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Based on document review, interview and observation, the facility failed to ensure patients are free from restraint as a means of convenience for staff in 1 (patient 10) of 10 medical records (MR) reviewed:

Findings include:

1. Policy/procedure, No. I-A.9, Patient Rights and Responsibilities, revised/reviewed 6/18, indicated on page 3: "Be free from restraints and seclusion of any form used as a means of coercion, discipline, convenience or retaliation by staff".

2. Policy/procedure, No. II.C.8, Restraint or Seclusion Use, revised/reviewed 8/17, indicated: "Bedside rails - raising full side rails to limit a patient's ability to ambulate where the patient has no ability to lower them or easily move around them is considered a restraint".

3. Review of patient 10's Physician Orders lacked documentation of an order for restraint with raising of full side bedrails.

4. On 3/28/19 at approximately 1000 hours, staff N4 (CNA) was interviewed at time of tour and confirmed patient 10's full side bedrails had been raised to keep patient from moving around while he/she was giving a bath to another patient. Staff N4 stated he/she was not aware of a physician's order authorizing use of restraint per raising of full side bedrails.

5. On 3/28/19 at approximately 1000 hours, staff N11 (Director of Nursing) was interviewed at time of tour and confirmed patient 10's MR lacked documentation of a Physician's Order for restraint per raising of full side bedrails. Staff N10 confirmed staff should follow policy/procedure for restraint/seclusion.

6. On 3/28/19 at approximately 1000 hours, Patient 10 was observed in his/her room sitting in bed with full side bedrails raised while staff N4 (CNA) was in the patient's bathroom assisting another patient.

Based on document review and interview, the facility failed to ensure staff complete accurate documentation of a patient's skin assessment in 1 (patient 1) of 10 medical records (MR) reviewed:

Findings include:

1. Policy/procedure, No. III-A.55, Timeliness of Nursing Medical Record Completion, revised/reviewed 8/18, indicated: "All medical record entries must be legible, complete, dated, timed and signed promptly, in written or electronic form by the person (identified by name and discipline) who is responsible for the documentation".

2. Review of patient 1's MR lacked accurate documentation related to the Nursing Daily Assessment dated 3/9/19 at 1922 hours indicating a bruise to the left eye and Nursing Daily Assessments dated 3/8/19, 3/10/19, 3/11/19, 3/13/19, 3/14/19, 3/15/19, 3/16/19 and 3/18/19 indicating bruising to the right eye.

3. On 3/28/19 at approximately 1500 hours, staff N12 (Regulatory Compliance) was interviewed and confirmed the Nursing Daily Assessment dated 3/9/19 at 1922 hours indicated a bruise to the left eye. Staff N11 confirmed this documentation was inconsistent with the Nursing Daily Assessments dated 3/8/19, 3/10/19, 3/11/19, 3/13/19, 3/14/19, 3/15/19, 3/16/19 and 3/18/19 which indicated bruising to the right eye.