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Based on clinical record review, document review and staff interviews it was revealed the facility failed to ensure swing bed patients (patient #1, 2 and 4) had the right to be free from restraints, in any form, as a means of convenience to prevent falls by facility staff. This failure was identified in three (3) out of ten (10) clinical records reviewed. This failure has the potential to place all patients at risk for an adverse event.

Findings include:

1. A review of patient #1's clinical record revealed the patient had restraints ordered and implemented every twenty-four (24) hours from 08/10/21 at 6:00 p.m. through discharge on 08/23/21 at 9:28 a.m. A restraint for a bed alarm was ordered from 08/10/21 through 08/13/21. A restrictive positioning restraint was ordered from 08/14/21 through 08/19/21. A bed alarm, "Care Vue" video monitoring and roll belt restraint was ordered from 08/20/21 through 08/23/21. Nursing staff inconsistently documented various types of restraints in use of a bed alarm, "Care Vue" video monitoring, restrictive positioning, medication, enclosure bed, roll belt and bed rails from 08/10/21 through 08/23/21.

2. A review of patient #2's clinical record revealed the patient had restraints ordered and implemented every twenty-four (24) hours from 08/10/21 at 6:15 p.m. through discharge on 08/16/21 at 12:15 p.m. A restrictive positioning restraint was ordered from 08/10/21 through 08/11/21. A bed alarm restraint was ordered on 08/12/21. The restraint order on 08/13/21 did not specify the restraint type. A restrictive positioning restraint was ordered from 08/14/21 through 08/16/21. Nursing staff inconsistently documented various types of restraints in use of a bed alarm, restrictive positioning, and bed rails from 08/10/21 through 08/16/21.

3. A review of patient #4's clinical record revealed the patient had restraints ordered and implemented every twenty-four (24) hours from 08/10/21 at 12:46 a.m. through 08/11/21 at 4:00 p.m. The restraint order did not specify the type of restraint. Nursing staff inconsistently documented various types of restraints in use of bed alarms, "Care Vue" video monitoring, restrictive positioning and roll belt from 08/10/21 through 08/11/21.

4. A review of the "Patient Information Guide," undated, states in part: "Why Restraints Are Used. Some medications or illnesses can cause confusion. A patient may not remember where he or she is or why he or she is there. Restraints help keep patients from harming themselves. Restraints can help prevent such things as: Falls out of a bed or chair, Wandering out of a safe area ...

5. A review of facility policy, "Restraints and Seclusion," revised 10/23/21, states in part: "Self-Releasing Roll Belts - ... If the patient is not able to easily self-release, it is considered a restraint and must be prescribed by a physician. ... A valid restraint order must specify: the restraint type, the justification/behavior for the restraint, ..."

6. An interview was conducted on 10/12/21 at approximately 11:25 a.m. with the Director of Quality. When asked about bed alarms documented as a restraint, the director stated in part, "Bed alarms are considered restraints for swing bed patients, so we document it under restraints and have a physician's order. We treat it just like a restraint. Bed alarms ring at the nursing station ... Roll belts are not a restraint unless the patient can't release it. The roll belt is a reminder to call for help. If swing bed patients consent for video monitoring, it is a restraint."

7. An interview was conducted on 10/12/21 at approximately 12:33 p.m. with registered nurse (RN) #1. When asked about using restraints for swing bed patients, the nurse stated in part, "The roll belt is not a restraint unless the patient can't remove it. "Care Vue" is not a restraint. It's a camera, but we need permission to turn it on. We have to have signed permission by the medical power of attorney (MPOA) or surrogate." When asked what a "restrictive positioning" restraint is, the nurse stated in part, "It is if a patient is in danger of falling or the patient isn't steady to get out on their own. If a patient is a swing bed on a bed alarm, we chart every two (2) hours, and it is considered a restraint. Restrictive positioning is just saying the patient is in danger of falling, getting out of bed and on a bed alarm."

8. An interview was conducted on 10/12/21 at approximately 3:15 p.m. with RN #2. When asked about using restraints on swing bed patients, the nurse stated in part, "In swing bed, bed alarms are considered restraints because it restricts the position. On acute the alarm isn't a restraint. It's only swing bed patients." When asked what an enclosed bed is, the nurse stated in part, "We don't use enclosed beds." When asked what "restrictive positioning" is, the nurse stated in part, "Restrictive positioning means the patient is in a swing bed with a bed alarm." When asked what type of restraint "restrictive positioning" is and it is not specific, the nurse concurred the term is vague and not specific.

9. An interview was conducted on 10/12/21 at approximately 3:30 p.m. with RN #3. When asked what restraints are used on swing bed patients, the nurse stated in part, "Bed alarms, "Care Vue" and anything that restricts patient movements." When asked what "restrictive positioning" is, the nurse stated in part, "To me, the only thing I can think of is it's going to be if you tucked the patient in with the bed clothes, but I'm just speculating. I don't use that. I agree there are better options to pick from. To be honest, I don't know why that is an option. I am guessing. There are other options. ...we don't use bed enclosures."

10. An interview was conducted on 10/12/21 at approximately 4:00 p.m. with Licensed Practical Nurse (LPN) #1. When asked about restraints used for swing bed patients, the nurse stated in part, "When we have patients on swing bed and they need a bed alarm and are a high risk for falls, we have to consider it a restraint." When asked what "restrictive positioning" is, the nurse stated in part, "I think it would be a patient who can get up and potentially harm themselves and get hurt if confused. "Restrictive positioning" is a bed alarm." When asked what specific restraint "restrictive positioning" is, the nurse agreed the "restrictive positioning" term is vague and not specific.

11. An interview was conducted on 10/13/21 at approximately 9:29 a.m. with the Swing Bed Coordinator. When asked about the process for restraints with swing bed patients, the coordinator stated in part, "I was told we should view patients as they are in their home and any restriction, if by noise, verbal or alarm and it restricts their movements, then it's a restraint. The roll belt is a restraint if the patient can't remove it. Due to the home environment, this is how we look at it."

12. An interview was conducted on 10/13/21 at approximately 10:34 p.m. with the Director of Nursing Fifth (5th) floor. When asked about swing bed patients in restraints, the Director stated in part, "If the patient is swing bed and requires a bed alarm, it is a restraint. The hospital considers swing bed patients with bed alarms, "Care Vue" and belts, if a patient can't unattach or release it, then it's a restraint. ... They are for mobility and against the plan of care or if they try to pull out their IV." When asked about documenting "restrictive positioning" and is not a specific restraint and could be up to staff interpretation, the Director stated in part, "More clarity is better with restraints. I would help the patient for clarifying."

13. An interview was conducted on 10/13/21 at approximately 12:06 p.m. with the Director of Quality. When asked about bed alarms and the "Care Vue" video monitoring used as restraints, the Director stated in part, "We didn't think bed alarms or "Care Vue" was a restraint, but we were told it was for swing bed patients, so we treated it as a restraint."

14. An interview was conducted on 10/14/21 at approximately 11:00 a.m. with House Supervisor #1. When asked if the bed alarms and "Care Vue" video monitoring is part of the falls program, the supervisor concurred.

15. An interview was conducted on 10/14/21 at approximately 1:30 p.m. with the Chief Nursing Officer. When notified bed alarms and the "Care Vue" video monitoring was part of the falls program and violated patients' rights to be free from restrains, the CNO stated in part, "We have a call out to corporate to clarify and address this."

Based on clinical record review, document review and staff interviews it was revealed the facility failed to ensure nursing staff document evaluated specific restraints used for swing bed patients (patient #1, 2 and 4) following facility policy. This failure was identified in three (3) out of ten (10) clinical records reviewed. This failure has the potential to place all patients at risk for an adverse event.

Findings include:

1. A review of patient #1's clinical record revealed the patient had restraints ordered and implemented every twenty-four (24) hours from 08/10/21 at 6:00 p.m. through discharge on 08/23/21 at 9:28 a.m. A restraint for a bed alarm was ordered from 08/10/21 through 08/13/21. A restrictive positioning restraint was ordered from 08/14/21 through 08/19/21. A bed alarm, "Care Vue" video monitoring and roll belt restraint was ordered from 08/20/21 through 08/23/21. Nursing staff inconsistently documented various types of restraints in use of a bed alarm, "Care Vue" video monitoring, restrictive positioning, medication, enclosure bed, roll belt and bed rails from 08/10/21 through 08/23/21.

2. A review of patient #2's clinical record revealed the patient had restraints ordered and implemented every twenty-four (24) hours from 08/10/21 at 6:15 p.m. through discharge on 08/16/21 at 12:15 p.m. A restrictive positioning restraint was ordered from 08/10/21 through 08/11/21. A bed alarm restraint was ordered on 08/12/21. The restraint order on 08/13/21 did not specify the restraint type. A restrictive positioning restraint was ordered from 08/14/21 through 08/16/21. Nursing staff inconsistently documented various types of restraints in use of a bed alarm, restrictive positioning, and bed rails from 08/10/21 through 08/16/21.

3. A review of patient #4's clinical record revealed the patient had restraints ordered and implemented every twenty-four (24) hours from 08/10/21 at 12:46 a.m. through 08/11/21 at 4:00 p.m. The restraint order did not specify the type of restraint. Nursing staff inconsistently documented various types of restraints in use of bed alarms, "Care Vue" video monitoring, restrictive positioning and roll belt from 08/10/21 through 08/11/21.

4. A review of facility policy, "Restraints and Seclusion," revised 10/23/21, states in part: "Self-Releasing Roll Belts - ... If the patient is not able to easily self-release, it is considered a restraint and must be prescribed by a physician. ... A valid restraint order must specify: the restraint type, the justification/behavior for the restraint, ..."

5. An interview was conducted on 10/12/21 at approximately 11:25 a.m. with the Director of Quality. When asked about bed alarms documented as a restraint, the director stated in part, "Bed alarms are considered restraints for swing bed patients, so we document it under restraints and have a physician's order. We treat it just like a restraint. Bed alarms ring at the nursing station ... Roll belts are not a restraint unless the patient can't release it. The roll belt is a reminder to call for help. If swing bed patients consent for video monitoring, it is a restraint."

6. An interview was conducted on 10/12/21 at approximately 12:33 p.m. with registered nurse (RN) #1. When asked about using restraints for swing bed patients, the nurse stated in part, "The roll belt is not a restraint unless the patient can't remove it. "Care Vue" is not a restraint. It's a camera, but we need permission to turn it on. We have to have signed permission by the medical power of attorney (MPOA) or surrogate." When asked what a "restrictive positioning" restraint is, the nurse stated in part, "It is if a patient is in danger of falling or the patient isn't steady to get out on their own. If a patient is a swing bed on a bed alarm, we chart every two (2) hours, and it is considered a restraint. Restrictive positioning is just saying the patient is in danger of falling, getting out of bed and on a bed alarm."

7. An interview was conducted on 10/12/21 at approximately 3:15 p.m. with RN #2. When asked about using restraints on swing bed patients, the nurse stated in part, "In swing bed, bed alarms are considered restraints because it restricts the position. On acute the alarm isn't a restraint. It's only swing bed patients." When asked what an enclosed bed is, the nurse stated in part, "We don't use enclosed beds." When asked what "restrictive positioning" is, the nurse stated in part, "Restrictive positioning means the patient is in a swing bed with a bed alarm." When asked what type of restraint "restrictive positioning" is and it is not specific, the nurse concurred the term is vague and not specific.

8. An interview was conducted on 10/12/21 at approximately 3:30 p.m. with RN #3. When asked what restraints are used on swing bed patients, the nurse stated in part, "Bed alarms, "Care Vue" and anything that restricts patient movements." When asked what "restrictive positioning" is, the nurse stated in part, "To me, the only thing I can think of is it's going to be if you tucked the patient in with the bed clothes, but I'm just speculating. I don't use that. I agree there are better options to pick from. To be honest, I don't know why that is an option. I am guessing. There are other options. ...we don't use bed enclosures."

9. An interview was conducted on 10/12/21 at approximately 4:00 p.m. with Licensed Practical Nurse (LPN) #1. When asked about restraints used for swing bed patients, the nurse stated in part, "When we have patients on swing bed and they need a bed alarm and are a high risk for falls, we have to consider it a restraint." When asked what "restrictive positioning" is, the nurse stated in part, "I think it would be a patient who can get up and potentially harm themselves and get hurt if confused. "Restrictive positioning" is a bed alarm." When asked what specific restraint "restrictive positioning" is, the nurse agreed the "restrictive positioning" term is vague and not specific.

10. An interview was conducted on 10/13/21 at approximately 10:34 p.m. with the Director of Nursing Fifth (5th) floor. When asked about swing bed patients in restraints, the Director stated in part, "If the patient is swing bed and requires a bed alarm, it is a restraint. The hospital considers swing bed patients with bed alarms, "Care Vue" and belts, if a patient can't unattach or release it, then it's a restraint. ... They are for mobility and against the plan of care or if they try to pull out their IV." When asked about documenting "restrictive positioning" and is not a specific restraint and could be up to staff interpretation, the Director stated in part, "More clarity is better with restraints. I would help the patient for clarifying."

11. An interview was conducted on 10/13/21 at approximately 12:06 p.m. with the Director of Quality. When asked about bed alarms and the "Care Vue" video monitoring used as restraints, the Director stated in part, "We didn't think bed alarms or "Care Vue" was a restraint, but we were told it was for swing bed patients, so we treated it as a restraint."

12. An interview was conducted on 10/14/21 at approximately 11:00 a.m. with House Supervisor #1. When asked if the bed alarms and "Care Vue" video monitoring is part of the falls program, the supervisor concurred.

13. An interview was conducted on 10/14/21 at approximately 1:30 p.m. with the Chief Nursing Officer. When notified bed alarms and the "Care Vue" video monitoring was part of the falls program and violated patients' rights to be free from restrains, the CNO stated in part, "We have a call out to corporate to clarify and address this."

Based on clinical record review, document review and staff interviews it was revealed the facility failed to ensure nursing staff document specific restraints used for swing bed patients (patient #1, 2 and 4) following facility policy. This failure was identified in three (3) out of ten (10) clinical records reviewed. This failure has the potential to place all patients at risk for an adverse event.

Findings include:

1. A review of patient #1's clinical record revealed the patient had restraints ordered and implemented every twenty-four (24) hours from 08/10/21 at 6:00 p.m. through discharge on 08/23/21 at 9:28 a.m. A restraint for a bed alarm was ordered from 08/10/21 through 08/13/21. A restrictive positioning restraint was ordered from 08/14/21 through 08/19/21. A bed alarm, "Care Vue" video monitoring and roll belt restraint was ordered from 08/20/21 through 08/23/21. Nursing staff inconsistently documented various types of restraints in use of a bed alarm, "Care Vue" video monitoring, restrictive positioning, medication, enclosure bed, roll belt and bed rails from 08/10/21 through 08/23/21.

2. A review of patient #2's clinical record revealed the patient had restraints ordered and implemented every twenty-four (24) hours from 08/10/21 at 6:15 p.m. through discharge on 08/16/21 at 12:15 p.m. A restrictive positioning restraint was ordered from 08/10/21 through 08/11/21. A bed alarm restraint was ordered on 08/12/21. The restraint order on 08/13/21 did not specify the restraint type. A restrictive positioning restraint was ordered from 08/14/21 through 08/16/21. Nursing staff inconsistently documented various types of restraints in use of a bed alarm, restrictive positioning, and bed rails from 08/10/21 through 08/16/21.

3. A review of patient #4's clinical record revealed the patient had restraints ordered and implemented every twenty-four (24) hours from 08/10/21 at 12:46 a.m. through 08/11/21 at 4:00 p.m. The restraint order did not specify the type of restraint. Nursing staff inconsistently documented various types of restraints in use of bed alarms, "Care Vue" video monitoring, restrictive positioning and roll belt from 08/10/21 through 08/11/21.

4. A review of facility policy, "Restraints and Seclusion," revised 10/23/21, states in part: "Self-Releasing Roll Belts - ... If the patient is not able to easily self-release, it is considered a restraint and must be prescribed by a physician. ... A valid restraint order must specify: the restraint type, the justification/behavior for the restraint, ..."

5. An interview was conducted on 10/12/21 at approximately 11:25 a.m. with the Director of Quality. When asked about bed alarms documented as a restraint, the director stated in part, "Bed alarms are considered restraints for swing bed patients, so we document it under restraints and have a physician's order. We treat it just like a restraint. Bed alarms ring at the nursing station ... Roll belts are not a restraint unless the patient can't release it. The roll belt is a reminder to call for help. If swing bed patients consent for video monitoring, it is a restraint."

6. An interview was conducted on 10/12/21 at approximately 12:33 p.m. with registered nurse (RN) #1. When asked about using restraints for swing bed patients, the nurse stated in part, "The roll belt is not a restraint unless the patient can't remove it. "Care Vue" is not a restraint. It's a camera, but we need permission to turn it on. We have to have signed permission by the medical power of attorney (MPOA) or surrogate." When asked what a "restrictive positioning" restraint is, the nurse stated in part, "It is if a patient is in danger of falling or the patient isn't steady to get out on their own. If a patient is a swing bed on a bed alarm, we chart every two (2) hours, and it is considered a restraint. Restrictive positioning is just saying the patient is in danger of falling, getting out of bed and on a bed alarm."

7. An interview was conducted on 10/12/21 at approximately 3:15 p.m. with RN #2. When asked about using restraints on swing bed patients, the nurse stated in part, "In swing bed, bed alarms are considered restraints because it restricts the position. On acute the alarm isn't a restraint. It's only swing bed patients." When asked what an enclosed bed is, the nurse stated in part, "We don't use enclosed beds." When asked what "restrictive positioning" is, the nurse stated in part, "Restrictive positioning means the patient is in a swing bed with a bed alarm." When asked what type of restraint "restrictive positioning" is and it is not specific, the nurse concurred the term is vague and not specific.

8. An interview was conducted on 10/12/21 at approximately 3:30 p.m. with RN #3. When asked what restraints are used on swing bed patients, the nurse stated in part, "Bed alarms, "Care Vue" and anything that restricts patient movements." When asked what "restrictive positioning" is, the nurse stated in part, "To me, the only thing I can think of is it's going to be if you tucked the patient in with the bed clothes, but I'm just speculating. I don't use that. I agree there are better options to pick from. To be honest, I don't know why that is an option. I am guessing. There are other options. ...we don't use bed enclosures."

9. An interview was conducted on 10/12/21 at approximately 4:00 p.m. with Licensed Practical Nurse (LPN) #1. When asked about restraints used for swing bed patients, the nurse stated in part, "When we have patients on swing bed and they need a bed alarm and are a high risk for falls, we have to consider it a restraint." When asked what "restrictive positioning" is, the nurse stated in part, "I think it would be a patient who can get up and potentially harm themselves and get hurt if confused. "Restrictive positioning" is a bed alarm." When asked what specific restraint "restrictive positioning" is, the nurse agreed the "restrictive positioning" term is vague and not specific.

10. An interview was conducted on 10/13/21 at approximately 10:34 p.m. with the Director of Nursing Fifth (5th) floor. When asked about swing bed patients in restraints, the Director stated in part, "If the patient is swing bed and requires a bed alarm, it is a restraint. The hospital considers swing bed patients with bed alarms, "Care Vue" and belts, if a patient can't unattach or release it, then it's a restraint. ... They are for mobility and against the plan of care or if they try to pull out their IV." When asked about documenting "restrictive positioning" and is not a specific restraint and could be up to staff interpretation, the Director stated in part, "More clarity is better with restraints. I would help the patient for clarifying."

11. An interview was conducted on 10/13/21 at approximately 12:06 p.m. with the Director of Quality. When asked about bed alarms and the "Care Vue" video monitoring used as restraints, the Director stated in part, "We didn't think bed alarms or "Care Vue" was a restraint, but we were told it was for swing bed patients, so we treated it as a restraint."

12. An interview was conducted on 10/14/21 at approximately 11:00 a.m. with House Supervisor #1. When asked if the bed alarms and "Care Vue" video monitoring is part of the falls program, the supervisor concurred.

13. An interview was conducted on 10/14/21 at approximately 1:30 p.m. with the Chief Nursing Officer. When notified bed alarms and the "Care Vue" video monitoring was part of the falls program and violated patients' rights to be free from restrains, the CNO stated in part, "We have a call out to corporate to clarify and address this."