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Based on record review, review of policy and procedures, and staff interview it was determined the facility failed to ensure the least restrictive interventions were ineffective prior to the use of restraints for two (#1, #8) of eight records sampled. This practice does not ensure patients are free from unnecessary restraints,

Findings include:

Review of the facility's policy, "Restraints; Violent and Non-Violent", last revised 3/2011, stated alternative interventions will be documented in the patient's medical record.

1. Review of patient #1's medical record revealed the patient was intubated on 3/09/11 at 12:25 a.m. Review of the nursing documentation revealed bilateral wrist restraints were placed on the patient on 3/09/11 at 5:51 a.m. Review of the medical restraint physician's order and assessment form dated 3/09/11, 3/10/11, and 3/11/11 revealed no alternative interventions were attempted prior to applying bilateral wrist restraints.

Interview on 4/20/11 at 1:00 p.m. with the risk manager confirmed there was no documentation alternative interventions were attempted.

2. Review of patient #8's medical record revealed the patient was intubated on 4/19/11. Review of the nursing documentation revealed bilateral wrist restraints were applied on 4/19/11 at 3:00 p.m. Review of the medical restraint physician's order and assessment form dated 4/19/11 and 4/20/11 revealed no alternative interventions were attempted prior to applying bilateral wrist restraints.

Interview on 4/20/11 at 11:05 a.m. with the registered nurse in charge of the patient's care confirmed there was no documentation alternative interventions were attempted.

Based on record review, review of policy and procedures, and staff interview it was determined the facility failed to ensure staff modified the patient's plan of care when the use of restraints were utilized for two (#1, #8) of eight records reviewed. This does not ensure the patient's plan of care is modified to provide quality of care with a change in the patient's condition.

Findings include:

Review of the facility's policy, "Restraints; Violent and Non-Violent", last revised 3/2011, stated the patient's written plan of care, as described on the written order form and problem list, is modified to indicate the type of restraint, the reason for the restraint, individual who initiated the restraint, the alternative interventions attempted and the criteria for release. The plan of care will be updated on an ongoing basis while the patient is in restraints.


1. Review of patient #1's medical record revealed the patient was intubated on 3/09/11 12:25 a.m. Review of the nursing documentation revealed bilateral wrist restraints were placed on the patient on 3/09/11 at 5:51 a.m. Review of the patient's plan of care for 3/09/11, 3/10/11, and 3/11/11 revealed no change in the patient's plan of care identifying the use of restraints.

Interview on 4/20/11 at 1:00 p.m. with the risk manager confirmed the patient's plan of care was not updated to reflect a change in the condition.

2. Review of patient #8's medical record revealed the patient was intubated on 4/19/11. Review of the nursing documentation revealed bilateral wrist restraints were applied on 4/19/11 at 3:00 p.m. Review of the patient's plan of care for 4/19/11 and 4/20/11 revealed no change in the patient's plan of care identifying the use of restraints.

Interview on 4/20/11 at 11:05 a.m. with the registered nurse in charge of the patient's care confirmed the patient's plan of care was not updated to reflect a change in the patient's condition.

Based on record review, review of policy and procedures, and staff interview it was determined the facility failed to ensure staff monitored the condition of patients who were restrained, according to facility policy, for two (#1, #8) of eight records sampled. This does not ensure prevention of patient injury, as well as ensuring the use of the restraint was discontinued at the earliest possible time.

Findings include:

Review of the policy, "Restraints; Violent and Non-Violent", last revised 3/2011, stated non-violent behavior: physicians or other trained staff will assess the patient in restraints at least every 2 hours and assessments will be documented.

1. Review of patient #1's medical record revealed the patient was intubated on 3/09/11 12:25 a.m. Review of the nursing documentation revealed bilateral wrist restraints were placed on the patient on 3/09/11 at 5:51 a.m. Review of the restraint monitoring performed by the RN (Registered Nurse) revealed on 3/11/11 at 6:00 a.m. the patient was assessed. Review of the restraint monitoring revealed on 3/11/11 at 10:00 a.m. the patient was assessed. No further documentation of restraint monitoring was conducted after 10:00 a.m. on 3/11/11. Review of the documentation revealed no evidence of patient assessment from 6:00 a.m. to 10:00 a.m. on 3/11/11. Review of the nursing documentation revealed no evidence of when the bilateral wrist restraints were discontinued.

Interview with the risk manager on 4/20/11 at 12:50 p.m. confirmed there was no documentation of restraint monitoring from 6:00 a.m. to 10:00 a.m. on 3/11/11 and no documentation of when the bilateral wrist restraints were discontinued.

2. Review of patient #8's medical record revealed the patient was intubated on 4/19/11. Review of the nursing documentation revealed bilateral wrist restraints were applied on 4/19/11 at 3:00 p.m. Review of the nursing documentation revealed restraint monitoring was performed on 4/19/11 at 8:00 p.m. Review of the documentation revealed no evidence the patient was monitored from 3:00 p.m. to 8:00 p.m. on 4/19/11.

Interview on 4/20/11 at 11:05 a.m. with the registered nurse in charge of the patient's care confirmed there was no documentation the patient was assessed for restraint monitoring from 3:00 p.m. until 8:00 p.m. on 4/19/11.

Based on staff interview, review of medical records, and review of policy and procedures it was determined the facility failed to comply with the death reporting requirements for one (#1) of eight patients sampled.

Findings include:

Review of the medical record for patient #1 revealed the patient expired on 3/12/11 at 6:18 a.m. Review of the record of death revealed the patient was restrained within 24 hours of death.

Review of the facility's policy, "Restraints; Violent and Non-Violent", last revised 3/2011, stated the hospital will report to Center for Medicare and Medicaid Services (CMS) every death that occurs in patients within 24 hours of being removed from restraint or seclusion and each death must be reported to CMS by telephone no later than the close of business the next business day following knowledge of the patient's death.

An interview with the risk manager on 4/20/11 at 1:00 p.m. confirmed CMS was not notified of the patient's death.

Based on record review, review of policy and procedures, and staff interview it was determined the registered nurse failed to supervise and evaluate the nursing care, according to facility policy for restraints for two (#1, #8) of eight records sampled. This does not ensure the patient's needs, condition, as well as the patient's response to interventions were monitored.

Findings include:

1. Patient #1 nursing documentation revealed bilateral wrist restraints were placed on 3/09/11 at 5:51 a.m. Documentation of the restraint monitoring, performed by the RN (Registered Nurse), revealed on 3/11/11 at 6:00 a.m. the patient was assessed. Review of the restraint monitoring revealed on 3/11/11 at 10:00 a.m. the patient was assessed. No further documentation of restraint monitoring was conducted after 10:00 a.m. on 3/11/11. Review of the documentation revealed no evidence of the patient being assessed from 6:00 a.m. to 10:00 a.m. on 3/11/11. Review of the nursing documentation revealed no evidence of when the bilateral wrist restraints were discontinued from the patient.

Interview with the risk manager on 4/20/11 at 12:50 p.m. confirmed there was no documentation of restraint monitoring from 6:00 a.m. to 10:00 a.m. on 3/11/11 and no documentation of when the bilateral wrist restraints were discontinued.

2. Patient #8's nursing documentation revealed bilateral wrist restraints were applied on 4/19/11 at 3:00 p.m. Review of the nursing documentation revealed restraint monitoring was performed on 4/19/11 at 8:00 p.m. Review of the documentation revealed no evidence the patient was monitored from 3:00 p.m. to 8:00 p.m. on 4/19/11.

Interview on 4/20/11 at 11:05 a.m. with the registered nurse in charge of the patient's care confirmed there was no documentation the patient was assessed for restraint monitoring from 3:00 p.m. until 8:00 p.m. on 4/19/11. The nurse stated he applied the wrist restraints on 4/19/11 at 3:00 p.m. but did not document the patient's needs were met, the patient's condition, or the patient's response to the intervention.

Review of the policy, "Restraints; Violent and Non-Violent", last revised 3/2011, stated assessment is the responsibility of the RN and occurs at least every 2 hours for the Non-Violent, Non-Self-Destructive Behavior patient.

Based on record review, review of policy and procedures, and staff interview it was determined the facility failed to ensure nursing staff developed and kept current a nursing care plan for three (#1, #7, #8) of eight records sampled. This does not ensure appropriate nursing interventions are initiated in response to the patient's needs.

Findings include:

Review of the facility's policy, "Plan for Provision of Patient Care Services", last revised 6/2009, stated each patient has a plan of care; an interdisciplinary approach is utilized; and patient care goals are the expected outcomes.

1. Review of patient #1's nursing documentation revealed bilateral wrist restraints were placed on 3/09/11 at 5:51 a.m. Review of the patient's plan of care for 3/09/11, 3/10/11, and 3/11/11 revealed no change in the patient's plan of care identifying the use of restraints. There was no documentation of the patient care goals or expected outcomes.

Interview on 4/20/11 at 1:00 p.m. with the risk manager confirmed the patient's plan of care was not updated to reflect the application of bilateral wrist restraints therefore signifying a change in the patient's condition.

2. Review of patient #8's nursing documentation revealed bilateral wrist restraints were applied on 4/19/11 at 3:00 p.m. Review of the patient's plan of care for 4/19/11 and 4/20/11 revealed no change in the patient's plan of care identifying the use of restraints.

Interview on 4/20/11 at 11:05 a.m. with the registered nurse in charge of the patient's care confirmed the patient's plan of care was not updated to reflect a change in the patient's condition. defined in the plan of care.

3. Review of patient #7's medical record revealed the patient was admitted on 4/15/11 with a history of end stage renal disease and peritoneal dialysis. Review of the patient's plan of care initiated on 4/15/11 revealed no evidence the peritoneal dialysis was identified as a problem. There were no interventions initiated or goals

Interview with the nurse in charge of the patient's care on 4/20/11 confirmed the above findings.