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Based on staff interview and document review, it was determined the facility staff failed to ensure four (4) of twenty two patients in the survey sample, received patient rights and/or consent for treatment (Patient #1, #9, #16, and #22).

The findings included:

Patient #1's electronic medical record was reviewed on April 6, 2015 at approximately 9:00 am. No patient rights or consent for treatment was located in the electronic medical record.

Patient #9's electronic medical record was reviewed on April 6, 2015 at 11:33 am. Consent for Treatment and Patient Rights was found with signature of an individual. The form was not filled out in full. Unable to determine the relationship of the patient to the person who signed the form.

Patient #16's electronic medical record was reviewed on April 6, 2015 at 1:45 pm. Documentation by the registration staff indicated the patient was unable to sign the registration form. No documentation found of why the patient was unable to sign the form.

Patient #22's electronic medical record was reviewed on April 8, 2015 at approximately 1:00 pm. Documentation indicated the patient was unable to sign the registration form. No documentation of why the patient was unable to sign the form. The form was not filled out in full. Unable to determine who initialed the form (whether patient's family or registration staff).

Staff #18 and Staff #21 were present during the electronic medical record reviews on April 6, 2015. Staff #18, Staff #20, and Staff #21 were present during the electronic medical record reviews on April 8, 2015.

The facility's registration policy was requested and received on April 8, 2015 at approximately 1:30 pm.

Staff #8 was interviewed on April 8, 2015 at approximately 8:40 am. Staff #8 stated he/she could not locate the form acknowledging Patient #1 had consented for treatment or received his/her rights. Staff #8 was given the opportunity to find missing or incomplete registration forms. Staff #8 stated if the form is not signed and filled out completely the form "is not valid." Staff #8 further stated the registration staff is trained to obtain all signatures and initials on the form. Staff #8 stated if the patient is unable to sign the form, the registration staff are taught to document the reason the patient is unable to sign ( e.g. no family available). Staff #8 further stated the registration staff is taught to sign their name acknowledging the reason the patient was unable to sign the form.

Based on staff interviews, document review, and in the course of complaint investigation, it was determined the facility's staff failed to notify and document in the medical record a patient's family had been informed of a change in condition requiring the patient to be placed in soft wrist restraints for one (1) of ten patients in the survey sample, for whom restraints were used (Patient #2).

The findings include:

Twenty two medical records were reviewed on April 6, 2015 and April 8, 2015. Four electronic medical records (Patient Records #3, #4, #21, and #22) were reviewed of current patients in restraints. Six electronic medical records (Patient Records #2, #5, #6, #9, #19, and #20) were reviewed of patients who had been in restraints during hospitalization prior to discharge. Patient #2's medical record was reviewed on April 6, 2015 at 10:07 am. A copy of Patient #2's medical record was requested and received on April 6, 2016 at approximately 2:15 pm.

Patient #2 was admitted to the facility on 12/29/2014. Patient #2 presented to the emergency department with a diagnosis of unsteady gait/balance. Past history is significant for a history of falls, dementia, prostate cancer, kidney stones, small bowel resection, hernia repair, benign abdominal tumor, and appendectomy. Neurological status documented by emergency department staff on 12/29/2014 at 4:21 pm states "alert, some dementia and sometimes agitated."

Documentation in the electronic medical record of Patient #2 by Staff #5 on 01/01/2015 at 5:34 am states "patient is alert but confused. This shift became agitated. Getting out of bed and striking staff. Became an urgent safety concern. Frequent rounding done to prevent fall. MRI was completed. In sinus bradycardia on the monitor; heart rate in the low 50s. [He/she] is incontinent and needs frequent hygiene checks."

Documentation in the electronic medical record of Patient #2 indicated the last linen change was at 5:00 am on 01/01/2015.

Documentation in the electronic medical record progress notes for Patient #2 by Staff #5 on 01/01/2015 at 7:46 am stated, "soft wrist restraints were placed as a last resort to keep patient safe from self injury. Restraints were placed at 0200 [2:00 am] this am and they were removed at 0600 [6:00 am] today. Doctor [name of physician] was notified of this action."

Staff #5 was interviewed on April 8, 2015 at 8:10 am by two Medical Facilities Inspectors. Staff #5 stated he/she placed Patient #2 in soft wrist restraints at approximately 2:00 am without a physician order. Staff #5 stated he/she obtained the order for restraints at approximately 7:44 am after the restraints had been removed from Patient #2. Staff #2 stated Patient #2's spouse was "very upset" when he/she arrived and found Patient #2 in soft wrist restraints, incontinent of urine, and naked from the waist down. Staff #5 stated he/she did not contact the spouse of Patient #2 to inform the family of the change in Patient #2 requiring restraints. Staff #5 stated he/she thought the spouse of Patient #2 was tired from being at the bedside of Patient #2 for the last few nights.

The above named facility's Restraint Policy was requested and received on April 6, 2015. The policy titled "Restraints and Restraint Alternatives" states "family should be notified and may be encouraged to stay with the patient if appropriate or consider privately hiring additional support." The policy further states "family presence will be encouraged in cognitively impaired patients."

Based on staff interview, document review and during the course of a complaint investigation, it was determined the facility staff failed to ensure the right to personal privacy for one (1) of twenty two patients in the survey sample (Patient #2). Specifically, one (1) of twenty two patients (Patient #2) was found by the patient's spouse who entered the patient's room and found him/her lying in bed restrained with bilateral soft wrist restraints (without a physician order) incontinent of urine and unclothed from the waist down.

The findings included:

Documentation in the electronic medical record for Patient #2 by Staff #5 on 01/01/2015 at 5:34 am states "patient is alert but confused. This shift became agitated. Getting out of bed and striking staff. Became an urgent safety concern. Frequent rounding done to prevent fall. MRI was completed. In sinus bradycardia on the monitor; heart rate in the low 50s. [He/she] is incontinent and needs frequent hygiene checks."

Documentation in the electronic medical record of Patient #2 indicates the last linen change was at 5:00 am on 01/01/2015.

Documentation in the electronic medical record of Patient #2 by Staff #5 on 01/01/2015 at 7:46 am states "soft wrist restraints were placed as a last resort to keep patient safe from self injury. Restraints were placed at 0200 [2:00 am] this am and they were removed at 0600 [6:00 am] today. Doctor [name of physician] was notified of this action."

Staff #5 was interviewed on April 8, 2015 at 8:10 am by two Medical Facilities Inspectors. Staff #5 stated he/she placed Patient #2 in soft wrist restraints at approximately 2:00 am without a physician order. Staff #5 stated he/she obtained the order for restraints at approximately 7:44 am after the restraints had been removed from Patient #2. Staff #2 stated Patient #2's spouse was "very upset" when he/she arrived and found Patient #2 in soft wrist restraints, incontinent of urine, and naked from the waist down.

The above named facility's Restraint Policy was received and reviewed on April 6, 2015. The policy states "monitoring is accomplished by observations, interactions with the patient and/or direct examination of the patient by qualified staff. The monitoring determines that the patient's rights, dignity, and safety are maintained."

Based on staff interview, documentation review, and in the course of complaint investigation, it was determined the facility staff failed to ensure the Plan of Care was updated to reflect the use of restraints for three (3) of ten patients in the survey sample, for whom restraints were used (Patients #2, #5, and #20).

The findings included:

Twenty-two electronic medical records were reviewed were reviewed during the survey on April 6, 2015 and April 8, 2015. Restraints were used on ten of the patients.

Patient #2 was admitted to the above named facility on 12/29/14. The patient was placed in soft wrist restraints during his/her hospitalization. The Plan of Care had no documentation pertaining to restraints.

Patient #5 was admitted to the above named facility on 11/30/14. The patient was placed in soft wrist restraints during his/her hospitalization. The Plan of Care had no documentation pertaining to restraints.

Patient #20 was admitted to the above named facility on 12/19/14. The patient was placed in soft wrist restraints during his/her hospitalization. The Plan of Care had no documentation pertaining to restraints.

Staff #1 was present during the findings on April 6, 2015. Staff #1 stated he/she expected the Plan of Care to include restraint information if restraints are used.

Based on staff interview, document review and in the course of a complaint investigation, it was determined the facility staff failed to obtain a physician order for the use of restraints for two (2) of ten patients placed in restraints (Patient #2 and Patient #9).

The findings included:

Four electronic medical records (Patient Records #3, #4, #21, and #22) were reviewed of current patients in restraints. Six electronic medical records (Patient Records #2, #5, #6, #9, #19, and #20) were reviewed of patients who had been in restraints during hospitalization prior to discharge. Patient #2's medical record was reviewed on April 6, 2015 at 10:07 am.

Documentation in the electronic medical record for Patient #2 by Staff #5 on 01/01/2015 at 5:34 am stated "patient is alert but confused. This shift became agitated. Getting out of bed and striking staff. Became an urgent safety concern. Frequent rounding done to prevent fall. MRI was completed. In sinus bradycardia on the monitor; heart rate in the low 50s. [He/she] is incontinent and needs frequent hygiene checks."

Documentation in the electronic medical record of Patient #2 by Staff #5 on 01/01/2015 at 7:46 am states "soft wrist restraints were placed as a last resort to keep patient safe from self injury. Restraints were placed at 0200 [2:00 am] this am and they were removed at 0600 [6:00 am] today. Doctor [name of physician] was notified of this action."

Staff #5 was interviewed on April 8, 2015 at 8:10 am. Staff #5 verified he/she entered the Behavioral Restraint: "Violent and/or Self Destructive Behavior" order at 7:44 am. Staff #5 verified he/she initiated the restraints at 2:00 am (time appeared on order). Staff #5 stated he/she "did not call the doctor when [Patient #2] was placed in restraints." Staff #5 stated he/she did not call the doctor because it was in the middle of the night. Staff #5 stated the physician was notified after the restraints had been removed from Patient #2. Staff #5 was unable to recall the exact time the physician was notified. Staff #5 stated he/she entered the "Behavioral Restraint: Violent and/or Self-Destructive Behavior restraint" order in error. Staff #5 stated he/she meant to enter a "Medical Restraint: Non Violent and/or Non-Self Destructive Behavior." Staff #5 stated he/she "fell short" and did not document the required restraint assessments and monitoring. Staff #5 stated he/she "did the assessments and was watching the patient but did not document it." Staff #5 when asked by the surveyor if Patient #2's family had been notified of the change in the patient's condition requiring the application of restraints stated "no." Staff #5 confirmed he/she did not follow the above named facility's restraint policy.

Staff #7 was interviewed on April 8, 2015 at 9:25 am. Staff #7 stated his/her expectation is the physician should be notified within one hour of Non-Violent Restraints being initiated by the registered nurse.

The above named facility's restraint policy was requested and received on April 6, 2015. The policy titled "Restraints and Restraint Alternatives" states under the category "Orders for Non-Violent and/or Non-Self Destructive Behavior" the use of restraints "must be ordered by a Licensed Independent Practitioner (LIP), unless the patient's RN determines that the need to restrain the patient is clinically justified and an LIP is not immediately available, in which case restraint procedures may be initiated. In this instance, the LIP must be notified and a telephone or written order must be obtained as soon as possible." The policy further states under the category "Assessment and Monitoring" the patient must be monitored and documentation of monitoring must be recorded every two hours.

No documentation of assessment or monitoring every two hours of Patient #2, while in restraints, was located in the medical record of Patient #2.

Patient #9 had a diagnosis of a fall at home. Past medical history includes Lung Cancer, cardiomyopathy (enlarged heart) and asthma. Documentation of a physician order indicated Patient #9 was placed in Non-Violent and/or Non-Self Destructive Restraints soft wrist restraints on 12/13/2014. No physician order for restraints was found in the electronic medical record of Patient #9 on 12/15/2014. Restraint flow sheet documentation indicated the patient was in soft wrist restraints without a current order.

Staff #18 was present during the electronic medical record reviews on April 6, 2015 and April 8, 2015.

An interview was conducted with Staff #18 on April 8, 2015 at approximately 4:00 pm. Staff #18 was able to provide the survey team with evidence of staff retraining pertaining to restraints. Documentation provided indicates greater then 95 percent of the staff on the nursing unit where Patient #2 had received care had been retrained. Staff #18 stated all staff on the unit would be retrained by next week. A copy of the written post test pertaining to restraints was requested and received on April 6, 2015.

Based on staff interview, document review and in the course of complaint investigation, it was determined the facility's staff failed to have complete documentation of monitoring of two (2) of ten patients while in restraints (Patient #2 and Patient #20).

The findings included:

Patient #2 was placed in soft wrist restraints on 01/01/2015 without a physician order. No documentation of restraint monitoring was found in Patient #2's medical record.

Staff #6 was present during the findings in Patient #2's medical record, and acknowledged the lack of documentation of monitoring.

Patient #20 was placed in soft wrist restraints on 12/21/14 due to pulling at tubes. A physician order for the soft wrist restraints was located. Incomplete restraint monitoring pertaining to range of motion was found in Patient #20's medical record dated 12/21/14.

Staff #18 and Staff #20 were present during the review of Patient #20's medical record, and verified the incomplete documentation of monitoring.