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Based upon staff interview and record review the facility failed to attempt alternatives or less restrictive interventions prior to the use of restraints for 1 of 5 patients [Patient #1] of the sample group.
Findings include:
1. Per interview with the hospital ' s Executive Director of Quality and Care Management [EDQCM] on 9/3/13 at 10:43 A.M. and per record review, the hospital ' s Behavior Restraint Protocol includes attempting and documenting what alternatives were tried prior to the use of restraints, and why the alternatives failed. Per record review of Progress Notes and Behavioral Management Observation Records restraints were applied to Patient #1 on 6/14/13 at 9:20 P.M. and on 6/20/13 at 7:50 A.M.
The EDQCM confirmed there was no documentation that the Behavior Restraint Protocol was used, or that alternatives were attempted prior to restraining Patient #1 on both dates.

Based upon record review the facility failed to assure restraints were used in accordance with a written modification to the patient's plan of care for 1 of 5 patients [Patient #1] in the sample group.
Findings include:
1.) Per record review the facility ' s Restraint/Seclusion policy includes " Care Plan: the restraint/or secluded patient ' s written plan of care shall be modified to address appropriate interventions implemented to assure patient safety and encourage the least restrictive form of restraint as well as the prompt discontinuation of its use. "
Per record review of Progress Notes and Behavioral Management Observation Records restraints were applied to Patient #1 on 6/12/13 at 10:00 A.M., 6/13/13 at 3:30 P.M., 6/14/13 at 9:20 P.M. and on 6/20/13 at 7:50 A.M.
Per record review Patient #1 ' s Care Plan includes a section titled " Restraint " . Under the subheading ' Plan ' are options for ' behavioral restraints protocol ' and ' exhibiting behaviors of violence or potential for self-harm ' with goals including " discontinuation of restraint at earliest opportunity " and " patient treatment successfully administered " . Per record review Patient #1 ' s Care Plan under " Restraint " , " Plan " ,and " Goals " is blank; without notes, dates, or options checked.

Based upon staff interview and record review the facility failed to ensure restraints were used in accordance with the order of a physician or other licensed independent practitioner for 1 of 5 patients [Patient #1] in the sample group.
Findings include:
1.) Per record review Patient #1 ' s medical record contains a Physician ' s Order for Restraints with a 4 hour time limit signed for " 6/13/13, 3:30 P.M. " . There is a re- order for continuation of the restraints after the initial 4 hours signed on 6/13/13 at 8:00 P.M., and the restraints were discontinued at 8:47 P.M. on 6/13/13.
On the restraint order for 6/13/13, after the continuation, there is note dated 6/14/13 at 8:30 P.M. marked as a physician ' s voice order for a re-order of the restraints begun and ended on 6/13/13.
Per interview with the hospital ' s Executive Director of Quality and Care Management [EDQCM] on 9/3/13 at 10:43 A.M. and per record review, the hospital ' s policy and procedure for the use of restraints includes an order by a Licensed Independent Practitioner [LIP] is required for every separate instance a restraint is used. The EDQCM confirmed that the restraint use on 6/14/13 was separate and not a continuation from 6/13/13 and a separate order was required for their use but was not done.
2.) Per record review of Patient #1 ' s Behavioral Management Observation Record restraints were applied to Patient #1 on 6/20/13 at 7:50 A.M. " by sheriff ' s personnel " .
Per interview on 9/3/13 at 10:43 A.M. the hospital ' s Executive Director of Quality and Care Management [EDQCM] stated that the application of restraints by sheriff ' s personnel at 7:50 A.M. on 6/20/13 could indicate that Patient #1 was attempting to elope, and would therefore not require a physician ' s order.
Per record review of Nursing Progress Notes for 6/20/13 at 8:54 A.M. Patient #1 was yelling and using " threatening language " towards the nursing staff. Patient #1 was also cooperating with nursing by self-administering a dose of insulin, and had " calmed down after Jim from Sheriff ' s office arrived shortly after 8:00 A.M. "
The EDQCM confirmed there was no documentation that Patient #1 was attempting to elope,
and reported there is no written policy regarding the Sheriff ' s personnel and when a restraint order is or is not needed.
The EDQCM confirmed that the hospital ' s policy and procedure for the use of restraints includes an order by a Licensed Independent Practitioner [LIP] is required for every separate instance a restraint is used, and there was no order for the use of restraints on Patient #1 on 6/20/13.

Based upon staff interview and record review the facility failed to ensure a face to face assessment was conducted by a licensed independent practitioner within one hour of the initiation of restraint for 1 of 5 patients [Patient #1] in the sample group.
Findings include:
Per interview with the hospital ' s Executive Director of Quality and Care Management [EDQCM] on 9/3/13 at 10:43 A.M. and per record review, the hospital ' s policy and procedure for the use of restraints includes a face to face assessment of the restrained patient is to be conducted within one hour of the initiation of restraint by a licensed independent practitioner [LIP].
Per record review of Progress Notes and Behavioral Management Observation Records restraints were applied to Patient #1 on 6/14/13 at 9:20 P.M. and on 6/20/13 at 7:50 A.M.
Per record review of Physician Progress Notes for Patient #1, and confirmed by the EDQCM, there is no documentation a face to face assessment of Patient #1 was conducted within one hour of the initiation of restraint by a licensed independent practitioner on either 6/14/13 or 6/20/13.

Based upon staff interview and record review the facility failed to ensure a face to face assessment was conducted by a licensed independent practitioner within one hour of the initiation of restraint and documented in the medical record for 1 of 5 patients [Patient #1] in the sample group.
Findings include:
Per interview with the hospital ' s Executive Director of Quality and Care Management [EDQCM] on 9/3/13 at 10:43 A.M. and per record review, the hospital ' s policy and procedure for the use of restraints includes a face to face assessment of the restrained patient is to be conducted within one hour of the initiation of restraint by a licensed independent practitioner [LIP].
Per record review of Progress Notes and Behavioral Management Observation Records restraints were applied to Patient #1 on 6/14/13 at 9:20 P.M. and on 6/20/13 at 7:50 A.M.
Per record review of Physician Progress Notes for Patient #1, and confirmed by the EDQCM, there is no documentation a face to face assessment of Patient #1 was conducted by a licensed independent practitioner within one hour of the initiation of restraint on either 6/14/13 or 6/20/13.

Based upon staff interview and record review the facility failed to document any alternatives or less restrictive interventions attempted prior to the use of restraints for 1 of 5 patients [Patient #1] of the sample group.
Findings include:
1. Per interview with the hospital ' s Executive Director of Quality and Care Management [EDQCM] on 9/3/13 at 10:43 A.M. and per record review, the hospital ' s Behavior Restraint Protocol includes attempting and documenting what alternatives were tried prior to the use of restraints, and why the alternatives failed. Per record review of Progress Notes and Behavioral Management Observation Records restraints were applied to Patient #1 on 6/14/13 at 9:20 P.M. and on 6/20/13 at 7:50 A.M.
The EDQCM confirmed there was no documentation that the Behavior Restraint Protocol was used, and that alternatives were attempted prior to restraining Patient #1 on both dates.