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Based on record review and interview, the facility failed to ensure restraints were added to each patient's care plan upon initiation of restraints. This affected one (Patient #2) of four patients reviewed for restraint use. The facility census was 954 with 69 restrained patients on day of entrance.

Findings include:

Review of the medical record for Patient #2 revealed orders for an enclosure bed for 24 hours on 04/09/18 and 04/10/18. The plan of care lacked documentation of restraints, problems or issues.

During interview on 04/10/18 at 2:20 P.M., Staff A verified the above information.

Review of the policy titled "Restraint and Seclusion 03-30", undated, revealed a written modification to the patient's plan of care was required for every use of restraint.

Based on observation, record review and interview, the facility failed to ensure physician restraint orders were followed and failed to ensure the physician order was specific to the number of limbs to be restrained. This affected two (Patients #1 and #10) of four patients reviewed for restraint use. The facility census was 954 with 69 total patients with restraints on day of entrance.

Findings include:

1. Review of Patient #1's medical record revealed an admission date of 11/08/17. For the time period of 11/09/17 through 11/17/17, the patient had an order for soft limb restraints, however the number of limbs to be restrained was not identified.

Review of the restraint documentation flow sheet revealed soft limb restraints were placed on the right and left wrists during the time period 11/09/17 through 11/17/17.

During interview on 04/11/18, Staff B verified the number of limbs to be restrained was not identified.

2. Review of Patient #10's medical record contained physcian orders dated 04/09/18 and 04/10/18 for soft limb restraints for two extremities.

Review of the restraint documentation flow sheet revealed soft limb restraints were placed on three extremities: the right and left wrists and the left ankle.

Observation of Patient #10 on 04/10/18 at 8:16 A.M. revealed restraints on three limbs, the right wrist and the left wrist and ankle.

During interview on 04/11/18, Staff A verified the order was for only two limbs to be restrained.

Based on record review and interview, the facility failed to ensure restrained patients were monitored every two hours per the facility policy. This affected three (Patients #1, #2, and #10) of four patients reviewed for restraint use. The facility census was 954 with 69 total patients with restraints on day of entrance.

Findings include:

1. Review of the medical record for Patient #2 revealed orders for an enclosure bed for 24 hours on 04/09/18 and 04/10/18. Review of the the restraint flow sheet revealed no documented restraint checks from on 04/10/18 from 5:30 A.M. to 8:25 A.M.

During interview on 04/10/18 at 2:20 P.M., Staff A verified the lack of documentation.

2. Review of the medical record for Patient #1 revealed orders for soft limb restraints 11/09/17 through 11/17/17. Review of the restraint flow sheet revealed no documented restraint checks on 11/10/17 from 3:00 A.M. to 8:00 P.M.; 11/12/17 from 4:00 A.M. to 8:00 A.M.; 11/14/17 from 10:00 A.M. to 2:00 P.M.; 11/15/17 from 4:37 A.M. to 8:00 A.M.; and 11/16/17 from 8:00 A.M. to 9:00 P.M.

During interview on 04/11/18, Staff B verified the lack of documentation.

3. Review of the medical record for Patient #10 revealed orders for soft limb restraints for two extremities on 04/09/18 and 04/10/18. Review of the restraint flow sheet revealed no documented restraint checks on 04/091/8 from 10:00 A.M. to 8:00 P.M.

During interview on 04/11/18, Staff A verified the lack of documentation.

Review of the policy titled "Restraint and Seclusion 03-30", undated, revealed the restrained patient would be periodically observed and monitored, including checking general safety and well being and would be provided meals, fluids, toileting, and ambulation at least every two hours.