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Based on medical record review, interview and review of policy and procedures, the facility failed to ensure the use of a lap buddy was the least restrictive device for one of one patients reviewed with a lap buddy (Patient #9). The sample size was ten. The patient census was 68.

Findings include:

Review of the policy and procedure titled Restraint and Seclusion, last revised 08/2015, procedure update 07/2012, administrative manual policy #78, approved by the chief executive officer revealed non-physical activities, as identified in the care plan will be the first choice as an intervention unless safety issues demand an immediate physical response. Patients' safety needs will be individually evaluated and the least restrictive, effective type of restraint utilized.

Review of the medical record for Patient #9 was completed on 05/01/18. The medical record revealed the patient was admitted to the behavioral health unit (BHU) on 03/07/18. The patient was admitted from home with a diagnosis of vascular dementia and aggressive behavior.

Patient #9's plan of care created on 03/07/18 was inclusive of the following goals: stays in group half time without anxiety, shows proper intellect and judgement, takes meds as prescribed by physician, shows decreased confusion and disorientation, expresses logical/goal directed thoughts, shos less than three delusional thoughts everyday, assess for increasing anxiety, complies with nursing regarding fall precautions, will have no falls while in the hospital. Fall prevention interventions include yellow tape placed on patient's chart, fall protocol noted in patient's kardex, post please help prevent falls sign, fall protocol discussed with patient/family, room assignment is close to nurse station, bed maintained in low position, frequent toileting - remain with patient, ultilize fall alarm devices, provide diversional activities, call bell in reach, appropriate footwear on when out of bed, use lap buddy for safety reminder.

Review of the behavior, intervention, response, plan (BIRP) nursing assessment completed by Staff E, dated 03/11/18 at 2:24 PM revealed Patient #9 was aggressive with staff in the morning, not redirectable, removing clothing, reaching pulling on patients as they passed by the patient, pushing staff several times, throwing objects and not eating well. The patient was given 0.5 mg Ativan as needed for anxiety which was effective about one hour after administration. The patient remained calm and cooperative with care.

Review of a late entry general nursing note dated 03/12/18 at 10:00 AM revealed the nurse talked to Patient #9's family. The concerns identified by the family in regard to the observations made of Patient #9 on 03/11/18 during their visit included the patient was sitting in his/her wheelchair with a lap buddy in place. There was no documented evidence as to why the patient had a lap buddy in place, nor was there a nursing assessment to determine if the patient could easily remove the lap buddy or that it was the least restrictive device.

Interview with the Chief Nursing Officer (CNO) on 05/01/18 at 12:45 PM revealed a lap buddy was not considered a restraint according to the hospital's policy and procedure. The CNO confirmed an assessment was not completed to determine if the lap buddy was considered a restraint for Patient #9.