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Based on medical record review, staff interview and review of the facility's policy and procedures it was determined that the facility failed to obtain a physician order for the continued use of a restraint for one (#5) of five patients sampled. This practice does not ensure care of the patient in restraints is maintained.

Findings include:

1. Patient #5's medical record noted the patient was admitted to the PCU (Progressive Care Unit) on 2/06/10. Nursing documentation on 2/12/10 revealed the patient was confused and attempting to pull out necessary intravenous lines. Nursing documentation and physician orders revealed on 2/12/10 at 11:55 a.m. the patient was restrained with bilateral soft wrist restraints.

Nursing documentation revealed the patient was restrained from 2/12/10 to 2/15/10. Review of physician orders revealed an initial order for restraints on 2/12/10 at 11:55 a.m. There was no order for restraints on 2/13/10, 2/14/10 or 2/15/10.

Review of the facility's policy, "Patient Restraint", last revised 11/09, revealed to continue restraint use beyond the initial order duration, the physician must see the patient, perform a clinical assessment and determine if continuation of restraint is necessary. If reassessment indicates an ongoing need for restraint, a new order must be written each calendar day by the physician.

Interview with the the Director of PCU on 2/16/10 at approximately 2:30 p.m. confirmed the above findings.

Based on record review, staff interview and review of the facility's policy and procedures, it was determined the facility failed to monitor the condition of restrained patients at intervals determined by the facility's policy for one (#2) of five patients sampled. This practice does not provide for safety of the restrained patient.

Findings include:

1. Patient #2 was admitted to the facility's PCU (Progressive Care Unit) on 10/03/09. Nursing documentation on 10/03/09 at 5:00 p.m. revealed the patient was confused with increasing agitation and attempting to pull out a necessary urinary catheter. Nursing documentation revealed on 10/03/09 at 6:45 p.m. the patient was placed in an enclosure bed. Nursing documentation revealed the enclosure bed was utilized for the patient from 10/03/09 to 10/07/09. Review of the facility policy, "Patient Restraint", last revised 11/09, states an RN (Registered Nurse) will assess the patient at least every 2 hours. Nursing documentation revealed the patient was not monitored every 2 hours on: 10/04/09 at 8:00 p.m. to 10/05/09 at 7:54 a.m., a time period of approximately eight hours, and on 10/06/09 at 9:58 a.m. to 10/06/09 at 2:32 p.m., a time period of approximately four and a half hours.

Interview on 2/16/10 at approximately 3:00 p.m. with the Director of Quality Improvement confirmed the above findings.

Based on record review, interview and review of policy and procedures it was determined that the Registered Nurse failed to evaluate the patient's nursing needs according to facility policy for two
(#2, #5) of five patients sampled. This does not ensure the patient's needs are met.

Findings include:

1. Patient #2 was admitted to the facility's PCU (Progressive Care Unit) on 10/03/09. Review of the nursing admission history and assessment revealed the patient was disoriented, blind, and unable to speak due to a tracheostomy in place. Review of nursing notes revealed on 10/03/09 the patient was becoming increasingly agitated and trying to pull out the urinary catheter. The physician was notified and an order at 4:00 p.m. for an enclosure bed was received. At 6:45 p.m. the patient was placed in an enclosure bed. Review of nursing notes and assessments revealed no documentation of assistance with ADL's (Activities of Daily Living) on 10/03/09, 10/04/09, 10/06/09 or 10/07/09. On 10/03/09 a cardiac diet was ordered by the physician. There was no documentation that the patient was assisted with meals. Nursing documentation revealed fluids by mouth on 10/06/09 at 6:56 p.m. of 120 ml (milliliters) and on 10/07/09 at 4:07 a.m. of 360 ml. Nursing documentation revealed on 10/04/09 the patient consumed 0% of breakfast, 5% of lunch, 10% of dinner. On 10/05/09 the patient consumed 0% of breakfast, and 0% of lunch. On 10/06/09 the patient consumed 0% of breakfast, 0% of lunch, and 0% of dinner.

Interview with the Director of Quality improvement on 2/16/10 at approximately 3:00 p.m. confirmed the above findings.


2. Patient #5 was admitted to the facility's PCU (Progressive Care Unit) on 2/06/10 with a diagnosis of acute renal failure. Review of the facility's policy, "Assessment/Reassessment", last reviewed 4/2009, states patient reassessment is performed by a RN (Registered Nurse) at the beginning of the shift and at least every four (4) hours, with a change in care giver or more frequently as indicated by the patient's condition. Review of nursing documentation revealed the patient was not assessed according to facility policy on the following dates and times:

On 2/09/10 at 4:51 p.m. the patient was assessed. The patient was next assessed on 2/10/10 at 3:00 a.m., a time gap of approximately 10 hours in which the patient was not assessed.

On 2/10/10 at 3:00 a.m. the patient was assessed. The patient was next assessed on 2/10/10 at 10:10 a.m., a time gap of approximately 7 hours in which the patient was not assessed.

On 2/13/10 at 8:00 p.m. the patient was assessed.
The patient was next assessed on 2/14/10 ar 4:22 a.m., a time gap of approximately 8 hours in which the patient was not assessed.

On 2/14/10 at 4:00 p.m. the patient was assessed.
The patient was next assessed on 2/14/10 at 10:00 p.m., a time gap of approximately 6 hours in which the patient was not assessed.

On 2/15/10 at 3:50 p.m. the patient was assessed.
The patient was next assessed on 2/15/10 at 10:30 p.m., a time gap of approximately 6.5 hours in which the patient was not assessed.

On 2/15/10 at 10:30 p.m. the patient was assessed. The patient was next assessed on 2/16/at 10 8:00 a.m., a time gap of approximately 9.5 hours in which the patient was not assessed.

Interview with the Director of Quality on 2/16/10 at approximately 2:30 p.m. confirmed the above findings.