Westchester Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 17636 . Based on medical record review, document review, and interview, in one (1) of 28 medical records reviewed, the facility failed to conduct an appropriate medical screening examination (MSE) during a patient’s Emergency Department (ED) visit. These findings were evident in medical record (MR) #1. Findings include: Review of the medical record identified that Patient #1 had a previous history of Bipolar Disorder with Psychotic Features, Schizophrenia, polysubstance abuse (Alcohol, cocaine, Heroin, and Fentanyl), K2 (synthetic cannabinoids), and Post Traumatic Stress Disorder. The patient was homeless. On 1/21/25, correctional officers brought Patient #1 to the ED for clearance after the patient was released from jail, where they had been on a watch for self-harm. There was no documented evidence that the patient received a comprehensive medical screening examination before their discharge from the ED. See detailed findings at A-2406. .”

“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: 17636 . Based on medical record review, document review, and interview, in one (1) of 28 medical records reviewed, the facility failed to conduct an appropriate medical screening examination (MSE) during a patient’s Emergency Department (ED) visit (Patient #1). Findings include: On 1/21/25 at 2:27 PM, the ED physician documented that Dutchess County Jail (DCJ) correction officers brought the patient to the ED for clearance after they were released from the county jail, where they had been on a safety watch. The physician noted, “The patient currently does not require any involuntary psychiatric evaluation. The patient denies suicidal or homicidal ideation. The patient is stable for discharge.” Review of the form titled “Dutchess County Sheriff’s Office Correction Division Request for Mental Health Evaluation of an Emotionally Disturbed,” signed on 1/21/25, revealed on 1/19/25, the patient indicated self-harm in jail and had been on constant observation. The ED disposition on 1/21/25 at 2:36 PM, eleven minutes after the patient presented, noted, “Home with self-care/family.” There was no documented evidence that the patient received a comprehensive psychiatric evaluation. During a phone interview conducted on 02/14/25 at 1:00 PM, Staff L (System Psychiatrist Chair) stated that they did not directly encounter the patient; however, they are aware of the patient’s history and multiple ED visits. Usually, the ED physician conducts an independent assessment of the patient and will request a psychiatry consultation if warranted. During an interview on 02/14/25 at 02:00 PM via phone, Staff D (ED System Director) reported that the patient is a challenging patient with multiple ED presentations, mostly secondary to behavioral health issues. Staff D stated that the referral of a patient for psychiatric evaluation is based on the ED physician’s assessment and discretion. On 2/14/25 at 3:30 PM, during an interview, these findings were shared with Staff B, Director of Nursing, Emergency Services/Pediatrics/Medical Surgical units).”

“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: 48940 Based on medical record (MR) review, document review, and interview, the facility failed to discuss changes in the patient’s condition with the patient and/or representative. This finding was evidenced in two (2) of nine (9) medical records reviewed (Patient #3, #4). MR review revealed Patient #3 was admitted to the facility on 8/24/24 for altered mental status and low blood count. The patient was transfused and was admitted for further evaluation. On 10/2/24 at 7:30 AM, the assigned nurse documented a new stage 2 pressure injury that was not present on arrival. The wound was located on the middle sacrum. On 10/7/24 at 3:10 PM, the Wound Care Nurse (WCN) documented a Nursing Note stating the wound to be a deep tissue pressure injury that was not present on arrival. MR review revealed Patient #4 was admitted to the facility on 10/9/24 for a sternal fracture after a fall. The patient was admitted for further evaluation and monitoring. On 10/19/24 at 7:00 AM, the assigned registered nurse (RN) documented a new unstageable pressure injury measuring two (2) centimeters by two (2) centimeters that was not present on admission and documented that the doctor was notified. There was no documented evidence that the findings of the pressure injuries were discussed with the patient or designated family member for Patient #3 or #4. The facility’s booklet, “Your Rights as a Hospital Patient in New York State” (last revised 3/2023), provided to all patients upon admission stated, “As a patient in a hospital in New York State, you have the right, consistent with the law, to Receive complete information about your diagnosis, treatment, and prognosis.” During an interview with Staff Z (Physician) on 2/7/25 at 1:42 PM, Staff Z stated that he did not recall if Patient #3 had a pressure injury and did not recall discussing the pressure injury with the patient’s family member. He stated that he would typically receive a notification from the nurse to inform him of a new wound and would typically go examine the patient after receiving the notification, but he could not recall if this occurred for this patient. During an interview with Staff X (Physician) on 2/7/25 at 12:21 PM, Staff X stated that he did not recall if Patient #4 had a pressure injury. He said that four (4) providers care for the patient as a team and that it could be possible that another member of the team was aware. Staff X did not recall speaking to the patient’s family regarding the wound.”

“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: 48940 Based on medical record review, document review, and interview, it was determined that the nursing staff did not ensure prompt identification of pressure injuries. These findings were evidenced in two (2) of nine (9) records of patients with pressure ulcers (Patient #3, #4). Findings include: The facility’s policy, “Pressure Injury Protocol: Assessment, Prevention & Management” (last revised 11/2022), states, “A head-to-toe skin assessment and risk assessment shall be completed on admission, every shift, and as indicated by the patient’s condition.” Patient #3 was admitted to the facility on 8/24/24 for altered mental status and low blood count. The patient was transfused and was admitted for further evaluation. The initial nursing assessment for Patient #3 on 8/25/24 at 4:28 AM identified the patient as being at high risk for developing a pressure injury, as evidenced by a Braden Score (clinical tool for predicting pressure injury risk) of 12. There was no sacral pressure injury present on admission. The daily nursing assessments for Patient #3 failed to identify changes in the patient’s skin condition. The patient’s sacral pressure injury was identified on 10/2/24 at 7:30 AM as a stage II injury, but it was later documented by the wound care nurse on 10/7/24 at 3:10 PM in a later stage of development as a deep tissue pressure injury measuring seven (7) centimeters in length, eight (8) centimeters in width, and unknown depth. No assessment or treatment was documented for the pressure injury before 10/2/24. These findings were acknowledged by Staff Y on 2/7/25 at 12:46 PM. During an interview with Staff Y (RN) on 2/7/25 at 12:46 PM, Staff Y was asked regarding the initial documentation of the wound by the primary nurse staged as a stage II versus her assessment as a deep tissue injury. She explained that the wound had an area in the middle with some open skin, which could be mistaken for a Stage II, but her assessment of the sacral area was that the small open area was surrounded by maroon and non-blanchable skin, which would classify the patient’s wound as a deep tissue injury. Patient #4 was admitted to the facility on 10/9/24 for a sternal fracture after a fall. The patient was admitted for further evaluation and monitoring. The initial nursing assessment for Patient #4 on 10/9/24 at 10:10 AM identified the patient as being at moderate risk for developing a pressure injury, as evidenced by a Braden Score of 14. There was no thoracic pressure injury present on admission. The daily nursing assessments for Patient #4 failed to identify changes in the patient’s skin condition. The patient’s thoracic pressure injury was identified on 10/19/24 at 7:00 AM as an unstageable pressure injury measuring two (2) centimeters in length, two (2) centimeters in width, and zero (0) centimeters in depth. No assessment or treatment was documented for the pressure injury before 10/19/24. During an interview with Staff W (RN) on 2/7/25 at 12:00 PM, Staff W could not recall the patient but referred to her documentation in her nursing note. Staff W acknowledged the surveyor’s findings.”

“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: 17636 Based on medical record review, document review and interview, in one (1) of 31 medical records reviewed, it was determined the facility failed to implement appropriate fall strategies to prevent the patient from falling in the ED. (Patient #2). Findings include: The policy titled “Fall Prevention and Management” which was last revised 7/2024 states the purpose of the policy is to implement appropriate fall prevention strategies. Review of Medical Record for Patient #2 identified, EMS brought this patient to the ED on 9/14/24 at 2:22 PM. The patient’s son convinced the patient to come to the hospital because the patient had suicidal ideation. The triage nurse documented at 2:38 PM the “patient refuses to speak.” The vital signs were within normal limits. At 3:06 PM the provider ordered close supervision for suicidal ideation, which was started at 3:15 PM. The Patient Care Technician who was providing the close supervision documented the 15-minute checks and noted the patient was awake from 5:45 AM through 10:45 AM on 9/15/24. On 9/15/24 at 11:42 AM, the ED doctor’s note documented, “at 11:05 AM I was informed that the patient while on constant observation and with siderails up was attempting to get off the end of the stretcher and got tangled in the blankets falling forward and hitting their head on the countertop.” The patient’s head and spinal CT-Scans were done at 11:11 AM and they were negative for fracture or trauma. The policy titled “Observation & Management of Patients at Risk to Self Or Others,” which was last revised 03/2023 states, “One staff-member must observe multiple patients in a designated area within a field of vision.” During interview with Staff A, Patient Care Technician which was conducted on 10/3/24 at 10:45 AM, Staff A stated, on 9/15/24 they were assigned to monitor this patient as well as some other patients, but they could not recall how many patients they were watching. Staff A stated they were seated at the nurses’ station when the patient fell. Staff A stated they were speaking to another patient when the patient to whom they were speaking, stated Patient#1 had gotten tangled in the sheet and fallen. Staff A stated they found the patient at the foot of the bed near the garbage can. This finding was shared with Staff A, Regional Director, Quality and Safety on 10/30/24 at approximately 3:30 PM.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 17636 Based on medical record review, document review and interview, one (1) of 16 incidents reviewed, it was determined the facility failed document and investigate a patient report of assault and failed to identify and implement measures to prevent reoccurrence. (Patient #1) Findings include: The policy titled “Occurrence/Serious Safety Event/Near Miss Reporting,” which was last reviewed 4/2023 states, “If an event involves an allegation of harm or abuse of a patient or harm to a staff member the staff member who first becomes aware of the allegation is to: immediately provide or obtain necessary patient treatment and inform the appropriate clinical care team members. The immediate supervisor is to conduct a preliminary investigation of the incident including patient interviews and obtaining all known facts about the incident. In situations that endanger the patient, such as neglect or abuse, an investigation shall be conducted immediately, given the seriousness of the allegations and the potential for harm to the patient(s).” Review of medical record for Patient #1, identified a patient presented to the Emergency Department (ED) on 9/30/24 at 8:08 PM for suicidal ideation. The triage nurse documented that per the police department, the patient made a call to the suicide hotline and made suicidal statements. The patient was agitated and uncooperative and the patient refused blood tests, EKG and a vital signs assessment. The patient remained in the ED until 10/3/24 at 7:30 PM and was transferred to the Behavioral Health Unit where a nurse documented the patient arrived on the unit at approximately 8:00 PM that night, and that the patient angrily states “I was assaulted downstairs, I don’t want to be here. Patient said they were assaulted downstairs, showing bruise on the inner aspect of the arm and left wrist. Patient also said they were thrown on the floor and hit their forehead. Observed with slight redness to forehead. There was slight swelling on patient’s left upper eyebrow.” Review of the facility’s list of incidents revealed this allegation was not listed in the incident database nor was an investigation done. During interview with Staff A, Regional Director, Quality and Safety which was conducted on 10/24/24 at approximately 2:30 PM, Staff A confirmed the incident was not listed in the incident database (MIDAS) nor was an investigation completed.”

“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: 17636 Based on medical record review, document review and interview, in one (1) of 16 medical records reviewed, it was determined the nursing staff failed to reassess a patient’s condition when bruises and swelling were noted on the patient’s skin. (Patient #1). Findings include: The policy titled “Assessment and Reassessment of the Patient” which was last reviewed 03/2023 states, “Each patient is reassessed as necessary based on his or her plan of care or changes in his or her condition.” Review of medical record for Patient #1 identified, a patient presented to the Emergency Department (ED) on 9/30/24 at 8:08 PM, brought in by the police for suicidal ideation. The triage nurse documented that per the police department, the patient made a call to the suicide hotline and made suicidal statements. The patient was agitated and uncooperative and the patient refused blood tests, electrocardiogram (EKG) and a vital signs assessment. The patient remained in the ED until 10/3/24 at 7:30 PM and was transferred to the Behavioral Health Unit where a nurse documented the patient arrived on the unit at approximately 8:00 PM that night and that the patient angrily states, ‘I was assaulted downstairs, I don’t want to be here. Patient said they were assaulted downstairs, showing bruises on the inner aspect of the arm and left wrist. Patient also said they were thrown on the floor and hit their forehead. Observed with slight redness to forehead. There was slight swelling on her left upper eyebrow.” A nurse documented on 10/3/24 at 9:22 PM there are bruises on the anterior left arm, posterior left arm, and anterior right leg. There was no documentation of the size of the bruises and swelling. There was no further documentation in the medical record of a nursing reassessment of any of the patient’s bruises, redness of the forehead or swelling on the left upper eyebrow after the patient’s admission to the Behavioral Health Unit on 10/3/24. During interview with Staff A, Regional Director, Quality and Safety which was conducted on 10/30/24 at approximately 3:30 PM, Staff A confirmed there was no documentation of a nursing reassessment of the patient’s bruises, redness of the forehead or swelling on the left upper eyebrow.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 17636 Based on medical record review, document review and interview, in one (1) of 16 medical records reviewed it was determined the nursing staff failed to create a nursing care plan to address patient’s bruises and swelling of the patient’s skiin. Patient #1. Findings include: The policy titled “Initial Patient Assessment and Care Planning” which was last reviewed 03/2023 states, “Initial patient assessment and care planning shall be initiated by the Registered Nurse at time of inpatient admission and completed within twenty-four (24) hours. The collection and analysis of information during the initial assessment shall be utilized to formulate patient problem list, plan of care and begin the process of medication reconciliation.” Review of medical record for Patient #1 identified, a patient presented to the Emergency Department (ED) on 9/30/24 at 8:08 PM, brought in by the police for suicidal ideation. The triage nurse documented that per the police department, the patient made a call to a suicide hotline and made suicidal statements. The patient was agitated and uncooperative and the patient refused blood tests, electrocardiogram (EKG) and a vital signs assessment. The patient remained in the ED until 10/3/24 at 7:30 PM and was transferred to the Behavioral Health Unit where a nurse documented the patient arrived on the unit at approximately 8:00 PM that night and that the patient angrily states “I was assaulted downstairs, I don’t want to be here. Patient said they were assaulted downstairs showing bruises on the inner aspect of the arm and left wrist. Patient also said they were thrown on the floor and hit their forehead. Observed with slight redness to forehead. There was slight swelling on the left upper eyebrow.” A nurse documented on 10/3/24 at 9:22 PM, there are bruises on the patient’s anterior left arm, posterior left arm, and anterior right leg. There was no documentation in the medical record that a nursing care plan was created to address the patient’s bruises, redness of the forehead or swelling on the left upper eyebrow. During interview with Staff A, Regional Director, Quality and Safety which was conducted on 10/30/24 at approximately 3:30 PM, Staff A confirmed there was no documentation of a nursing care plan to address the patient’s bruises, redness of the forehead or swelling on the left upper eyebrow.”

“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: 17636 Based on medical record review, document review and interview, in three (3) of 12 medical records (MR) reviewed, it was determined the facility failed to ensure that the use of restraints was consistent with the physicians’ orders and to follow its policy to document physicians’ orders for the use of restraints. (Patients #s 1, 2, and 3). Findings include: The policy titled “Restraint and Seclusion-Behavioral Health Services,” revised 4/2022 states, “An order for restraint is to be obtained prior to the application of any Restraint, except in emergency situations when the need for intervention may occur quickly and the Physician is not immediately available. In these emergency application situations, the order is to be obtained either during the application of Restraint or as soon as possible after the Restraint has been applied.” Review of MR for Patient #1 identified a 34-year-old patient who presented to the Emergency Department (ED) on 4/1/24 at 10:26 PM for suicidal ideation. The patient’s previous history was significant for Schizoaffective Disorder, Obsessive Compulsive Disorder, Anxiety Disorder, Marijuana intoxication, and Hypothyroidism. A nurse documented the patient became agitated on 4/2/24 and four (4) point restraints were applied at 1:51 PM. The nurse also documented Five (5)-point restraints were applied at 2:18 PM until 5:00 PM that day. The physician’s restraint order 4/2/24 at 1:52 PM noted “Restraint Initiate Violent 18 years or older. Duration 4 hours, 4-point extremity, less restrictive alternatives failed.” There was no documentation in the medical record of a physician’s order for the five (5) point restraints that were applied on 4/2/24 2:18 PM. Review of MR for Patient #2 identified a 23-year-old patient presented to the ED on 4/15/24 and was triaged at 4:31 PM with a complaint of erratic behavior. The patient presented in handcuffs with police. The patient’s previous medical history was significant for Autism, Seizure Disorder and Mental Health Disorder. The physician’s restraint order 4/15/24 at 6:20 PM noted “Restraint Initiate Violent 18 years or older. Duration 4 hours, 4-point extremity, less restrictive alternatives failed.” Nursing documentation indicate that four (4) point restraints were applied at 6:20 PM on 4/15/24 when the patient’s safety became an issue, and the patient became violent and was acting out towards ED staff. On 4/15/24 at 6:28 PM, a nurse documented “patient placed in 5th point for safety.” The nurse documented the restraints were removed at 7:15 PM that day. There was no physician order for the five (5) point restraints. Review of MR for patient #3 identified a 41-year-old patient presented to the ED in handcuffs on 2/29/24 and the nurse triaged the patient at 5:40 PM. At that time the patient was combative and with paranoid delusions and stating that police are after him. The patient’s previous medical history included Unspecified Schizophreniform Disorder. The physician’s restraint order on 2/29/24 at 5:39 PM noted, “Restraint Initiate Violent 18 years or older. Duration 4 hours, 4-point extremity, less restrictive alternatives failed.” On 2/29/24, a nurse documented on the flow sheet, the patient was in five (5) point restraints from 5:30 PM to 7:50 PM. At 7:04 PM, the nurse documented, “patient was restrained upon arrival due to paranoid delusions and aggressive behavior towards staff and not responsive to any de-escalation attempts. The patient began to scream profanities at staff and was uncooperative with lab work and EKG. Patient remains in restraints.” The ED doctor documented at 5:40 PM that the patient was in ankle and wrist restraints. There was no documentation in the order forms for the five (5) point restraints. These findings were shared with Staff A, Regional Director, Quality and Safety Northern Region during an interview conducted on 5/31/24 at 3:45 PM.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(7) The attending physician must be consulted as soon as possible if the attending physician did not order the restraint or seclusion. This Standard is not met as evidenced by: 17636 Based on medical record review, document review and interview, in one (1) of 12 medical records (MR) reviewed, it was determined the nursing staff failed to notify a provider that the patient was placed in five (5) point restraints. (Patient #2). Findings include: The policy titled “Restraint and Seclusion-Behavioral Health Services,” revised 4/2022 states, “An order for restraint is to be obtained prior to the application of any Restraint, except in emergency situations when the need for intervention may occur quickly and the Physician is not immediately available. In these emergency application situations, the order is to be obtained either during the application of Restraint or as soon as possible after the Restraint has been applied.” Review of the MR for Patient#2 identified a 23-year-old patient presented to the Emergency Department (ED) on 4/15/24 and was triaged at 4:31 PM with a complaint of erratic behavior. The patient presented in handcuffs and was accompanied with police. The patient’s previous medical history was significant for Autism, Seizure Disorder and Mental Health Disorder. A doctor documented at 6:20 PM on 4/15/24 a restraint order for “Restraint Initiate Violent 18 years or older. Duration 4 hours, 4-point extremity, less restrictive alternatives failed.” Nursing documentation indicate that four (4) point restraints were applied at 6:20 PM on 4/15/24 when the patient safety became an issue, and the patient became violent and was acting out towards the ED staff. A nurse also documented on 4/15/24 at 6:28 PM the “patient placed in 5th point for safety.” The nurse documented the restraints were removed at 7:15 PM that day. There was no documentation in the medical record that a nurse informed a provider the patient was placed in five (5) point restraints on 4/15/24 and there was no documentation in the medical record of the time the five (5) point restraints were applied or removed. These findings were shared with Staff A, Regional Director, Quality and Safety Northern Region during an interview conducted on 5/31/24 at 3:55 PM.”