HospitalInspections.org

Based on interview and record review, the facility failed to use a soft vest restraint only when less restrictive interventions had been determined to be ineffective to protect the patient, a staff member, or others from harm. As a result of this deficient practice, Patient (P)1 was placed at risk of avoidable injury related to continued and prolonged restraint use and had his right to be free from restraints compromised.

Findings include:

Patient (P)1 is an 84-year-old male admitted to the facility on 08/08/23 for encephalopathy (A broad term for any brain disease that alters brain function or structure. Causes include infection, tumor, and stroke), where he was found to have small cell carcinoma (A fast-growing type of lung cancer).

On 08/24/23 the facility reported to the Centers for Medicare & Medicaid Services (CMS) that P1 had passed away within 24 hours of physical restraints being used. After review of the mandated report, CMS referred the report to the State Agency (SA) for onsite investigation.

On 09/12/23 the SA entered the facility for investigation. Review of the electronic health record (EHR) for P1 noted that a vest restraint (a physical restraint secured at the hips that restricts a person's ability to move about freely) was applied to P1 on 08/16/23 at 10:59 AM with the justification of "Patient is confused and/or exhibits impaired judgement which interferes with therapy/treatment." The vest restraint was not documented as removed until 08/23/23 at 06:00 AM, 24 minutes prior to P1's death. At 11:04 AM, the Registered Nurse (RN)1 caring for him documented the following on the restraint flowsheet:

Visual Check: restless; confused.

Clinical Justification: Confused and/or exhibits impaired judgement which interferes with therapy/treatments.

Less Restrictive Alternatives: comfort measures, tubing/lines covered with cloth, modify environment, patient education, reality orientation/psych intervention.

Restraint Removal Criteria: absence of activity

On 09/13/23 at 10:35 AM, an interview was done with the 3rd Floor (the floor P1 was admitted to) Nurse Supervisor (NS)1 and Nurse Manager (NM)1 in the Conference Room. Both NS1 and NM1 reported that from their review of the EHR, the vest restraint was applied "for safety" after multiple attempts by P1 to get out of bed without calling for help, including attempts to climb over the raised bed rails. The restraint was to restrict P1 from climbing out of bed and potentially suffering a fall. Neither NS1 or NM1 could explain which therapies or treatments were interfered with (used as the clinical justification for initiating the restraint) by P1's attempts to get out of bed, but repeated that the restraint was a safety measure given P1's history of falls. When asked if there were any other less restrictive alternatives that could have been used, NS1 answered that in situations like this, she would usually expect to see documentation that the patient had been placed under close observation or assigned a sitter (a caregiver who provides patients in need of supervision with continuous companionship and care) prior to use of a restraint. After further review of the EHR, NS1 reported that she could find no documentation that a sitter had been utilized during P1's hospital stay.

On 09/14/23 at 08:19 AM, random interviews were done with clinical staff regarding restraint use.

An interview was done with RN2 at 08:19 AM at the 3rd floor Nurses' Station. RN2 reported that she was relatively new to the facility. When asked what would be the clinical indications that a restraint was needed, RN2 answered "pulling out devices, self-harm or harm to others, or behaviors that interfere with medical care." When specifically asked what she would do if she had a patient that was trying to climb out of bed repeatedly without calling for help, RN2 answered that while that was a safety issue, it was "not an excuse" for a restraint, and she would "get a sitter."

At 08:36 AM, an interview was done with RN3 at the 4th floor Nurses' Station. When asked what would be the clinical indications that a restraint was needed, RN3 answered pulling out an IV (intravenous) line or other medical device, or harm to self or others. When specifically asked what she would do if she had a patient that was trying to climb out of bed repeatedly without calling for help, RN3 "we don't usually use [restraints] for climbing out of bed, we should get a sitter."

A review of the facility's policy and procedure for Restraints and Seclusion, last reviewed 04/21, noted the following statement: "Restraint may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time." Under Prohibitions on the use of restraint: "The rationale that a patient should be restrained because he or she "might" fall does not constitute an adequate basis for using a restraint. A history of falling without a current clinical basis for a restraint intervention is inadequate to demonstrate the need for restraint." Under Alternatives to the use of restraint and seclusion: "The use of restraint is limited to those situations for which there is adequate and appropriate clinical justification ... Restraint may only be used when less restrictive interventions have been determined to be ineffective to protect the patient a staff member or others from harm ... The use of restraint occurs only after alternatives to such use have been considered and/or attempted as appropriate. Such alternatives may include, but are not necessarily limited to: ... Use of a sitter ..."

Based on interview and record review, the facility failed to discontinue a vest restraint at the earliest possible time. As a result of this deficient practice, Patient (P)1 was placed at risk of avoidable injury related to continued and prolonged restraint use and had his right to be free from restraints compromised.

Findings include:

Patient (P)1 is an 84-year-old male admitted to the facility on 08/08/23 for encephalopathy (A broad term for any brain disease that alters brain function or structure. Causes include infection, tumor, and stroke), where he was found to have small cell carcinoma (A fast-growing type of lung cancer).

On 08/24/23 the facility reported to the Centers for Medicare & Medicaid Services (CMS) that P1 had passed away within 24 hours of physical restraints being used. After review of the mandated report, CMS referred the report to the State Agency (SA) for onsite investigation.

On 09/12/23 the SA entered the facility for investigation. Review of the electronic health record (EHR) for P1 noted that a vest restraint (a physical restraint secured at the hips that restricts a person's ability to move about freely) was applied to P1 on 08/16/23 at 10:59 AM with the justification of "Patient is confused and/or exhibits impaired judgement which interferes with therapy/treatment." The vest restraint was not documented as removed until 08/23/23 at 06:00 AM, 24 minutes prior to P1's death. At 11:04 AM, the Registered Nurse (RN)1 caring for him documented the following on the restraint flowsheet:

Visual Check: restless; confused.

Clinical Justification: Confused and/or exhibits impaired judgement which interferes with therapy/treatments.

Less Restrictive Alternatives: comfort measures, tubing/lines covered with cloth, modify environment, patient education, reality orientation/psych intervention.

Restraint Removal Criteria: absence of activity

On 09/13/23 at 10:35 AM, an interview was done with the 3rd Floor (the floor P1 was admitted to) Nurse Supervisor (NS)1 and Nurse Manager (NM)1 in the Conference Room. Both NS1 and NM1 reported that from their review of the EHR, the vest restraint was applied "for safety" after multiple attempts by P1 to get out of bed without calling for help, including attempts to climb over the raised bed rails. The restraint was to restrict P1 from climbing out of bed and potentially suffering a fall. Neither NS1 or NM1 could explain which therapies or treatments were interfered with (used as the clinical justification for initiating the restraint) by P1's attempts to get out of bed, but repeated that the restraint was a safety measure given P1's history of falls. When asked to clarify which activity needed to be absent to fulfill the restraint removal criteria, NM1 answered "confusion." After further discussion, both NM1 and NS1 agreed that confusion was not an appropriate clinical justification for a restraint, nor the absence of it a valid criteria for removal. Upon further review of the EHR, NS1 could not find documentation that P1 had ever been assessed specifically for potential removal of the restraint.

Continued review of the EHR by the SA noted the following:

During a review of the Routine Care Flowsheet, the last time P1 was documented trying to get out of bed was 08/16/23.

During a review of the Restraint Flowsheet, P1 was marked as "subdued" during the 2-hour visual checks three times on 08/17/23, three times on 08/18/23, and three times on 08/19/23. The last time P1 was documented as trying to get out of bed on this flowsheet was 08/18/23 at 08:00 PM.

During a review of the Nursing Shift Summary notes, the last time P1 was documented as trying to get out of bed was 08/18/23 at 01:22 AM. On 08/20/23 at 06:11 AM, Registered Nurse (RN)4 documented "Still confused. Follow to commands and redirection ... Patient is redirectable ..."

On 09/14/23 at 08:50 AM, an interview was done with NS1 in her office. When questioned about the review of the EHR and the rationale for the vest restraint, NS1 agreed that there was not enough documentation to justify the application or continuation of the vest restraint.

A review of the facility's policy and procedure for Restraints and Seclusion, last reviewed 04/21, noted the following statement: "Restraint may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time." Under Discontinuation of Restraint: "Restraint must be discontinued at the earliest possible time ... Restraint may only be employed while the unsafe situation (clinical justification) continues."

Based on interview and record review, the facility failed to document an appropriate rationale for continued use of a vest restraint in the patient's medical record. As a result of this deficient practice, Patient (P)1 was placed at risk of avoidable injury related to continued and prolonged restraint use and had his right to be free from restraints compromised.

Findings include:

Patient (P)1 is an 84-year-old male admitted to the facility on 08/08/23 for encephalopathy (A broad term for any brain disease that alters brain function or structure. Causes include infection, tumor, and stroke), where he was found to have small cell carcinoma (A fast-growing type of lung cancer).

On 08/24/23 the facility reported to the Centers for Medicare & Medicaid Services (CMS) that P1 had passed away within 24 hours of physical restraints being used. After review of the mandated report, CMS referred the report to the State Agency (SA) for onsite investigation.

On 09/12/23 the SA entered the facility for investigation. Review of the electronic health record (EHR) for P1 noted that a vest restraint (a physical restraint secured at the hips that restrict a person's ability to move about freely) was applied to P1 on 08/16/23 at 10:59 AM with the justification of "Patient is confused and/or exhibits impaired judgement which interferes with therapy/treatment." The vest restraint was not documented as removed until 08/23/23 at 06:00 AM, 24 minutes prior to P1's death. At 11:04 AM, the Registered Nurse (RN)1 caring for him documented the following on the restraint flowsheet:

Visual Check: restless; confused.

Clinical Justification: Confused and/or exhibits impaired judgement which interferes with therapy/treatments.

Less Restrictive Alternatives: comfort measures, tubing/lines covered with cloth, modify environment, patient education, reality orientation/psych intervention.

Restraint Removal Criteria: absence of activity

On 09/13/23 at 10:35 AM, an interview was done with the 3rd Floor (the floor P1 was admitted to) Nurse Supervisor (NS)1 and Nurse Manager (NM)1 in the Conference Room. Both NS1 and NM1 reported that from their review of the EHR, the vest restraint was applied "for safety" after multiple attempts by P1 to get out of bed without calling for help, including attempts to climb over the raised bed rails. The restraint was to restrict P1 from climbing out of bed and potentially suffering a fall. Neither NS1 or NM1 could explain which therapies or treatments were interfered with (used as the clinical justification for initiating the restraint) by P1's attempts to get out of bed, but repeated that the restraint was a safety measure given P1's history of falls. When asked to clarify which activity needed to be absent to fulfill the restraint removal criteria, NM1 answered "confusion." After further discussion, both NM1 and NS1 agreed that confusion was not an appropriate clinical justification for a restraint, nor the absence of it a valid criteria for removal.

Continued review of the EHR by the SA noted the following:

During a review of the Routine Care Flowsheet, the last time P1 was documented trying to get out of bed was 08/16/23.

During a review of the Restraint Flowsheet, P1 was marked as "subdued" during the 2-hour visual checks three times on 08/17/23, three times on 08/18/23, and three times on 08/19/23. The last time P1 was documented as trying to get out of bed on this flowsheet was 08/18/23 at 08:00 PM.

During a review of the Nursing Shift Summary notes, the last time P1 was documented as trying to get out of bed was 08/18/23 at 01:22 AM. On 08/20/23 at 06:11 AM, Registered Nurse (RN)4 documented "Still confused. Follow to commands and redirection ... Patient is redirectable ..."

On 09/14/23 at 08:50 AM, an interview was done with NS1 in her office. When questioned about the review of the EHR and the rationale for the vest restraint, NS1 agreed that there was not enough documentation to justify the application or continuation of the vest restraint.

A review of the facility's policy and procedure for Restraints and Seclusion, last reviewed 04/21, noted the following statement: "Restraint may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time." Under Prohibitions on the use of restraint: "The rationale that a patient should be restrained because he or she "might" fall does not constitute an adequate basis for using a restraint. A history of falling without a current clinical basis for a restraint intervention is inadequate to demonstrate the need for restraint."