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Based on interview and record review, the facility failed to ensure restraint care plans and orders were complete for 2 (P-1, 4) of 2 patients reviewed for restraints and failed to complete restraint monitoring documentation for 1 (P-1) of 2 patients reviewed for restraints, resulting in the potential for unrecognized care needs and the potential for harm. Findings include:

See tags:

A-0166 Failure to complete restraint care plan
A-0173 Failure to obtain order for restraints
A-0175 Failure to complete restraint monitoring documentation

Based on interview and record review, the facility failed to consistently document use of restraints in a plan of care for two restrained patients (P-1 and 4) of 2 patients reviewed for restraints, resulting in possible negative outcomes for the patients. Findings include:

P-1
Record review for P-1 on 3/03/25 revealed the following documentation:

Physician order- non-violent 2-point soft restraints on 09/25/24 1113, discontinued on 09/26/24 at 0318.
No nursing documented care plan for restraints was identified for a day shift on 09/25/24.

P-4
P-4 medical record was reviewed on 3/04/25 and revealed:

Patient was placed in 2-point soft restraints (per provider's order) on 2/25/25 at 2054. Restraints were discontinued on 03/02/25 at 2122.

Review of nursing plan of care for restraints revealed that no updates to care plan were documented on 2/26/25 night shift, 2/27/25 day and night shift, 2/28/25 day and night shift, and 3/01/25 night shift.

On 3/04/25 at 1200 nurse educator, Staff V, was asked how often nurses should document plan of care for patients in restraints. Staff V stated that nurses need to update plan of care every shift.

Facility policy "Restrains: Care of the Patient in Restraints", effective 07/21/24, was reviewed and revealed:
"III. Use of Restraints
A. Ordering Requirements
1. Non-Violent Restraints
m. Restraints will be documented on the patient's plan of care."

Facility policy "Patient Plan of Care", effective 07/21/24, was reviewed and revealed:
C. Inpatient and Inpatient Rehab Plan of Care:
vi. Documentation of patient progress and an outcome/summary statement is recommended on change in patient condition and minimally twice per day for hospitalized patients."

Based on interview and record review, the facility failed to assure there was a provider order for the restraints for two restrained patients (P-1 and 4) of 2 patients reviewed for restraints, resulting in possible negative outcomes for the patients. Findings include:

P-1
Record review for P-1 on 3/03/25 revealed the following documentation:
There was a nursing note dated 9/24/24 1819: "Patient verbalized behaviors needed to remain out of restraints. Restraints initiated at 1345 and discontinued 1435." Further review of the nursing documentation indicated that P-1 was placed in 4-point soft restraints.

Internal medicine note dated 9/25/2024 1121 revealed: under "assessment and plan- Acute agitation, Possible Delirium.
- Patient has fluctuating cognition and has had multiple episodes of aggressive and agitated behavior.
- 9/24: removed foley catheter and IV lines. Had to be placed on soft restraints for a few hours
- 9/25: In morning was pleasant and understandable to plan, later in day was attempting to remove NG (nasogastric tube) tube and IV (intravenous) lines. Plan- Placed on soft restraints again."
Further record review for P-1 revealed no provider order for application or discontinue of 4-point soft restraints on 9/24/24.

P-4
P-4's medical record was reviewed on 3/04/25 and revealed the following:
P-4 had nursing Q2h (every 2 hours) non-violent restraints assessments documented consistently on 02/28/25.
No provider order for 2-point restraints were found for 02/28/25.

On 03/03/25 at 1206 during interview with nurse manager, Staff L, regarding restraints policy and provider's orders he stated that provider has to re-new restraints orders daily and assess the patients.

Facility policy "Restraints: Care of the Patient in Restraints", effective 07/21/24, was reviewed and revealed:
"II. Purpose of Restraints
A. Non-Violent Restraint: Restraints are used when needed to manage non-violent behavior that jeopardizes the immediate physical safety of the patient.
III. Use of Restraints.
A. Ordering Requirements
a. Restraints may be initiated by the order of the physician, NP or PA (Provider) responsible for the patient's care.
d. In emergent situations, when the need for intervention occurs so quickly that an order cannot be obtained prior to application of physical restraints, an RN may initiate physical restraint based on assessment of the patient. The RN will notify the Provider within minutes of restraint application once the patient is safe and obtain the appropriate order. The assessment and restraint intervention must be documented by the RN.
f. A daily evaluation of the patient by a Provider is required.
l. Orders must be renewed daily."

Based on interview and record review, the facility failed to consistently assess and monitor 1 restrained patient (P-1) of 2 patients reviewed for restraints, resulting in risk for patients' physiological needs not being met, potentially unnecessary restraints, and incomplete restraint assessments. Findings include:

Record review for P-1 revealed the following documentation:
Physician order- non-violent 2-point soft restraints on 09/25/24 1113, discontinued on 09/26/24 at 0318.
Nursing note dated 09/25/24 1431 indicated: "1105 am TMS (telemonitoring system) alarming. RN walked into room. Leads off. Found patient (P-1) getting out of bed again. Pulling on NG (nasogastric tube). Patient redirected back to bed and bilateral soft wrist restraints applied, Dr. [name] notified. Received order for bilateral soft wrist restraints. Order placed."

Further record review revealed nursing Q2h (every 2 hours) non-violent restraints assessment completed on 09/25/24 at 1112 and next on 09/25/24 at 1714 (with 2 assessments missing).

Physician order for P-1 for non-violent 2-point soft restraints was placed on 09/26/24 0319, discontinued on 09/26/24 at 2246.
Nursing Q2h (every 2 hours) non-violent restraints assessment review revealed the last assessment was completed on 09/26/24 at 1600. No assessments were documented for 1800, 2000 and 2200 before restraints were removed at 2247.

On 03/03/25 at 1206 during interview with nurse manager, Staff L, regarding restraints policy, assessments and orders he stated that nursing assessments are completed Q2h for non-violent restraints, including the assessment for the need of the restraints.

Facility policy "Restraints: Care of the Patient in Restraints", effective 07/21/24, was reviewed and revealed:
"2. Non-violent Restraint: Assessment and Documentation
c. Every 2 hours, the RN will complete and document (or delegate to an LPN or NSS the:
i. Offering of nutrition, hydration, and toileting
ii. Repositioning of the patient
iii. Completion of range of motion as appropriate
iv. Release/reapplication of physical restraints
d. Every 2 hours, the RN will complete and document an assessment that includes:
i. Patient behavior continues to require restraints
ii. Current restraints continue to be appropriate for the behavior
iii. Condition of restrained area including circulation, evidence of edema and skin condition
iv. Patient's behavior that places the patient or others at risk
v. Physical and psychological status
vi. Comfort."