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Based on record review, document review and interview it was determined the facility failed to monitor the condition of the patient who was restrained at an interval determined by hospital policy in three (3) out of ten (10) patients who were restrained, patient #1, 2 and 20. This failure has the potential to negatively impact all patients restrained at the facility.

Findings include:

1. A medical record review was conducted of patient #1's medical record. The patient was admitted on 04/10/21 via the emergency department (ED) with altered mental status. The patient was agitated, combative and documented to be "kicking and biting" at the staff. On 04/23/21 it is documented soft limb bilateral upper restraints were initiated. On 04/27/21 from 6:29 a.m. until 5:45 p.m. there was no documentation of pain, skin color, skin temperature or capillary refill.

2. A review was conducted of patient #2's medical record. The patient was admitted on 05/08/21 with a diagnosis of altered mental status. The patient was combative and agitated and on 05/08/21 a security bed enclosure restraint was initiated. On 05/08/21 from 4:00 p.m. until 8:00 p.m. there was no restraint assessment documentation. The restraints were discontinued on 05/10/21. The patient was discharged back to home with home health on 05/10/21.

3. A review was conducted of patient #20's medical record. The patient was admitted on 05/03/21 with a diagnosis of closed head injury and alcohol use withdrawal. The patient was agitated and combative and required initiation of soft limb bilateral upper restraints on 05/05/21 at 6:09 p.m. On 05/07/21 there was no restraint assessments documented from 4:00 a.m. until 8:00 a.m. On 05/14/21 there was no restraint assessment of pain, skin color, skin temperature or capillary refill from 05/14/21 at 6:00 p.m. until 05/15/21 at 8:01 a.m. The restraints were discontinued on 05/26/21 at 12:00 p.m.

3. A review was conducted of the policy titled, "Restraining a Patient," publication date 03/30/20. The policy states in part: " ...V. Procedure. 6. Assessment and or documentation in the patient's medical record should include: a description of the patient's behavior, the intervention used, alternatives and less restrictive interventions attempted, patient's response to the intervention used, capillary refill distal to the restraints, pain, need for fluid nutrition, hygiene elimination and skin care, and the rationale for the continued use of restraint if applicable ..."

4. An interview was conducted with the Nursing Practice Director of Innovation and Informatics on 06/14/21 at 2:25 p.m. She concurred there was no documentation in patient #2's medical record of restraint assessments or response to restraints from 4:00 p.m. until 8:00 p.m. on 05/08/21.

5. An interview was conducted with the Corporate Director of Regulatory Compliance on 06/16/21 at 11:00 a.m. She concurred the nursing documentation and auditing of restraint medical records process needs improvement.

Based on medical record review, document review and interview it was determined the facility failed to document alternatives or other less restrictive interventions attempted prior to the initiation of restraints in one (1) out of ten (10) restrained patients, patient #21. This failure has the potential to negatively impact all patients restrained at the facility.

Findings include:

1. A review was conducted of patient #21's medical record. The patient was admitted on 05/12/21 with a diagnosis of "Stroke-like symptoms." The patient became agitated and a specialty bed enclosure restraint was initiated on 05/14/21 at 3:20 a.m. There was no documentation of alternatives attempted prior to the initiation of the restraints. The specialty bed enclosure was discontinued on 05/15/21 at 2:00 p.m.

2. A review was conducted of the policy titled, "Restraining a Patient," publication date 03/30/20. The policy states in part: "V. Procedure. 6. Assessment and or documentation in the patient's medical record should include: a description of the patient's behavior, the intervention used, alternatives and less restrictive interventions attempted ..."

3. An interview was conducted with the Corporate Director of Regulatory Compliance on 06/16/21 at 11:00 a.m. She concurred the nursing documentation and auditing of restraint medical records process needs improvement.

A. Based on record review, document review and interview it was determined nursing failed to adhere to the nursing policies and procedures of the hospital by failing to document all staff present upon initiation of restraints in eight (8) out of ten (10) patients restrained at the facility, patients #1, 2, 14, 16, 18, 19, 20 and 21. This failure has the potential to negatively impact all patients restrained at the facility.

Findings include:

1. A medical record review was conducted of patient #1's medical record. The patient was admitted on 04/10/21 via the emergency department (ED) with altered mental status. On 04/23/21 it is documented soft limb bilateral upper restraints were initiated. There was no documentation of staff present at time of initiation. On 04/28/21 at 6:00 p.m. restraints were re-initiated. There was no documentation of staff present at time of re-initiation.

2. A review was conducted a patient #2's medical record. The patient was admitted on 05/08/21 with a diagnosis of altered mental status. The patient was combative and agitated and on 05/09/21 at 10:19 p.m. a security bed enclosure restraint was initiated. There was no documentation of the staff present that assisted in the initiation of the restraint.

3. A review was conducted of patient #14's medical record. The patient was admitted to the facility on 05/04/21 with a diagnosis of acute sigmoid diverticulitis. The patient had episodes of agitation and combativeness and was ultimately placed in a safety bed enclosure for safety. There was no documentation of staff present upon the initiation of restraints.

4. A review was conducted of patient #16's medical record. The patient was admitted on 05/05/21 with a diagnosis of acute respiratory failure with hypoxemia. The patient was restless, agitated and combative and soft bilateral upper limb restraints were initiated. There was no documentation in the medical record of the staff present upon initiation of the restraints.

5. A review was conducted of patient #18's medical record. The patient was admitted on 04/23/21 with a diagnosis of gangrene of the toe on the left foot. On 05/02/21 it was noted that the patient was combative, had torn out her intravenous (IV) line and refused to wear oxygen. Soft limb bilateral upper restraints were initiated at this time. There was no documentation of the staff present upon the initiation of the restraints.

6. A review was conducted of patient #19's medical record. The patient was admitted on 04/27/21 with a diagnosis of acute on chronic respiratory failure with hypoxia. The patient had episodes of agitation and combativeness. On 04/30/21 the patient had initiation of soft limb bilateral upper restraints. There was no documentation of the staff who assisted in the initiation of the restraints.

7. A review was conducted of patient #20's medical record. The patient was admitted on 05/03/21 with a diagnosis of closed head injury and alcohol use withdrawal. The patient was agitated and combative and required initiation of soft limb bilateral upper restraints on 05/05/21 at 6:09 p.m. There was no documentation of staff present upon the initiation of restraints.

8. A review was conducted of patient #21's medical record. The patient was admitted on 05/12/21 with a diagnosis of "Stroke-like symptoms." The patient became agitated and a specialty bed enclosure was initiated on 05/14/21 at 3:20 a.m. There was no documentation of staff present upon the initiation of restraints.

9. A review was conducted of the policy titled, "Restraining a Patient," publication date 03/30/20. The policy states in part: " ...C. Nursing (e.g., monitoring and documentation). 1. Physical restraint may only be applied by licensed staff who obtained competency in the application of restraints. Initial documentation of restraint will be done by a registered nurse and will include a list of all staff and their credentials who were involved in the occurrence ..."

10. An interview was conducted with the Nursing Practice Director of Innovation and Informatics on 06/16/21 at 11:00 a.m. Regarding documentation of nurses listing which staff were present upon initiation of any restraint for all patients, she stated, "I could not find any documentation of staff present."

11. An interview was conducted with the Corporate Director of Regulatory Compliance on 06/16/21 at 11:00 a.m. She concurred the nursing documentation and auditing of restraint medical records process needs improvement.

B. Based on record review, document review and interview it was determined nursing failed to adhere to the nursing policies and procedures of the hospital by failing to document the removal of restraints in three (3) out of ten (10) restrained patients, patients #1, 14 and 19. This failure has the potential to negatively impact all patients restrained at the facility.

Findings include:

1. A medical record review was conducted of patient #1's medical record. The patient was admitted on 04/10/21 via the ED with altered mental status. The patient was agitated, combative and documented to be "kicking and biting" at the staff. On 04/23/21 it is documented soft limb bilateral upper restraints were initiated. On 05/05/21 at 1:34 p.m. when the patient was discharged there was no documentation of discontinuation of restraints.

2. A review was conducted of patient #14's medical record. The patient was admitted to the facility on 05/04/21 with a diagnosis of acute sigmoid diverticulitis. The patient had episodes of agitation and combativeness and was ultimately placed in a safety bed enclosure for safety. No documentation was noted of the safety bed being removed, however the restraint documentation stopped on 05/13/21 at 5:58 a.m.

3. A review was conducted of patient #19's medical record. The patient was admitted on 04/27/21 with a diagnosis of acute on chronic respiratory failure with hypoxia. The patient had episodes of agitation and combativeness. On 04/30/21 the patient had initiation of soft limb bilateral upper restraints. There was no documentation in the medical record of the discontinuation of the restraints.

4. A review was conducted of the policy titled, "Restraining a Patient," publication date 03/30/20. The policy states in part: "V. Procedure. D. Release from restraint. #3. The registered nurse is responsible for the documentation of patient removal from restraint."

5. A telephone interview was conducted on 06/15/21 at 9:22 a.m. with Registered Nurse (RN) #3. Regarding the restraint documentation of patient #1, she stated, "We usually just discontinue the whole order if we don't need them anymore."

6. An interview was conducted with the Corporate Director of Regulatory Compliance on 06/16/21 at 11:00 a.m. She concurred the nursing documentation and auditing of restraint medical records process needs improvement.

C. Based on record review, document review and interview it was determined nursing failed to adhere to the nursing policies and procedures of the hospital by failing to notify the Medical Emergency Team (MET) upon the initiation of restraints in three (3) out of ten (10) restrained patients, patients #2, 14, and 21. This failure has the potential to negatively impact all patients restrained at the facility.

Findings include:

1. A review was conducted of patient #2's medical record. The patient was admitted on 05/08/21 with a diagnosis of altered mental status. The patient was combative and agitated and on 05/09/21 at 10:19 p.m. a security bed enclosure restraint was initiated. There was no documentation that the MET team was notified upon initiation.

2. A review was conducted of patient #14's medical record. The patient was admitted to the facility on 05/04/21 with a diagnosis of acute sigmoid diverticulitis. The patient had episodes of agitation and combativeness and was ultimately placed in a safety bed enclosure for safety. On 05/09/21 the safety bed was initiated with documentation stating MET team notified., "No."

3. A review was conducted of patient #21's medical record. The patient was admitted 05/12/21 with a diagnosis of "Stroke-like symptoms." The patient became agitated and a specialty bed enclosure was initiated on 05/14/21 at 3:20 a.m. There was no documentation of the MET team being notified.

4. A review was conducted of the policy titled, "Restraining a Patient," publication date 03/30/20. The policy states in part: "V. Procedure. Decision making. 2. The decision to request a provider order for physical restraint must be made collaboratively between the registered nurse and if required the medical emergency team. Refer to the chart below to determine if your unit is required to call medical emergency team. Nonviolent restraint for the ICU, emergency department, do not call MET. For all others call MET ..."

5. The interview was conducted with Nurse Manager #1 on 06/15/21 at 3:00 p.m. Regarding patient #2, she acknowledged the MET team was not called. She saw in policy where it stated the Net bed Specialty bed enclosure is a restraint. She checked with the Charge Nurse on her unit and confirmed they do not call MET for the net beds.

6. An interview was conducted on 06/15/21 at 8:37 a.m. with the MET RN. She received several additional trainings alongside her normal annual training which included restraints. The MET team responds to all situations including initiation of restraints.

7. An interview was conducted with the Nursing Practice Director of Innovation and Informatics on 06/16/21 at 11:00 a.m. Regarding safety bed enclosures, also called "Net Beds," she stated, "The net bed is considered a restraint. The MET team should always be called prior to initiating a net bed."

A. Based on observation, document review and interview it was determined the facility failed to prevent and control the transmission of infections related to Novel Coronavirus 2019 (COVID-19) within the facility at two (2) of the facility locations by not posting signs of how and when to perform hand hygiene. This failure has the potential to negatively impact all patients and visitors presenting to the facility.

Findings include:

1. An observation was conducted throughout facility location #1 from 06/14/21 through 06/16/21. No signs were present throughout the facility with hand hygiene or respiratory hygiene instructions.

2. An observation was conducted throughout facility location #2 by surveyor #2 from 06/14/21 through 06/16/21. No signs were present throughout the facility with hand hygiene or respiratory hygiene instructions.

3. The CDC (Centers for Disease Control and Prevention) Guidance from CDC.gov "Infection Control Guidance," updated Feb. 23, 2021 states in part: "1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic, Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19. Although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented. Take steps to ensure that everyone adheres to source control measures and hand hygiene practices while in a healthcare facility. Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide instructions (in appropriate languages) about wearing a well-fitting form of source control and how and when to perform hand hygiene."

4. An interview was conducted with the Corporate Director of Regulatory Compliance on 06/14/21 at 12:07 p.m. She concurred that there was no respiratory hygiene or hand hygiene signs in the emergency department (ED) or the front entrance of facility location #2.


B. Based on observation, document review and interview it was determined the facility failed to prevent and control the transmission of infections within the facility by not screening all visitors presenting to the facility for COVID-19. This failure has the potential to negatively impact all patients and visitors at the facility.

Findings include:

1. Upon surveyor #1 entering the facility location #1 on 06/14/21 at 10:30 a.m., a screening table with two (2) staff were present. One (1) asked, "What are you here for?" I explained I was here to see Administration, but I didn't work here. They said, "You are good to go then." No screening questions were asked.

2. Upon surveyor #1 entering the facility location #1 on 06/15/21 at 7:45 a.m., a screening table with two (2) staff were present. One (1) asked, "What are you here for?" I explained I was here to see Administration, but I didn't work here. They said, "You are good to go then." No screening questions were asked.

3. CDC Guidance from CDC.gov, "Infection Control Guidance," updated Feb. 23, 2021 states in part: "1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic. Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19. Although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented. Establish a process to ensure everyone (patients, healthcare personnel and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control."

4. The DNV (Det Norske Veritas) Accreditation Coordinator concurred that all visitors, including surveyors, should be screened upon entrance into the facility.


C. Based on observation, document review and interview it was determined the facility failed to prevent and control the transmission of infections within the facility at two (2) of the facility locations by not screening all visitors presenting to the facility for all signs and symptoms of COVID-19. This failure has the potential to negatively impact all patients and visitors presenting to the facility.

Findings include:

1. An observation was conducted of the main entrance of facility location #2 on 06/14/21 at 11:40 a.m. by surveyor #2. The screening process was observed to ask about symptoms of COVID-19. All symptoms recommended by the CDC were mentioned except loss of taste or smell.

2. An observation was conducted of the ED of facility location #2 on 06/14/21 at 11:50 a.m. by surveyor #2. The screening process was observed to ask symptoms of COVID-19. All symptoms recommended by the CDC were mentioned except loss of taste or smell.

3. CDC Guidance from CDC.gov, "Infection Control Guidance," updated Feb. 23, 2021 states in part: "1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic. Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19. Although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented. Establish a process to ensure everyone (patients, healthcare personnel and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control."

4. CDC.Gov: "Symptoms," updated Feb. 22, 2021, states in part: "People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. Anyone can have mild to severe symptoms. People with these symptoms may have COVID-19 ... New loss of taste or smell ..."

5. An interview was conducted with the Corporate Director of Regulatory Compliance on 06/14/21 at 12:07 p.m. She stated there was no sign at entrance listing signs and symptoms of COVID-19.

6. An interview was conducted with the Infection Prevention Specialist on 06/15/21 at 10:45 a.m. regarding the sense of taste and smell not in the screening question. She stated, "There was redundancy in the current process so this question was removed."