Atrium Medical Center

“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: 42492 Based on record review, interview, and policy review, the facility failed to ensure patients had appropriate orders for restraints and new orders were obtained when patient restraints were modified. This affected two (Patients #1 and #4) of ten patients reviewed for restraints. The facility census was 160. Findings include: 1. Review of the medical record revealed Patient #1 was admitted to the hospital on 04/28/25 for acute encephalopathy. He was discharged on 05/16/25 to an extended care facility in fair condition. Review of physician orders revealed Patient #1 had multiple orders for violent and nonviolent restraints during this admission. New orders were not obtained when violent restraints were removed, and nonviolent restraints were applied on 04/29/25. Bilateral soft wrist and ankle restraints were removed and discontinued on 04/29/25 at 8:00 P.M. and at the same time nonviolent bilateral soft wrist and ankle restraints were placed. There was no order to initiate nonviolent restraints on 04/29/25. There was no order to renew nonviolent restraints on 04/30/25 or 05/01/25. During concurrent interviews on 11/17/25 at 2:45 PM Clinical Nurse Educator D and Regulatory Specialist B confirmed Patient #1 had no active physician orders for nonviolent bilateral wrist and ankle restraints from 04/29/25 to 05/01/25 when the restraints were removed. 2. Review of the medical record revealed Patient #4 admitted on 05/07/ with acute GI bleeding and was discharged on 05/14/25 to acute rehab in good condition. Review of physician orders revealed Patient #4 was ordered and placed in Nonviolent soft limb, bilateral wrist restraints on 05/07/25 at 9:20 P.M. for pulling on lines/tubes. There were no orders to discontinue or modify bilateral soft limb wrist restraints until a new order was placed on 05/09/25 at 7:35 A.M. for nonviolent bilateral mitt restraints. Review of restraint monitoring revealed Patient #4 was in bilateral nonviolent mitt restraints from 05/08/25 at 2:00 P.M. until 05/09/25 at 8:00 AM. During an interview on 11/18/25 at 3:20 P.M. Clinical Nurse Educator D verified Patient #4 was changed from bilateral soft wrist restraints to bilateral Mitt restraints on 05/08/25, and no order was written for bilateral mitt restraints until 05/09/25 at 7:35 A.M. Review of policy titled “Premier Nursing Services Non-Violent Restraint Policy” dated 03/27/25, revealed non-violent restraints required a verbal or electronic order from a Licensed Independent Practitioner (LIP) immediately or within a few minutes after the restraint is applied. When a patient’s restraints are removed for any reason other than providing direct care, a new order was required to reapply. Each order for Non-Violent Restraints was limited to 24 hours for adults.”

“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: 42492 Based on record review, interview and policy review, the facility failed to ensure wound care treatments were completed as ordered and failed to ensure patients were reassessed for pain control after the administration of pain medications. This affected four (Patients #1, #2, #3 and #14) patients. The facility census was 160. Findings include: 1. Review of the medical record revealed Patient #2 was admitted to the hospital on 02/06/25 for sepsis due to cellulitis and metabolic encephalopathy. Review of the medical record revealed Patient #2 had a referral on 02/06/25 at 9:40 P.M. for a wound/ostomy consult. Review of the wound consult on 02/07/25 at 8:25 A.M revealed Patient #2 had a stage IV sacral wound that required surgical debridement. The wound was debrided with a curette and nonviable tissue including devitalized subcutaneous tissue and necrotic muscle. The total surface area debrided was 20 cubic centimeters. There were no other wound measurements available in this note or elsewhere documented in the record. Review of wound consult progress note dated 02/07/25 at 8:25 A.M. revealed Patient #2 had a sacral ulcer present on admission that received excisional debridement on 02/07/25. Review of the medical record revealed Patient #2 had physician orders for daily wound care dated 02/07/25 for 1/8 Dakin’s-soaked gauze to sacral decubitus with Mepilex. Review of the medical record revealed daily wound treatments were not completed on 02/24/25, 02/25/25, 02/26/25, 03/01/25, 03/06/25, and 03/07/25. During an interview on 11/18/25 at 1:18 P.M. Clinical Nurse Educator D verified there were no measurements for Patient #2’s sacral wound in the medical record for this admission and confirmed there was no documentation to support if the wound was healing or not. Clinical Nurse Educator D stated wound measurements were recorded upon admission and were re-measured every seven days. During an interview on 11/18/25 at 1:29 P.M. Clinical Nurse Educator D verified Patient #2 did not receive daily wound care treatments as ordered on 02/24/25, 02/25/25, 02/26/25, 03/01/25, 03/06/25, and 03/07/25. 2. Review of the medical record revealed Patient #3 was admitted to the hospital on 08/25/25 for acute renal failure with hypoxia. Review of the flow sheet date 08/25/25 at 8:20 P.M. revealed Patient #3 had an abrasion to the right lower anterior leg upon admission. Review of the medical record revealed Patient #3 had physician orders dated 08/25/25 at 4:00 P.M. to apply Thera honey to the scab on the right shin daily and cover with a two by two dressing. Review of the medical record revealed daily wound treatments were not completed on 08/26/25, 08/29/25, and 09/04/25. During an interview on 11/18/25 at 3:00 P.M. Clinical Nurse Educator D verified Patient #3 did not receive daily wound care treatments to his right shin on 08/26/25, 08/29/25, and 09/04/25. Review of policy titled “Premier Nursing Services Skin Integrity Maintenance Program and Pressure Prevention Program Incentives” dated 06/24/24 revealed patients identified at risk for skin breakdown had action-based interventions implemented to treat wounds already present and to prevent pressure injuries. 3. Review of the medical record revealed Patient #1 was admitted to the hospital on 04/28/25 for acute encephalopathy. He was discharged on 05/16/25 to an extended care facility in fair condition. Review of the medical record revealed Patient #1 had physician orders for pain medication from 04/29/25 to 05/12/25 including Tylenol 650 milligrams (mg) by mouth every four hours as needed for mild pain; an order on 05/03/25 for methocarbamol 500 mg by mouth three times daily as needed; an order on 05/11/25 for tramadol 50 mg by mouth one time, and from 05/12/25 to 05/16/25, an order for Percocet 5/325 mg by mouth every eight hours as need for pain. Review of the medical record revealed on 05/11/25 at 7:39 Patient #1 was assessed and reported general aching pain, rating it a five on a one to ten scale. Ativan 1 mg was administered by mouth at 7:45 A.M. There was no follow up reassessment for pain until 11:51 A.M. Review of the medical record revealed on 05/11/25 11:33 PM, Patient #1 complained of constant, aching back pain, rating a seven on a one to ten scale. He was medicated at that time with Tramadol 50 mg by mouth. There was no follow-up pain reassessment. He was not assessed again for pain until 05/12/25 at 4:00 A.M. Review of the medical record revealed on 05/13/25 at 2:25 P.M. Patient #1 complained of pain rating it a nine on a one to ten scale. He received one dose of as needed (PRN) Percocet 5/325 mg. There was no follow-up, and his pain was not assessed again until 9:00 P.M. Review of the medical record revealed on 05/14/25 at 6:10 AM Patient #1 complained of constant, aching back pain rating it a seven on a one to ten scale. He was medicated with Percocet 5/325 mg. There was no follow-up reassessment, and he was not assessed for pain again until 8:00 A.M. During an interview on 11/17/25 at 3:46 P.M. Clinical Nurse Educator D confirmed Patient #1 was not reassessed for pain on 05/11/25, 05/12/25, 05/13/25, and 05/14/25 in a timely manner after receiving PRN pharmacological intervention for pain. 4. Review of the medical record revealed Patient #14 was admitted to the hospital on 11/11/25 for a left foot infection. Additional diagnoses included type II diabetes, right foot partial amputation of all toes, and excisional debridement of left foot ulcer on 11/14/25. Review of the medical record revealed Patient #14 had physician orders for PRN pain medication on 11/11/25 including Tylenol 650 mg by mouth every four hours as needed for mild pain and Oxycodone Immediate release 5 mg by mouth every four hours as needed for pain. Review of the medical record revealed on 11/11/25 at 8:58 P.M. Patient #14 complained of moderate pain to the left foot, rating it a six on a one to ten scale. He received oxycodone 5 mg by mouth. The next pain assessment was completed on 11/12/25 at 9:57 A.M. Review of the medical record revealed Patient #14 complained of pain to the left foot on 11/16/25 at 8:15 A.M., rating it a six on a one to ten scale. He received Oxycodone 5 mg by mouth. He was not reassessed for pain until 12:04 P.M. Review of the medical record revealed on 11/17/25 at 5:46 A.M. Patient #14 complained of pain to the left foot, rating it a three on a one to ten scale. He received Tylenol 650 mg by mouth. He was not reassessed for pain until 8:30 A.M. During an interview on 11/20/25 at 11:05 A.M. Regulatory Specialist B confirmed Patient #14 was not reassessed in a timely manner for pain after receiving PRN pain medications on 11/11/25, 11/16/25, and 11/17/25. Review of policy titled “Premier Nursing Services Pain Assessment” dated 09/13/24, revealed pain reassessments were performed within 60 minutes of administering pain medications.”