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Based on observation, interview, and record review, the facility failed to ensure least restrictive measures were utilized, for one of 20 sampled patients (Pt 2). This failure had the potential to result in unnecessary restricted movement for patient.

Findings:

On 9/19/17 at 12:50 p.m., during the initial tour of the facility with several administrative staff, Pt 2 was observed lying diagonally in the bed, and had a vest restraint. The patient appeared to be asleep.

A review of Pt 2's clinical record indicated the patient was admitted to the acute care hospital on 9/7/17, with diagnoses that included encephalopathy (disease, damage, or malfunction of the brain that is generally manifested by an altered mental state), urinary tract infection, and left mastoiditis (an infection of the mastoid, a bone that surrounds the inner and middle ear).

A review of Pt 2's flowsheet, dated 9/19/17, indicated the patient was confused, was incontinent of bladder, and required total staff assistance for meals, bathing, and repositioning.

A review of a Care Planning Progress Note by Registered nurse (RN) 1, dated 9/18/17 at 3:39 p.m., indicated the following:

"Pt very agitated and trying to get out of bed. Reorient as needed. Dr made aware... [vest] restraint applied..."

A care plan progress note by RN 2, dated 9/18/17 at 8:33 p.m., indicated Pt 2 was restless and trying to get out of bed. The patient was repositioned and Haldol (antipsychotic medication) intramuscular (IM) given as ordered.

There was no documented evidence that the facility attempted to obtain a sitter (someone who constantly stays at a patient's bedside, in order to prevent the patient from getting up), a less restrictive method, prior to obtaining an order for a restraint.

On 9/19/17 at 1:50 p.m., during an interview, RN 1 stated that the order for the vest restraint was obtained the day before because Pt 2 was very confused and agitated, and was trying to climb out of the bed. When questioned further, RN 1 stated the patient dangled her leg over the bed rail.

A review of a physician order, dated 9/19/17 at 3:40 p.m., indicated to discontinue vest restraint. Another order, dated 9/19/17 at 5 p.m., stipulated to provide a one on one sitter at bedside.

According to the facility's policy, titled, "Restraint Use", review date 12/14, restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective, or to protect the patient, a staff member, or others from harm...When an assessment indicates the need for restraint, the least restrictive device should be utilized...

Based on observation, interview, and record review, the facility failed to ensure proper care and treatment was provided in order to prevent potential skin breakdown, for two of 20 sampled patients (P2,3). Patient 2's back and buttocks were reddened and had crease marks from vest restraint ties and wrinkled bedsheets. The patient also had a Stage 2 pressure injury (partial thickness loss of dermis, or top skin layer presenting as a shallow open ulcer with a red pink wound bed) on her coccyx that was covered with a Duoderm dressing (a dressing that is used to treat bed sores) that was starting to peel off. Patient 3's back and buttocks were also reddened, and there were crease marks caused by the bed sheet. This deficient practice placed the patients at risk for further skin breakdown.

Findings:

1. On 9/19/17 at 1:50 p.m., during the initial tour with several executive staff members, Patient 2 was observed lying diagonally in the bed, and had a vest restraint. An observation of the patient's back and buttocks, conducted with Registered nurse (RN) 4 revealed large crease marks from the restraint ties and wrinkled bed sheets. RN 4 stated the staff should ensure sheets were free from wrinkles, and frequent skin checks performed, in order to prevent skin breakdown.

A review of Patient 2's electronic medical record indicated the patient was admitted to the acute care hospital on 9/17/17, with diagnoses that included encephelopathy (disease, damage, or malfunction of the brain manifested by an altered mental state) and urinary tract infection.

According to the 9/19/17 Flow Sheet, Patient 2 was alert with confusion, was incontinent of urine, and was dependent on staff for all daily living activities. The Braden Scale (a written tool that indicates a person's risk for acquiring a pressure ulcer) assessment was scored at "11" (a score of 10-12 indicates high risk).

A review of the facility's policy, titled, "Pressure Ulcer Prevention", and dated 3/16, stipulates to keep linen clean, dry, wrinkle free, and avoid multiple layers.


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2. During a tour of the facility on September 19, 2017 at 2:45 PM, Patient 3 was lying on her back in bed with bilateral foam boots. Under the patient, on top of the bed, was a folded bed sheet. The patient's hair appeared disheveled and greasy. The Director of Nursing Adult Services (DON) helped RN 3 turn the patient in her bed to see the condition of her skin on the sacral area; the DON had earlier stated that the patient had developed redness on her buttocks and was admitted with Deep Tissue Pressure Injuries (DTPI, pressure related injury to tissue under intact skin initially having the appearance of deep bruising) to both of her heels.

Upon inspection of the patient's heels, they were found to be free of injury with intact and pink skin. The patient's back and buttocks appeared moderately red and with crease marks, from the folded sheet, on both areas of her skin. The skin was otherwise intact.

At that time RN 3 acknowledged the appearance of Patient 3's skin; the DON stated that the staff should do a better job of using single layered materials as draw sheets to reposition patients in bed.

During a discussion with the attending physician for Patient 3 on September 20, 2017 at 10:30 AM he stated that the current plan for skin care for this patient is frequent repositioning to offload her from the buttocks.

Based on interview and record review, the facility failed to ensure a certified nursing assistant (CNA) did not leave a patient who was assessed as high risk for falls, unattended. Patient 1 attempted to stand by herself, and fell. This deficient practice compromised the patient's safety, and placed the patient at unnecessary risk for injury.

Findings:

On 9/18/17 at 10:30 a.m., during a telephone interview with Complainant 1, the complainant alleged that on 12/2/16, Patient 1 (P1), who was very weak, had fallen while being admitted to the Emergency Department. The complainant then stated that P1 was re-admitted to the Oncology Unit the following week. During that particular admission, a CNA assisted P1 to the bathroom, then left her alone, and the patient fell.

A review of Patient 1's clinical record indicated the patient presented to the Emergency Department on 12/2/16 for bowel blockage. The History and Physical (H&P) indicated the patient had a history of urethral (tube that connects the kidney to the bladder) cancer that had metastasized (spread from a primary site to a different or secondary site in the body), and recurrent bowel obstruction (a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion).

A review of the Nursing Assessment, dated 12/9/16, indicated Patient 1 had generalized weakness, and had a ureterostomy (the creation of a stoma- a new, artificial outlet- for a ureter or kidney- in order to divert the flow of urine away from the bladder when the bladder is not functioning or has been removed). The Schmid Fall Risk Assessment (an assessment of a person's risk for falls) score was "three", which indicated the patient was high risk).

A review of a Physician Progress Note dated 12/15/16 indicated called by one of the nurses to evaluate Patient 1 after a fall. According to the note, Patient 1 stated that she fell trying to maneuver off the seat after being helped onto the toilet by nursing staff. The patient struck her head, but denied loss of consciousness (LOC). Nursing staff aware to closely monitor patient.

On 9/20/17 at 3:15 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 1, who stated that she assisted Patient 1 to the bathroom and with sitting on the toilet seat, then briefly left the bathroom in order to obtain fresh linen. When she returned to the patient's room, she observed one of the nurses in the bathroom, and the patient was on the floor. When CNA 1 asked the patient why she got up by herself, the patient stated, "I don't know." CNA 1 then stated that she should not have left the patient alone because the patient was high risk for falls.