Beth Israel Deaconess Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 41143 The Condition of Participation: Patient Rights was out of compliance. Based on record review and interview, the Hospital failed to ensure the use of a physical restraint was implemented in accordance with a physician’s order for two Patients (#3 and #4) out of a total sample of 10 patients; Patient #3 was mechanically restrained by 4 limbs without a written physician’s order and was subsequently identified to have a left wrist fracture. Cross Reference: 482.13(e)(5): Patient Rights: Restraint or Seclusion (168).”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 37556 The Condition of Participation: Quality Assessment and Performance Improvement Program (QAPI) was out of compliance. Based on record review and interview, the Hospital failed to ensure opportunities for improvement were identified and actions aimed at performance improvement were taken for two Patients (#3 and #4) out of a total sample of 10 Patients; Patient #3 was not assessed according to Hospital policy while physically restrained nor was the Patient restrained in accordance with a written Physician’s order and was subsequently found to have a left wrist fracture following the restraint. On 10/17/23, Patient #4 did not have a written physician order for a physical restraint, and he/she was not observed according to Hospital Policy while in a violent four-point physical restraint; additionally, Patient #4 was not assessed according to Hospital Policy following an unwitnessed fall with a head injury. Cross Reference: 482.21(b)(2)(ii), (c)(1), (c)(3): Quality Assessment and Performance Improvement: Quality Improvement Activities (283).”

“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: 37556 The Condition of Participation: Nursing Services was out of compliance. Based on record review and interview, the Hospital failed to ensure the nursing care for 2 Patients (#3 and #4) was appropriately evaluated by a Registered Nurse (RN) out of a total sample of 10 Patients; Patient #3 was not assessed according to Hospital policy while physically restrained and was subsequently found to have a left wrist fracture following the restraint. On 10/17/23, Patient #4 was not observed according to Hospital Policy while in a violent four-point physical restraint; additionally, Patient #4 was not assessed according to Hospital Policy following an unwitnessed fall with a head injury. Cross Reference: 482.23(b)(3): Nursing Services: RN Supervision of Nursing Care (395).”

“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: 41143 Based on record review and interview, the Hospital failed to ensure the use of a physical restraint was implemented in accordance with a physician’s order for two Patients (#3 and #4) out of a total sample of 10 patients; Patient #3 was mechanically restrained by 4 limbs without a written physician’s order and was subsequently identified to have a left wrist fracture. Findings include: Review of the Hospital policy titled “Use of Restraints and/or Seclusion”, dated 8/1/22, indicated the following: -A physician must complete the order for restraint of a patient immediately -Orders for violent and/or self-destructive behavior restraint must only be ordered for 4 hours for adults. -Restraint ordering must be completed via CPOE (computerized provider order entry). Each order must be time limited and written for a specific behavior which puts the Patient at imminent risk of assault or self-harm, extreme aggression, and impulsivity. -Documentation of initial in-person evaluation: Restraint/Seclusion intervention must be incorporated into plan of care. Documentation must reflect the evaluation of the patient’s immediate situation, reaction to the intervention, medical/behavioral condition; and the need to continue/terminate the intervention. -Reapplication of restraint requires a new order. Review of the Hospital policy titled “Requirements for Physician and Licensed Independent Practitioner Orders”, dated 3/15/23, indicated the following: -Verbal orders are given only in emergent circumstances where patient care must proceed without any delay for a physician, designee, or LIP to record an order. A Registered Nurse (RN) or other licensed health professional will enter the order into POE or write it on the order form. Verbal orders must be signed by the ordering provider as soon as possible. 1. Patient #3 was presented to the Hospital Emergency Department on 10/22/23 with altered mental status after being found in the community wandering. Review of Patient #3’s medical record indicated Patient #3 presented to the Emergency Department with altered mental status, a past medical history of brain infarction (death of tissue), and cognitive decline (per the Patient’s family). Patient #3 was evaluated by Physician #2 on 10/22/23 at 6:02 P.M.; Physician #2 ordered CT (computerized tomography) scans to assess the Patient for possible intracranial bleeding due to his/her altered mental status. Patient #3 returned to the Emergency Department at 9:45 P.M. after a code purple was called due to the Patient’s extreme agitation and combative behaviors while at his/her CT exam. Patient #3 was brought back to his/her room in the Emergency Department by security staff, was placed in soft-restraints, and medicated with Zyprexa (antipsychotic medication). At 10:45 P.M. Patient #3 was able to get out of his/her soft restraints and remove his/her IV (intravenous) device; the Patient was then placed in leather restraints by security and the Patient was again medicated with Zyprexa. RN #3 notified Physician #3 regarding Patient #3’s continued altered and impaired cognition at 3:00 A.M. on 10/23/23. Patient #3 was removed from restraints by RN #3 at 4:40 A.M. on 10/23/23, over five hours from initiation of the soft restraints and over four hours from the initiation of the leather restraints on the Patient. At 6:05 A.M. on 10/23/23 Patient #3 was complaining of left wrist pain; an x-ray examination was performed, and it was identified Patient #3 had sustained a fracture of his/her left distal ulna (the end of a bone in the forearm close to the wrist). Further Review of Patient #3’s medical record failed to indicate any physician orders entered on 10/22/23 for the physical restraint of the Patient. Physician #3 entered an order for Restraints: Initial order, method: right wrist, left wrist, right ankle, and left ankle on 10/23/23 at 4:20 A.M., over five hours from the initial restraint on Patient #3 at 9:45 P.M. on 10/22/23. The nursing documentation of Patient #3’s restraint assessments indicated Patient #3 was placed in 4-point physical restraints at 9:45 P.M. on 10/22/23. Four additional assessments were documented by RN #3 at 11:45 P.M. on 10/22/23, 1:45 A.M. on 10/23/23, 3:45 A.M., and 4:20 A.M.; all four assessments indicated Patient #3 was only in seclusion and failed to indicate he/she was physically restrained. During an interview with Physician #2 on 12/6/23 at 3:00 P.M., she said she interviewed Patient #3 when he/she presented to the Emergency Department on 10/22/23. She said the Patient was confused and CT exams were ordered as part of the work up for Patient #3’s altered mental status. She said Patient #3 had been brought back to his/her room by security following a code purple during his/her CT exam. She said when she arrived at Patient #3’s room, he/she was being held by security on his/her bed; the Patient’s agitation could not be de-escalated. She said Patient #3 was at high risk for hurting him/herself or others and was physically restrained with 4-point soft restraints and medicated with Zyprexa. She said Patient #4 was pulling with his/her arm after being restrained. She said she did not enter an order into the CPOE system following the event. She said any provider involved in the Patient’s care can enter an order in the CPOE system for the Patient. She said restraint orders need to be renewed by a Physician. She said she was unaware of any other incidents with Patient #3 following his/her initial restraint and signed off with Physician #3 at 11:00 P.M. on 10/22/23. During an interview with RN #3 on 12/7/23 at 7:30 A.M., she said Physician #2 gave a verbal order to physically restrain Patient #3 during the code purple on 10/22/23. She said security officers placed the Patient in soft 4-point restraints initially. She said Patient #3 was able to move and almost get off the bed, and at that point security was called and placed the Patient in leather restraints with his/her left arm above his/her head. During an interview with Physician #4 on 12/7/23 at 10:10 A.M., he said he was the attending physician when Patient #3 was brought to the Emergency Department. He said there was a verbal order provided to physically restrain Patient #3, however, there was a delay in placing an order for the restraint in Patient #3’s record. He said verbal orders should be entered into CPOE following an event. During an interview with Physician #3 on 12/7/23 at 10:30 A.M., he said Patient #3 was signed out to him from Physician #2 on 10/22/23 at 11:00 P.M. He said he was not aware Patient #3 was physically restrained until RN #3 reported it to him later in his shift in the Emergency Department. He said he put an order for restraints into the medical record for Patient #3 prior to evaluating him/her. He said when he evaluated Patient #3 the Patient was physically restrained. He said if he provided a verbal order for restraints, he would enter the order as soon as possible after providing that order when safe to do so. Patient #3 was mechanically restrained by 4 limbs without a written physician’s order and was subsequently identified to have a left wrist fracture. 37556 2. Review of Patient 4’s medical record indicated that in October 2023, he/she was transferred from a subacute rehabilitation Facility via emergency medical services on Section 12 (involuntarily) for evaluation of agitation and altered mental status in the Emergency Department (ED). Patient #4 diagnoses included a history of epilepsy, hypertension, diabetes, hypothyroidism, osteoarthritis, osteoporosis, and recurrent falls. Review of the Hospital’s internal Investigation, dated 10/17/23, indicated that while in the ED, Patient #4 attempted to assault staff; therefore, staff administered one dose of an antipsychotic (Olanzapine, 5 milligrams, intramuscular) chemical restraint and placed Patient #4 in a four-point mechanical/physical restraint due to his/her behaviors and safety concerns. Review of the Nurse Progress Note, dated 10/17/23 at 12:14 P.M., indicated Patient #4 attempted to elope and became violent towards staff (hitting, kicking, and attempting to bite), requiring an order for restraints. The Note indicated that Hospital security placed Patient #4 in four-point soft physical restraints. Review of Patient #4’s medical record indicated there was no documentation to support the Hospital ensured staff implemented the Use of Restraints/Seclusion Policy by obtaining a written physician order for Patient #4’s physical restraint on 10/17/23, at approximately 12:14 P.M. During an interview on 12/6/23 at 1:55 P.M., the ED Patient Safety Coordinator/Risk Manager said that during an internal investigation and record review, the Hospital identified that Patient #4 did not have a written physician order for the physical four-point physical restraint applied on 10/17/23. During an interview on 12/7/23 at 9:05 A.M., the ED Assistant Nurse Director said that a physician could provide a verbal order for a patient restraint; however, the restrain order(s) would need to also be documented in the patient’s medical record, in accordance with the Hospital Policies.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 41143 Based on record review and interview, the Hospital failed to ensure opportunities for improvement were identified and actions aimed at performance improvement were taken for two Patients (#3 and #4) out of a total sample of 10 Patients; Patient #3 was not assessed according to Hospital policy while physically restrained nor was the Patient restrained in accordance with a written Physician’s order and was subsequently found to have a left wrist fracture following the restraint. Findings include: Review of the Hospital 2023 Integrated Patient Safety, Quality and Performance Improvement Plan indicated the following: -The leadership of the Hospital and Health System are responsible for identifying the priorities for patient safety, equitable care, quality, performance measurement, assessment, and improvement. -The leadership of the Hospital establishes the priorities for performance improvement and provides those resources necessary to measure, assess, and sustain the improvements that are attained. -Additional priorities may be identified through a root cause analysis of an adverse outcome or sentinel event. Review of the Hospital policy titled “Use of Restraints and/or Seclusion”, dated 8/1/22, indicated the following: -Documentation of initial in-person evaluation: Restraint/Seclusion intervention must be incorporated into plan of care. Documentation must reflect the evaluation of the patient’s immediate situation, reaction to the intervention, medical/behavioral condition; and the need to continue/terminate the intervention. -Documentation on the Restraint and Seclusion Flow Sheet must include an assessment using the guidelines defined within this policy: Consideration of less restrictive interventions, basic needs, skin condition, patient’s response to the restraint, exercise of restrained extremities, signs of injury associated with application of restraint, behavior indicating reason for continuation of restraint. -Document a patient’s response to trial/early release and less restrictive measures. -A physician must complete the order for restraint of a patient immediately -Restraint ordering must be completed via CPOE (computerized provider order entry). Each order must be time limited and written for a specific behavior which puts the Patient at imminent risk of assault or self-harm, extreme aggression, and impulsivity. Patient #3 was presented to the Hospital Emergency Department on 10/22/23 with altered mental status after being found in the community wandering. Review of Patient #3’s medical record indicated Patient #3 presented to the Emergency Department with altered mental status, a past medical history of brain infarction (death of tissue), and cognitive decline (per the Patient’s family). Patient #3 was evaluated by Physician #2 on 10/22/23 at 6:02 P.M.; Physician #2 ordered CT (computerized tomography) scans to assess the Patient for possible intracranial bleeding due to his/her altered mental status. Patient #3 returned to the Emergency Department at 9:45 P.M. after a code purple was called due to the Patient’s extreme agitation and combative behaviors when at his/her CT exam. Patient #3 was brought back to his/her room in the Emergency Department by security staff, was placed in soft-restraints, and medicated with Zyprexa (antipsychotic medication). At 10:45 P.M. Patient #3 was able to get out of his/her soft restraints and remove his/her IV (intravenous) device; the Patient was then placed in leather restraints by security and the Patient was again medicated with Zyprexa. Patient #3 was removed from restraints by RN #3 at 4:20 A.M. on 10/23/23. At 6:05 A.M. on 10/23/23 Patient #3 was complaining of left wrist pain; an x-ray examination was performed, and it was identified Patient #3 had sustained a fracture of his/her left distal ulna (the end of a bone in the forearm close to the wrist). Further Review of Patient #3’s Emergency Department Nursing Chart for Patient #3’s restraint assessments indicated Patient #3 was placed in 4-point physical restraints at 9:45 P.M. on 10/22/23. Four additional assessments were documented by RN #3 at 11:45 P.M. on 10/22/23, 1:45 A.M. on 10/23/23, 3:45 A.M., and 4:20 A.M.; all four assessments indicated Patient #3 was only in seclusion and failed to indicate he/she was physically restrained. Further, Patient #3’s nursing restraint assessments failed to indicate if the Patient was assessed for signs of injury, extremity pulses, extremity ROM (range of motion), skin condition, release from restraint, nor continuation reasoning for a physical restraint. A Registered Nurse (RN) progress note written at 4:40 A.M. on 10/23/23 indicated Patient #3 was released from restraints. Patient #3’s medical record failed to indicate any physician orders entered on 10/22/23 for the physical restraint of the Patient. Patient #3’s medical record failed to indicate any order for seclusion on while he/she was restrained from 10/22/23 to 10/23/23. Review of the Hospital incident report dated 10/23/23 indicated Patient #3 was placed in violent-restraints on 10/22/23 and was found to have an ulna (bone in the forearm) fracture of the left wrist after removal from restraints. The time of the fracture was indeterminate from the Hospital investigation; however, the fracture could have occurred while Patient #3 was restrained or due to his/her agitation. The fracture was in the correct location for restraint injury. The Hospital report/investigation indicated there was a delay from initiation of restraints to POE order for restraints. The report indicated education was being provided to the Emergency Department Nursing Staff regarding the immediate need for written restraint orders to protect the rights of the patients. RN completion of restraint documentation meets standard (despite the nursing restraint assessments failing to indicate Patient #3 was physically restrained, incorrectly assessing the Patient to be in seclusion only, and missing assessment of his/her signs of injury, ROM, and skin condition for over five hours while the Patient was in 4-point physical restraints). During an interview with the ED Patient Safety Coordinator on 12/7/23 at 1:52 P.M., she said Patient #3 was physically restrained on 10/22/23, and was released after 4:00 A.M. on 10/23/23. She said a physician should have written an order for the correct type of restraint following the code purple and should have documented an evaluation as to why the restraint was necessary. She said it was identified there was confusion amongst physicians in the Emergency Department on the restraint process and documentation. She said the event was likely not preventable due to Patient #3’s mental status and behaviors. She said the opportunity for improvement identified from the event with Patient #3 was to create a grid to assist physicians with ordering restraints and constant observation for Patient’s requiring those interventions. She did not provide any evidence the grid was completed, nor medical staff or nursing staff were educated/trained on its use. She did not discuss any interventions regarding nursing assessment of patients with restraints. During an interview with Physician #4 on 12/7/23 at 10:10 A.M., he said he was the attending physician when Patient #3 was brought to the Emergency Department. He said there was a verbal order provided to physically restrain Patient #3, however, there was a delay in placing an order for the restraint in Patient #3’s record. He said verbal orders should be entered into CPOE following an event. During an interview with the Assistant Nurse Director of the Emergency Department on 12/7/23 at 9:00 A.M., he said nursing assessment for patients in restraints should correspond to the order given by a provider for the correct method of restraint for a patient (4-point, 2-point, chemical, seclusion, etc ...) He said each restraint type requires documentation of assessment specific to the type of restraint based on the Hospital’s policy. He said the nursing staff trigger the correct assessments to document when in the Emergency Department Nursing Chart in the Hospital’s electronic medical record. Patient #3 was not assessed according to Hospital policy while physically restrained nor was the Patient restrained in accordance with a written Physician’s order and was subsequently found to have a left wrist fracture following the restraint; the Hospital failed to ensure opportunities for improvement were identified and actions aimed at performance improvement were taken for Patient #3. 37556 2. Review of the Hospital’s policy titled Risk to Fall/Injury Prevention and Post-Fall Patient Care Guidelines, dated 1/15/22, indicated that post-fall care for patients with actual/potential injury from a fall included nurse documentation within a nurse note of the patient’s vital signs and neurological assessments every four hours for 24 hours, and then as clinically indicated, in addition to process/devices used to mobilize the patient from the floor, post-fall injuries, pain assessment and treatment provided, patient and/or environmental circumstances which contributed to the fall, names of persons notified after the fall, change in care plan to reflect prevention of repeated falls. Review of the Hospital’s policy titled Use of Restraints and/or Seclusion, dated 8/1/22, indicated that a constant observer should be employed for patients in restraint or seclusion for reasons of violent or self-destructive behavior. The Policy indicated the required 15-minute assessment by the observer or RN must be documented using the Observer Section of the Restraint or Seclusions Flow Sheet. Review of the Hospital’s policy titled Patient Observer Guideline, dated 3/17/23, indicated that a patient’s plan of care would include observation when necessary to address patient safety or to ensure the safety of others who might be harmed by the patient. The Policy indicated the nurse would document the indications for observation each shift in the nursing progress notes and written Handoff form and provide the observer with the Restraint/Seclusion Sheet. Review of Patient 4’s medical record indicated that in October 2023, he/she was transferred from a subacute rehabilitation Facility via emergency medical services on Section 12 (involuntarily) for evaluation of agitation and altered mental status in the Emergency Department (ED). Patient #4 diagnosis included a history of epilepsy, hypertension, diabetes, hypothyroidism, osteoarthritis, osteoporosis, and recurrent falls. Review of the Nurse Progress Note, dated 10/17/23 at 12:14 P.M., indicated Patient #4 attempted to elope and became violent towards staff requiring Hospital security to place Patient #4 in four-point physical restraints. The Note indicated Patient #4’s physical restraints were removed at 12:50 P.M. Review of Patient #4’s medical record indicated there was no documentation to support the Hospital implemented the Use of Restraints/Seclusion Policy by the assigned staff and completed the required 15-minute assessment and documented using the Observer Section of the Restraint or Seclusions Flow Sheet. Review of the Hospital’s internal Investigation, dated 10/17/23, indicated that while in the ED, Patient #4 had an unwitnessed fall and sustained a fracture of the left orbital roof extending to the inner table of the left frontal sinus. The recommendations included sinus precautions for one week (such as no nose blowing, head elevated, etc.) and to monitor for a cerebrospinal fluid leak. Further review of the Hospital’s internal Investigation, indicated there was no documentation to support Hospital implemented the Risk to Fall/Injury Prevention and Post-Fall Patient Care Guidelines Policy by ensuring that nursing staff assessed and/or documented the details of Patient #4’s fall event or restraint event on 10/17/23 within Patient #4’s medical record. Review of the Hospital’s Corrective Actions for Patient #4’s fall event on 10/17/23, indicated that in response to a knowledge gap regarding the appropriate orders for seclusion, restraint and observer for patients, there was a plan to develop a tool to assist staff with restraint orders and continuous observation, along with nursing and physician education. During an interview on 12/6/23 at 1:55 P.M., the ED Patient Safety Coordinator/Risk Manager said that although the Hospital developed a Corrective Action Plan following Patient #4’s fall on 10/17/23, no corrective action interventions had been implemented at the time of the Survey.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 41143 Based on record review and interview, the Hospital failed to ensure the nursing care for 2 Patients (#3 and #4) was appropriately evaluated by a Registered Nurse (RN) out of a total sample of 10 Patients; Patient #3 was not assessed according to Hospital policy while physically restrained and was subsequently found to have a left wrist fracture following the restraint. On 10/17/23, Patient #4 was not observed according to Hospital Policy while in a violent four-point physical restraint; additionally, Patient #4 was not assessed according to Hospital Policy following an unwitnessed fall with a head injury. Findings include: The Hospital policy titled “Use of Restraints and/or Seclusion”, dated 8/1/22, indicated the following: -Documentation of initial in-person evaluation: Restraint/Seclusion intervention must be incorporated into plan of care. Documentation must reflect the evaluation of the patient’s immediate situation, reaction to the intervention, medical/behavioral condition; and the need to continue/terminate the intervention. -Documentation on the Restraint and Seclusion Flow Sheet must include an assessment using the guidelines defined within this policy: Consideration of less restrictive interventions, basic needs, skin condition, patient’s response to the restraint, exercise of restrained extremities, signs of injury associated with application of restraint, behavior indicating reason for continuation of restraint. -Document a patient’s response to trial/early release and less restrictive measures. 1. Patient #3 was presented to the Hospital Emergency Department on 10/22/23 with altered mental status after being found in the community wandering. Review of Patient #3’s medical record indicated Patient #3 presented to the Emergency Department with altered mental status, a past medical history of brain infarction (death of tissue), and cognitive decline (per the Patient’s family). Patient #3 was evaluated by Physician #2 on 10/22/23 at 6:02 P.M.; Physician #2 ordered CT (computerized tomography) scans to assess the Patient for possible intracranial bleeding due to his/her altered mental status. Patient #3 returned to the Emergency Department at 9:45 P.M. after a code purple was called due to the Patient’s extreme agitation and combative behaviors when at his/her CT exam. Patient #3 was brought back to his/her room in the Emergency Department by security staff, was placed in soft-restraints, and medicated with Zyprexa (antipsychotic medication). At 10:45 P.M. Patient #3 was able to get out of his/her soft restraints and remove his/her IV (intravenous) device; the Patient was then placed in leather restraints by security and the Patient was again medicated with Zyprexa. Patient #3 was removed from restraints by RN #3 at 4:20 A.M. on 10/23/23. At 6:05 A.M. on 10/23/23 Patient #3 was complaining of left wrist pain; an x-ray examination was performed, and it was identified Patient #3 had sustained a fracture of his/her left distal ulna (the end of a bone in the forearm close to the wrist). Further Review of Patient #3’s Emergency Department Nursing Chart for Patient #3’s restraint assessments indicated Patient #3 was placed in 4-point physical restraints at 9:45 P.M. on 10/22/23. Four additional assessments were documented by RN #3 at 11:45 P.M. on 10/22/23, 1:45 A.M. on 10/23/23, 3:45 A.M., and 4:20 A.M.; all four assessments indicated Patient #3 was only in seclusion and failed to indicate he/she was physically restrained. Further, Patient #3’s nursing restraint assessments failed to indicate if the Patient was assessed for signs of injury, extremity pulses, extremity ROM (range of motion), skin condition, release from restraint, nor continuation reasoning for a physical restraint. A RN progress note written at 4:40 A.M. on 10/23/23 indicated Patient #3 was released from restraints. Patient #3’s medical record failed to indicate any physician orders entered on 10/22/23 for the physical restraint of the Patient. Patient #3’s medical record failed to indicate any order for seclusion on while he/she was restrained from 10/22/23 to 10/23/23. During an interview with Physician #2 on 12/6/23 at 3:00 P.M., she said she interviewed Patient #3 when he/she presented to the Emergency Department on 10/22/23. She said the Patient was confused and CT exams were ordered as part of the work up for Patient #3’s altered mental status. She said Patient #3 had been brought back to his/her room by security following a code purple during his/her CT exam. She said when she arrived at Patient #3’s room, he/she was being held by security on his/her bed; the Patient’s agitation could not be de-escalated. She said Patient #3 was at high risk for hurting him/herself or others and was physically restrained with 4-point soft restraints and medicated with Zyprexa. She said Patient #4 was pulling with his/her arm after being restrained. She said we she was unaware of any other incidents with Patient #3 following his/her initial restraint and signed off with Physician #3 at 11:00 P.M. on 10/22/23. During an interview with RN #3 on 12/7/23 at 7:30 A.M., she said Physician #2 gave a verbal order to physically restrain Patient #3 during the code purple on 10/22/23. She said security officers placed the Patient in soft 4-point restraints initially. She said Patient #3 was able to move and almost get off the bed, and at that point security was called and placed the Patient in leather restraints with his/her left arm above his/her head. She said nursing staff perform assessments on patients in restraints every two hours. She said nursing staff should remove a patient’s limbs one at a time to assess for injury/ROM on each extremity. She said all Emergency Department nursing assessments/progress notes are documented in the Emergency Department Nursing Chart. During an interview with the Assistant Nurse Director of the Emergency Department on 12/7/23 at 9:00 A.M., he said nursing assessment for patients in restraints should correspond to the order given by a provider for the correct method of restraint for a patient (4-point, 2-point, chemical, seclusion, etc ...) He said each restraint type requires documentation of assessment specific to the type of restraint based on the Hospital’s policy. He said the nursing staff trigger the correct assessments to document when in the Emergency Department Nursing Chart in the Hospital’s electronic medical record. The Hospital failed to ensure Patient #3 was assessed accurately according to Hospital policy while physically restrained and was subsequently identified to have a wrist fracture following his/her restraint. 37556 2. Review of the Hospital’s policy titled Risk to Fall/Injury Prevention and Post-Fall Patient Care Guidelines, dated 1/15/22, indicated that post-fall care for patients with actual/potential injury from a fall included nurse documentation within a nurse note of the patient’s vital signs and neurological assessments every four hours for 24 hours, and then as clinically indicated, in addition to process/devices used to mobilize the patient from the floor, post-fall injuries, pain assessment and treatment provided, patient and/or environmental circumstances which contributed to the fall, names of persons notified after the fall, change in care plan to reflect prevention of repeated falls. Review of the Hospital’s policy titled Use of Restraints and/or Seclusion, dated 8/1/22, indicated that a constant observer should be employed for patients in restraint or seclusion for reasons of violent or self-destructive behavior. The Policy indicated the required 15-minute assessment by the observer or RN must be documented using the Observer Section of the Restraint or Seclusions Flow Sheet. Review of the Hospital’s policy titled Patient Observer Guideline, dated 3/17/23, indicated that a patient’s plan of care would include observation when necessary to address patient safety or to ensure the safety of others who might be harmed by the patient. The Policy indicated the nurse would document the indications for observation each shift in the nursing progress notes and written Handoff form and provide the observer with the Restraint/Seclusion Sheet. Review of Patient 4’s medical record indicated that in October 2023, he/she was transferred from a subacute rehabilitation Facility via emergency medical services on Section 12 (involuntarily) for evaluation of agitation and altered mental status in the Emergency Department (ED). Patient #4 diagnosis included a history of epilepsy, hypertension, diabetes, hypothyroidism, osteoarthritis, osteoporosis, and recurrent falls. Review of the Nurse Progress Note, dated 10/17/23 at 12:14 P.M., indicated Patient #4 attempted to elope and became violent towards staff and Hospital security placed Patient #4 in four-point soft physical restraints. The Note indicated Patient #4’s physical restraints were removed at 12:50 P.M. Review of Patient #4’s medical record indicated there was no documentation to support the Hospital implemented the Use of Restraints/Seclusion Policy by the assigned staff completed the required 15-minute assessment and documented using the Observer Section of the Restraint or Seclusions Flow Sheet. Review of the Hospital’s internal Investigation, dated 10/17/23, indicated that while in the ED, Patient #4 had an unwitnessed fall and sustained a fracture of the left orbital roof extending to the inner table of the left frontal sinus. The recommendations included sinus precautions for one week (such as no nose blowing, head elevated, etc.) and to monitor for a cerebrospinal fluid leak. Further review of the Hospital’s internal Investigation, indicated there was no documentation to support Hospital implemented the Risk to Fall/Injury Prevention and Post-Fall Patient Care Guidelines Policy by ensuring that nursing staff assessed and/or documented the details of Patient #4’s fall event on 10/17/23 within Patient #4’s medical record. Review of the Hospital’s Corrective Actions for Patient #4’s fall event on 10/17/23, indicated that in response to a knowledge gap regarding the appropriate orders for seclusion, restraint and observer for patients, there was a plan to develop a tool to assist staff with restraint orders and continuous observation, along with nursing and physician education. During an interview on 12/7/23 at 9:05 A.M., the ED Assistant Nurse Director acknowledged that Patient #4’s medical record lacked nursing documentation in response to his/her fall on 10/17/23. During an interview on 12/6/23 at 1:55 P.M., the ED Patient Safety Coordinator/Risk Manager said that although the Hospital developed a Corrective Action Plan following Patient #4’s fall on 10/17/23, no corrective action interventions had been implemented at the time of the Survey.”