Hurley Medical Center

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 45246 Based on observation, interview and record review, the facility failed to maintain a clean and sanitary environment in peri-operative areas, resulting in the potential for transmission of infection and risk for patients’ negative outcomes. Findings include: On 08/11/26 from 10:05 AM to 12:00 PM, an initial tour of peri-operative areas was conducted with facility Director of Surgical and Procedural Services, Staff D, and OR (operating rooms) Nurse Manager, Staff E. The following findings were observed: -two doors with automatic closures with brown fluid spillage from the closures down to the surface of the doors -multiple walls with tape residue, sticky surfaces, missing paint and a hole with cement underneath exposed (above the sink in pod 2 area) - four tall, blue containers with white residue and spills used by staff for storage of clean supplies (two containing clean supplies and two filled with used gloves, Styrofoam cup and various debris) in pod 1 and pod 2 areas -three anesthesia carts with multiple clear tape and sticky residue areas on the corners -suture storage room had dust and debris on the floor under the storage carts, packets of sutures were found on the floor as well -sterile supplies room had dust and multiple paper and plastic debris on the floor with supplies fallen behind and underneath the storage racks -under three clean storage supplies shelves in pod 3 had there was debris, dust and supplies on the floor -blanket warmer in pod 3 had high dust on top -multiple OR doors were observed with chipped paint -doorway plastic protectors were observed with exposing metal mounding underneath During the tour Staff D and E confirmed the findings and were asked how often environmental services should clean the peri-operative areas. They stated it should be done daily and maintained clean. On 08/12/2026 at 10:08 AM during interview with facility Infection Control Director, Staff G, she confirmed that cleaning of the peri-operative areas should be done on a regular basis to a maintain clean and sanitary environment. Facility policy “Environmental Services Cleaning Manual” dated 12/2025 and signed by Environmental Services Manager and Infection Control Director was reviewed and revealed: “Damp Mopping. Routine daily maintenance is critical to maintaining and extending the life of the floor finish. Vinyl Composition Tile (VCT) and Sheet Vinyl must be maintained by daily dust mopping, and damp mopping. This process plays a critical role in extending the life of the floor finish by removing dirt and grime before it gets embedded into the finish, causing discoloration and premature wearing. Procedure. For rooms, mop the perimeter of the room or area. Beginning at door or perimeter of area, mop all edges and baseboards, and around any item you are unable to move. When the perimeter is done, start damp mopping at the far corner of the room, using figure 8 strokes by moving backwards towards the doorway. Remember to clean behind doors, under beds and furniture. Inspect your work. Replace all furniture and equipment to its original location. Clean the equipment and store it neatly. All equipment must be kept in a clean and professional condition. Doors, Frames, Latches and Jambs. Use a disinfectant wipe and damp dust the inside and outside surfaces of all doors, door top, door latches, door frames, hinges, and automatic closures. Remove spillage and clean all kick plates. After surface has remained wet for the required time, polish dry to a streak free appearance if needed. Inspection standards. Doors are free of stains and spillage. Kick plates are clean. Doors and door components are dust free. All surfaces are visibly clean. Floor Care. Inspection standards. Floor is clean and free of dust, debris, and spills. Refrigerators. Refrigerator exterior is clean, sparkling in appearance, and free of dust, dirt, and residue.” “Environmental Services Daily Checklist for 4 North Surgery- OR” was reviewed and revealed: “Daily. Dust and damp mop corridors- inside OR and outside hallways. Detail cleaning: Corridor walls/Doors. Blanket warmer. Any storage rooms off the corridor. Daily. Sterile supply room. Spot clean walls daily. Clean utility room and med room, The entire area must be detail cleaned daily.””

“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: 50585 Based on observation, interview, and record review, the facility failed to ensure self-harming items were removed from areas where patients at risk for harm may obtain access, resulting in the increased likelihood of negative consequences for all patients at risk for self harm who receive access to that area. Findings include: One 6/23/2025 at 1010, after unlocking and entering the restroom associated with the facility’s adolescence behavioral health unit seclusion room, a 200-milliliter glass bottle of air freshener was observed next to the sink. Director of Behavioral Health Staff M was immediately queried if the bottle was appropriate for this location and Staff M confirmed that it was not appropriate. According to the facility’s patient guide, dated 5/7/2024, under “Patient Rights” that the (Facility) Recognizes That Patients Have a Right to: Receive care in a safe setting.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to renew a violent restraint order after four hours for 1 (P-14) of 3 patients reviewed for restraint and seclusion resulting in the loss of patient rights. Findings include: On 6/24/2025 at 1230, during medical record review with Director of Nursing Staff L and Quality and Patient Safety Director Staff B, P-14 had an order for 4-point violent restraints on 3/11/2025 at 1106 for four hours and the order was discontinued on 3/11/2025 at 1838. P-14 was in 4-point restraints for 7 hours and 22 minutes. Director of Nursing Staff L was queried at the time of discovery and confirmed there was no renewal order present four hours after the initial order at 1106. According to the facility’s policy “Restraint and Seclusion,” dated 6/26/2024, “Each order for restraint or seclusion used for the management of violent or self-destructive behavior may only be ordered in accordance with the following limits; 4 hours for adults 18 years of age or older.” The policy also revealed that If the patient needs restraint or seclusion order renewed, it must be completed prior to the expiration of the current order but not greater than 30 minutes prior to expiration: otherwise a new order must be obtained.”

“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: 45246 Based on observation, interview, and record review, the facility failed to provide and maintain a safe and sanitary environment for all patients in the facility’s Emergency Department resulting in the potential for negative outcomes. Findings include: Initial tour of facility’s Emergency Department (ED) was conducted on 8/6/24 from 1153 untill approximately 1300, with facility’s Chief Nursing Officer, Staff C, and Department Nurse Managers, Staff F and Staff G. Approximately at 1214 oxygen tank was observed unsecured at the nurses’ station in the pediatric area of the ED. At 1225 two oxygen tanks were observed unsecured in the medication room. Staff F was present during both observations and confirmed the findings. When queried, he stated that staff was busy attending to pediatric patients and did not have a moment to store tanks right away after use. Facility’s Policy Compressed Gas and Oxygen Use was requested and reviewed on 8/7/24. Policy, dated 11/16/22, revealed: Cylinders must be secured at all times so they cannot fall. 50585 On 8/7/2024 at 1145, during a tour of the facility’s resuscitation room in the ED, on the back counter six 50 milliliter bags of 0.9% Sodium Chloride were observed. Each bag did not contain the protective plastic overwrap. Staff C was interviewed at this time and confirmed the findings. According to the facility’s policy “Intravenous Admixture,” dated 2/22/2022, the policy indicated that “Expiration dates must be assigned to all fluid bags when they are removed from the protective overwrap packaging provided by the manufacturer, unless the bag is going to be used immediately to prepare a custom admixture. Fluid bags that are less than 100 mLs will be assigned a 15-day expiration date. Fluid bags that are 100 mLs or greater will be assigned a 30-day expiration date.” On 8/7/2024 at 1150, during a tour of the facility’s room containing the Computed Tomography (CT) scanner in the Emergency Department, two one-liter bags of 0.9% Sodium Chloride were spiked (administration set attached to the bag) and hanging next to the CT scanner. Each bag did not have any facility-prepared label attached. CT Technician Staff M was asked how long these bags were good for. She replied by pointing to the expiration date on the bag (8/2025). According to the facility’s policy “Medication Administration”, dated 7/18/2024, the policy indicated “IV solutions and irrigation bottles (normal saline, sterile water) shall be marked with the expiration date and time. The date/time shall be 24 hours after the product is opened/spiked. Any unused product should be discarded after the noted expiration date/time.””

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48030 Based on interview and record review, the facility failed to provide continued monitoring until it was determined whether the individual had an Emergent Medical Condition for one (P-1) out of 20 patients, resulting in delayed treatment and less than optimal outcomes for the patient. Findings include: On 8/6/2024 at 1515 record review revealed P-1 arrived at the facility on 6/18/2024 at 0322, triage was completed at 0326, EKG (electrocardiogram) was taken at 0331 and reviewed by ED provider. P-1 remained in the waiting room and vitals signs (VS) were re-taken at 0546. P-1 was taken to a room in the ED at 0549 and repeat EKG was completed at 0613 which revealed he was having a STEMI (ST elevation myocardial infarction). P-1 reported 10/10 heavy mid-sternal chest pain, that woke him up at 2300 the evening prior to arrival, left arm pain which radiated to the chest and shortness of breath. VS in triage revealed an elevated blood pressure (BP) of 180/117 and a heart rate of 125. On 8/6/2024 at 1551 an interview was conducted with the ED Medical Director (Staff D) who reviewed P-1’s medical record including the first EKG that was completed in triage. Staff D revealed patients that arrive to the ED by private vehicle with chest pain should have an EKG upon arrival during triage, the ED staff will take the EKG to the ED provider for review. Staff D added the ED provider determines if the patient can wait in the waiting room when all of the ED rooms are full and tells the Registered Nurse (RN) whether the patient needs to be brought back immediately or they are stable to wait. Staff D revealed review of the first EKG for P-1 was not “normal” because it did have ST elevation in V2 (one of the EKG leads or views), but did not warrant a “STEMI” alert activation at that time. Staff D added indicated P-1 was symptomatic based on review of the record, and he should have been brought back for evaluation. When queried whether it was appropriate for P-1 to have waited in the waiting room with his presenting symptoms and the initial EKG findings, Staff D stated “no”. On 8/7/2024 at 0916 an interview was conducted with the triage RN (Staff DD), Staff DD indicated she remembered triaging P-1. Staff DD stated P-1 “did not look ill” and he was not pale, diaphoretic but he was having a lot of chest pain. Staff DD added P-1 had a history of hypertension and his blood pressure was high in triage and assigned an Emergency Severity Index (ESI) of 2 (high risk situation). Staff DD indicated she took the EKG to the ED provider for review and “told him the backstory” regarding P-1 and was told he could wait because there were no rooms available. Staff DD stated she told P-1 to let the staff know if his symptoms changed or worsen, and she did not recall him coming back up to the desk to report changes. When queried if the triage nurse has standing orders available for patients waiting in triage, Staff DD stated “yes, but that is a newer process, and I didn ’ t do that” and added she would be using these orders in the future if needed. On 8/7/2024 at 1015 an interview with the ED Co-Manager (Staff F) was conducted. When queried if nursing has standing orders available for patients waiting in the waiting room, Staff F stated “yes they do, but we need to have staff available to draw the labs and at 0300 we go down in staffing and we were very busy that day”. When asked if the standing orders for chest pain would have helped the triage nurse and provider identify the STEMI sooner, Staff DD stated that the elevated troponin of 0.36 would have been a “red flag” and indicated he needed to be treated immediately. On 8/7/2024 at 1045 an interview was conducted with the ED Educator/Clinical Specialist (Staff EE). She explained that she has been re-educating the ED RN ’ s to use standing orders. Staff EE agreed the chest pain standing orders may have helped to identify P-1’s need for immediate care. On 8/7/2024 at 1300 review of facility policy #0703, titled “Responding to Emergencies Hospital Property and Off-Campus Facilities”, last reviewed 3/27/2023 revealed on page 6, “Section B. If an individual comes to the Emergency Department: #2. The Hospital will: (a) provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to stabilize the emergency medical condition”.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 36887 Based on record review and interview, the facility failed to develop policies to ensure the prevention and protection of patients from an alleged hospital staff abuser resulting in the potential for unsatisfactory patient outcomes for all patients served by the facility. Findings include: Review of the medical record on 5/14/2024 at 1420 revealed P-29 was a 51-year-old female with a past medical history of chronic pain issues, chronic kidney disease stage 3, depression, diabetes with neuropathy, hypertension, and peripheral artery disease. P-29 was admitted to the facility on 1/10/2024 for osteomyelitis, and, during her admission, had complications with acute respiratory failure and was placed on a ventilator. Multiple nursing notes between 1/21/2024-1/23/2024 revealed P-29 had “frequent complaints” was “unsatisfied with care she has been receiving” and was “very demanding, calling various staff members inappropriate names.” The nursing notes also revealed house director, management, security, and police involvement. On 1/24/2024 at 0034, Registered Nurse (RN) Staff S documented that at 2110 P-29 was talking to her daughter on the phone making complaints. When the nurse attempted to explain what was happening, P-29 threw her medications across the room and “dumped her metamucil on bed as she was stating out loud for daughter to hear, that RN was doing those things... Daughter called desk telling unit clerk that she wanted a different RN caring for (P-29) stating the RN was rude to pt (patient) and slapped pt face.” Further review of the medical record revealed P-29 chose to leave AMA (against medical advice) on 1/23/2024 at 2345. Security took her by wheelchair to the discharge area. On 1/24/2024 at 0106, P-29 presented to the Emergency Department (ED) with a chief complaint of “Generalized Weakness (Recently admitted on 1/10 and Left AMA today. States she was hit by nurse and had IV ‘tugged out’...” ED Provider note dated 1/24/2024 at 0727 stated, “Of note, patient left last night AMA after possible altercation with nursing staff on our medical floor. Patient states however that she never left (hospital name) because she felt too weak. At this time, she has no new complaints however states that she does not feel like she is safe here and would like to go to another hospital.” Physical exam stated, “No acute distress...SKIN: Normal for ethnicity.” Nothing further was mentioned regarding the alleged assault. P-29 was offered re-admission to the facility; however, she refused. On 5/16/2024 at 0840, Quality Director and Risk Manager Staff C reported after multiple phone calls and text messages there was no response for an interview from RN Staff S. Additionally, ED Physician Staff HH was out of the country and unreachable. On 5/16/2024 at 0900, review of facility policy #4009 titled “(Facility Name) Standard Practice Allegations of Abuse By Staff” last revised 2/7/2022 states, “ Definitions: A. ‘Immediate’ means at the time of witnessing conduct or receiving an allegation of conduct that is the subject of this policy. The requirements in this policy for ‘immediate notification’ apply even if the incident occurs after hours and/or on weekends and holidays... ‘Assault’ means any non-consensual touching. Assault includes physical and/or sexual assault... All employees, medical staff members and contractors are expected to immediately report any suspicions of abuse, neglect, or assault... Immediate Actions: Any employee, contractor or member of the medical staff who witnesses or receives an allegation of sexual or, physical abuse, neglect or assault of any patient or other individual must immediately ensure the safety of that individual, including but not limited to ensuring that a physical examination, if applicable given the nature of the allegations, is conducted... Once the immediate medical needs of the individual have been addressed, the Administrator on Call (AOC), or his or her designee, must be notified. The AOC, or his or her designee, must verify the safety of the individual, gather preliminary facts, and notify Associate General Counsel... Investigation: All internal reviews will be directed by Associate General Counsel. The Vice President of Human Resources or Chief Medical Officer, as appropriate, will be immediately notified and involved in the entire investigation... In responding to allegations of abuse, assault, or neglect made by a patient, the (initials for facility name) policy on Complaints and Grievances will also be adhered to and the Patient Relations Department must be notified... Individuals involved in the investigation will be responsible for maintaining complete documentation of the following: 1) All allegations of abuse, neglect, or assault; 2) The specifics of the allegations made; 3) The specific steps taken to investigate and review the allegations; 4) And the results of the review including the results of any review by law enforcement or other external agency. 5) Following the completion of the investigation, all documentation will be submitted to the Legal Department for retention.” The policy failed to include removal of the alleged perpetrator from all patient care pending investigation. On 5/16/2024 at 0920, Director of Quality and Risk Management Staff C was queried as to if there was an incident report relating to the alleged abuse of P-29 to which she stated there was not. She further stated Public Safety had been with the patient near or at the time of the alleged assault and had conducted an investigation and the medical record had plenty of information regarding P-29’s demeanor and behaviors. On 5/15/2024 at 1025, a Security Report dated 1/23/2024 at 2318 revealed under the “Injury Status” area it stated, “No Injuries.” There was no mention of an alleged assault or of a slap or a punch to P-29’s face. When interviewed on 5/15/2024 at 1618, Public Safety Officer Staff CC stated he “did not recall the patient saying she was slapped. If she had, it would have been put in the report.” He denied having investigated the alleged assault. He stated he had just gone to the room and talked with both the patient and the nurse. On 5/16/2024 at 0846, House Director Staff FF stated he was not notified by staff of an alleged assault from nurse to patient. He stated he was called directly by the patient when she was waiting to be seen in the ED lobby. He recalled P-29 had been “abusive to staff” and that he was aware of the allegation of alleged assault of the patient. When queried as to if he had made an incident report or had documented this anywhere, Staff FF stated he had not and stated he was new to his position at the time and there was not really a place to document this. On 5/16/2024 at 0929, Chief Nursing Officer (CNO) Staff B stated the house director should be notified of an alleged employee assault and would determine the need to contact the AOC. He stated the desired steps in this case would have been for the staff to contact the house director sooner, an incident report could have been made, and then public safety, the sheriff on site, and quality/risk could be involved. There was no process for the house director to call the risk manager directly. On 5/16/2024 at 0943, Vice President of Patient Care Services Staff D, who was the administrator on call the night of 1/23/2024, stated not all calls would be recorded in a log, but rather, only ones of significance. When queried as to if an alleged staff to patient assault would have been recorded in the log, she stated, “Yes.” Staff D was then asked to review the log to determine if an alleged staff to patient assault had been called to her on the night shift of 1/23/2024. Staff D confirmed on 5/16/2024 at 1015 there was no such entry on her log.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36887 Based on record review and interview, the facility failed to document restraint/seclusion orders, face-to-face evaluations, and/or monitoring for 3 (#2, 5, 6) of 3 patients reviewed for restraint/seclusion and failed to provide an informed anesthesia consent to 1 (#7) of 3 patients reviewed for anesthesia consents resulting in the potential for loss of patient rights and poor patient outcomes. Findings include: See Specific Tags: A-131 Failure to specify type of anesthesia being provided A-168 Failure to have a physician order/renewal for restraint A-175 Failure to monitor the patient during restraint A-178 Failure to conduct a 1-hour face-to-face evaluation”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 36887 Based on record review and interview, the facility failed to provide an informed consent for anesthesia to 1 (#7) of 3 patients reviewed for anesthesia consents resulting in the loss of patient rights and the potential for unrecognized, unsafe patient outcomes. Findings include: On 1/11/2024 at 1451, review of the medical record for P-7 revealed an anesthesia consent that was signed by the provider and the patient; however, the type of anesthesia to be given was left blank. On 1/11/2024 at 1455, Staff G was queried as to if the type of anesthesia was to be indicated on the consent. She stated that was why the boxes on the consent were present. Facility policy #0203 titled “Standard Practice Patient Rights and Responsibilities” last revised 8/13/2021 states, “A patient is entitled to... Receive, from the appropriate individual within the facility, information about his or her medical condition, proposed course of treatment, informed consent, prospects for recovery, and ability to make decisions relating to end of life care, in terms and in a language that the patient can understand, unless medically contraindicated as documented by the attending physician in the medical record.””

“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: 36887 Based on record review and interview, the facility failed to have a physician order or renewal order for 2 (#5, 6) of 3 patients reviewed for restraints resulting in the loss of patient rights and the potential for unsafe patient outcomes. Findings include: On 1/11/2024 at 1359, review of the medical record for P-5 revealed restraints were initiated on 11/19/2023 at 1938. The face-to-face evaluation was done at 1944, and the restraints were discontinued at 2002. The order for the restraint was given at 2030 (52 minutes post initiation, 46 minutes post face-to-face evaluation, and 28 minutes post discontinuation). On 1/11/2024 at 1415, Staff G was queried as to why the order would have been given so long after the restraint process was complete. She stated it must have been noticed the order was not obtained and was entered late. On 1/11/2024 at 1427, review of the medical record for P-5 revealed an order was given on 6/29/2023 at 2109 for 4-point locking restraints for a duration of 2 hours. Restraints were initiated at 2100 and were discontinued on 6/30/2023 at 0020 (3 hours, 11 minutes). No renewal order was given for the additional 1 hour and 11 minutes past the original 2 hour order. On 1/11/2024 at 1435, Staff G stated, “This is not good.” Review of facility policy #0217 titled “Standard Practice Restraint and Seclusion” last revised 11/29/2023 states, “Each order for restraint or seclusion used for the management of violent or self-destructive behavior may only be ordered in accordance with the following limits: 4 hours for adults 18 years of age or older; 2 hours for children and adolescents 9 to 17 years of age; 1 hour for children under 9 years of age The order can be renewed by a physician for a total of 24 hours before a face to face evaluation by a physician must be completed.If the patient needs the restraint or seclusion order renewed, it must be completed prior to the expiration of the current order but no greater than 30 minutes prior to expiration; otherwise a new order must be obtained.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 36887 Based on record review and interview, the facility failed to monitor 1 (#6) of 3 patients reviewed for restraint/seclusion resulting in the potential for unsafe patient outcomes. Findings include: On 1/11/2024 at 1427, review of P-6’s medical record revealed an order for 4-point locking restraints on 6/29/2023 at 2109 for a duration of 2 hours. Review of the restraint flowsheet documentation indicated the restraints were initiated at 2100. No monitoring documentation is present until the restraints were discontinued on 6/30/2023 at 0020. On 1/11/2024 at 1440, Staff G stated there was no documentation and did not understand why it was not present. She went back and verified the order and the discontinuation of the restraint. Review of facility policy #0217 titled “Standard Practice Restraint and Seclusion” last revised 11/29/2023 states, “Immediate assessment by a trained RN after restraints are applied to ensure proper and safe application. Documentation of restraint type daily and with change in limbs restrained and type of restraint. Patients in violent or self-destructive behavior restraints must be monitored with direct 1:1 observation Frequency of monitoring may be increased based on patient condition. Every 2 hour monitoring required to be completed by a trained RN includes: assessment of patient safety; readiness for release from restraints; clinical justification. At least every 4 hours VS(vital signs) monitoring if patient is being medicated (document in VS flowsheet) Every 15 minute monitoring, q2hr monitoring (as mentioned below) and q4hr VS can be done by a trained patient unit aide, nursing assistant, mental health tech, ED tech or RN Every 15 minute monitoring includes: Visual check, Psychological status, Physical comfort, Circulation Every 2 hour monitoring includes: Fluid/hydration needs, Hygiene/toileting/elimination needs, Range of Motion.””

“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: 36887 Based on record review and interview, the facility failed to provide a face-to-face evaluation within one hour of restraint or seclusion for 2 (#2, 5) of 3 patients reviewed for restraint/seclusion resulting in the potential for violation of patient rights and poor patient outcomes. Findings include: On 1/11/2024 at 1313 review of the medical record for P-2 revealed she was placed into seclusion on 10/5/2023 at 1036. Restraint flowsheet documentation stated in the section for face-to-face evaluation “No”, indicating the face-to-face evaluation had not been done. On 1/11/2024 at 1359, review of the medical record for P-5 revealed she had been placed in restraints multiple times. Face-to-face evaluations were not completed for 5 (11/1/2023, 11/17/2023, 11/23/2023, and twice on 11/24/2023) of 11 times she was placed in restraint. The documentation revealed the following: 11/1/2023 Face-to-face evaluation left blank 11/17/2023 Face-to-face evaluation stated, “No” 11/23/2023 Face-to-face evaluation stated, “No.” 11/24/2023 at 0030 Face-to-face evaluation left blank. 11/24/2023 at 1148 Face-to-face evaluation left blank. On 1/11/2024 at 1415, Staff G stated, “It should be documented right here... This makes us look really bad.” Faciliy policy #0217 titled “Standard Practice Restraint and Seclusion” last revised 11/29/2023 states, “The patient must be seen face to face, by a physician, within 1 hour after the initiation of the intervention to evaluate: The patient’s immediate situation; The patient’s reaction to the intervention; The patient’s medical and behavioral condition and The need to continue or terminate the restraint or seclusion.””