Sierra Medical Center

“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: 30250 Based on a review of documenation and interview, the facility failed to ensure the condition of the patient who is restrained or secluded was monitored by a physician, other licensed practitioner or trained staff at an interval determined by hospital policy. Findings included: According to CMS Interpretive Guidelines, “Hospital policies are expected to guide staff in determining appropriate intervals for assessment and monitoring based on the individual needs of the patient, the patient’s condition, and the type of restraint or seclusion used. The selection of an intervention and determination of the necessary frequency of assessment and monitoring should be individualized, taking into consideration variables such as the patient’s condition, cognitive status, risks associated with the use of the chosen intervention, and other relevant factors...Hospital policies should address: frequencies of monitoring and assessment...” Facility based policy entitled, “Restraint and Seclusion: (CO- 4.004)” stated in part, “C. Monitoring and Reassessment l. Monitoring is accomplished by observation, direct face-to-face interaction with the patient or related direct examination of the patient by trained and competent staff. 2. Appropriate interval for re-assessment is based on the patient needs, condition, and type of Restraint use. The patient who is simultaneously Restrained and Secluded is continually monitored by trained staff either in-person or through the use of both video and audio equipment that is in close proximity to the patient ... 5. Monitoring must include, but is not limited to: a. Ability to clear airway, b. Circulation (including vascular checks such as capillary), c. Heart Rate, d. Respirations, e. Skin Integrity, f. Sensation, g. Ability to move extremities, h. Level of distress and agitation, 1. Behavior, J. Mental status, k. Cognitive functioning, 1. Elimination needs, m. Patient safety and comfort, during and after Restraint is removed, and n. Other criteria based on the type of intervention used and the patient’s condition. 6. Provision of Care Care will not be compromised by the use of Restraints and shall include: a. Provision of nutritional needs, b. Provision of hydration needs, c. Provision of elimination needs, d. Provision of hygiene needs, e. Provision of range of motion exercises, f. Provision of patient safety and comfort, and g. Systemic release of the restrained limbs.” Review of the facility Restraint and Seclusion policy, revealed there is no established time frames for offering fluids and nourishment, toileting/elimination, range of motion, exercise of limbs and systematic release of restrained limbs, and/or established time frames described for how often a patient is monitored for vital signs, respiratory and cardiac status, and skin integrity checks. In interview on 03/31/26, staff member #1 verfied the current facility policy does not have established time frames intervals for assessment and monitoring of patients in restraint/seclusion. Staff member #1 verified that for non-violent restraints, the facility practice is monitoring every 2 hours, however this is not specified in policy. Review of medical records for patients in no-violent restraints, revealed an order for monitoring every 2 hours that accompanied physician ordered for restraint initiation/renewal. Review of medical record for patients in non-violent restraints in March 2026, revealed 1 of 4 patients (Patient #7) had a large gap in documenation of monitoring. * Patient #7 had a physician order for a non-violent 2 point restraint on 03/03/26 at 0755-03/04/26 at 1746. * Review of monitoring documentation for Patient #7 revealed documented monitoring every 2 hours: on at 03/03/26 at 0800, 1000, 1200, 1400, 1600, and 1800 and on 03/04/26 at 0800. * There was no documented monitoring of Patient #7 from 03/03/26 at 1800-03/04/26 at 0800, creating a gap in monitoring of over 12 hours. * There was no documented discontinuation of the non-violent restraint during this time period, to explain the missing monitoring. In interview on 04/01/26, staff members #1 and 3 verfied there was not discontinuation documenation to explain the gap in monitoring. With no discontinuation of the non-violent restraint document the patient would have required documented monitoring every 2 hours. Active monitoring of patients in restraint, and documentation of monitoring , at timeframes established by facility policy, is needed to ensure patient safety.”

“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: 30250 Based on a review of documentation and interview, the facility failed to ensure medical records documented information necessary to monitor the patient’s condition, by failing to photograph skin integrity issues per facility policy. Findings included: Facility Based Policy entitled, “Tissue and Pressure Ulcer Management” stated in part, “POLICY: Guidelines are established to: ... o Ensure comprehensive assessment, documentation and accurate description of pressure ulcer .... I. Assessment ... B. At the time of the patient admission, the RN will ensure: 1. Objective assessment data collection that is based on a systematic tissue assessment including: a. Tissue Color Describe the color of the tissue. Include any notation of cyanosis, jaundice, pallor, bruising, uneven pigment distribution, or any area of discoloration. b. Tissue Condition, especially over bony prominences. Describe the condition of the tissue. Include the intactness; temperature; moisture/dryness; consider the turgor, elasticity; note any break in tissue integrity and/or trauma such as abrasions, tissue tears, insect or other bites, edema, surgical or other wounds including pressure ulcers; note any scars and any areas with exudate and describe ... d. Inspection Under Dressings Any dressing found at the time of admission will be removed (utilizing appropriate technique in accordance with standards of care) and the condition of the tissue covered by the dressing will be assessed and documented. Wet to dry dressing applied after visualization and pictures are taken ... 3. Documentation of Assessment a. Documentation will be on the appropriate computer documentation form to include identification of abnormal skin conditions including pressure ulcers and wounds, and location of such abnormal skin condition. Obtain photo documentation of all pressure ulcers and/or wounds and ensure placement in the medical record. (See Addendum C) ...” Review of 10 patient records 5 of 10 patients did not have their skin issues photographed when initially identified, photographs were documented days and or weeks after identification of the skin issue. * Patient #3 had the following skin integrity issues noted: 01/11/25 Pressure Injury to the Sacrum was noted. 01/13/25 at 0800 IV Infiltrate wound to the Left Arm was noted. 01/25/25 at 0800 a right heel deep injury was noted. 01/25/25 at 1500 an Abdominal Surgical Wound was noted. Photo Documentation was present: 01/31/25 at 1334 for the abdominal wound. 02/05/25 at 1032 and 1124 for the upper arm infiltrate wound. There was no photograph documentation of the right heel deep tissue injury. * Patient #7 had the following skin integrity issue noted: 01/31/25 at 1tissue 300 Left Hip Wound was noted Eschar, Necrotic. Packing in place. Clean Dry and Intact (CDI). Wound Vacuum was changed. Photo Documentation was present: 02/05/25 at 1121 for left hip wound. * Patient #10 had the following skin integrity issue noted: 02/01/25 at 2000 a Surgical Site Abdominal Midline with foam dressing in place. CDI. Wound Vacuum in place. Photo Documentation was present: 02/05/25 at 1126. * Patient #11 had the following skin integrity issue noted: 01/12/25 at 0800 Pressure Injury Coccyx Stage 2 pressure injury with foam dressing in place, CDI. Photo Documentation was present: 01/22/25 on 0537 and 01/25/25 at 1529. * Patient #12 had the following skin integrity issues noted: 01/17/25 at 1928 Fistula to the coccyx noted, unstageable soughing with eschar. Kerlix in place. 01/17/25 at 1930 Left Posterior Shoulder Skin tear present on arrival, noted to be pink, red, with dressing in place. 01/17/25 at 1920 Right elbow skin tear present on arrival, noted to be pink and red, with foam dressing in place. Photo Documentation of the coccyx fistula was present on 01/22/25 at 1156, 01/27/25 at 1159, and 02/05/24 at 0958. By failing to photograph the skin integrity issues when initially noted, it is difficult to gauge whether the skin issues are improving or worsening over time. Photographs are an effective method to monitor the patients skin condition over time. In interview on 02/11/25, staff members # 2 and 3 verfied the facility was not following their policy to photograph skin integrity issues.”