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Based on review of facility policy and procedures, review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure physician or licensed independent provider orders for restraints followed the approved facility policy and were accurate or complete in 10 of 19 medical records reviewed (MR3, MR4, MR5, MR6, MR8, MR22, MR23, MR24, MR25, MR26).

Findings include:

Review on April 10, 2019, of facility policy and procedure, "Restraints in Acute Care, Admin clinical," dated November 2017 revealed, " ... Procedure Orders: Restraint shall be ordered by a physician or LIP primarily responsible for the patient's ongoing care ... The order shall specify the method of restraint to be used ... Restraint or seclusion shall be discontinued when the behavior or condition which was the basis for the restraint order is resolved, regardless of the duration of the enabling order ... ".

Review on April 10, 2019, of MR3 revealed a "Restraint Order and Evaluation," dated February 2, 2019, for "Emergent/Crisis Management" restraints. Further review of the restraint order revealed documentation in the section "Discontinue Restraints as Soon as Criteria are met," was not completed.

Review on April 10, 2019, of MR4 revealed a "Restraint Order and Evaluation," dated February 2, 2019, for Medical/Surgical restraints. Further review of the restraint order revealed documentation in the section "Discontinue Restraints as Soon as Criteria are met," was not completed.

Review on April 10, 2019, of MR5 revealed a "Restraint Order and Evaluation," dated February 6, 2019. Further review of the restraint order revealed documentation in the "Reason for Restraints" restraints were "Medical/Surgical" or "Emergent/Crisis Management" was not completed.

Review on April 10, 2019, of MR6 revealed a "Restraint Order and Evaluation," dated February 13, 2019. Further review of the restraint order revealed documentation for the type of restraints ordered indicated both "Medical/Surgical" and "Emergent/Crisis Management."

Review on April 10, 2019, of MR8 revealed a "Restraint Order and Evaluation," dated February 9, 2019, for Emergent/Crisis Management" restraints. Further review of the restraint order revealed documentation of the "Type of Restraint" (indicating "Limb, soft waist belt, vest, leather, other") and "Discontinue Restraints as Soon as Criteria are met" were not completed.

Review on April 10, 2019, of MR22 revealed a "Restraint Order and Evaluation," dated January 30, 2019. Further review of the restraint order revealed documentation in the section "Reason for Restraints" to indicate "Medical/Surgical" or "Emergent Crisis Management" restraints and the section to "Discontinue Restraints as Soon as Criteria are met," were not completed.

Review on April 11, 2019, of MR23 revealed a "Restraint Order and Evaluation," dated March 14, 2019, for Medical/Surgical Restraints. Further review of the restraint order revealed documentation in the section "Physical Examination" and "Discontinue Restraints as Soon as Criteria are met," were not completed.

Review on April 11, 2019, of MR24 revealed a "Restraint Order and Evaluation," dated February 25, 26, and March 3, 2019, for Medical/Surgical Restraints. Further review of the restraint orders revealed documentation in the section "Discontinue Restraints as Soon as Criteria are met" were not completed.

Review on April 11, 2019, of MR25 revealed a "Restraint Order and Evaluation," dated March 25, 27, 29, 31, and April 4, 2019, for Medical/Surgical Restraints. Further review of the restraint orders revealed documentation in the section "Discontinue Restraints as Soon as Criteria are met" were not completed.

Review on April 11, 2019, of MR26 revealed a "Restraint Order and Evaluation," dated February 2, 2019, for Medical/Surgical restraints. Further review of the restraint order revealed documentation in the section " "Discontinue Restraints as Soon as Criteria are met" was not completed.

Interview with EMP3 on April 10, 2019, at 1:00 PM confirmed the restraint documentation in MR3, MR4, MR5, MR6, MR7, MR8 and MR22 was not complete or not accurate.

Interview with EMP1 on April 12, 2019 at 9:30 AM confirmed the restraint documentation in MR23, MR24, MR25, MR26 was incomplete.

Based on review of facility policy and procedures, review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure their approved policy was followed for documentation by trained staff for assessment of patients while in restraints in two of 19 medical records reviewed (MR3, MR7).

Findings include:

Review on April 10, 2019, of facility policy and procedure, "Restraints in Acute Care, Admin clinical," dated November 2017 revealed, " ... Documentation and Monitoring: ... Each episode of use of restraints and reassessment for non-violent behavior (medical- surgical restraints) shall be documented in the EMR ... every two hours an assessment is completed and documented on the Nonviolent restraint assessment ... The patient in behavioral restraints is visually monitored continuously to ensure the patient is physically safe. Every 15 minutes, an assessment is completed and documented on the Restraint Flow record ... ".

Review on April 10, 2019, of MR3 revealed a "Restraint Order and Evaluation," dated February 2, 2019, for "Emergent/Crisis Management" restraints. Further review of MR3 revealed no documentation of a "Restraint Flow Sheet" for the use of the restraints.

Review on April 10, 2019, of MR7 revealed a "Restraint Order and Evaluation" dated February 4, 2019, for "Emergent/Crisis Management" restraints. Further review of MR7 revealed no documentation a "Restraint Flow Sheet" was completed for the use of the "Emergent/Crisis Management" restraints.

Interview with EMP3 on April 10, 2019, at 1:00 PM confirmed there was no documentation of a "Restraint Flow Sheet" for assessments of the patient in restraints in MR3 and MR7.

Based on review of facility documents and interview with staff (EMP) it was determined the facility failed to develop distinct performance improvement indicators for the use of restraints in the Emergency Department.

Findings include:

Review of facility policy "Restraints in Acute Care, Admin, Clinical" reviewed November 3, 2017, revealed "Scope/Applicability: All acute care non-behavioral health units inpatient units at Nazareth Hospital ... Purpose: To achieve a restraint free environment that utilizes as a last resort when no other intervention exists to keep the patient safe ... Performance Improvement:... as part of the Nursing Performance Improvement Program, 100% of incidents of restraints will be measured. assessed and reported for control purposes and performance improvement ..."

Review on April 10, 2019, of facility document "Nazareth Hospital Performance Improvement Plan, 2019" revealed no documentation performance improvement indicators were developed for the use of restraints in the Emergency Department.

Review on April 10 2019, of MR3, MR4, MR5, MR6 and MR7 revealed restraints were utilized in the care and management for these patients in the Emergency Department (ED).

A request was made on April 10, 2019, at 11:00 AM to EMP2 for the performance and quality improvement data related to the use of restraints in the ED. None provided.

Interview on April 10, 2019, at 11:00 AM with EMP2 confirmed quality performance indicators were not developed for the use of patient restraints in the ED.