Southern Hills Hospital and Medical Center

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 33980 Based on interview, record review and document review, the facility failed to ensure an assessment for the use of a lap was completed, education was provided to a patient, and family was notified regarding the use of a lap belt for 1 of 28 sampled patients (Patient 20). The deficient practice had the potential to cause harm to the patient and not promote the rights of the patient and authorized representatives. Findings include: Patient 20 (P20) presented to the emergency department (ED) on 07/24/2024 and discharged on 08/04/2024, with diagnoses including syncope, fall, and history of Alzheimer’s disease. The Registered Nurse (RN) Patient Notes dated 07/25/2024 at 7:45 AM, documented the patient was alert oriented to person and place. Lap belt present, patient was attempting to get out of bed, bed alarm present. The Physical Therapy (PT) Progress Note dated 07/28/2024, documented PT diagnoses which included impaired functional mobility and impaired balance. The patient was on fall precautions and lap belt due to confusion. The Assessment portion of the note documented the patient continued to present with confusion therefore decrease safety with mobility. The patient was assisted back to bed at the end of session. Lap belt reapplied. The PT Progress Note dated 07/31/2024, documented the patient was on fall precautions and lap belt due to confusion. The patient was assisted to bedside chair upon return to room. Sit-stand from chair at minimum assist to put on chair alarm. Required to put on lap belt on chair. The RN was in room towards end of session, agreeable to leaving the patient up in chair with lap belt and chair alarm on. The PT Progress Note dated 08/01/2024, documented the patient was on fall precautions and lap belt due to confusion. The patient was supine in bed upon entry. The patient was more difficult to arouse today but able with sternal rub. Removed lap belt. Supine to sit at moderate assistance due to lethargy. Stand pivot transfer to chair at minimum assistance. The patient was assisted to stand for pericare (perineal care) at minimum assistance. The patient was then assisted back to bed after changing gown and pericare. Lap belt put on. Bed alarm applied. The patient was still on virtual sitter due to confusion. The RN’s Body System Assessment for P20 dated 07/29/2024, 07/30/2024, and 08/01/2024, documented the following: - Alert and oriented: No - Oriented to: Person The RN’s Patient/Family Teaching record for P20 dated 07/25/2024, 07/28/2024, 08/01/2024, and 08/04/2024, documented the following: - Primary learner: Patient - Barriers to communication/learning: Cognitive impairment - Person(s) educated: Patient The Hospital course portion of P20’s Discharge Summary dated 08/04/2024, documented the following: - 08/03/2024, Removed lap belt as unable to place the patient in rehabilitation facility while in restraints, need to be off for 24 hours. - 08/04/2024, Lap belt had been removed. The patient was discharged to a rehabilitation facility. P20’s medical record lacked documented evidence of the assessment, education provided to the patient, and family notification regarding the use of a lap belt. There was no physician order for the use of the lap belt as a restraint. On 01/28/2026 at 9:46 AM, the Vice-President (VP) of Quality and Risk Management explained the use or application of lap belt to P20 was a fall and safety precaution and not a restraint because the patient could remove the lap belt. A physician order was not required because the lap belt was not used as a restraint. On 01/28/2026 at 2:05 PM, an RN indicated a lap belt could be used as a restraint or a fall precaution. The RN revealed a lap belt could be applied for safety if a patient was climbing out of bed or removing lines (such as intravenous line or tubing). The RN explained the use of a lap belt was not a restraint if a patient was alert oriented, had manual dexterity, able to demonstrate the application and removal of lap belt, and able to verbalize understanding of the education provided regarding the use of lap belt. The RN revealed the patient should have been assessed and evaluated to determine if the patient could apply and remove the lap belt. The assessment, evaluation, and education provided would have been documented in the nurse’s notes and in the Patient/Family Teaching section of the electronic health record. The RN confirmed the use of a lap belt could be a restraint if the patient was not alert and oriented or had confusion, unable to verbalize understanding of the education provided regarding the use of lap belt, and unable to apply and remove the lap belt. The RN acknowledged a physician order should have been obtained regarding the use of lap belt as a restraint. The patient’s authorized representative should have been informed regarding the use of a restraint. On 01/28/2026 at 3:48 PM, the VP of Quality and Risk Management confirmed there was no documentation of the assessment and education provided to P20, and family notification regarding the use of a lap belt. There was no documentation P20 was able to apply and remove the lap belt. On 01/29/2026 at 1:49 PM, the Chief Nursing Officer indicated a patient should be able to self-release the lap belt so it would not be considered a restraint. The facility policy titled “Patient Restraint/Seclusion” dated 07/26/2023, documented generally if a patient could easily remove a device, the device would not be considered a restraint. In this context, “easily remove” would mean that the manual method, device, material, or equipment could be removed intentionally by the patient in the same manner as it was applied by the staff considering the patient’s physical condition and ability to accomplish objective.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 26251 Based on record review and interview, the facility failed to ensure 1 of 32 medical records reviewed (Patient 22) documented a physician order and contained an accompanying lab result for a specimen removed for pathology. Findings include: On 12/11/2024, the facility admitted Patient 22 and Patient 21 with rectal polyp for transanal excision of rectal polyp. On 12/11/2024 at 8:57 AM, informed consent was obtained from Patient 22 for transanal excision of rectal mass via flexible sigmoidoscopy. On 12/11/2024, Patient 22’s operative report revealed a dissection, and excision was completed on the rectal mass, and a low rectal polyp, right posterior specimen was removed. Patient 22’s specimen was later mislabeled with Patient 21 when two specimen orders were entered for Patient 21, instead of one for each patient (Patient 21 and 22). On 5/23/2024 in the morning, Patient 22’s medical record lacked documented evidence of a physician order and pathology report for the specimen removed. The Director of Regulatory Compliance indicated the medical record was not corrected because there was no order to remove a specimen. On 6/10/2025 at 8:30 AM, the Surgeon indicated nursing was supposed to enter the specimen order correctly in order to process the respective specimens. Patients were notified as soon as the surgeon was notified of the specimen mix-up.”