North Carolina Baptist Hospital

“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: 41946 Based on hospital policy review, medical record review, and staff interview, the hospital failed to complete vital signs per patient acuity on 1 of 5 patients, (Patient #3) and failed to complete pain reassessments in 3 of 5 records reviewed. (Patient #3, Patient #6, Patient #13.) Review on 10/29/2025 of the policy titled, Waiting Room Reassessments Policy Adult and Pediatric ED...effective date 10/18/2022 revealed “ ...Purpose: the purpose of this procedure is to outline the reassessment guidelines for patients in the Adult ...Emergency Department [ED] lobby/waiting room of [named health system.] ...Procedure Guidelines A. ESI [emergency severity index] Level 2: vitals signs should be reassessed no less frequently than every hour for first 4 hours, then every 2 hours if clinically stable. B. ESI Level 3: Patient with normal vital signs should be reassessed at the discretion of the nurse, but no less frequently than every 4 hours. Patients with abnormal vital signs should be reassessed no less frequently than every 2 hours for the first 4 hours, then every 4 hours if clinically stable. ...” Review on 10/28/2025, of the policy titled, ED Assessment - Reassessment, document number 29510 with last reviewed date 10/07/2025, [correct version] revealed “Purpose: ...To ensure that established criteria will be assessed and reassessed on all Emergency Department patients ...IV. Policy: A. Triage and Required Documentation 1. All patients presenting to the Emergency Department will be assessed by a Registered Nurse [RN] and categorized using the Emergency Severity Index (ESI) 5 Level Triage System. ...3. Required documentation includes, at a minimum ...d. emergency severity index acuity (appendix A), e. presence of pain .... C. Reassessment 1. Reassessment of initial assessment findings are to be documented after interventions, change in patient condition, or according to provider orders ...Appendix B: ED Documentation Guidelines, Reassessment ...include pain. A. Closed medical record review revealed Patient #3, a 62-year-old female patient who arrived at the emergency department [ED] on 09/29/2025 at 2154 with complaint of left sided chest pain. Review of the Triage Note dated 09/29/2025 at 2200 by ED RN #1 revealed “patient coming in via [named]EMS [emergency medical services] for left sided chest pain that has been going on for days. History of recent aortic valve repair as well as blood clot in her heart requiring open heart surgery. Takes two Xarelto [medication used to thin blood and prevent blood clotting] at home. Patient given two nitro [nitroglycerin-given to treat chest pain] in route with EMS with relief.” At 2212 vital signs: temperature: 98.1. heart rate 65. Blood pressure 111/80. Respirations 16, oxygen 100% on room air, and pain score of 7 out of 10 [numerical pain screening, 1 is least pain, and 10 most severe pain]. At 2213, Patient #3 was given an emergency severity index score of 2-emergent. At 2214, an EKG was started, and lab work was ordered, that included troponins, ultrasound of the lower extremities and chest x-ray. Patient #3 was returned to the ED waiting room. Lab work was drawn at 2223, and chest x-ray completed at 2254. The troponin resulted 09/30/2025 at 0003 at 9 [ref range < 15 indicates heart muscle damage]. The chest x-ray showed no acute findings,. Vitals taken in the ED waiting room at 0214 by ED Certified Nursing Assistant [CNA] #8, temperature 98.2. heart rate 57. Respirations 18. Blood pressure 120/72. Oxygen 100% on room air. On 09/30/2025 at 0530, Patient #3 was roomed in the ED in Exam room 12, Pod 2. At 0532, ED MD #2, completed the medical screening exam. At 0532 partial vital signs were completed by ED RN #3 Respiration 19. Heart rate 53. Oxygen 98%, no pain reassessment documented. At 0612, Patient #3 went for more radiology, Computed Tomography/ Angiogram chest pulmonary embolism [a cat scan to rule out blood clots in the lungs]. Vital Signs were recorded again at 0633 respirations 15. Heart rate 56. Blood pressure 128/73. Oxygen 100% on room air by ED RN #3, no pain reassessment documented. The cat scan was completed and resulted at 0928 as negative. A new ED MD #4, and Mid-Level Provider, Physician’s Assistant, ED PA #5, were assigned at shift change, 0655. Patient #3 was taken for ultrasound of the lower extremities at 0733. A new ED RN #6 was assigned at 0803. At 0824, vital signs were recorded by ED RN #6, temperature 97.8. heart rate 71. respirations 16. blood pressure 135/82. oxygen 98%. No pain assessment was documented. A cat scan of the abdomen/pelvis was also completed at 0940. At 1046, a cardiology consult was placed by the ED PA #5 and discontinued at 1139. Discharge disposition at 1154 was documented by ED PA #5. Vitals signs taken at 1155 by ED RN #7 before discharge. No pain reassessment was documented. Patient #3 was discharged home at 1229 on 09/30/2025. Vital signs and pain assessment did not follow policy for ESI 2 patient with chest pain while in the ED. Telephone interview on 10/29/2025 at 1106 with ED RN #3 revealed, “ ...chest pain would be assessed by me verbally. I normally do document that ...I would pull the patient back into a triage room ...vital signs are not automatically updated into the medical record; we manually put them in and should document pain assessments. ...” Interview on 10/29/2025 at 1316 with the discharge nurse, ED RN #6 revealed “I’m not sure I remember this patient. ..I do typically ask about pain at same time as I do vital signs. The room has a bedside telemetry monitor, ...I may not have charted the pain assessment ...” Interview on 10/30/2025 at 0910 with ED Charge Nurse #9 revealed “ ...Pain assessments start at triage, within 1 hour of any pain intervention, and should be reassessed with vital signs. ...” Interview on 10/30/2025 at 0936 with ED Nurse Manager, #10 revealed “ ...the RN should do the head-to-toe assessments, including pain. ...” The interview revealed vital signs should follow the patient acuity, pain reassessments should be completed every 2-3 hours for an ESI 2 patient, with any pain intervention and with vital sign assessment. B. Closed medical record review on 10/29/2025 revealed Patient #6, an 84-year-old female patient who arrived to the emergency room [ED] on 06/01/2025 at 1121 with drug overdose. The Triage Note at 1122 by ED RN #11 revealed “ ...son reports he did a pill count and the count was off. He reports pt. has been hallucinating since Friday. ...Pt had a fall last night; son denies head injury during the fall. ..” The patient was roomed at 1122 in exam room 6. Vital signs recorded at 1132 as temperature 98.2. heart rate 88. Respirations 17. Blood pressure 161/89 and oxygen at 94%. Pain score was 10/10 [numerical pain score where 1 is least pain, and 10 is the most severe pain]. At 1134, ED RN #11 scored the emergency severity index at 3-urgent. Vital signs were completed again at 1145 by ED RN #13, respiration 18. heart rate 86. blood pressure 160/80. oxygen 92% on room air. No pain assessment. At 1212 lab work and radiology was ordered by ED MD #12. ED RN #13 completed an assessment at 1220. no pain reassessment documented. Lab work and Radiology was completed by 1237, which revealed an acute urinary cystitis.Vital signs were completed again at 1401 by ED RN #13, respirations 18. heart rate 86. blood pressure 208/108, oxygen 93%. No pain reassessment documented. At 1419 the ED RN #13’s Nurses Note revealed “ ...pt [patient] ambulated in hallway per [named MD]. ...c/o [complained] of left hip and leg pain. Pt. requested to sit in chair due to leg and buttock pain. MD notified. ..” At 1440 the ED Disposition was selected to discharge by the ED MD #12. Patient #6 was discharged home at 1503. No pain reassessment was documented since arrival to the ED for Patient #6 even with complaint of hip and leg pain. There was not a follow-up blood pressure taken for 208/108. Interview requested for ED RN #11, not available for interview. Interview on 10/30/2025 at 0910 with ED Charge Nurse #9 revealed “...Pain assessments start at triage, within 1 hour of any pain intervention, and should be reassessed with vital signs. ...” Interview on 10/30/2025 at 0936 with ED Nurse Manager, #10 revealed “...the RN should do the head-to-toe assessments, including pain. ...” The interview revealed vital signs should follow the patient acuity, and pain reassessments should be completed ... with any pain intervention and with vital signs. C. Closed medical record review on 10/29/2025, revealed Patient #13, a 70-year-old female patient who arrived to the emergency department [ED] on 09/03/2025 at 0134 for shortness of breath, nausea and elevated heart rate. Patient #13 was roomed at 0136 to exam room 8, and had first evaluation by provider, ED MD #14. At 0137an EKG was performed. At 0145 Vital signs were completed by ED RN #15, respirations 25. heart rate 108. blood pressure 123/81. oxygen 95%. Triage began at 0151 “...patient endorses SHOB [shortness of breath] after waking around midnight. Also endorse nausea and back pain that occurred after waking as well. Cardiac hx [history]. Denies chest pain. Hx Asthma. ..” At 0156 a head-to-toe assessment was completed by ED RN #15, acknowledging “musculoskeletal; back pain..” No pain assessed. At 0158, ED MD #14 completed the medical screening exam and at 0201 Lab work and radiology was ordered. Vital signs were documented at 0315 Respirations 15. Heart rate 111. Blood pressure 129/98. Oxygen 97%. No pain assessment. At 0436 vital signs were documented at 0436 blood pressure 120/64. Heart rate 104. Respiration 21and oxygen 95%. At 0453, lab work and radiology scans completed and reviewed by ED MD #14, “ ...Clinical Impression: Shortness of breath, Tachycardia. .. condition stable ...” At 0544, Discharge Disposition was set to discharge. At 0545 vital signs were completed, respirations 17, heart rate 116, blood pressure 95/62. oxygen 93%, without a pain assessment. Patient #13 was discharged at 0609. Patient #13 did not have a pain assessment and emergency severity index acuity score during triage, or reassessments on review. Request to interview ED RN #15, revealed they were unavailable for interview. Interview on 10/30/2025 at 0910 with ED Charge Nurse #9 revealed “...Pain assessments start at triage, within 1 hour of any pain intervention, and should be reassessed with vital signs. ...” The interview revealed an emergency severity index acuity score, and pain assessment should be completed during the initial triage assessment. Interview on 10/30/2025 at 0936 with ED Nurse Manager, #10 revealed “...the RN should do the head-to-toe assessments, including pain. ...” The interview revealed vital signs should follow the patient acuity, and pain reassessments should be completed ...with any pain intervention and with vital signs. NC00233921 NC00233302”

“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: 50111 Based on hospital policy review, medical record review and staff interviews, the nursing staff failed to ensure there was a physician order for a non-violent restraint in 1 of 2 non-violent restraint patient records reviewed (Patient # 14). The findings include: Review on 08/28/2025 of hospital policy, “Restraints and Seclusion,” effective 02/26/2024, revealed, “... The use of restraints/seclusion is in accordance with the order of a physician, physician assistant (PA) or nurse practitioner (NP) who is responsible for the care of the patient ... “ Closed medical record review on 08/28/2025 for Patient #14 (Pt) revealed a 62-year-old patient that was admitted on 08/06/2025 at 0046 with a diagnosis of encephalopathy (a disease that alters brain function, often caused by infection) and shock (a life-threatening condition where the internal organs do not receive adequate blood flow) with unclear etiology (cause). Record review revealed an arterial line (a catheter that is inserted into the artery to continuously monitor blood pressure and obtain blood samples) was placed on 08/25/2025 at 0325. Review of the Restraint Record on 08/25/2025 at 0700 revealed a left-sided soft wrist restraint and a right-sided unsecured mitt (a soft padded glove) were “continued.” Review failed to reveal the date and time restraints were applied. Review of the Provider Order on 08/25/2025 at 0726 revealed an order for “Restraints non-violent or non-self destructive: Restraint type: Mitt secured; Mitt Secured Laterality: Right, Left.” Review of the Provider Orders failed to reveal an order for a left soft wrist restraint or an order for a right-sided unsecured mitt. Review of the Restraint Record revealed the left-sided soft wrist restraint and the right-sided unsecured mitt were “continued” at 0900 and discontinued at 1030. Review of the Death Discharge Summary on 08/25/2025 at 1409 revealed Pt #14 passed away at 1359 with a diagnosis of septic shock (a wide-spread, life-threatening infection that causes organ failure). Telephone interview on 08/28/2025 at 1240 with Registered Nurse #1 (RN) revealed the patient had a right-sided unsecured mitt and a left-sided soft wrist restraint applied when RN #1 first entered the patient’s room on the morning of 08/25/2025 at 0700. RN #1 revealed the restraints were applied by the patient’s previous nurse (RN #2). RN #1 thought RN #2 had requested an order from the provider when the restraints were applied. Interview revealed the RN was responsible for ensuring the applied restraints matched the provider order. Interview revealed RN #1 could not recall why the order was not verified. Telephone interview on 08/28/2025 at 1306 with RN #2 revealed a right-sided unsecured mitt and a left-sided soft wrist restraint were applied within 30 minutes of an arterial line being placed, at approximately 0400 on 08/25/2025. Interview revealed RN #2 requested an order for the restraints from the two providers that were at the bedside when the restraints were placed on the patient. RN #2 did not verify the order was placed in the patient’s medical record. Telephone interview on 08/28/2025 at 1255 with RN Manager #3 revealed restraint orders were typically entered into the medical record soon after the restraint was applied. Providers sometimes remained at the bedside until the patient was calm, then placed the order. The nurse should check the restraint order as soon as possible. Nursing staff should verify that the restraints that were ordered matched the restraints that were applied. If the restraints did not match the order, the restraints should have been removed or the order should have been changed to match the necessary restraints. In summary, the investigation revealed non-violent restraints were applied on 08/25/2025 at approximately 0400. Review failed to reveal a Provider Order for restraints until 0726 (approximately 3 hours and 26 minutes after restraints were applied). Review of the Provider Order revealed an order for bilateral secured mitts. The patient was restrained from approximately 0400 until 1030 with a right-sided unsecured mitt and a left-sided soft wrist restraint (6 hours and 30 minutes) without a provider order.”

“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: 50111 Based on hospital policy review, medical record reviews and staff interviews, the nursing staff failed to monitor a restraint patient per the hospital policy in 2 of 5 restraint patient records reviewed (Patient # 10, Patient #14). The findings include: Review on 08/28/2025 of hospital policy, “Restraints and Seclusion,” effective 02/26/2024, revealed, “... Non-Violent/Non Self-Destructive Restraints ... Initiation/Order Entry ... RN (Registered Nurse) to assess and document on initiation: * patient affect/behavior * mental status * device in use * clinical justification * less restrictive methods/alternative strategies attempted ... Ongoing Assessment & (and) Monitoring RN or LPN (Licensed Practical Nurse) assess and document every 2 hours: * mental status * strategies to reduce or remove restraint * if less restrictive alternatives are available * criteria for continued restraint use ... RN, LPN, or trained clinical teammate monitor and document every 2 hours: * patient affect/behavior * safety check *circulation status * skin integrity * signs of injury related to restraints * range of motion ... * assistance with food, hydration, elimination, and/or hygiene while awake ... Violent/ Self-Destructive Restraint and Seclusion ... Ongoing Assessment & Monitoring ... RN or LPN to assess and document every 15 minutes: * mental status * strategies to reduce or remove restraint * if less restrictive alternatives are available * meets criteria to continue restraint/seclusion ... RN, LPN, or trained clinical teammate to monitor and document every 15 minutes: * patient affect/behavior * signs of injury related to restraints * respiratory status * safety check * circulation status * skin integrity ...” 1. Open medical record review on 08/27/2025 for Patient #10 (Pt) revealed a 35-year-old patient that arrived in the Emergency Department (ED) on 08/20/2025 at 1305 with a chief complaint of suicidal ideation (thoughts). Record review revealed violent 4-point restraints (restraints to all 4 extremities) were applied on 08/21/2025 at 0130 for “Attempting self harm.” Review of the Restraint Record failed to reveal evidence that restraints were monitored every 15 minutes from 0334 until 0534 (2 hours). Review of the Restraint Record at 0534 revealed the patient no longer met criteria to continue restraints. Record review failed to reveal evidence that violent 4-point restraints were discontinued at 0534. The patient was free if restraints and was a current patient in the ED during record review. Telephone interview on 08/28/2025 at 0858 with RN #4 revealed violent restraints were typically monitored every 15 minutes. Monitoring included assessing tightness, skin integrity, circulation, and breathing. RN #4 took over care for Pt #10 from another nurse on 08/21/2025 at 0334. Interview revealed the type of restraints were not stated during nursing handoff. RN #4 thought the patient was in non-violent restraints and was documenting under the non-violent restraint flowsheet which required documentation every 2 hours rather than every 15 minutes. Interview revealed RN #4 did not monitor the patient every 15 minutes per the policy requirements. RN #4 did not check the restraint order when taking over care of the patient. RN #4 normally checked the restraint order when initiating restraints but not when taking over care. Interview revealed RN #4 started removing restraints, one at a time, at 0534. A restraint was removed every 15 minutes until all 4 restraints were discontinued at approximately 0615. Interview revealed RN #4 forgot to document the discontinuation of restraints in the medical record. Interview on 08/28/2025 at 0930 with RN Manager #5 revealed violent restraints should be monitored and documented every 15 minutes in the medical record. 2. Closed medical record review on 08/28/2025 for Patient #14 (Pt) revealed a 62-year-old patient that was admitted on 08/06/2025 at 0046 with a diagnosis of encephalopathy (a disease that alters brain function, often caused by infection) and shock (a life-threatening condition where the internal organs do not receive adequate blood flow) with unclear etiology (cause). Record review revealed an arterial line (a catheter that is inserted into the artery to continuously monitor blood pressure and obtain blood samples) was placed on 08/25/2025 at 0325. Review of the Restraint Record on 08/25/2025 at 0700 revealed a left-sided soft wrist restraint and a right-sided unsecured mitt (a soft padded glove) were “continued.” Review failed to reveal the date and time restraints were initiated or monitoring of restraints prior to 0700. Review of the Restraint Record revealed the left-sided soft wrist restraint and the right-sided unsecured mitt were “continued” at 0900 and restraints were discontinued on 08/25/2025 at 1030. Review of the Death Discharge Summary on 08/25/2025 at 1409 revealed Pt #14 passed away at 1359 with a diagnosis of septic shock (a wide-spread, life-threatening infection that causes organ failure). Telephone interview on 08/28/2025 at 1240 with Registered Nurse #1 (RN) revealed the patient had a right-sided unsecured mitt and a left-sided soft wrist restraint applied when RN #1 first entered the patient’s room on the morning of 08/25/2025 at 0700. RN #1 revealed the restraints were applied by the patient’s previous nurse (RN #2). Telephone interview on 08/28/2025 at 1306 with RN #2 revealed a right-sided unsecured mitt and a left-sided soft wrist restraint were applied within 30 minutes of an arterial line being placed, at approximately 0400 on 08/25/2025. Interview revealed RN #2 was not sure why restraint application and monitoring was not documented from 0400 until 0700 but stated it had been a “difficult morning” due to the patient’s condition. Non-violent restraint monitoring was normally documented every 2 hours. In summary, non-violent restraints were initiated for Pt #14 on 08/25/2025 at approximately 0400 per interview with RN #2. Record review failed to reveal evidence that Pt #14 was assessed upon initiation of restraints or monitored from 0400 until 0700 (approximately 3 hours and 26) per hospital policy. NC00218644; NC00232116; NC00227886; NC00219757; NC00229902”