Wellstar North Fulton Medical Center

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 42060 Based on a review of medical records, facility policies and procedures, Governing Body Bylaws, and staff interviews,it was determined that the facility’s Governing Body failed to ensure that patients received nursing services per facility protocol and in a safe setting when one (1) patient (P#1) of four (4) patients (P#1, P#2, P#3, P#4) sampled was placed in soft restraints and was not removed from restraints timely despite documentation that patient was ‘calm’. Further, P#1 was found to have a fractured wrist after removal from restraints. Findings Included: Review of the Governing Body Bylaws, amended on 6/6/2024, under Article 4, Section 4.1(a) and (b) it was revealed The supreme authority of the Corporation and the government and management of the affairs of the Corporation shall be vested in the Board of Trustees; and all the powers, duties, and functions of the Corporation conferred by the Articles of Incorporation, these Bylaws, state statutes, common law, court decisions, or otherwise, shall be exercised, performed, or controlled by the Board of Trustees. Responsibilities: The governing body of the Corporation shall be the Board of Trustees. The Board of Trustees shall have supervision, control and direction of the management, affairs and property of the Corporation; shall determine its policies or changes therein. Cross refer to A-0115 as it relates to the facility’s failure to ensure that patients are removed from restraints as soon as safely possible. Cross refer to A-0385 as it relates to the facility’s failure to ensure that nursing staff adhered to policies regarding assessments while restrained.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42060 Based on a review of medical records, facility policies and procedures, staff interviews,and personnel files it was determined that the facility failed to ensure that patient’s rights were promoted and protected and that care was received in a safe setting when one (1) patient (P#1) of four (4) patients (P#1, P#2, P#3, P#4) sampled was placed in restraints and found to have sustained a wrist fracture once the restraints were discontinued. Findings Included: Cross-refer to A-0154 as it relates to the facility’s failure to ensure that restraints are discontinued per the facility’s policy. Cross-refer to A-0167 as it relates to the facility’s failure to ensure that patients in restraints are monitored per the facility’s policy.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 42060 Based on review of medical records, staff interviews, policies and procedures, and personnel files it was determined the nursing services failed to provide appropriate restraint monitoring for one (1) patient (P #1) of five (5) patients placed in restraints on 12/20/24 at 8:20 p.m. After discontinutation of the restraint on 12/21/24 at 7:00 a.m. it was determined that P #1’s had a right wrist fracture. Cross-refer to A-0154 as it relates to facility’s failure to ensure that restraints were discontinued at the earliest possible time for P#1. Cross refer to A-0398 as it relates to the facility’s failure to ensure that nursing staff followed restraint monitoring policies.”

“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: 42060 Based on review of medical records, staff interviews, and policies and procedures, it was determined the facility failed to ensure that patients were released from restraints at the earliest possible time for one (1) patient (P #1) of five (5) patients reviewed. P#1 was placed in soft wrist restraints on 12/21/24 at 8:20 p.m. for agitation and interfering with medical devices. The restraints were discontinued on 12/21/24 at 7:00 a.m. despite documentation of calm behavior at 10:25 p.m. and on 12/21/24 at 12:25 a.m., 2:25 a.m., 4:17 a.m. and 4:25 a.m. Findings include: P #1 was admitted on 12/19/24 for a posterior cervical fusion C2-T6, possible T7 (surgical procedure that joins two or more vertebrae in the neck). The surgery started at 8:00 a.m. and ended at 5:17 p.m. P #1 was transferred and arrived at the Neuro Intensive Care Unit at 5:56 p.m. Patient arrived on the unit intubated (tube inserted to assist breathing). On 12/20/24 at 8:00 p.m. RN AA documented in the nursing progress notes that P #1 was very agitated, screaming and saying that she wanted to leave the facility. RN AA documented that P #1 was trying to remove IV tubing (intravenous line) and trying to get up. RN AA notified the on-call neuro NP (HH) who ordered bilateral soft restraints and Zyprexa (medication to calm down a patient during agitation) IM. RN AA stated P #1’s Vital signs were stable at this time, and he continued monitoring the patient. A review of ‘Flowsheets’ revealed restraints were ordered by the provider and applied on 12/20/24 at 8:25 p.m. for interference with medical treatment. RN AA documented P#1 as agitated; safety checks within defined limits; range of motion performed; food/fluids offered; and patient resting. A review of ‘Flowsheets’ revealed on 12/20/24 at 10:25 p.m. P#1 was calm, safety checks within defined limits, range of motion performed On 12/21/24 at 12:25 a.m. P#1 was calm, safety checks within defined limits; range of motion performed; food/fluids offered; and patient resting. On 12/21/24 at 2:25 a.m. P#1 was calm, safety checks within defined limits; range of motion performed; food/fluids offered; and patient resting. On 2/21/24 at 4:25 a.m. P#1 was calm, safety checks within defined limits; range of motion performed; food/fluids offered; and patient resting. On 2/21/24 at 7:00 a.m., RN BB documented that restraints were discontinued. On 12/21/24 at 7:00 a.m., RN BB completed the morning shift nursing assessment as he took over care from RN AA and the wrist restraints were discontinued. An interview with unit Director FF took place on 1/6/25 at 2:57 p.m. in the board room. Director FF recalled P#1 and the incident that took place leading to her wrist fracture. Director FF recalled that staff reported P#1 became aggressive, was kicking, and pulling IV lines late one evening. Nursing staff notified the provider (NP HH) who ordered restraints. Director FF explained that it was the morning after when P#1 complained of wrist pain and an x-ray was ordered. The x-rays revealed a fractured right wrist. Director FF said the type of restraint used was a soft cloth restraint. Director FF explained that nurses follow a protocol for restraints that included assessing the patient every two hours including vital signs. Director FF said the nurse should look at the restraint for skin changes, check for range of motion, making sure the patient could move the limb where the restraint was placed. Director FF said there should be an overall continuous safety check per protocol. Director FF explained that if the safety checks were performed, she expected a patient with a fracture to display signs of pain upon assessment. A phone interview with Nurse Practitioner (NP) HH took place on 1/7/25 at 10:37 a.m. NP HH recalled the event with P #1 as she was covering the floor that night. NP HH said when it came to applying and removing restraint, the nurses had a protocol they followed, and she was unable to speak to that. NP HH said a restraint order was valid for 24 hours, and it was up to the nursing staff to determine if it was safe to discontinue the restraint. NP HH said she was not aware that P #1 suffered a fracture until yesterday (1/6/25) she was told about the fracture. A phone interview with RN AA took place on 1/7/24 at 3:01 p.m. RN AA said he recalled P #1, and he confirmed P #1 was under his care on the night of 12/20/24. RN AA said when he came on shift, he remembered P #1 was drowsy and by 8:00 p.m. P#1 began to wake up, was agitated and tried to jump out of the bed. RN AA tried to explain to P #1 that she was in the hospital and keep her calm. RN AA said there were other nurses that came in the room trying to talk to her, but nothing worked. RN AA said that P #1 was yelling at staff to call her an Uber to take her home. RN AA notified the provider, NP HH who ordered a bilateral soft restraint and a one-time order for medication to calm her down. RN AA said during the application of the restraint there were other nurses that helped hold P #1 because she would not cooperate with staff. RN AA said P #1 went to sleep after the injection and she slept through the night. RN AA said he removed the restraint sometime toward the end of his shift but could not remember the time he removed it. A phone interview with RN CC took place on 1/8/25 at 9:45 a.m. RN CC said she was a Charge Nurse on the unit, but she was not the Charge Nurse in the overnight hours when P #1 was placed on restraint. RN CC was familiar with the patient (P #1). RN CC said she did not see the patient put on restraints because there were a lot of nurses in the room and the curtain was pulled. RN CC heard P #1 yelling loudly and was agitated. RN CC explained that nursing staff follow a restraint protocol as to when it was necessary to put a patient in restraints and when it became safe to release the patient from restraint. RN CC said a patient in restraints should be monitored every two hours after the restraints are applied. RN CC said every two-hour assessment by the RN should include assessment of the patients ability to stretch arms and legs, skin tone, and patient hydration. RN CC said restraints should be discontinued once the patient is no longer aggressive such as kicking, pulling IV tubes. RN CC said a patient that was medicated, and sleeping should not be kept on restraints in her professional judgement. RN CC could not talk specifically about the case involving P #1 because she did not witness the restraint incident. RN CC said in her opinion once P #1 was calm and under the effect of medication, sleepy, it was an indication to release her from the restraint. An interview with RN BB took place on 1/8/25 at 10:20 a.m. in the boardroom. RN BB recalled P#1 as he had cared for her on a few shifts. He assumed P#1’s care on the morning the had been in restraints. RN BB recalled discontinuing P#1’s restraint during shift assessment the morning of 12/21/24. He explained that he discontinued the restraint because P #1 was calm, alert and was not trying to pull her lines; therefore, there was no reason to keep the patient in restraints. RN BB recalled that P#1 complained of right-hand pain when she woke up. RN BB did not note an abrasion on the patient’s hand. RN BB explained the safe way to restrain a patient and stated staff must monitor a patient when a restraint was in place and make sure circulation was not compromised. RN BB said because P #1 was medicated, once she was calm and fell asleep, the restraint should have been removed. RN BB said he was not there when P #1 was displaying aggressive behavior and therefore he was not in a position to talk specifically about the case; however, in general terms once a patient calmed down it was safe to discontinue the restraint. A review of the facility’s policy number RI-01-01 titled “Patient Rights and Responsibilities’, published 11/1/22 revealed that the purpose was to define a process to delineate the rights and responsibilities that a patient has within the system. Continued review revealed that patient rights included: -be treated in a respectful, safe environment that preserves dignity and contributes to a positive self-image -be free from the use of restraints and/or seclusion unless clinically necessary -be free from all forms of abuse or harassment Review of policy and procedure # RI-40-01 Published Date 11/2/2024, title “Restraints and Seclusion”, last revised date 5/12/23 revealed it is the policy of to ensure the usage of restraints and seclusion are safe, effective, and comply with regulatory and accreditation guidelines. The purpose of the policy is to define processes to protect the patient’s health and safety while preserving the patient’s rights, dignity, and wellbeing during the use of Restraints and Seclusion. Further review of the policy under Step 2, Section 2.4 indicates the Nurse (RN or LPN) has to Assess patient for release from restraint at the earliest possible time; and when a restraint is removed based upon the patient’s reassessment, a new order is required for reapplication of the restraint. A review of the policy #RI-40-01, titled “REQUIREMENTS FOR RESTRAINT USE FOR NON-VIOLENT, NON-SELF-DESTRUCTIVE REASONS, JOB AID 2’, last revised 5/12/23 revealed that intervention monitoring was at least every two hours and included: Observed Behavior Safety Checks: checking that restraints are applied appropriately, respiratory status and circulation, signs of injury associated with restraint, dignity and safety maintained. -Range of motion -Nutrition and hydration -Elimination and hygiene Monitoring was the responsibility of the RN and occurred at initiation and every two hours at minimum. More frequent monitoring and readiness for discontinuing was based on the patient’s assessment and situation as determined by the RN. Discontinuation was the responsibility of the RN and was ongoing while restraints were in use. Included: -Assess to discontinue at the earliest opportunity including use of less restrictive intervention. -Restraint discontinued when the RN determined that the patient could be managed safely. -Criteria for release: patient appears to understand reason for medical therapies and is not trying to disrupt.”

“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: 42060 Based on review of medical records, staff interviews, and policies and procedures, it was determined the facility failed to ensure that restraints were implemented in accordance with safe and appropriate techniques for one patient (P #1) of five patients reviewed. P#1 was placed in soft wrist restraints on 12/21/24 at 8:20 p.m. for agitation and interfering with medical devices and was released on 12/21/24 at 7:00 a.m. After release, it was determined that P#1 had sustained a right wrist fracture. Review of medical record revealed Patient #1 (P #1) was a76 year-old-female presented to the facility for a prescheduled surgery under Neurology Service. P #1 was admitted to the facility on 12/19/24 at 5:16 a.m. Review of P #1’s History and Physical (H&P) revealed P #1 had had chronic neck pain for 10 years. P #1 endorsed right hand weakness where she could not pick up objects. A review of the physical exam revealed that P#1 had full strength in upper extremities bilaterally. She had decreased sensation of palmer aspect of right hand. P #1 was admitted for a posterior cervical fusion C2-T6, possible T7 (surgical procedure that joins two or more vertebrae in the neck). P #1 gave consent for the procedure. P #1 was admitted postoperatively to the Neuro Intensive Care Unit at 5:56 p.m. Patient arrived on the unit intubated (tube inserted to assist breathing). A review of a Physician Assistant Progress Note dated 12/20/24 at 7:23 a.m. revealed that P#1 remained intubated, was alert with eyes open and followed commands. She moved all extremities and had sensation to light touch in all extremities. A review of ‘Flowsheets’ revealed that P#1 was extubated (breathing tube removed) on 7/20/24 at 8:53 a.m. A review of “Flowsheets’ revealed that RN AA documented that a “shift assessment” was completed on 12/20/24 at 8:00 p.m. The shift assessment revealed that the right and left hand had strong grip, normal strength and full sensation A review of ‘Flowsheets’ revealed restraints were ordered by the provider and applied on 12/20/24 at 8:25 p.m. for interference with medical treatment. RN AA documented P#1 as agitated; safety checks within defined limits; range of motion performed; food/fluids offered; and patient resting. A review of ‘Flowsheets’ revealed on 12/20/24 at 10:25 p.m. P#1 was calm, safety checks within defined limits, range of motion performed On 12/21/24 at 12:25 a.m. P#1 was calm, safety checks within defined limits; range of motion performed; food/fluids offered; and patient resting. On 12/21/24 at 2:25 a.m. P#1 was calm, safety checks within defined limits; range of motion performed; food/fluids offered; and patient resting. On 2/21/24 at 4:25 a.m. P#1 was calm, safety checks within defined limits; range of motion performed; food/fluids offered; and patient resting. On 2/21/24 at 7:00 a.m., RN BB documented that restraints were discontinued. On 12/21/24 at 7:00 a.m., RN BB completed the morning shift nursing assessment as he took over care from RN AA and the wrist restraints were discontinued. A shift assessment by RN BB on 12/21/24 at 8:00 a.m. revealed right hand grip was moderate, limited, sensation was decreased and P#1 complained of pain A progress note written on 12/21/24 at 2:36 p.m. by PA EE revealed that P#1 complained of right wrist pain and P#1 daughter explained that P#1 had been in wrist restraints the evening prior for agitation and confusion. Continued review of PA EE progress notes revealed an order for right wrist X-ray. At 3:10 p.m. the result of the X-ray showed P #1 suffered a fracture of the right wrist. The radiologist report revealed: “FINDINGS: Essentially nondisplaced extra-articular oblique fracture through the distal ulna. Mild osteoarthrosis. Decreased osseous mineralization.” P #1’s neurosurgeon ordered an orthopedic consult for P #1 who recommended a splint be put in place. P #1 was discharged to the facility’s acute rehabilitation on 12/24/24 at 10:25 a.m. An interview with Director FF took place on 1/6/25 at 2:57 p.m. in the board room. Director FF recalled P#1 and the incident that took place leading to her wrist fracture. Director FF recalled that staff reported P#1 became aggressive, was kicking, and pulling IV lines late one evening. Nursing staff notified the provider (NP HH) who ordered restraints. Director FF explained that it was the morning after when P#1 complained of wrist pain and an x-ray was ordered. The x-rays revealed a fractured right wrist. Director FF said the type of restraint used was a soft cloth restraint. Director FF explained that nurses follow a protocol for restraints that included assessing the patient every two hours including vital signs. Director FF said the nurse should look at the restraint for skin changes, check for range of motion, making sure the patient could move the limb where the restraint was placed. Director FF said there should be an overall continuous safety check per protocol. Director FF explained that if the safety checks were performed, she expected a patient with a fracture to display signs of pain upon assessment. A phone interview with Nurse Practitioner (NP) HH took place on 1/7/25 at 10:37 a.m. NP HH recalled the event with P #1 as she was covering the floor that night. NP HH received a call from a nurse about P#1 being very agitated. NP HH recalled that she then placed a restraint order for P #1. NP HH recalled that she went on the unit to assess the patient (P #1), and she (P#1) was yelling, kicking, and was attempting to pull IV tubing. Upon arrival there were a lot of nurses in the room trying to hold her .NP HH offered oral medication to calm her, but P #1 refused. NP HH said P #1 was adamant that staff needed to call an Uber for her because she wanted to leave the hospital. NP HH said she put an order to administer a one-time dose of Zyprexa (medication to calm the patient down) intramuscular (IM). NP HH explained that she did not hear anything about the patient the rest of the night until in the early morning hours when she went to see the patient to place a catheter. NP HH did not recall the exact time, but P#1 was calm and not agitated. NP HH could not recall if the restraint was still on when she was with the patient. NP HH said when it came to applying and removing restraint, the nurses had a protocol they followed, and she was unable to speak to that. NP HH said a restraint order was valid for 24 hours, and it was up to the nursing staff to determine if it was safe to discontinue the restraint. NP HH said she was not aware that P #1 suffered a fracture until yesterday (1/6/25) she was told about the fracture. An interview with Physician Assistant (PA EE) took place on 1/7/25 at 1:57 p.m. in the boardroom. PA EE worked with the Neurosurgery Group that performed the procedure on P #1, and she was familiar with P#1. PA EE recalled that on 12/21/24 during rounds, P#1 complained of right wrist pain and was guarded with movement. P#1’s daughter was at the bedside and informed PA EE that P#1 had been placed in restraints the evening prior for agitation. PA EE said she saw P #1’ right wrist had bruises, swelling, and was tender to palpation. PA EE said the injury was noticeable. PA EE said the doctor was there and assessed the hand as well. An x-ray was ordered at that time. The daughter at the bedside said that the pain was due to the restraint. PA EE was later notified by the nurse of the x-ray results. An orthopedic consult was ordered. PA EE recalled that she followed up with the orthopedist and was told a splint was ordered. A phone interview with RN AA took place on 1/7/24 at 3:01 p.m. RN AA said he recalled P #1, and he confirmed P #1 was under his care on the night of 12/20/24. RN AA said when he came on shift, he remembered P #1 was drowsy and by 8:00 p.m. P#1 began to wake up, was agitated and tried to jump out of the bed. RN AA tried to explain to P #1 that she was in the hospital and keep her calm. RN AA said there were other nurses that came in the room trying to talk to her, but nothing worked. RN AA said that P #1 was yelling at staff to call her an Uber to take her home. RN AA notified the provider, NP HH who ordered a bilateral soft restraint and a one-time order for medication to calm her down. RN AA said during the application of the restraint there were other nurses that helped hold P #1 because she would not cooperate with staff. RN AA said P #1 went to sleep after the injection and she slept through the night. RN AA said he removed the restraint sometime toward the end of his shift but could not remember the time he removed it. RN AA said when he came back to work, he was informed that P #1 had a fracture of the right arm. RN AA said Director FF had a conversation with him regarding the case. An interview with the Director of Quality and Safety (GG) took place on 1/7/25 at 3:15 p.m. in the boardroom. Director GG said she was aware of the incident involving P #1, and it was reported to the system and her office was the department in charge to investigate all incidents related to patient’s safety. RN Director HH said she reviewed the record, and they were following the process. Director GG said the incident was being investigated and the investigation was ongoing at the current time. No further details were made available to the writer. A phone interview with RN CC took place on 1/8/25 at 9:45 a.m. RN CC said she was a Charge Nurse on the unit, but she was not the Charge Nurse in the overnight hours when P #1 was placed on restraint. RN CC was familiar with the patient (P #1). RN CC said she did not see the patient put on restraints because there were a lot of nurses in the room and the curtain was pulled. RN CC heard P #1 yelling loudly and was agitated. RN CC explained that nursing staff follow a restraint protocol as to when it was necessary to put a patient in restraints and when it became safe to release the patient from restraint. RN CC said a patient in restraints should be monitored every two hours after the restraints are applied. RN CC said the every two-hour assessment by the RN should include assessment of the patients ability to stretch arms and legs, skin tone, and patient hydration. RN CC said restraints should be discontinued once the patient is no longer aggressive such as kicking, pulling IV tubes. RN CC said a patient that was medicated, and sleeping should not be kept on restraints in her professional judgement. RN CC could not talk specifically about the case involving P #1 because she did not witness the restraint incident. RN CC said in her opinion once P #1 was calm and under the effect of medication, sleepy, it was an indication to release her from the restraint. An interview with RN BB took place on 1/8/25 at 10:20 a.m. in the boardroom. RN BB recalled P#1 as he had cared for her on a few shifts. He assumed P#1’s care on the morning the had been in restraints. RN BB recalled discontinuing P#1’s restraint during shift assessment the morning of 12/21/24. He explained that he discontinued the restraint because P #1 was calm, alert and was not trying to pull her lines; therefore, there was no reason to keep the patient in restraints. RN BB recalled that P#1 complained of right-hand pain when she woke up. RN BB did not note an abrasion on the patient’s hand. RN BB explained the safe way to restrain a patient and stated staff must monitor a patient when a restraint was in place and make sure circulation was not compromised. A review of the facility’s policy number RI-01-01 titled “Patient Rights and Responsibilities’, published 11/1/22 revealed that the purpose was to define a process to delineate the rights and responsibilities that a patient has within the system. Continued review revealed that patient rights included: -be treated in a respectful, safe environment that preserves dignity and contributes to a positive self-image -be free from the use of restraints and/or seclusion unless clinically necessary -be free from all forms of abuse or harassment Review of policy and procedure # RI-40-01 Published Date 11/2/2024, title “Restraints and Seclusion”, last revised date 5/12/23 revealed it is the policy of to ensure the usage of restraints and seclusion are safe, effective, and comply with regulatory and accreditation guidelines. The purpose of the policy is to define processes to protect the patient’s health and safety while preserving the patient’s rights, dignity, and wellbeing during the use of Restraints and Seclusion. A review of the policy #RI-40-01, titled “REQUIREMENTS FOR RESTRAINT USE FOR NON-VIOLENT, NON-SELF-DESTRUCTIVE REASONS, JOB AID 2’, last revised 5/12/23 revealed that intervention monitoring was at least every two hours and included: Observed Behavior Safety Checks: checking that restraints are applied appropriately, respiratory status and circulation, signs of injury associated with restraint, dignity and safety maintained. -Range of motion -Nutrition and hydration -Elimination and hygiene Monitoring was the responsibility of the RN and occurred at initiation and every two hours at minimum. More frequent monitoring and readiness for discontinuing was based on the patient’s assessment and situation as determined by the RN. Discontinuation was the responsibility of the RN and was ongoing while restraints were in use. Included: -Assess to discontinue at the earliest opportunity including use of less restrictive intervention. -Restraint discontinued when the RN determined that the patient could be managed safely. -Criteria for release: patient appears to understand reason for medical therapies and is not trying to disrupt.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 42060 Based on review of policies, medical records, staff interviews, and personnel files it was determined that the facility failed to ensure that nursing staff complied with facility policies regarding restraint monitoring and discontinuation of restraints for one (1) patient (P #1) of five (5) patients reviewed. Per documentation, P#1 was placed in soft wrist restraints on 12/20/24 at 8:20 p.m. for agitation and interfering with medical devices. P#1’ s behavior was calm at 10:25 p.m. and on 12/21/24 at 12:25 a.m., 2:25 a.m., 4:17 a.m. and 4:25 a.m. but the restraints were not discontinued until 12/21/24 at 7:00 a.m. After the restraints were discontinued, P#1 complained of right wrist pain 12/21/24 at 7:00 a.m. It was later determined that P#1 had a right wrist fracture. Findings included: Review of policy and procedure # RI-40-01 Published Date 11/2/2024, title “Restraints and Seclusion”, last revised date 5/12/23 revealed it is the policy of to ensure the usage of restraints and seclusion are safe, effective, and comply with regulatory and accreditation guidelines. The purpose of the policy is to define processes to protect the patient’s health and safety while preserving the patient’s rights, dignity, and wellbeing during the use of Restraints and Seclusion. DEFINITION(S) included: Non-Violent, Non-Self-Destructive (NSD) Reason for Restraint - Restraints used to promote physical healing by preventing treatment interruptions enabling active interventions and preventing life threatening or harmful consequences for patients with a clinical condition or cognitive impairment contributing to the disruption of medical therapies and when repeated instruction and implementation of alternatives and least restrictive measures have been unsuccessful. Physical Hold - The application of physical force, without the use of any device, for the purpose of restricting the free movement of a patient’s body and is considered a form of restraint. A physical hold does not include briefly holding the patient without undue force to calm or comfort the patient, holding the patient by the hand or by the shoulders or back, to walk the patient safely from one area to another where the patient is not forcefully resisting the assistance, or assisting the patient in voluntarily participating in activities of daily living or other functional activities. Restraint - Any manual method, physical, chemical, or mechanical device, material, or equipment that the patient cannot easily remove that restricts freedom of movement. Violent or Self Destructive (VSD) Reason for Restraints/Seclusion - Restraints used to protect the safety of the patient and others when a patient’s behavior is severely violent, aggressive, or posing an immediate danger that has not responded to early interventions (e.g., Hitting, kicking, biting at others and or throwing objects). Further review of the policy under Step 2, Section 2.4 indicates the Nurse (RN or LPN) has to Assess patient for release from restraint at the earliest possible time; and when a restraint is removed based upon the patient’s reassessment, a new order is required for reapplication of the restraint. A review of the policy #RI-40-01, titled “REQUIREMENTS FOR RESTRAINT USE FOR NON-VIOLENT, NON-SELF-DESTRUCTIVE REASONS, JOB AID 2’, last revised 5/12/23 revealed that intervention monitoring was at least every two hours and included: Observed Behavior Safety Checks: checking that restraints are applied appropriately, respiratory status and circulation, signs of injury associated with restraint, dignity and safety maintained. -Range of motion -Nutrition and hydration -Elimination and hygiene Monitoring was the responsibility of the RN and occurred at initiation and every two hours at minimum. More frequent monitoring and readiness for discontinuing was based on the patient’s assessment and situation as determined by the RN. Discontinuation was the responsibility of the RN and was ongoing while restraints were in use. Included: -Assess to discontinue at the earliest opportunity including use of less restrictive intervention. -Restraint discontinued when the RN determined that the patient could be managed safely. -Criteria for release: patient appears to understand reason for medical therapies and is not trying to disrupt. Review of medical record revealed Patient #1 (P #1) was a76 year-old-female presented to the facility for a prescheduled surgery under Neurology Service. P #1 was admitted to the facility on 12/19/24 at 5:16 a.m. Review of P #1’s History and Physical (H&P) revealed P #1 was a 76- year- old female who presented to the neurosurgery clinic by the referral of her cardiologist, for chronic neck pain for 10 years. P #1 endorsed right hand weakness where she could not pick up objects. A review of the physical exam revealed that P#1 had full strength in upper extremities bilaterally. She had decreased sensation of palmer aspect of right hand. P #1 was admitted for a posterior cervical fusion C2-T6, possible T7 (surgical procedure that joins two or more vertebrae in the neck). P #1 gave consent for the procedure. P #1 was admitted for a posterior cervical fusion C2-T6, possible T7 (surgical procedure that joins two or more vertebrae in the neck). The surgery started at 8:00 a.m. and ended at 5:17 p.m. P #1 was transferred and arrived at the Neuro Intensive Care Unit at 5:56 p.m. Patient arrived on the unit intubated (tube inserted to assist breathing). A review of a Physician Assistant Progress Note dated 12/20/24 at 7:23 a.m. revealed that P#1 remained intubated, was alert with eyes open and followed commands. She moved all extremities and had sensation to light touch in all extremities. A review of ‘Flowsheets’ revealed that P#1 was extubated (breathing tube removed) on 7/20/24 at 8:53 a.m. A review of “Flowsheets’ revealed that RN AA documented that a “shift assessment” was completed on 12/20/24 at 8:00 p.m. The shift assessment revealed that P#1 was agitated, slightly confused and pulling on IV tubes. Further review revealed that the right and left hand had strong grip, normal strength and full sensation On 12/20/24 at 8:00 p.m. RN AA documented in the nursing progress notes that P #1 was very agitated, screaming and saying that she wanted to leave the facility. RN AA documented that P #1 was trying to remove IV tubing (intravenous line) and trying to get up. RN AA notified the on-call neuro NP (HH) who ordered bilateral soft restraints and Zyprexa (medication to calm down a patient during agitation) IM. RN AA stated P #1’s Vital signs were stable at this time, and he continued monitoring the patient. A review of ‘Flowsheets’ revealed restraints were ordered by the provider and applied on 12/20/24 at 8:25 p.m. for interference with medical treatment. RN AA documented P#1 as agitated; safety checks within defined limits; range of motion performed; food/fluids offered; and patient resting. On 12/20/24 at 10:00 p.m. a review of a Progress Note by Nurse Practitioner (NP HH) revealed that she (NP HH) had previously been called to P #1’s bedside for agitation being combative. NP HH documented that upon arrival, P #1 was screaming she was ready to go, and they were holding her against her will. NP HH attempted unsuccessfully to converse with P #1 who continued to be combative and fight the nurses. P#1 refused medication by mouth. P #1 was placed in bilateral upper restraints. P #1 was given Zyprexa (a medication used to treat psychosis) by injection. A review of ‘Flowsheets’ revealed on 12/20/24 at 10:25 p.m. P#1 was calm, safety checks within defined limits, range of motion performed On 12/21/24 at 12:25 a.m. P#1 was calm, safety checks within defined limits; range of motion performed; food/fluids offered; and patient resting. On 12/21/24 at 2:25 a.m. P#1 was calm, safety checks within defined limits; range of motion performed; food/fluids offered; and patient resting. On 2/21/24 at 4:25 a.m. P#1 was calm, safety checks within defined limits; range of motion performed; food/fluids offered; and patient resting. On 2/21/24 at 7:00 a.m., RN BB documented that restraints were discontinued. On 12/21/24 at 7:00 a.m., RN BB completed the morning shift nursing assessment as he took over care from RN AA and the wrist restraints were discontinued. A shift assessment by RN BB on 12/21/24 at 8:00 a.m. revealed right hand grip was moderate, limited, sensation was decreased and P#1 complained of pain A progress note written on 12/21/24 at 2:36 p.m. by PA EE revealed that P#1 complained of right wrist pain and P#1 daughter explained that P#1 had been in wrist restraints the evening prior for agitation and confusion. Continued review of PA EE progress notes revealed an order for right wrist X-ray. At 3:10 p.m. the result of the X-ray showed P #1 suffered a fracture of the right wrist. Radiologist report revealed: FINDINGS: Essentially nondisplaced extra-articular oblique fracture through the distal ulna. Mild osteoarthrosis. Decreased osseous mineralization. P #1’s neurosurgeon ordered an orthopedic consult for P #1 who recommended a splint be put in place. P #1 was discharged to the facility’s acute rehabilitation on 12/24/24 at 10:25 a.m. An interview with unit Director FF took place on 1/6/25 at 2:57 p.m. in the board room. Director FF recalled P#1 and the incident that took place leading to her wrist fracture. Director FF recalled that staff reported P#1 became aggressive, was kicking, and pulling IV lines late one evening. Nursing staff notified the provider (NP HH) who ordered restraints. Director FF explained that it was the morning after when P#1 complained of wrist pain and an x-ray was ordered. The x-rays revealed a fractured right wrist. Director FF said the type of restraint used was a soft cloth restraint. Director FF explained that nurses follow a protocol for restraints that included assessing the patient every two hours including vital signs. Director FF said the nurse should look at the restraint for skin changes, check for range of motion, making sure the patient could move the limb where the restraint was placed. Director FF said there should be an overall continuous safety check per protocol. Director FF explained that if the safety checks were performed, she expected a patient with a fracture to display signs of pain upon assessment. A phone interview with Nurse Practitioner (NP) HH took place on 1/7/25 at 10:37 a.m. NP HH recalled the event with P #1 as she was covering the floor that night. NP HH received a call from a nurse about P#1 being very agitated. NP HH recalled that she then placed a restraint order for P #1. NP HH recalled that she went on the unit to assess the patient (P #1), and she (P#1) was yelling, kicking, and was attempting to pull IV tubing. Upon arrival there were a lot of nurses in the room trying to hold her .NP HH offered oral medication to calm her, but P #1 refused. NP HH said she put an order to administer a one-time dose of Zyprexa (medication to calm the patient down) intramuscular (IM). NP HH explained that she did not hear anything about the patient the rest of the night until in the early morning hours when she went to see the patient to place a catheter. NP HH did not recall the exact time, but P#1 was calm and not agitated. NP HH could not recall if the restraint was still on when she was with the patient. NP HH said when it came to applying and removing restraint, the nurses had a protocol they followed, and she was unable to speak to that. NP HH said a restraint order was valid for 24 hours, and it was up to the nursing staff to determine if it was safe to discontinue the restraint. NP HH said she was not aware that P #1 suffered a fracture until yesterday (1/6/25) she was told about the fracture. An interview with Physician Assistant (PA EE) took place on 1/7/25 at 1:57 p.m. in the boardroom. PA EE worked with the Neurosurgery Group that performed the procedure on P #1, and she was familiar with P#1. PA EE recalled that on 12/21/24 during rounds, P#1 complained of right wrist pain and was guarded with movement. P#1’s daughter was at the bedside and informed PA EE that P#1 had been placed in restraints the evening prior for agitation. PA EE observed that P #1 had bruises, swelling, and was tender to palpation. PA EE said the injury was noticeable. PA EE said the doctor was there and assessed the hand as well. An x-ray was ordered at that time. The daughter at the bedside said that the pain was due to the restraint. PA EE was later notified by the nurse of the x-ray results. An orthopedic consult was ordered. PA EE recalled that she followed up with the orthopedist and was told a splint was ordered. A phone interview with RN AA took place on 1/7/24 at 3:01 p.m. RN AA said he recalled P #1, and he confirmed P #1 was under his care on the night of 12/20/24. RN AA said when he came on shift, he remembered P #1 was drowsy and by 8:00 p.m. P#1 began to wake up, was agitated and tried to jump out of the bed. RN AA tried to explain to P #1 that she was in the hospital and keep her calm. RN AA said there were other nurses that came in the room trying to talk to her, but nothing worked. RN AA said that P #1 was yelling at staff to call her an Uber to take her home. RN AA notified the provider, NP HH who ordered a bilateral soft restraint and a one-time order for medication to calm her down. RN AA said during the application of the restraint there were other nurses that helped hold P #1 because she would not cooperate with staff. RN AA said P #1 went to sleep after the injection and she slept through the night. RN AA said he removed the restraint sometime toward the end of his shift but could not remember the time he removed it. RN AA said when he came back to work, he was informed that P #1 had a fracture of the right arm. RN AA said Director FF had a conversation with him regarding the case. RN AA said he did have training on the use of restraint when he was hired. A phone interview with RN CC took place on 1/8/25 at 9:45 a.m. RN CC said she was a Charge Nurse on the unit, but she was not the Charge Nurse in the overnight hours when P #1 was placed on restraint. RN CC was familiar with the patient (P #1). RN CC said she did not see the patient put on restraints because there were a lot of nurses in the room and the curtain was pulled. RN CC heard P #1 yelling loudly and was agitated. RN CC explained that nursing staff follow a restraint protocol as to when it was necessary to put a patient in restraints and when it became safe to release the patient from restraint. RN CC said a patient in restraints should be monitored every two hours after the restraints are applied. RN CC said every two-hour assessment by the RN should include assessment of the patient’s ability to stretch arms and legs, skin tone, and patient hydration. RN CC said restraints should be discontinued once the patient is no longer aggressive such as kicking, pulling IV tubes. RN CC said a patient that was medicated, and sleeping should not be kept on restraints in her professional judgement. RN CC could not talk specifically about the case involving P #1 because she did not witness the restraint incident. RN CC said in her opinion once P #1 was calm and under the effect of medication, sleepy, it was an indication to release her from the restraint. An interview with RN BB took place on 1/8/25 at 10:20 a.m. in the boardroom. RN BB recalled P#1 as he had cared for her on a few shifts. He assumed P#1’s care on the morning the had been in restraints. RN BB recalled discontinuing P#1’s restraint during shift assessment the morning of 12/21/24. He explained that he discontinued the restraint because P #1 was calm, alert and was not trying to pull her lines; therefore, there was no reason to keep the patient in restraints. RN BB recalled that P#1 complained of right-hand pain when she woke up. RN BB did not note an abrasion on the patient’s hand. RN BB explained the safe way to restrain a patient and stated staff must monitor a patient when a restraint was in place and make sure circulation was not compromised. RN BB said because P #1 was medicated, once she was calm and fell asleep, the restraint should have been removed. RN BB said he was not there when P #1 was displaying aggressive behavior and therefore he was not in a position to talk specifically about the case; however, in general terms once a patient calmed down it was safe to discontinue the restraint. A review of personnel files revealed that P#1 received restraint education 5/4/24.”