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Based on document review and interview, it was determined in 3 of 6 (Pt #1, #2 and #3) patient's records reviewed who were restrained, the Hospital failed to ensure physician orders for restraints were obtained per policy. This has the potential to affect all patients that require the use of restraints.

Findings include:

1. PolicyStat ID: 3350293, "Restraint and Seclusion Management" (reviewed 9/5/17) was reviewed on 3/2/18 at approximately 3:45 PM. The policy required a physician's restraint order for a Non-Violent/Non-Self-Destructing Behavior to be reviewed once daily, every calendar day and include the reason for the restraint, type of restraint, Patient Clinical Justification, Alternative Interventions and Clinical Interventions.

2. The clinical record of Pt #1 was reviewed on 3/2/18 at approximately 11:30 AM. Pt #1 was admitted on 1/29/18 with a diagnoses of Intracranial Hemorrhage, Status Epilepticus, Atrial Fibrillation, and Cardio Respiratory Failure. Between 1/29/18 and 2/3/18, nursing documentation stated Pt #1 required the use of bilateral soft wrist restraints. The record lacked physician orders for the bilateral soft wrist restraints on 1/30/18 and 2/1/18.

An interview was conducted with the Nursing Informatics Coordinator (E#3) on 3/2/18 at approximately 12:30 PM. E#3 had reviewed Pt #1's record and verbally agreed the record lacked restraint orders for 1/30/18 and 2/1/18 and the Hospital's policy was not followed.

3. The clinical record of Pt #2 was reviewed on 3/2/18 at approximately 2:00 PM. Pt #2 was admitted on 2/6/18 with a diagnosis of Seizures. The Restraint Flowsheet noted Pt #2 was restrained with soft restraints on both wrist from 2/24/18 at 8:00 AM through 2/25/18 at 8:00 AM. The clinical record lacked a physician's order for the soft restraint use as of 3/2/18.

During an interview on 3/2/18 at approximately 2:30 PM, E#6 (Clinical Educator Scholar) verbally agreed Pt #2's record lacked a physician's order for the soft restraints applied on 2/24/18 and 2/25/18 and the Hospital's policy was not followed.

4. The clinical record of Pt #3 was reviewed on 3/2/18 at approximately 3:00 PM. Pt #3 was admitted on 2/22/18 with a diagnosis of Stroke. The Restraint Flowsheet noted Pt #3 was restrained from 2/22/18 through 3/2/18. The clinical record lacked a physician's order for the restraints on 2/24/18, 2/27/18 and 3/1/18. The Restraint Flowsheet noted a "waist" restraint was applied on 2/27/18 at 10:00 PM. A physician's order for the waist restraint was obtained on 3/2/18 at 10:45 AM, 3 days after the daily requirement.

During an interview on 3/2/18 at approximately 3:30 PM, E#5 (Informatic Scholar) verbally agreed Pt #3's record lacked a physician's order for the restraints applied on 2/24/18, 2/27/18 and 3/1/18 and the Hospital's policy was not followed.

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Based on document review and interview, it was determined for 3 of 10 (Pts #2, #6, and #1) patients restrained,
the Hospital failed to ensure restrained patients were monitored in accordance with its policy. This has the potential to affect all patients requiring restraint usage, approximately 25 patients in February 2018.

Findings include:

1. The policy titled "PolicyStat ID: 3350293, Restraint and Seclusion Management" (reviewed 9/5/17) was reviewed on 3/2/18 at approximately 3:00 PM. On page 4, the policy required "8. Registered nurses....trained staff as authorized ...monitor the following...Restraint for Non-Violent /Non-Self-Destructive Behavior...Frequency ...Every 2 hours or more often as needed...Monitoring includes Visual check of patient in restraint for mental status... (physical comfort)....Circulation and skin integrity at site if restraint... Frequency... Every 4 hours or more often as needed... Vital signs".

2. Pt #2's record was reviewed on 3/2/18 at approximately 2:00 PM. Pt #2 was admitted to the Hospital on 2/6/18 with the diagnosis of Breakthrough Seizure. Nursing documentation included Pt #2 had non-violent soft restraints and surround bed restraints during the time of 2/24/18 thru 2/25/18. The record lacked every 2 hour monitoring between 0400 (4:00 AM) on 2/24/18 to 1000 (10:00 AM) on 2/25/18 (6 hours).

3. Pt #6's record was reviewed on 3/2/18 at approximately 2:45 PM. Pt #6 was admitted to the Hospital on 2/12/18 with the diagnosis of Acute Respiratory Failure. Nursing documentation included Pt #6 had non-violent soft restraints during the time of 2/21/18 thru 2/22/18. The record lacked every 2 hour monitoring between 1800 (6:00 PM) on 2/21/18 to 0800 (8:00 AM) on 2/22/18 (14 hours).

During the interview with E# 6 (Clinical Educator Scholar) on 3/2/18 at approximately 2:00 PM to 3:00 PM, it was verbally confirmed pt. #2 and #6 were in restraints during the times above and should have been monitored every 2 hours.

4. Pt #1's record was reviewed 3/2/18 and 3/6/18. Pt #1 was admitted to the Hospital on 1/29/18 with the diagnoses Intracranial Hemorrhage, Status Epilepticus, Atrial Fibrillation, and Cardio Respiratory Failure. On 2/5/18 at 1:11 AM, there was a physician order for a waist restraint. Pt #1's record lacked every 4 hour vital signs on 2/5/18, between 12:58 AM and 4:16 PM.

An interview was conducted with the Nursing Informatics Coordinator (E#3) on 3/6/18 at approximately 10:00 AM. E#3 had reviewed Pt #1's record and verbally agreed vital signs were not monitored every 4 hours on 2/5/18 and should have been.

Based on document review and interview, it was determined for 1 of 7 (Pt #1) reportable death in restraint patient, the Hospital failed to ensure the Centers for Medicare and Medicaid Services (CMS) was notified of the reportable death in restraint no later than the close of business on the next business day following knowledge of the patient's death. This has the potential to affect all restrained patients.

Findings include:

1. The Hospital PolicyStat ID: 3350293, "Restraint and Seclusion Management" (last reviewed 9/5/17) was reviewed on 3/2/18 at approximately 10:30 AM. On page 3, the policy stated "11. Death or injury associated with the use of restraints or seclusion is reported to the Centers for Medicare and Medicaid Services (CMS)..."

2. Pt #1's record was reviewed 3/2/18 and 3/6/18. Pt #1 was admitted to the Hospital on 1/29/18 with the diagnoses Intracranial Hemorrhage, Status Epilepticus, Atrial Fibrillation, and Cardio Respiratory Failure. On 2/5/18 at 1:11 AM, there was a physician order for a waist restraint. On 2/5/18 at 6:20 PM, a "Code Blue (cardiac arrest)" was called and Pt #1 expired at 6:49 PM.

3. The February 2018 restraint log was reviewed on 3/2/18 at approximately 10:30 AM. On 2/9/18, the log stated Pt #1 "Date Death... 2.5.18 (Monday)... expired while in waist restraint. CMS notified on 2/9/18 at" 8:10 AM.

4. An interview was conducted with Quality Management Specialist (E#2) on 3/2/18 at approximately 11:30 AM. The Nursing Informatics Coordinator (E#3) and the Manager Quality and Safety (E#4) were present. E#2 stated the recent death in restraint report is run every morning and faxes CMS at that time with the ones that require CMS notification. E#2 stated "It (the death in restraint of Pt #1 on 2/5/18) didn't come up on my report until 2/9/18. I don't know why it didn't come up on my report." All verbally agreed the death in waist restraint was not reported to CMS no later than the close of business the next business day and it should have been.