John Randolph Medical Center

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 42042 Based on review of medical records (MR), review of facility documents, and interview with staff (EMP), the facility failed to conduct a face-to-face assessment within 1 hour of restraint or seclusion initiation for the management of violent behavior for one (1) of six (6) restraint/seclusion records reviewed (MR5). Findings: In the afternoon of 06/09/26, the surveyor initiated medical record review with the assistance of EMP9 as primary navigator. A total of six (6) restraint/seclusion records were reviewed (MR4, MR5, MR6, MR7, MR8, MR9) between 06/09/26 through 06/10/26. During review of MR5, the surveyor identified a seclusion episode initiated by EMP12 on 04/26/26 at 10:45 pm for the treatment of violent behavior. The surveyor was unable to identify documentation of a face-to-face assessment for the associated seclusion intervention. 06/09/26 at 3:18 pm, the surveyor conducted a phone interview with EMP12 regarding the one-hour face-to-face assessment. The employee stated they were unable to recall whether a face-to-face assessment was done but stated that if one was done, there should be documentation present in the medical record. On 06/09/26 at 1:11 pm, EMP9 confirmed with surveyor during interview that there was no documentation supporting a face-to-face assessment for MR5 pertaining to the seclusion initialized on 04/26/26. Review of facility document titled, “Patient Restraint/Seclusion, COG.COG.001”, read in part that a face-to-face assessment “must be done within one hour of restraint or seclusion initiation...to manage violent or self-destructive behavior ...[sic]”.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 19883 Based on medical record review, facility document review, and staff interview, the facility failed to document the administration of a PRN (as needed) medication in the nurse’s shift assessment/progress note per the facility’s policy. The findings include: Review of the facility’s policy titled: “Charting Medications PH-2” with an expiration date of 11/2027 reads in part: “...D. The person administering the medication is ultimately responsible for recording all medication information in the patient’s electronic medical record. E. PRN medications, the reason for giving PRN medications and the patient’s response are recorded in the nurse’s shift assessment/progress note.” Review of Patient #1’s medical record revealed that Patient #1 received the antipsychotic medication Haldol 2.5 mg I.M. injection, as per order from the ED provider on the following dates and times: 11/2/25: 6:13 PM 11/3/25: 10:56 AM 11/4/25: 6:35 PM 11/5/25: 8:36 AM 11/7/25: 6:25 PM Review of the nurse’s notes for those dates revealed that the nurse failed to document the administration of Haldol to Patient #1 and failed to document Patient #1’s response to the Haldol. Patient #1 received Haldol on 11/2/25 at 6:13 PM. Review of the nursing notes for 11/2/25 revealed the following documentation: 1:07 AM: “Patient in bed sleeping, respirations are even and unlabored. Police in room at bedside, sitter at bedside.” 4:13 AM: “Patient is in bed sleeping. Respirations are even and unlabored. Sitter and police at bedside.” 6:48 AM: “Patient is in bed resting, respirations are even and unlabored. Sitter and police at bedside.” There was no nursing documentation related to the administration of Haldol for Patient #1. Patient #1 received Haldol on 11/3/25 at 10:56 AM. Review of the nursing notes for 11/3/25 revealed the following documentation: 8:58 AM: “Received report from (name of staff nurse). Assumed care of patient.” 9:10 AM: “Patient laying in emergency room stretcher. Requesting a warm blanket. Warm blanket provided. Sitter and PD at bedside.” 9:30 AM: “Obtained vital signs. Patient sitting on emergency room stretcher watching TV. Sitter and PD at bedside.” 10:04 AM: “Writer went to get scheduled meds for patient. Per PD (police department) patient started getting up out of bed and trying to shut door after repeatedly being told to keep door open. Patient yelling and screaming. PD placed patient in restraints. Patient yelled at writer to ‘get out of my room!’. Patient continually screaming. PD at bedside. No signs of distress.” 10:09 AM: “Patient refusing to take scheduled medication. No signs of distress. Sitter and PD at bedside.” 11:26 AM: “Patient in emergency room stretcher eating lunch tray. No signs of distress. PD and sitter at bedside.” 1:00 PM: “Patient resting in emergency room stretcher. Observed chest rise and fall. Sitter and PD at bedside. No signs of distress.” 1:43 PM: “Writer talked to (Patient #1’s family member) after (family member) called for updates. (Patient #1’s family member) given updated. Informed (Patient #1’s family member) that Patient #1 is still a bed search.” There was no nursing documentation related to the administration of Haldol for Patient #1. Patient #1 received Haldol on 11/4/25 at 6:35 PM. Review of the nursing notes for 11/4/25 revealed the following documentation: 7:03 AM: “Pt (patient) is resting in bed; resp are even and unlabored; sitter at bedside . Will continue to monitor.” 8:00 AM: “Pt is resting in bed; resp are even and unlabored; sitter at bedside. Will continue to monitor.” 9:01 AM: “Pt is resting in bed on back; resp are even and unlabored; sitter at bedside. Will monitor.” 18:05 PM: “Pt left room and ran outside to parking lot; security escorted back in; when Pt got back to room (Patient #1) took green gown off and gets naked; nursing supervisor notified and responded.” 18:50 PM: “Spoke with (Patient #1’s family member) for safety concerns and the need to place restraints at this time.” 7:44 PM: “Pt resting on stretcher with eyes closed and equal and even rise and fall of chest. NAD (no acute distress). Soft restraints remain in place on all extremities. No injuries noted at this time. Pts safety, right, and dignity maintained at this time. Sitter remains in place at bedside.” 8:30 PM: “Pt remains resting on stretcher with eyes closed and equal and even rise and fall of chest. Restraints removed from all extremities at this time. (Name of ED provider) made aware. No injury noted. Room safety maintained. Sitter remains at bedside.” 9:15 PM: “No change in pts condition. Pt remains resting on stretcher with eyes closed and equal rise and fall of chest. NAD. Sitter at bedside.” There was no nursing documentation related to the administration of Haldol for Patient #1. Patient #1 received Haldol on 11/5/25 at 8:36 AM. Review of the nursing notes for 11/5/25 revealed the following documentation: 1:40 AM: “No change in pts condition. Pt remains resting on stretcher with eyes closed and equal rise and fall of chest. NAD. Sitter at bedside.” 3:25 AM: “No change in pts condition. Pt remains resting on stretcher with eyes closed and equal rise and fall of chest. NAD. Sitter at bedside.” 5:10 AM: “No change in pts condition. Pt remains resting on stretcher with eyes closed and equal rise and fall of chest. NAD. Sitter at bedside.” 9:14 PM: “Sitter with patient.” There was no nursing documentation related to the administration of Haldol for Patient #1. Patient #1 received Haldol on 11/7/25 at 6:25 PM. Review of the nursing notes for 11/7/25 revealed the following documentation: 2:42 PM: “Spoke with (name of outside psychiatric crisis entity), states that they sent over the requested paperwork to (name of outside inpatient psychiatric facility). (Name of outside inpatient psychiatric facility) is still reviewing paperwork at this time, will call back with an update.” There was no nursing documentation related to the administration of Haldol for Patient #1. Patient #1 also received the following PRN medications: Ativan 2 mg I.M. injection on 11/1/25; 11/2/25; 11/3/25; 11/4/25; 11/5/25 and 11/6/25. Motrin on 11/1/25. Benadryl PRN on 11/2/25; 11/3/25; 11/4/25; 11/5/25; and 11/7/25. There was no nursing documentation in the nursing notes regarding the administration of Ativan, Benadryl or Motrin for Patient #1. Staff Member #1 reported during an interview on 12/9/25 that there should have been nursing documentation in the nursing notes regarding the administration of PRN medications for Patient #1.”