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Based on review of medical records, document reviews and staff interviews it was revealed the facility failed to ensure restraints were used in accordance with a physician's order (see tag 168) and failed to ensure restraints were discontinued at the earliest possible time (see tag 169).

Based on document review, staff interview and medical record review it was revealed the facility failed to ensure an appropriate physician's order for restraints was obtained and documented in the medical records. This failure was identified in four (4) of four (4) medical records reviewed (patients #12, 16, 17 and 18). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #12 revealed the nurse documented the patient climbed out of the bed to the chair on 12/17/20 at 10:02 a.m. Nursing documentation stated "generally comfortable, not combative, bath and am care while up." On 12/17/20 at 10:41 a.m. the nurse documented, "Back to bed wrist restraints continue.. vss. sats maintaine.. attempting to sleep. No order or reassessment was completed for the need for restraints for 12/17/20 at 10:41 a.m.

2. A review of the medical record for patient #16 revealed patient #16 was documented as wrist restraints applied on 1/4/21 at 5:40 p.m. An order for restraints was written for 1/4/21 at 6:40 p.m. No order or assessment for wrist restraints was documented at 5:40 p.m.

3. A review of the medical record for patient #17 revealed patient #17 was documented as in soft wrist restraints from 12/21/20 to 1/6/21. The orders stated in part:
The physician's order for 12/25/20 stated soft wrist restraint but did not specify right or left wrist.
The physician's order for restraints for 12/26/20 failed to have the type of restraints needed and failed to have the date and time of the physician's signature. The nurse dated and timed the physician's signature on the restraint order for 12/26/20.
The physician's order for restraints for 12/27/20 failed to have the date and time of the physician's signature. The nurse dated and timed the physician's signature for the restraint order for 12/27/20.
The physician's order for restraints for 12/30/20 failed to have the type of restraints needed on the order.
The physician's order for restraints for 12/31/20 failed to have the date and time of the physician's signature. The nurse dated and timed the physician's signature for the restraint order for 12/31/20.
The physician's order for restraints for 1/2/21 failed to have the time of the physician's signature. The nurse timed the physician's signature for the restraint order for 1/2/21.
The physician's order for restraints for 1/3/21 failed to have the time of the physician's signature. The nurse timed the physician's signature for the restraint order for 1/3/21.
The physician's order for restraints for 1/5/21 failed to have a correct physician's order. The physician's signature was located under verbal/telephone orders, not under the physician order section. The nurse timed and dated the physician's signature for the restraint order for 1/5/21.
The physician's order for restraints for 1/6/21 failed to have a correct physician's order. The physician's signature was located under verbal/telephone orders, not under the physician order section. The nurse timed and dated the physician's signature for the restraint order for 1/6/21.

4. A review of the medical record for patient #18 revealed patient #18 was documented in restraints from 12/23/20 to 12/29/20. The orders stated in part:
The physician's order for restraints for 12/26/20 failed to have the date and time of the physician's signature. The nurse dated and timed the physician's signature on the restraint order for 12/26/20.
The physician's order for restraints for 12/27/20 failed to have the date and time of the physician's signature. The nurse dated and timed the physician's signature on the restraint order for 12/27/20.
The physician's order for restraints for 12/28/20 failed to have the date and time of the physician's signature. The nurse dated and timed the physician's signature for the restraint order for 12/28/20.
The physician's order for restraints for 12/29/20 failed to have the date and time of the physician's signature. The nurse dated and timed the physician's signature for the restraint order for 12/29/20.

5. A review of the medical staff rules and regulation, dated 03/02/20, stated in part: "Verbal/telephone orders must be countersigned within 24 hours or the next visit. Each verbal order is specified as being a verbal order, is dated, timed."

6. A review of the policy titled "Restraint and Seclusion Policy," approval date:4/24/2017, stated in part: "In an emergency application situation ...the order must be obtained either during the emergency application of the restraint or seclusion or immediately (within a few minutes) after the restraint or seclusion has been applied. If a patient was recently released from restraint or seclusion and exhibits behavior that can only be handled through the reapplication of restraint or seclusion, a new order is required. Staff cannot discontinue restraint or seclusion as a trial and then re-start it under the same order."

7. An interview was conducted with the Risk Manager on 1/6/21 at approximately 3:30 p.m. She concurred the restraints orders were not completed correctly. She concurred all physician's orders are to be signed, dated and timed by the physicians and not dated and timed by the nurse.

Based on a review of documents and medical record review it was revealed the facility failed to discontinue restraints at the earliest possible time. This failure was identified in one (1) of four (4) restraint records reviewed (patient #12). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #12 revealed patient #12 was placed in restraints on 12/17/20 at 4:30 a.m. A review of the restraint and seclusion observation sheet revealed nursing staff documented the patient as calm on 12/17/20 at 6:15 a.m. The observation sheet revealed the patient remained calm until 8:30 a.m. on 12/17/20. No other documentation noted on the restraint/seclusion observation sheet. A review of the restraint monitoring flowsheet revealed patient #12 remained in restraints. A review of the nursing documentation for 12/17/20 at 8:55 a.m. stated in part: "The patient is awake and generally calmer. Sitter in with patient and patient calm and interactive at this time." The nurse documentation for 12/17/20 at 10:02 a.m. stated in part: "Patient climbed out of bed to chair, generally comfortable, not combative." On 12/17/20 at 10:41 a.m. the nurse documented, "Back to bed wrist restraints continue.. vss. sats maintaine.. attempting to sleep."

2. No order or reassessment was completed for the need for restraints for 12/17/20 at 10:41 a.m.

Based on a tour of the COVID Unit (3rd floor), observations and staff interviews it was revealed the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection. This failure has the potential to adversely affect all patients.

Findings include:

1. A tour of the COVID Unit was conducted on 1/4/21 at approximately 10:40 a.m. During the tour a respiratory therapist donned personal protective equipment (PPE) to enter the patient's room. She failed to use hand sanitizer before donning gloves to enter room 317. Certified Nurse Assistant (CNA) #2 donned PPE before entering room 317 and failed to use hand sanitizer before donning gloves. Registered Nurse (RN) #1 donned gloves before handing supplies to staff in room 317 and failed to use hand sanitizer before donning gloves. After removing the soiled gloves, RN #1 used hand sanitizer and failed to let the hand sanitizer dry before attempting to don another pair of gloves. RN #1 was unable to properly don gloves due to her hands being wet from hand sanitizer. The Clinical Nurse Manager (CNM) donned PPE and entered room 316. While in room 316 the CNM opened the door six (6) times and stood with the door open, attempting to get the primary nurse to come to the room for assistance. The CNM failed to keep the door to room 316 closed. CNA #2 exited room #327 and removed her gown outside of the COVID patient's room. CNA #2 placed her gown in the garbage container outside of the COVID room and failed to use hand sanitizer after placing her gown in the garbage container.

2. A review of the policy titled "Isolation Protocols and Procedures Policy," Revision Date 6/1/2016, stated in part: "If unable to place the patient requiring All in one of the negative pressure, a private room is to be utilized, with the door kept closed... Wash hands... Gowns is not worn out of the room... Isolation attire is not to be worn outside of the room.... Hand-hygiene (wash or hand sanitizer) must be performed on exiting the room."

3. An interview was conducted with the Director of the Medical Surgical Unit and the Chief Nursing Officer during the tour of the COVID Unit. They concurred the staff were not following infection control policies.