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Based on interview, record review, and policy review, the hospital failed to ensure restraint orders were renewed in a timely manner for three current patients (#43, #56, and #58) and four discharged patients (#44, #50, #52, and #54) of 26 medical records reviewed and provide evidence they monitored patients while in restraints for six current patients (#43, #56, #58, #59, #61 and #63) and four discharged patients (#47, #48, #49, and #60) of 26 medical records reviewed.

These failures had the potential to place all patients admitted to the hospital at risk for their safety. The cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation: Patient's Rights. The hospital census was 319.

Based on interview, record review and policy review the hospital failed to ensure the physician renewal orders for restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) were written within 24 hours of the initial restraint order prior to the application of restraints on two current patients (#56 and #58), and three discharged patients (#50, #52, and #54), of 26 restraint patients reviewed and failed to implement the restraint type ordered by the physician for one current patient (#43) and one discharged patient (#44), of 26 restraint patients reviewed. These failures created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety. The hospital census was 319.

Findings included:

Review of the hospital's policy titled, "Patient Restraint/Seclusion," dated 12/01/20, showed an initial order for restraint must not exceed 24 hours. If reassessment indicates an ongoing need for restraint, a renewal restraint order must be entered into the medical record within 24 hours of the initial restraint order. The order must specify the type of restraint to be used. Monitoring of the patient in restraints includes the type and design of the device.

Review of Patient #56's medical record showed the following:
- On 07/22/23 at 11:28 PM, he was in the surgical intensive care unit (SICU, an intensive care unit devoted to the care of critically ill patients recovering from surgery) and an initial restraint order was placed for non-violent soft bilateral upper extremity (BUE) restraints. The time limit for the restraint order was 24 hours.
- On 07/24/23 at 4:33 PM, a renewal order was placed for non-violent soft BUE restraints, one day, 17 hours and five minutes after the initial restraint order expired.
- Nursing documentation showed that Patient #56 was in restraints from 07/24/23 at 12:00 AM until 07/24/23 at 4:00 PM, with no order for restraints.

Review of Patient #54's medical record showed the following:
- On 05/27/23 at 6:14 PM, he was in the SICU and a restraint renewal order was placed for non-violent soft BUE restraints. The time limit for the restraint order was one calendar day.
- On 05/29/23 at 7:30 PM, an initial restraint order was placed for non-violent soft BUE restraints, one day, one hour and 16 minutes after the previous restraint order expired.
- Nursing documentation showed that Patient #54 was in restraints from 05/28/23 at 8:00 PM until 05/29/23 at 6:00 PM, with no order for restraints.

Review of Patient #52's medical record showed the following:
- On 07/17/23 at 7:43 AM, she was in the Medical Intensive Care Unit (MICU, an intensive care unit devoted to the care of critically ill patients) and an initial order was placed for non-violent soft BUE restraints. The time limit for the restraint order was 24 hours.
- On 07/18/23 at 9:51 AM, an initial order was placed for non-violent soft BUE restraints, two hours and eight minutes after the first restraint order expired.
- On 07/18/23, nursing documentation showed that Patient #52 was in restraints at 8:00 AM with no orders for restraints.

Review of Patient #58's medical record showed the following:
- On 07/25/23 at 12:47 PM, he was in the Neurological Intensive Care Unit (Neuro-ICU, an intensive care unit devoted to the care of patients with immediately life-threatening nervous system problems) and an initial restraint order was placed for non-violent left upper extremity mitten restraint. The time limit for the restraint order was 24 hours.
- On 07/26/23 at 4:33 PM a renewal order was placed for non-violent left upper extremity mitten restraint, three hours and 46 minutes after the initial restraint order expired.
- Nursing documentation showed that Patient #58 was in restraints from 07/26/23 at 2:00 PM until 07/26/23 at 4:00 PM, with no order for restraints.

Review of Patient #50's medical record showed the following:
- On 03/06/23 at 11:28 AM, he was in the SICU and an initial restraint order was placed for non-violent soft BUE restraints. The time limit for the restraint order was 24 hours.
- On 03/07/23 at 12:47 PM a renewal order was placed for non-violent soft BUE restraints, one hour and 19 minutes after the initial restraint order expired.
- Nursing documentation showed that Patient #50 was in restraints on 03/07/23 at 12:00 PM, with no order for restraints.

During an interview on 08/01/23 at 8:45 AM, Staff HHH, RN, stated that the initial restraint order would expire in 24 hours. Renewal restraint orders would be renewed every calendar day. Nurses were responsible to notify the physician regarding expiring restraint orders.

During an interview on 08/01/23 at 9:55 AM, Staff Q, Chief Nursing Officer (CNO), stated that the initial restraint order would expire in 24 hours. Renewal restraint orders must be renewed every calendar day. It was the responsibility of the physician to renew restraint orders in a timely manner. Nursing would notify physicians when restraint orders were scheduled to expire.

Review of Patient #43 medical record showed the following:
- On 07/23/23 at 10:28 AM, he was on the telemetry unit (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) an initial restraint order was placed for non-violent soft BUE restraints.
- On 07/23/23 at 10:45 AM, an additional initial restraint order was placed for non-violent right upper extremity mitten restraint.
- Nursing documentation showed that Patient #43 was placed in non-violent soft BUE and BUE mittens on 07/23/23 at 7:00 PM until 07/24/23 at 8:00 AM without a left upper extremity mitten restraint order.
- On 07/25/23 at 10:28 AM, a restraint order was placed for non-violent BUE mittens. This order was renewed daily from 07/26/23 through 07/31/23 at 11:08 AM.
- Nursing documentation showed that Patient #43 was placed in non-violent soft BUE restraints and BUE mittens from 07/25/23 at 12:00 PM until 07/31/23 at 10:00 AM without a non-violent soft BUE restraint order.

Review of Patient #44's medical record showed the following:
- On 07/04/23 at 9:51 AM, she was in the intensive care unit (ICU; a unit where critically ill patients are cared for) and an initial order was placed for non-violent soft BUE restraints and BUE extremity mittens.
- On 07/05/23 at 11:28 AM, the order was renewed as previously written.
- On 07/06/23 at 8:08 AM, the order was renewed but only for non-violent soft BUE restraints.
- Nursing documentation showed that Patient #44 was placed in soft BUE restraints and BUE mittens from 07/06/23 at 8:00 AM until 07/26/23 at 7:17 PM without a BUE mittens order.

During an interview on 08/01/23 at 8:45 AM, Staff HHH, RN, stated that she had not seen both bilateral soft restraints and bilateral mitten restraints used together. Each type of restraint used would require a physician order. Mittens were considered a restraint and needed a separate order.

During an interview on 08/01/23 at 9:55 AM, Staff Q, CNO, stated that mittens are considered a restraint. Each type of restraint used would require a physician order.



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Based on interview, record review and policy review the hospital failed to ensure appropriate monitoring and nursing documentation during the use of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) for six current patients (#43, #56, #58, #59, #61 and #63) and four discharged patients (#47, #48, #49 and #60) of 26 restraint patients reviewed. This failure created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety. The hospital census was 319.

Findings included:

Review of the hospital's policy titled, "Patient Restraint/Seclusion," dated 12/01/20, showed patients are assessed by a Registered Nurse (RN) immediately after restraints are initiated to assure safe application/initiation of the restraint. An RN will assess the patient at least every two hours.

Review of Patient #43's medical record showed the following:
- On 07/23/23 at 10:28 AM, he was on the telemetry unit (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) and an initial restraint order was placed for non-violent soft bilateral upper extremity (BUE) restraints.
- On 07/23/23 at 10:45 AM, an additional initial restraint order was placed for a non-violent right upper extremity mitten.
- On 07/23/23, there were no nursing restraint assessments documented for nine hours and 30 minutes (missing restraint assessments at 10:28 AM, 12:00 PM, 2:00 PM, 4:00 PM, and 6:00 PM). Nursing restraint assessment began nine hours and 30 minutes after the restraints had been applied.
- On 07/30/23, there was no nursing restraint assessment documented at 4:00 PM. The restraints were not documented as discontinued.

Review of Patient #49's medical record showed the following:
- On 01/01/23 at 12:03 AM, she was in the Medical Intensive Care Unit (MICU, an intensive care unit devoted to the care of critically ill patients) and an initial restraint order was placed for non-violent soft BUE restraints.
- On 01/01/23, there were no nursing restraint assessments documented for five hours and 30 minutes (missing restraint assessments at 2:00 PM and 4:00 PM).
- The restraints were documented as discontinued at 5:30 PM.

Review of Patient #59's medical record showed the following:
- On 07/17/23 at 8:19 AM, he was in the Neurological Intensive Care Unit (Neuro-ICU, an intensive care unit devoted to the care of patients with immediately life-threatening nervous system problems) and a restraint renewal order was placed for non-violent soft BUE restraints.
- On 07/18/23, there were no nursing restraint assessments documented for four hours (missing restraint assessments at 10:00 AM and 12:00 PM). The restraints were not documented as discontinued.

Review of Patient #58's medical record showed the following:
-On 07/17/23 at 10:46 AM, he was in the Neuro-ICU and a restraint renewal order was placed for non-violent BUE mittens.
-On 07/18/23 there were no nursing restraint assessments documented for four hours (missing restraint assessments at 4:00 AM and 6:00 AM). The restraints were not documented as discontinued.

Review of Patient #56's medical record showed the following:
- On 07/24/23 at 4:33 PM, he was in the Surgical Intensive Care Unit (SICU, an intensive care unit devoted to the care of critically ill patients recovering from surgery) and a restraint renewal order was placed for non-violent soft BUE restraints.
- On 07/24/23, there was no nursing restraint assessment documented for two hours (missing restraint assessment at 6:00 PM). The restraints were not documented as discontinued.

Review of Patient #47's medical record showed the following:
- On 07/21/23 at 12:26 AM, he was in the SICU and an initial restraint order was placed for non-violent BUE restraints.
- On 07/21/23, there was no nursing restraint assessment documented for two hours (missing restraint assessment at 6:00 AM). The restraints were not documented as discontinued.

Review of Patient #48's medical record showed the following:
- On 05/14/23 at 1:08 PM, she was in the MICU and an initial restraint order was placed for non-violent soft BUE restraints.
- On 05/14/23, there was no nursing restraint assessment documented immediately after restraints were initiated.
- On 05/14/23, the first nursing restraint assessment was documented at 3:00 PM, two hours after the restraints had been initiated.

Review of Patient #61's medical record showed the following:
- On 07/17/23 at 5:58 PM, he was in the Progressive Care Unit (PCU, a telemetry monitored unit that provides care for adult patients requiring continuous cardiac monitoring) and an initial restraint order was placed for non-violent soft BUE restraints.
- On 07/19/23 there was no nursing restraint assessment documented for two hours (missing a restraint assessment at 6:00 AM). The restraints were not documented as discontinued.
- On 07/23/23 there were no nursing restraint assessments documented for four hours (missing restraint assessments at 12:00 AM and 2:00 AM). The restraints were not documented as discontinued.

Review of Patient #63's medical record showed the following:
- On 07/23/23 at 7:31 PM, he was in the Neuro-ICU and an initial restraint order was placed for non-violent soft BUE restraints.
- On 07/25/23 there were no nursing restraint assessments documented for two hours at two separate times (missing a restraint assessment at 6:00 AM and one at 6:00 PM). The restraints were not documented as discontinued.

During an interview on 08/01/23 at 8:45 AM, Staff HHH, RN, stated that nursing restraint assessments were documented with the restraint application and then every two hours.

During an interview on 08/01/23 at 9:55 AM, Staff Q, Chief Nursing Officer (CNO) stated that RN's assessed and documented for safety with restraints upon initiation of restraints and then every two hours.




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