grievance. The finding includes: a. Patient #133 filed a grievance on 5/7/25 identifying the Physician Assistant (PA) had an attitude and they had an unpleasant interaction with a PA. The grievance identified the patient alleged that the PA rolled their eyes at the patient and did not want to wrap the patient’s elbow. Review of the hospital documentation and interview with a representative from Patient Relations on 7/1/25 at 9:20AM identified when a grievance is filed, it is shared with the leadership team and management of the area identified in the grievance. The representative stated in this case, there was no response from the PA and the staff person assigned to complete the grievance was unavailable to review the concerns. However, there was documentation that a closure letter was sent to the complainant although the investigation was not completed. The representative stated the expectation is that the allegations are addressed, and a written response letter is sent to the complainant which was not done in this case. Review of the hospital policy for patient complaint and grievance management identified that all grievances will be investigated and resolved promptly.”

“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: 14216 Based on a review of clinical records, hospital documentation, and staff interviews, for 1 of 3 sampled patients reviewed for bruising of unknown origin, the hospital failed to investigate how the bruises occurred and failed to document the location and size of the bruises. The finding includes: a. Patient #125 was admitted to the hospital on 2/26/25 for shortness of breath and found to have a right upper lobe pneumonia. Review of the H&P dated 2/26/25 at 9:30PM noted the patient’s skin was warm, dry, with no edema and negative for a rash. Review of the nursing admission assessment dated 2/27/25 at 5:32AM identified the Heparin drip (blood thinner) was infusing at 15 units/kg/hr. The assessment lacked documentation of the patient’s skin assessment. A Physician’s order dated 2/27/25 at 11:25AM directed to administer Lovenox (blood thinner) 80mg subcutaneous every 12 hours. The physician orders identified the Lovenox 80mg was discontinued on 2/28/25 at 10:50AM. A Physician’s order dated 2/28/25 at 10:50AM directed to administer Eliquis (blood thinner) 10mg every 12 hours and was discontinued on 3/6/25 at 9:55PM. The Physician’s order dated 3/7/25 at 9:00AM directed to administer Eliquis 5mg every 12 hours. Review of the clinical record with RN #121 on 7/1/25 at 11:30AM identified the first indication of bruising was noted in the patient’s flow sheets on 2/28/25 (2 days after admission) at 4:00PM. The assessment failed to include the location or size of the bruising. Review of the flow sheets during the period of 3/1/25 through 3/12/25 identified the patient had bruising. The documentation failed to identify the location, appearance or size of the bruising on the patient. Review of a nurses note dated 3/3/25 at 6:38PM identified the patient had multiple eccyhmotic bruising on the upper extremities. Nurse’s notes dated 3/4/25 at 5:18PM identified skin to upper and lower extremities ruddy in appearance which family reports is new since patient became ill. An interview with RN #121 on 7/1/25 at 11:30AM stated that when a patient is identified with bruising, it is the expectation that nurses document the location, size and appearance. RN #121 stated that will help to determine when new bruising occurs. Interview with the Director of Quality on 7/1/25 at 12:00PM stated that the hospital does not have a policy for bruising of unknown origin, but staff are expected to document the bruises and implement interventions to help protect the patient’s skin. The Director further identified that they did not conduct an investigation as to how the bruises occurred. The interview with the Chief of Medicine on 7/1/25 at 12:15PM stated that it is relatively normal for a patient to bruise while on anticoagulant therapy. The Chief of medicine stated that he reviewed the patient’s chart and identified several risk factors for the bruising including agitation, medications, and a pulmonary embolism.”

“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: 14216 Based on clinical record review, hospital policy and staff interview for 2 of 4 sampled patients reviewed for restraints, (Patient #126 and #127) the hospital failed to ensure a Physician’s order was obtained for the use of violent restraints. The findings include: a. Patient #126 was admitted on 4/11/25 on a PEC (Physician emergency certificate). A nurse’s note dated 4/12/25 at 6:51PM reflected that between 3:00PM and 7:00PM the patient was in non-violent restraints for escalating behaviors and threatening to leave. The patient was actively removing the non-violent restraints, the MD was notified, and the patient was transferred to violent restraints at 4:00PM. Review of the clinical record and interview with the Clinical Coordinator for Critical Care on 6/30/25 at 11:30AM identified that when the patient was placed in violent restraints staff did not obtain a physician order. The Clinical Coordinator stated that when a patient’s restraints go from non-violent to violent a physician’s order must be obtained. b. Patient #127 presented to the ED on 5/30/25 for agitation and combativeness. The nurse’s note dated 5/30/25 at 2:45AM identified the patient was screaming, using profanity, and attempting to hit and kick staff in the ambulance bay. The note identfied that the patient was placed in 4-point restraints for safety. The ED provider note dated 5/30/25 at 3:10AM reflected that upon arrival to the ED the patient was extremely agitated, combative and attempting to hit and kick staff requiring 4-point restraints. Review of the clinical record and interview with the Clinical Coordinator for Critical Care on 6/30/25 at 11:45AM failed to identify a physician’s order was written for the use of restraints. The Clinical Coordinator stated when the patient was placed in 4-point restraints, a physician’s order is to be written for the use of restraints within one hour of the application. Review of the hospital policy for restraint and seclusion identified restraint standards for violent, self-destructive behavior, orders are to be written within one hour of restraint initiation.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 14216 Based on a review of clinical records, hospital documentation, and staff interviews, for 2 of 5 sampled patients reviewed for restraints, (Patient #126 and #127) the hospital failed to ensure the patient’s behaviors were documented while the patient was in restraints in accordance with hospital policy. The findings include: a. Patient #126 was admitted on 4/11/25 on a PEC (Physician emergency certificate). A nurse’s note dated 4/12/25 at 6:51PM reflected that between 3:00PM and 7:00PM the patient was in non-violent restraints for escalating behaviors and threatening to leave. The patient was actively removing the non-violent restraints, the MD was notified, and the patient was transferred to violent restraints at 4:00PM. The nurse’s note dated 4/13/25 at 3:58AM reflected that the patient was removed from the violent restraints at 2:45AM and placed in 4-point soft wrist restraints applied. Review of the clinical record and interview with the Clinical Coordinator for Critical Care on 6/30/25 at 11:50AM identified that from 6:00PM until 7:30PM and from 10:30PM until 2:45AM (time of discontinuation) the patient’s behaviors were not documented in the clinical record. The Clinical Coordinator stated that the patient’s behaviors are to be documented every fifteen minutes while the patient is in restraints to determine when the restraints can be discontinued. b. Patient #127 presented to the ED on admitted on 5/30/25 for agitation and combativeness. A nurse’s note dated 5/30/25 at 2:45AM noted patient screaming, using profanity, attempting to hit and kick staff in the ambulance bay, the patient was placed in 4-point restraints for safety. Review of the behavior flow sheets dated 5/30/25 identified the patient was in 4-point restraints from 2:45AM until 4:15AM when the restraints were removed. The flowsheets identified that at 3:30AM and at 3:45AM, the patient’s behaviors were not documented and at 4:00AM the patient’s behavior was documented as calm. Review of the clinical record and interview with the Clinical Coordinator for Critical Care on 6/30/25 at 12:00PM identified the patient’s behaviors were not documented at 3:30AM and 3:45AM while the patient was in 4-point restraints. The Clinical Coordinator stated that the patient’s behaviors are to be documented every fifteen minutes while the patient is in restraints to determine when the restraints can be discontinued. Review of the hospital policy for restraint and seclusion identified restraints are discontinued at the earliest possible time when the behaviors necessitating the use of the restraint cease, regardless of the length of time identified in the order. The policy identified staff are to conduct and document patient visual checks every fifteen minutes which include the behavior of the patient.”

“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: 14216 Based on a review of clinical record, hospital documentation, and staff interview for 1 of 5 sampled patients reviewed for restraints, (Patient #126) the hospital failed to ensure a face-to-face evaluation was completed within one hour of the application of the restraint. The finding includes: Patient #126 was admitted on 4/11/25 on a PEC (Physician emergency certificate). A nurse’s note dated 4/12/25 at 6:51PM noted between 3:00PM and 7:00PM the patient was in non-violent restraints for behaviors escalating, threatening to leave. The patient was actively removing the non-violent restraints, the MD was notified, and the patient was transferred to violent restraints at 4:00PM. Review of the clinical record and interview with the Clinical Coordinator for Critical Care on 6/30/25 at 11:30AM identified when the patient was placed in violent restraints, a face-to-face evaluation was not completed on the patient. The Clinical Coordinator stated that a face-to-face evaluation is to be completed within one hour of the initiation of a restraint. Review of the hospital policy for restraint and seclusion identified within one hour of the restraint initiation, the provider or trained RN must make a face-to-face evaluation of the patient. The evaluation shall include a physical and behavioral health assessment which includes both a face-to-face assessment and discussion with staff of the patients physical and psychosocial status and evaluation of the immediate situation, the patients reaction to the intervention, the patients behavioral and medical condition and the need to continue or terminate the restraint.”