Dominion Hospital

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 42929 Based on review of medical records (MR), review of documents, and interviews with staff (EMP) it was determined the facility failed to modify the patient’s plan of care referred to as “recovery plan” with the use of restraints for two (2) of three (3) patients’ restraint documentation reviewed, MR4 and MR5. Findings: Review of facility document “Patient Restraint/Seclusion Policy” last revised February 2024 reads in part: “... Care of the Patient/Plan of Care. A. The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications.... Documentation Requirements. The medical record contains documentation of: ... N. Modifications of the plan of care....” Review of the facility document “Recovery Planning - Inpatient Services” last revised August 2025 reads in part: “... D. Recovery Plan Review. a. Following the development of the Master Recovery Plan, a recover plan review is conducted minimally every [seven] 7 days for the duration of hospitalization. Recovery plan reviews are also conducted whenever there is a significant change in patient condition warranting a recovery plan revision.... c. The results of the review must be documented with the changes entered on the recovery plan review as indicated. Each recover plan review must be dated and indicate who was involved in the review.” Review of the medical record for MR4 on March 30, 2026, revealed the last treatment plan of care was updated on March 18, 2026. There was no documentation that a treatment plan of care/recovery plan was updated every seven (7) days or with a significant change in patient condition to include the use of restraints as per facility policy. Review of the medical record for MR5 revealed the patient was placed in a violent restraint, a physical hold, two (2) separate instances on March 16, 2026. The last documented treatment plan of care/recovery plan was dated March 5, 2026, and the patient was discharged on March 18, 2026. There was no documentation of an updated treatment plan of care/recovery plan updated every seven (7) days or with a significant change in patient condition to include the use of restraints as per facility policy. Interview on March 30, 2026, in the afternoon, EMP9 indicated that the “recovery plan”is the patient’s plan of care that should be updated at least every seven (7) days and when there is a significant change in the patient’s condition like the use of restraints. EMP9 confirmed that MR4 and MR5’s recovery plans were not not updated at least every seven (7) days or with a significant change in patient condition to include the use of restraints as per facility policy.”

“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: 42929 Based on review of medical records (MR), review of documents, and interviews with staff (EMP) it was determined the facility staff: failed to obtain a physician or other licensed practitioner’s order for the use of restraint and seclusion for two (2) of three (3) patients’ restraint documentation reviewed, MR4 and MR5; and failed to sign verbal orders within twenty-four (24) hours as per facility policy for one (1) of three (3) patients’ restraint documentation reviewed, MR1. Findings: Review of facility document “Patient Restraint/Seclusion Policy” last revised February 2024 reads in part: “... Note: In an emergency application of the restraint or seclusion, the above review will be done immediately after the application of restraint. A. Order for Restraint or Seclusion. A. An order for restraint or seclusion must be obtained from a physician or other licensed practitioner who is acting within their State Scope of Practice, authorized by State Law as having authority for ordering restraints, and is responsible for the care of the patient prior to the application of restraint and seclusion.... 2. If a patient was recently released from restraint or seclusion and exhibits behavior that can only be handled through the reapplication of restraint or seclusion, a new order is required. B. If a telephone order is required, the RN must enter the order in while the physician or other licensed practitioner, authorized by State law to order restraints, is on the phone and read-back the order to verify accuracy.... D. ... In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint or seclusion is initiated.... C. Once restraints or seclusion are discontinued, a new order for restraint or seclusion is required to reapply or reinitiate.... Documentation Requirements. The medical record contains documentation of: ... F. Order for restraint or seclusion and any renewal orders for restraint or seclusion.... P. Restraint or seclusion removal/termination....” Review of facility document “Provider Orders and Verification” last revised December 2024 reads in part: “... Verbal/Telephone Order Verification Process ... 3. Telephone and Verbal orders must be signed electronically by the responsible provider within [twenty-four] 24 hours....” MR1 Review of the restraint documentation for MR1 dated March 21, 2026, revealed verbal orders for three (3) violent restraints: a physical hold at 5:46 AM; a physical hold at 5:48 AM; and seclusion at 5:50 AM. The three (3) violent restraint orders were electronically signed by the physician on March 23, 2026, at 3:26 PM, not within 24 hours of the verbal order as per facility policy. MR4 Review of the nursing restraint flow sheets for MR4 dated March 29, 2026, revealed MR4 was placed in violent restraints: a physical hold and seclusion simultaneously started at 1:04 PM and discontinued at 1:11 PM. There was no order for that documented instance of seclusion. Review of the nursing restraint flow sheets for MR4 dated March 29, 2026, revealed MR4 was placed in a violent restraint: seclusion started at 1:12 PM and discontinued at 1:15 PM. There was no order for that documented instance of seclusion. Review of a nursing note for MR4 dated March 29, 2026, at 3:39 PM revealed MR4 was placed in violent restraints, a physical hold, on three (3) separate instances between 1:04 PM through 2:08 PM documented as “... Staff subsequently restrained the patient, who was combative and physically aggressive. The patient was taken to the seclusion room and given PRN [as needed] medications. The patient then began attempting to self harm using [the patient’s] sweater. Attempts were made to redirect [the patient], but [MR4] required restraint again, and the sweater was removed. The patient then attempted to self harm with [the patient’s] shirt, requiring another restraint ...” There was no order or flow sheet documentation for a third restraint of a physical hold during that time. MR5 Review of the nursing restraint flow sheets for MR5 dated March 16, 2026, revealed MR5 was placed in violent restraints: a physical hold started at 5:40 PM and discontinued at 5:45 PM; and a physical hold started at 5:50 PM and discontinued at 5:55 PM. There were no orders for the two (2) violent restraints (physical holds) on March 16, 2026. Interview on March 30, 2026, in the afternoon, EMP9 indicated that all instances of restraints and seclusion must be documented with the time started and discontinued, and there must be an order for all instances of restraints and seclusion. EMP9 confirmed there were no orders for the restraints and seclusions mentioned above. EMP9 indicated that all telephone and verbal orders are to be signed by the ordering provider within twenty-four (24) hours.”

“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: 42929 Based on review of medical records (MR), review of documents, and interviews with staff (EMP) it was determined the facility staff failed to document all required restraint documentation and monitoring for restraint, a physical hold, for one (1) of three (3) patients’ medical records reviewed, MR4. Findings: Review of facility document “Patient Restraint/Seclusion Policy” last revised February 2024 reads in part: “... The medical record contains documentation of: A. Assessment for risk for restraint or seclusion. B. Restraint or seclusion alternatives employed. C. The patient’s condition or symptom(s) that warranted the use of restraint or seclusion. D. Determination of effectiveness/ineffectiveness of restraint or seclusion alternatives. E. Second-tier review of need for restraint or seclusion. F. Order for restraint or seclusion and any renewal orders for restraint or seclusion. G. Restraint or seclusion application/initiation. H. Family notification of restraint or seclusion use. I. Patient and family education regarding restraint or seclusion use. J. Assessment of the patient in restraint or seclusion. K. Monitoring of the patient in restraint or seclusion. L. Medical and behavioral evaluation for restraint or seclusion management of violent or self-destructive behavior. M. The patient’s response to the intervention(s) used, including rationale for continued use of the intervention. N. Modifications of the plan of care. O. Physician notification of changes in patient condition. P. Restraint or seclusion removal/termination....” Review of a nursing note for MR4 dated March 29, 2026, at 3:39 PM revealed MR4 was placed in violent restraints, a physical hold on three (3) separate instances between 1:04 PM through 2:08 PM documented as “... Staff subsequently restrained the patient, who was combative and physically aggressive. The patient was taken to the seclusion room and given PRN [as needed] medications. The patient then began attempting to self harm using [the patient’s] sweater. Attempts were made to redirect [the patient], but [MR4] required restraint again, and the sweater was removed. The patient then attempted to self harm with [the patient’s] shirt, requiring another restraint ...” There was no flow sheet documentation to include all required restraint documentation for a third restraint instance of a physical hold during that time. Interview on March 30, 2026, in the afternoon, EMP3 and EMP9 confirmed that the nurse documented that MR4 was placed in a physical hold on three (3) separate instances on March 29, 2026, but the required restraint documentation in the nursing flow sheet was only documented for two (2) instances of the restraint for physical hold. EMP3 confirmed that each physical hold should be documented on the nursing flow sheet to include all required documentation, monitoring, and assessments.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 36946 Based on staff (EMP) interview and document review, it was determined the hospital failed to ensure each employee maintained the required qualifications to meet patient needs. Specifically, one (1) of fourteen (14) personnel files reviewed in the survey sample failed to contain documentation of current Basic Life Support (BLS) certification. EMP2. Findings: The personnel file for EMP2, a mental health technician hired in 2024 contained documentation of Basic Life Support (BLS) certification that expired November 30, 2024. There was no evidence of basic life support training after November 30, 2025. There was no documentation of a current BLS certification. EMP2’s job description was reviewed and indicated that the mental health technician was required to obtain and maintain active BLS within 90 days of hire. An interview was conducted with EMP2 at 3:00 PM on March 30, 2026, who confirmed all nurses and mental health technicians are required to maintain basic life support certification. The hospital failed to provide current BLS certification for EMP2.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 42929 Based on interviews and document review, it was determined the facility staff failed to timely report an allegation of abuse as per mandated reporting requirements and failed to conduct an assessment to include documentation of the alleged injury for one (1) patient (Patient #2). Findings: On February 5, 2024, the surveyor conducted a medical record review for Patient #2 (P2). That review revealed a nursing note from 10/05/2023 at 8:03 p.m. advising that the reason P2 is leaving the facility against medical advice (AMA) was due to facility staff holding the patient’s arm during the patient’s stay at the facility. An admission health history completed by the physician on 10/04/2023 at 1:00 p.m. documented there were no skin abnormalities identified. There was no documentation in the health history of the allegation from P2. There was no other documentation in the medical record that staff assessed P2 for bruises or injuries after learning of the allegation of bruising by a staff member grabbing the patient’s arm. During a surveyor interview on February 5, 2024 at 12:48 p.m., Staff Member #2 (SM2) stated that (P2) told P2’s parent that P2 was held on the wrist/arm by a staff member and the parent reported the allegation to the facility staff. SM2 stated that SM2 was notified on 10/04/2023 about the concern from P2’s parent that P2 had bruises on P2’s arm caused by a staff member grabbing P2’s arm. SM2 spoke with P2 on 10/04/2024 at 4:00 p.m. to gather more information about the incident. SM2 stated that based on the information obtained from P2 and P2’s parent, the alleged incident occurred on 10/04/2023 around 3:00 a.m. SM2 stated that child protective services was notified about the alleged incident on 10/06/2023 at 6:35 p.m., more than twenty-four (24) hours after the staff was made aware of the allegation. A review of the facility’s policy titled “Guidelines for Reporting of Suspected Neglect, Abuse, or Mistreatment of a Patient” approved 09/2022 states in part: ... Responsible Persons: All health care professionals are legally responsible for reporting all suspected child or adult/elder abuse neglect and exploitation and certain injuries from domestic violence.... 1. Reporting Abuse or Neglect - Must be completed within [twenty-four] 24 hours of first knowledge of abuse.... ... Mandated reporters directly involved in the care of the patient must report all suspected abuse, neglect, and exploitation of children, incapacitated adults and elders within 24 hours to the local welfare/social services agency of the county or city where the individual resides, or where the abuse is believed to have occurred. ... Guidelines: The person required to make the report shall disclose all information which is the basis for his suspicion of abuse, neglect or exploitation. ... Documentation: Documentation in the medical record is essential in order to protect the patient and for the outcome of any legal case. Records should include, whenever possible: 1. Chief complaint and description of abusive even, using the patient’s own words 2. Medical and social history 3. Detailed description of injuries, type, size, number, location, resolution, possible causes and explanations given. Use a body chart if needed or the State Physical Assessment form. The above concerns were discussed with SM1, SM2, SM4, and SM6 at the exit conference on 02/05/2024 at 4:00 p.m.”