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Based on observation, resident interview, staff interview and record review, the hospital failed to provide evidence that medical restraints were utilized based on assessed need rather than staff convenience. The hospital failed to show evidence that alternatives to medical restraints were being discussed and failed to show attempts at medical restraint reduction for 2 of 2 sampled residents with medical restraints (#45 and #48).

The findings:

Resident #48

Observations were conducted for resident #48 on 3/17/14 at (all times are approximate) 12:40pm, 2:00pm, and 3:10pm. On 3/18/14 observations were conducted at 9:10am, 11:15am, 12:10pm, 12:25pm, 2:00pm and 3:10pm. In all of these times, resident #48 was observed in a Geri-chair with both a Posey vest restraint and a mini-pelvic restraint in place.

On 3/18/14 at approximately 3:10pm, an interview was conducted with resident #48. Resident #48 stated that he finds the Geri-chair comfortable, but does not like the restraints.

On 3/19/14 at approximately 11:10am, an interview was conducted with the Team Nurse (Nurse A). Nurse A stated that resident #48 was unhappy about not being allowed to get up and walk. He used to walk around on the unit while holding onto a wheelchair. His gait started to become unsteady and he had some falls in November and December 2013. That was when the restraints were ordered. He prefers the the Geri-chair over the wheelchair, he stated it is more comfortable. Resident #48 goes to Physical Therapy twice a week. Nurse A was asked about documentation related to medical restraints. Nurse A stated that the recovery team does a 180 day review which was filed under the consult section. The nurses do a restraint assessment at the end of each month - this is documented in nursing progress notes. The nurses also check the restraints a minimum of twice each shift - when they arrive and 4 hours later. The physician re-orders medical restraints monthly.

On 3/18/14 at 10:26am, an interview was conducted with the psychiatric Advanced Registered Nurse Practitioner (ARNP). The ARNP stated that resident #48 was ambulatory, but became very unsteady on his feet. He would walk behind a wheelchair and we would find him on the ground still holding on to the wheelchair as it got away from him. He goes to Physical Therapy which he loves. Resident #48 had discharge plans for a nursing home, but he got a UTI (urinary tract infection) and had increased behaviors, so the nursing home declined.

A record review was conducted for resident #48.

The physician orders were reviewed.
12/30/13 11:00am: Posey vest with wheelchair due to frequent falls from wheelchair.
01/02/14 2:22pm: Posey vest with siderails up in bed until reviewed by treatment team. Rationale - Fall risk.
01/08/14 2:25pm: Geri-chair / wheelchair (GC/WC) with Mini-pelvic Restraint and Posey vest when out of bed. Posey vest with side rails up when in bed. Rationale - Fall Risk, Risk of Injury.
01/23/14: to medical unit, diagnosis Urinary Tract Infection rule out sepsis
02/17/14 1:45pm: (Continue) Mini-pelvic Restraint and Posey vest with Geri-chair / wheelchair when out of bed. Posey vest with siderails up when in bed. Add this order to the monthly treatment orders. Rationale increased risk of injury.
03/08/14 8:50: resident #48 was diagnosed with a second UTI.

A Neurology clinic note dated 2/21/14 stated that resident #48 was able to walk with mild assistance.

The Recovery team notes were reviewed as documented in the Progress notes, the Recovery Plan Meeting Minutes and on the Consultation Referral/Report (details of notes to follow). No individualized resident assessment was found. There was no documentation that the team discussed safety interventions other than restraint that could be taken to reduce the risk of resident #48 falling. There was no documentation that the team considered any medical changes (urinary tract infects, Bell's Palsy) or medication changes that could attribute to the decline in balance. There was no documentation that indicated the team considered assistive devices or a walking program that will improve the resident's ability to self ambulate. There was no plan for regular walking with a staff person (except for therapy twice a week).

The restraint review form (Consultation Referral/Report (Form 29) from 2/19/14 was reviewed. Under the reason for referral the form stated, "Evaluation / Recommendations on continuing current medical restraints due to increased risk of injury." The report stated, "Recovery team met and agreed to continue medical restraints as ordered." There was no information about how the team arrived at this conclusion, whether alternative measures were attempted or whether attempts at restraint reductions were made.

Recovery team notes:
On 12/30/13 at 11:21 the recovery team documented on the Progress and Event notes that they met to review resident #48's Freedom of Movement (FOM) status due to his medical order for a Posey vest due to recent fall / risk of injury. The team agreed to place resident on escorted status. The team will review FOM at the resident's next 30 day meeting review. There was no discussion on this note about the order for the medical restraint.

On 1/24/14 the team documented on the Recovery Plan Meeting Minutes that resident #48 was escorted into the team room by staff due to him being in a Geri-chair with restraints to prevent falls. The team noted that resident #48 currently has a medical order for Geri-chair with Posey vest and Mini-pelvic restraint while of of bed to prevent falls. Rehab staff reported that the residents attendance of classes "has been significantly affected by his confinement to the wheelchair and Posey vest." There was no documented discussion about alternatives to restraints or attempts at reduction.

On 2/19/14 the recovery team documented on the Recovery Plan Meeting Minutes that they met with resident #48. Resident #48 stated, "that he was feeling much better. He laughed and told his Psych ARNP that her hair looks terrible." The team noted, "he currently has a medical order for Geri-chair with Posey vest and mini-pelvic restraint while or of bed to prevent fall. Medical staff discussed the option of resident using a wheelchair instead of the Geri-chair ." There was no other documented discussion about alternatives to restraints or attempts at reduction.

On 3/18/14 at approximately 3:00pm, an interview was conducted with the Executive Nurse Director (Staff E). Staff E reviewed the medical record documentation related to restraints. Staff E stated that the team had done the progression. Resident #48 had no restraints and was ambulatory. Then on 12/30/13, the physician ordered a Posey vest while in wheelchair. On 1/2/14, the physician ordered a Posey vest and side rails up when in bed. On 1/8/14, when resident #48 continued to have issues, the physician ordered an additional restraint - the Mini-pelvic restraint (MPR). (Resident #48 was documented as removing the Posey). You can see the progression up. Every 180 days the recovery team looks at the restraints to see if the resident's condition might have improved so we can take some of that off. This is documented on a Form 29. There has been no restraint reduction since January 2014. We assess the restraints every 6 months.


Resident #45

Observations were conducted of resident #45 on 3/17/14 (all times are approximate) at 12:40pm, 1:00pm, 2:00pm, and 3:10pm. On 3/18/14 at 9:10am, 11:15am, 12:10pm and 2:00pm. In all observations, resident #45 was observed in a wheelchair and wearing a Posey vest restraint. Resident #45 had a history of an above the knee amputation of the right leg.

On 3/17/14 at approximately 1:00pm, an interview was conducted with resident #45. Resident #45 was able to discuss her rehabilitation and therapy classes, and describe some of her goals. She loves to paint and finds it very calming.

On 3/18/14 at approximately 9:10am, a follow-up interview was conducted with resident #45. She related her plans for the day. She was going to the gift shop and the carnival and playing Bingo this afternoon.

On 3/18/14 at approximately 2:00pm, resident #45 was observed propelling herself down the hallway in her wheelchair. Resident #45 reached behind her and untied the Posey vest restraint. Resident #45 did not attempt to get up, she sat there with it untied.

On 3/19/14 at approximately 1:54pm, an interview was conducted with the Team Nurse, Nurse A. Nurse A stated that back in February 2013, resident #45 stood up to be weighed and suffered a compound fracture of both bones in her leg. After that, she was ordered for no weight bearing, mechanical lift only. In June 2013 she started getting up on her own again. That was when the restraint -Posey vest- was ordered. She wears a Posey vest both when up in the wheelchair and in bed at night. She unties the restraint on a regular basis, but does not get up after she does this. Staff retie the restraint multiple times each day. She usually does not attempt to stand, she just unties it. She is aware that she only has one leg, and will not attempt to walk. We used to put the wheelchair on the other side of the room so that she could not reach it, but she would just get another resident to bring it to her. Her bedroom is monitored by staff during the night - constant visual observation. We have to unplug her bed now. Resident #45 will lower the side rails, raise the bed up and slide out and get to her wheelchair. This was all discussed during the team meeting. The responsible party sent an email asking that we take whatever means possible to keep her from standing. We have not tried a restraint reduction - because she keeps untying the Posey vest and getting out.

A record review was conducted for Resident #45. The physician orders were reviewed. On 8/6/13 a physician ordered a Posey vest restraint when out of bed in wheelchair, and a Posey vest restraint with side rails up when in bed. The rationale was "increased risk of injury." This order has been renewed monthly since written .

The restraint review forms (Consultation Referral/Report - Form 29) were reviewed.
On 8/7/13, the recovery team documented the restraint evaluation as follows: Posey vest with wheelchair out of bed. Posey vest with side rails up in bed. Order written 8/6/13 due to resident continuing to stand on leg without assistance. Recovery team reviewed and is in agreement with order as written. On 2/19/14 the form documented, "recovery team met and agreed to continue medical restraints as ordered". There was no other documented discussion about alternatives to restraints or attempts at reduction.

On 7/24/13 at 10:45am the recovery team documented on the Progress and Event Notes. The team met with resident #45 to discuss incidents of her getting up out of bed unassisted. The team asked resident #45 about the consequences and resident #45 stated, "my leg could break again."

Operating Procedure #150-14, dated October 10, 2013, "Medical Restraints and Safety Devices" was reviewed. Under the section for Philosophy the policy stated, "medical restraints of residents are methods of last resort and shell not be used unless lesser restrictive methods of intervention have been attempted and determined to be ineffective. Residents will be fully evaluated for restraint elimination and/or reduction at the time of each recovery team review (monthly, bi-monthly, 6 months and annual)." Under the section for Requirements the policy stated, "Prior to using medical restraint, less restrictive measures than restraint, such as pillows, pads, and removable lap trays coupled with appropriate exercise will have been tried and documented. Under the section for Recovery Team Responsibility, the policy stated, "The recovery team shall review the need for medical restraints as part of their total management of the resident. This is done during scheduled team meetings (monthly, bi-monthly, 6 months and annual cycle). The team will assure that adequate positioning interventions and other specific individual interventions are included in the Recovery Plan. Reduction plans as well as regular attempts/evaluations without restraint will be incorporated into the plan. Plans to reduce restraints shall include specific instruction and time frames for reduction. Under the section for the 180 day review the policy stated, "Each resident placed in extended medical restraints must be reviewed by the medical physician and Recovery Team at least every 180 days." "The review will document the rationale for the extended medical restraint. Efforts to reduce the level of restriction of the restraint and efforts to discontinue the restraint should be discussed and documented. The documentation of the review shall be done on Florida State Hospital Form 29 (Consultation Referral Report).

Based on observation, resident interview, staff interview and record review, the hospital failed to ensure that the accident prevention measures of medical restraints were the least restrictive interventions for injury prevention for 2 of 2 sampled residents, #45 and #48.

The findings:

Resident #45

Observations were conducted of resident #45 on 3/17/14 (all times are approximate) at 12:40pm, 1:00pm, 2:00pm, and 3:10pm. On 3/18/14 at 9:10am, 11:15am, 12:10pm and 2:00pm. During all observations, Resident #45 was observed in a wheelchair and wearing a Posey vest restraint. Resident #45 had a previous above the knee amputation of the right leg.

On 3/18/14 at approximately 2:00pm, resident #45 was observed propelling herself down the hallway in her wheelchair. Resident #45 reached behind her and untied the Posey vest restraint. Resident #45 did not attempt to get up, she sat there with it untied.

On 3/17/14 at approximately 1:00pm, an interview was conducted with resident #45. Resident #45 was able to discuss her rehabilitation and therapy classes, and describe some of her goals. She loves to paint and finds it very calming.

On 3/19/14 at approximately 1:54pm, an interview was conducted with the Team Nurse, Nurse A. Nurse A stated that back in February 2013, resident #45 stood up to be weighed and suffered a compound fracture of both bones in her leg. After that, she was ordered for no weight bearing, mechanical lift only. In June 2013 she started getting up on her own again. That is when the restraint -Posey vest- was ordered. She wears a Posey vest both when up in the wheelchair and in bed at night. She unties the restraint on a regular basis, but does not get up after she does this. Staff retie the restraint multiple times each day. She usually does not attempt to stand, she just unties it. She is aware that she only has one leg, and will not attempt to walk. We used to put the wheelchair on the other side of the room so that she could not reach it, but she would just get another resident to bring it to her. Her bedroom is monitored by staff during the night - constant visual observation. We have to unplug her bed now. Resident #45 will lower the side rails, raise the bed up and slide out and get to her wheelchair. This was all discussed during the team meeting. The responsible party sent an email asking that we take whatever means possible to keep her from standing. We have not tried a restraint reduction - because she keeps untying the Posey vest and getting out.

A record review was conducted for Resident #45. The interventions of moving the wheelchair out of reach and unplugging the bed were not documented in the progress notes, team notes or nurses notes. There was no documentation of any less restrictive interventions prior to using the restraint.

On 7/24/13 at 10:45am the recovery team documented on the Progress and Event Notes. The team met with resident #45 to discuss incidents of her getting up out of bed unassisted. The team asked resident #45 about the consequences and resident #45 stated, "my leg could break again."

The physician orders were reviewed. On 8/6/13 a physician ordered a Posey vest restraint when out of bed in wheelchair, and a Posey vest restraint with side rails up when in bed. The rationale was "increased risk of injury." This order has been renewed monthly since written (for 7 months).

The restraint review forms (Consultation Referral/Report - Form 29) were reviewed.
On 8/7/13, the recovery team documented the restraint evaluation as follows: Posey vest with wheelchair out of bed. Posey vest with side rails up in bed. Order written 8/6/13 due to resident continuing to stand on leg without assistance. Recovery team reviewed and is in agreement with order as written. On 2/19/14 the form documented, "recovery team met and agreed to continue medical restraints as ordered". No individualized resident assessment was found. There was no documentation that the team discussed safety interventions other than restraint that could be taken to reduce the risk injury. There was no documentation that indicated the team considered alternative assistive devices (such as a removable seat belt) or an exercise program.


Resident #48

A record review was conducted for resident #48. Resident #48 was admitted in the summer of 2013. At the time of admission, resident #48 was ambulatory. Nursing notes and physician orders revealed that resident #48 began having accidents in November 2013 and restraints were ordered beginning in December:

11/22/13 resident #48 fell in the hallway by the men's bathroom, wheelchair observed on its side. Wheelchair not locking on right side.
12/9/13 12:58 on floor in dayroom. Abrasion to elbow.
12/13/13 5:33am Fell to ground hitting head in hallway while pushing wheelchair.
12/30/13 10:45 Resident was noted to attempt to get out of chair by the med room. When in process of standing upright, observed him fall frontwards.
12/30/13 11:00am: Physician order: Posey vest with wheelchair due to frequent falls from wheelchair. (no interventions prior to the Posey vest were documented)
1/2/14 11:43 staff doing a hall check, resident had taken off his restraint, running with his head bleeding. Laceration to right eyebrow and abrasion right knee. Order for Posey Vest and Mini Pelvic Restraint with wheelchair due to history of frequent fall from wheelchair.
01/02/14 2:22pm: Physician order: Posey vest with siderails up in bed until reviewed by treatment team. Fall risk.
1/7/14 22:10 Notified by Direct Care Staff that resident #48 was lying on the floor beside his bed. Posey vest restraint was tied to the bed and the side rails were up.
01/08/14 2:25pm: Physician order: Geri-chair / wheelchair (GC/WC) with Mini-pelvic Restraint and Posey vest when out of bed. Posey vest with side rails up when in bed. Rationale - Fall Risk, Risk of Injury.
01/23/14: Physician order: to medical unit, diagnosis Urinary Tract Infection rule out sepsis
02/17/14 1:45pm: Physician order: (Continue) Mini-pelvic Restraint and Posey vest with Geri-chair / wheelchair when out of bed. Posey vest with siderails up when in bed. Add this order to the monthly treatment orders. Rationale increased risk of injury.
03/08/14 8:50: Resident #48 was diagnosed with a second UTI.

A record review for rationale, alternatives and reduction of medical restraints was conducted. No documentation was found describing the less restrictive measures that were tried or considered. The rationale for restraints was documented as fall prevention. The rationale did not discuss the concurrent UTIs or any medication side effects or changes that could attribute to the decline in balance. There was no documentation that indicated the team considered assistive devices or a walking program that would improve the resident's ability to self ambulate.

Observations were conducted for resident #48 on 3/17/14 at (all times are approximate) 12:40pm, 2:00pm, and 3:10pm. On 3/18/14 observations were conducted at 9:10am, 11:15am, 12:10pm, 12:25pm, 2:00pm and 3:10pm. In all of these times, resident #48 was observed in a Geri-chair with both a Posey vest restraint and a mini-pelvic restraint in place.

On 3/18/14 at approximately 3:10pm, an interview was conducted with resident #48. Resident #48 stated that he finds the Geri-chair comfortable, but does not like the restraints.

On 3/19/14 at approximately 11:10am, an interview was conducted with the Team Nurse (Nurse A). Nurse A stated that resident #48 was unhappy about not being allowed to get up and walk. He used to walk around on the unit while holding onto a wheelchair. His gait started to become unsteady and he had some falls in November and December 2013. That was when the restraints were ordered. Resident #48 goes to Physical Therapy twice a week. Nurse A was asked about documentation related to medical restraints. Nurse A stated that the recovery team does a 180 day review which was filed under the consult section. The nurses do a restraint assessment at the end of each month which is documented in nursing progress notes. The nurses also check the restraints a minimum of twice each shift - when they arrive and 4 hours later. The physician re-orders medical restraints monthly.

On 3/18/14 at 10:26am, an interview was conducted with the psychiatric Advanced Registered Nurse Practitioner (ARNP) The ARNP stated that resident #48 was ambulatory, but became very unsteady on his feet. He would walk behind a wheelchair and we would find him on the ground still holding on to the wheelchair as it got away from him. He goes to Physical Therapy which he loves. Resident #48 had discharge plans for a nursing home, but he got a UTI (urinary tract infection) and had increased behaviors, so the nursing home declined.

Neurology clinic note 2/21/14 - resident #48 is able to walk with mild assistance.

The restraint review form (Consultation Referral/Report (Form 29) from 2/19/14 was reviewed. Under the reason for referral the form stated, "Evaluation / Recommendations on continuing current medical restraints due to increased risk of injury." The report stated, "Recovery team met and agreed to continue medical restraints as ordered." There was no information about how the team arrived at this conclusion, whether alternative measures were attempted or whether attempts at restraint reductions were made.

Recovery team notes:
On 12/30/13 at 11:21 the recovery team documented on the Progress and Event notes that they met to review resident #48's Freedom of Movement (FOM) status due to his medical order for a Posey vest due to recent fall / risk of injury. The team agreed to place resident on escorted status. The team will review FOM at the resident's next 30 day meeting review. There was no discussion on this note about the order for the medical restraint.

On 1/24/14 the team documented on the Recovery Plan Meeting Minutes that resident #48 was escorted into the team room by staff due to him being in a Geri-chair with restraints to prevent falls. The team noted that resident #48 currently has a medical order for Geri-chair with Posey vest and Mini-pelvic restraint while of of bed to prevent falls. Rehab staff reported that the residents attendance of classes "has been significantly affected by his confinement to the wheelchair and Posey vest." There was no documented discussion about alternatives to restraints.

On 2/19/14 the recovery team documented on the Recovery Plan Meeting Minutes that they met with resident #48. Resident #48 stated, "that he was feeling much better. He laughed and told his Psych ARNP that her hair looks terrible." The team noted, "he currently has a medical order for Geri-chair with Posey vest and mini-pelvic restraint while or of bed to prevent fall. Medical staff discussed the option of resident using a wheelchair instead of the Geri-chair ." There was no other documented discussion about alternatives to restraints.

On 3/18/14 at approximately 3:00pm, an interview was conducted with the Executive Nurse Director (Staff E). Staff E reviewed the medical record documentation related to restraints. Staff E stated that the team had done the progression. Resident #48 had no restraints and was ambulatory. Then on 12/30/13, the physician ordered a Posey vest while in wheelchair. On 1/2/14, the physician ordered a Posey vest and side rails up when in bed. On 1/8/14, when resident #48 continued to have issues, the physician ordered an additional restraint - the Mini-pelvic restraint (MPR). (Resident #48 was documented as removing the Posey). You can see the progression up. Every 180 days the recovery team looks at the restraints to see if the resident's condition might have improved so we can take some of that off. This is documented on a Form 29. There has been no restraint reduction since January 2014. We assess the restraints every 6 months.

Operating Procedure #150-14, dated October 10, 2013, "Medical Restraints and Safety Devices" was reviewed. Under the section for Philosophy the policy stated, "medical restraints of residents are methods of last resort and shell not be used unless lesser restrictive methods of intervention have been attempted and determined to be ineffective." Under the section for Requirements the policy stated, "Prior to using medical restraint, less restrictive measures than restraint, such as pillows, pads, and removable lap trays coupled with appropriate exercise will have been tried and documented".

Based on observation, resident interview, staff interview and record review, the hospital failed to document active treatment received and assessed related to the usage of medical restraints. The treatment plans did not address the need for regular exercise and activities to lessen deterioration due to the usage of protective medical devices. The hospital failed to document evidence that attempts were made systematically to treat the resident in the least restrictive manner. The hospital failed to provide evidence that alternatives were considered prior to implementing medical restraints, and failed to document attempts at restraint reduction for 2 of 2 sampled residents ordered medical restraints (#45 and #48).

The findings:

Observations were conducted for resident #48 on 3/17/14 at (all times are approximate) 12:40pm, 2:00pm, and 3:10pm. On 3/18/14 observations were conducted at 9:10am, 11:15am, 12:10pm, 12:25pm, 2:00pm and 3:10pm. In all of these times, resident #48 was observed in a Geri-chair with both a Posey vest restraint and a mini-pelvic restraint in place. Resident #48 was not observed out of the Geri-chair. Staff were not observed to assist him with walking, exercises or doing range of motion. On 3/18/14 at approximately 12:25pm, staff were observed to assist Resident #48 into the dining hall from the day room. Resident #48 was seated in the Geri-chair wearing both the Posey vest and the mini-pelvic restraint. Staff pushed the Geri-chair into the dining hall.

A record review was conducted for Resident #48. The treatment plan was reviewed. Resident #48 had physical therapy ordered twice a week to assist with walking. No other exercise program was found.

On 3/21/14 at approximately 9:55am, an interview was conducted with Nurse F. Nurse F was asked about exercise programs for the medically restrained residents. Nurse F stated that physical therapy comes about twice a week on scheduled days. The residents are assisted downstairs to therapy. There was no formal walking or exercise programs on the unit that she was aware of.

On 3/21/14 at approximately 10:05am, an interview was conducted with Direct Care Staff G. Staff G was asked about exercise for the restrained residents. Staff G stated that physical therapy comes once or twice a week. Staff G was asked about exercise between therapy sessions that the unit provides. Staff G stated that there were no planned exercise programs on the unit. Nothing like a "walk to dine" program. We do sometimes help them to walk on the unit, but no planned walking programs or range of motion programs.

On 3/21/14 at approximately 9:10am, an interview was conducted with the Physical Therapy Assistant (PTA, Staff D). PTA D stated that physical therapy is done on the unit. Resident #48 was not doing so well with therapy - he often refused. His gait was unsteady - about 50% unsteady - he scissored when he walked. We walk with him with a Merry Walker and he does strengthening exercises. he does pretty well. The Merry Walker has not been recommended for use on the unit, I am not sure why not. We also walk him with a gait belt. He walks about 200 feet. I don't know if they have a walking program on the ward. I would recommend that the floor did have a walking program. Staff could be walking residents to the bathroom and/or dining room. A range of motion (ROM) program would also be helpful. There are only 3 therapists to take care of the whole hospital. We have limits on what we can do. We can and do provide training to direct care staff.

On 3/18/14 at approximately 3:10pm, an interview was conducted with resident #48. Resident #48 stated that he finds the Geri-chair comfortable, but does not like the restraints.

On 3/19/14 at approximately 11:10am, an interview was conducted with the Team Nurse (Nurse A). Nurse A stated that resident #48 was unhappy about not being allowed to get up and walk. He used to walk around on the unit while holding onto a wheelchair. His gait started to become unsteady and he had some falls in November and December 2013. That was when the restraints were ordered. He prefers the the Geri-chair over the wheelchair, he stated it is more comfortable. Resident #48 goes to Physical Therapy twice a week. Nurse A was asked about documentation related to medical restraints. Nurse A stated that the recovery team does a 180 day review which is filed under the consult section. The nurses do a restraint assessment at the end of each month - this is documented in nursing progress notes. The nurses also check the restraints a minimum of twice each shift - when they arrive and 4 hours later. The physician re-orders medical restraints monthly.

On 3/18/14 at approximately 10:26am, an interview was conducted with the psychiatric Advanced Registered Nurse Practitioner (ARNP). The ARNP stated that resident #48 was ambulatory, but became very unsteady on his feet. He would walk behind a wheelchair and we would find him on the ground still holding on to the wheelchair as it got away from him. He goes to Physical Therapy which he loves. Resident #48 had discharge plans for a nursing home, but he got a UTI (urinary tract infection) and had increased behaviors, so the nursing home declined.

A record review was conducted for resident #48.

A Neurology clinic note dated 2/21/14 stated that resident #48 was able to walk with mild assistance.

The physician orders were reviewed. On 12/30/13 at 11:00am the physician ordered a Posey vest with wheelchair due to frequent falls from wheelchair. On 01/02/14 at 2:22pm the physician ordered a nighttime restraint: Posey vest with siderails up in bed until reviewed by the treatment team. Rational of Fall risk. This order was renewed on 2/17/14. On 01/08/14 at 2:25pm the physician ordered a second restraint: Geri-chair / wheelchair (GC/WC) with Mini-pelvic Restraint and Posey vest when out of bed. Posey vest with side rails up when in bed. Rationale - Fall Risk, Risk of Injury. This order was renewed on 2/17/14. No orders were found prior to this indicating other interventions had been attempted prior to ordering the restraints.

The Recovery team notes were reviewed as documented in the Progress notes, the Recovery Plan Meeting Minutes and on the Consultation Referral/Report (details of notes to follow). No individualized resident assessment was found. There was no documentation that the team discussed safety interventions other than restraint that could be taken to reduce the risk of resident #48 falling. There was no documentation that the team considered any medical changes (urinary tract infects, Bell's Palsy) or medication changes that could attribute to the decline in balance. There was no documentation that indicated the team considered assistive devices or a walking program that will improve the resident's ability to self ambulate. There was no plan for regular walking with a staff person (except for therapy twice a week).

On 12/30/13 at 11:21am the recovery team documented on the Progress and Event notes that they met to review resident #48's Freedom of Movement (FOM) status due to his medical order for a Posey vest due to recent fall / risk of injury. The team agreed to place the resident on escorted status. The team will review FOM at the resident's next 30 day meeting review. There was no discussion on this note about the order for the medical restraint.

On 1/24/14 the team documented on the Recovery Plan Meeting Minutes that resident #48 was escorted into the team room by staff due to him being in a Geri-chair with restraints to prevent falls. The team noted that resident #48 currently has a medical order for Geri-chair with Posey vest and Mini-pelvic restraint while of of bed to prevent falls. Rehab staff reported that the residents attendance of classes "has been significantly affected by his confinement to the wheelchair and Posey vest." There was no documented discussion about potential reversible causes of the falls, alternatives to restraints or attempts at reduction.

On 2/19/14 the recovery team documented on the Recovery Plan Meeting Minutes that they met with resident #48. Resident #48 stated, "that he was feeling much better. He laughed and told his Psych ARNP that her hair looks terrible." The team noted, "he currently has a medical order for Geri-chair with Posey vest and mini-pelvic restraint while or of bed to prevent fall. Medical staff discussed the option of resident using a wheelchair instead of the Geri-chair ." There was no other documented discussion about potential reversible causes of the falls, alternatives to restraints or attempts at reduction.

The restraint review form (Consultation Referral/Report (Form 29) from 2/19/14 was reviewed. Under the reason for referral the form stated, "Evaluation / Recommendations on continuing current medical restraints due to increased risk of injury." The report stated, "Recovery team met and agreed to continue medical restraints as ordered." There was no information about how the team arrived at this conclusion, whether alternative measures were attempted or whether attempts at restraint reductions were made.

On 3/18/14 at approximately 3:00pm, an interview was conducted with the Executive Nurse Director (Staff E). Staff E reviewed the medical record documentation related to restraints. Staff E stated that the team had done the progression. Resident #48 had no restraints and was ambulatory. Then on 12/30/13, the physician ordered a Posey vest while in wheelchair. On 1/2/14, the physician ordered a Posey vest and side rails up when in bed. On 1/8/14, when resident #48 continued to have issues, the physician ordered an additional restraint - the Mini-pelvic restraint (MPR). (Resident #48 was documented as removing the Posey). You can see the progression up. Every 180 days the recovery team looks at the restraints to see if the resident's condition might have improved so we can take some of that off. This is documented on a Form 29. There has been no restraint reduction since January 2014. We assess the restraints every 6 months.


Resident #45

Observations were conducted of resident #45 on 3/17/14 (all times are approximate) at 12:40pm, 1:00pm, 2:00pm, and 3:10pm. On 3/18/14 at 9:10am, 11:15am, 12:10pm and 2:00pm. During all observations, Resident #45 was observed in a wheelchair and wearing a Posey vest restraint. Resident #45 had a previous above the knee amputation of the right leg.

On 3/17/14 at approximately 1:00pm, an interview was conducted with resident #45. Resident #45 was able to discuss her rehab and therapy classes, and describe some of her goals. She loves to paint and finds it very calming.

On 3/18/14 at approximately 9:10am, a follow-up interview was conducted with resident #45. She related her plans for the day. She was going to the gift shop and the carnival and playing Bingo this afternoon.

On 3/18/14 at approximately 2:00pm, resident #45 was observed propelling herself down the hallway in her wheelchair. Resident #45 reached behind her and untied the Posey vest restraint. Resident #45 did not attempt to get up, she sat there with it untied.

On 3/19/14 at approximately 1:54pm, an interview was conducted with the Team Nurse, Nurse A. Nurse A stated that back in February 2013, resident #45 stood up to be weighed and suffered a compound fracture of both bones in her leg. After that, she was ordered for no weight bearing, mechanical lift only. In June 2013 she started getting up on her own again. That is when the restraint -Posey vest- was ordered. She wears a Posey vest both when up in the wheelchair and in bed at night. She unties the restraint on a regular basis, but does not get up after she does this. Staff retie the restraint multiple times each day. She usually does not attempt to stand, she just unties it. She is aware that she only has one leg, and will not attempt to walk. We used to put the wheelchair on the other side of the room so that she could not reach it, but she would just get another resident to bring it to her. Her bedroom is monitored by staff during the night - constant visual observation. We have to unplug her bed now. Resident #45 will lower the side rails, raise the bed up and slide out and get to her wheelchair. This was all discussed during the team meeting. The responsible party sent an email asking that we take whatever means possible to keep her from standing. We have not tried a restraint reduction - because she keeps untying the Posey vest and getting out.

A record review was conducted for Resident #45. The physician orders were reviewed. On 8/6/13 a physician ordered a Posey vest restraint when out of bed in wheelchair, and a Posey vest restraint with side rails up when in bed. The rationale was "increased risk of injury." This order has been renewed monthly since written.

The restraint review forms (Consultation Referral/Report - Form 29) were reviewed.
On 8/7/13, the recovery team documented the restraint evaluation as follows: Posey vest with wheelchair out of bed. Posey vest with side rails up in bed. Order written 8/6/13 due to resident continuing to stand on leg without assistance. Recovery team reviewed and is in agreement with order as written. On 2/19/14 the form documented, "recovery team met and agreed to continue medical restraints as ordered". There was no other documented discussion about alternatives to restraints or attempts at reduction. There was no documentation about the alternatives and assessments mentioned by Nurse A. The team did not document about keeping the wheelchair out of reach or unplugging the bed. There was no documentation that other interventions (like a removable seat belt for example) were discussed.

On 7/24/13 at 10:45am the recovery team documented on the Progress and Event Notes. The team met with resident #45 to discuss incidents of her getting up out of bed unassisted. The team asked resident #45 about the consequences and resident #45 stated, "my leg could break again."

Operating Procedure #150-14, dated October 10, 2013, "Medical Restraints and Safety Devices" was reviewed. Under the section for Philosophy the policy stated, "medical restraints of residents are methods of last resort and shall not be used unless lesser restrictive methods of intervention have been attempted and determined to be ineffective. Residents will be fully evaluated for restraint elimination and/or reduction at the time of each recovery team review (monthly, bi-monthly, 6 months and annual)." Under the section for Requirements the policy stated, "Prior to using medical restraint, less restrictive measures than restraint, such as pillows, pads, and removable lap trays coupled with appropriate exercise will have been tried and documented. Under the section for Recovery Team Responsibility, the policy stated, "The recovery team shall review the need for medical restraints as part of their total management of the resident. This is done during scheduled team meetings (monthly, bi-monthly, 6 months and annual cycle). The team will assure that adequate positioning interventions and other specific individual interventions are included in the Recovery Plan. Reduction plans as well as regular attempts/evaluations without restraint will be incorporated into the plan. Plans to reduce restraints shall include specific instruction and time frames for reduction. Under the section for the 180 day review the policy stated, "Each resident placed in extended medical restraints must be reviewed by the medical physician and Recovery Team at least every 180 days." "The review will document the rationale for the extended medical restraint. Efforts to reduce the level of restriction of the restraint and efforts to discontinue the restraint should be discussed and documented. The documentation of the review shall be done on Florida State Hospital Form 29 (Consultation Referral Report).