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Based on medical record review, review of policies and procedures for restraint usage of, and interview of hospital staff, it was determined that, one patient in a sample of six patients did not receive the safe implementation of restraints by trained staff. A hospital employee placed a restraint on patient 3 using a folded bed sheet, placing it across the patient's chest and tying it behind the headboard of his hospital bed. The bed sheet not being an appropriate restraint placed the patient at risk for injury including getting tangled in the sheet and possibly smothering.

Findings include:

MEDICAL RECORD REVIEW

Review of the physician's history and physical date 4/12/10, revealed the following information: Patient 1 was a 74 year old male who was admitted to the LTAC ( Long Term Acute Care Hospital), on 4/12/10, from the intensive care unit of an acute care hospital. His diagnoses were: bladder cancer, cystectomy with ileo-conduit. The patient's abdominal surgical wound dehisced, (the sutures opening spontaneously). This happened twice during patient 3's acute hospitalization. Upon admission to the LTAC patient 3's surgical wound was open down to the abdominal fascia. and required intensive wound care including a wound pump.

1. Review of the physician's dictated history and physical dated, 4/12/10, documented that patient 3 required ongoing intensive care including restraints. The physician documented that patient 3 also required ativan and other psychiatric medications to control his delirium, agitation and protect his multiple medical tubings.

2. The physician documented that patient 3 pulled out his feeding tube, wound vac pump, and other vital medical lines multiple times placing the patient's safety at risk. Review of the physician's orders revealed that patient 3's psychoactive medications were changed multiple times in an attempt to control patient 3's delirium caused agitation and aggression.

3. Interview with patient 3's wife revealed that when patient 3 arrived at the LTAC he was having problems with confusion and agitation. She stated that the patient became so agitated that the staff had difficulty keeping him in bed. She stated that the facility did not provide a "sitter" to stay with the patient and did not contact the family to come in and sit with the patient. The wife stated that she and her daughter came in to visit patient 3 and found him tied to the bed with a bed sheet. She stated that the sheet was placed over his chest and under his arm pit and was wrapped around the head board and tied. She stated that the sheet was tied with a knot behind the headboard. She stated that the knot was so tight she could not undo it. She stated that the staff informed her that they could not remove the sheet because the physician had ordered restraints and because of the patient's agitation they could not keep him in bed. The wife stated that patient 3 was complaining of having difficulty breathing and was struggling to get out of bed. She stated that the bed sheet was kept on patient 3 for several hours.

4. An interview was conducted with the chief nursing officer on 8/12/10. He stated that he was aware of the incident where an employee tied patient 3 down with a bed sheet. He stated that using a bed sheet for restraint was not appropriate and that the sheet was applied by a nurses aide who was not aware that it was not appropriate to do this. He stated the aide was frustrated, desperate and not knowing what else to do he used the bed sheet to keep patient 3 in bed. He stated that when the nurse found out about the bed sheet it was removed and a proper chest restraint was applied. He stated that patient was extremely agitated to the point of being violent and combative. He stated that patient 3 would hit, bite and kick the staff to the point that the staffs safety was an issue. He stated that providing a sitter was considered, but not implemented because of concerns for the staff's safety. He stated that anyone in the room, including the family seemed to increase the patient's agitation. He stated that the physician tried several different combinations of psychoactive medications to ease patient 3's agitation and decrease the need for physical restraints. The chief nursing officer stated that about mid-way through patient 3's stay the patient's delirium started to clear. He stated the patient became cooperative and and was nice. He stated that patient 3 became able to participate in his therapies and was discharged from the LTAC to another facility for rehabilitation.