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Based on the survey conducted related to patient rights, the facility failed to develop and implement systems and processes which are consistent with current restraint and seclusion regulations.

Findings include:

Interview with Staff #1 and Staff #2 on 2/10/10 revealed they were unaware of revisions/additions made to the CMS State Operations Manual (SOM), Appendix A 42 CFR Part 482.13, specifically regarding Patient Rights.

Specific findings related to patient rights (restraints) are evidenced in the following:

Tag #0166
Tag #0168
Tag #0169
Tag #0214

Based on medical record review, the facility failed to include the use of restraints in the plan of care for 3 of 4 medical/surgical patients (Patient #3, 4 and 7) and 2 of 2 behavioral health patients. (Patient #11 and 12)

Findings include:

Review on 2/11/10 of the policy CLIN-002 entitled "Restraints: Acute Medical Surgical" last revised 11/09 revealed each episode of restraint use is documented in the patient's medical record and shall include the plan of care. The plan of care includes the identified problem, outcome oriented goals, the planned intervention including the time limit for restraints and persons responsible for implementation and discontinuation of restraints.

Review on 2/11/10 of the policy NUR-099 entitled "Documentation of Nursing Care in the Electronic Medical Record" last revised 12/15/08 revealed the plan of care will be individualized to meet patient specific needs and will be reviewed daily by the RN assigned to the patient.

Review of Restraint Observation Assessments for Patient #3 dated 1/14/10- 2/10/10 revealed the use of physical restraints. Review of the Plan of Care dated 1/13/10 revealed no evidence of restraint interventions.

Review of Acute Medical Surgical Restraint order forms for Patient #4 dated 2/1/10 - 2/10/10 revealed orders for restraints. Review of the Plan of Care dated 1/14/10 revealed no evidence of restraint interventions.

Review of Restraint Observation assessments for Patient # 7 dated 10/12/09 -2/5/10 revealed use of physical restraints. Review of the Plan of Care dated 9/13/09, 9/14/09, 10/26/09, 1/13/10 and 1/14/10 revealed no evidence of restraint interventions.

Review of the Behavioral Health Restraint/Seclusion Application assessments for Patient #11 dated 2/3/10 -2/9/10 revealed the use of physical restraints. Review of the Plan of Care dated 1/31/10 revealed no evidence of restraint interventions.

Review of the Behavioral Health PRN Intervention evaluation for Patient #12 dated 1/31/10 and 2/9/10 revealed the use of physical restraints. Review of the Plan of Care dated 1/30/10 revealed no evidence of restraint interventions.

Based on record review and document review, medical staff failed to assess and/or authorize the use of restraints in 3 of 10 Patients. (Patient #1 ,2 and 10)

Findings include:

Review of policy CLIN-002 entitled "Restraints: Acute Medical Surgical" last revised 11/09 revealed in an emergency, a restraint may be applied by, or under the supervision and direction of a RN. The nurse must immediately request an assessment by a physician. The physician should make every effort to assess the patient within 30 minutes of notification. Orders for restraints will include the specific reason for the restraint, type of restraint and time limit.

Review of Nursing Note dated 9/19/09 at 2300 revealed Patient #1 was in a Posey Vest. Review of Physician Orders revealed no evidence medical staff wrote restraint orders for this patient and assessed patient after the application of restraints.

Review of Nursing Note dated 9/29/09 at 0230 revealed Patient #2 was admitted to telemetry. A call was placed to the physician due to Patient # 2's altered mental status and requested an order to continue telemetry and restraints. The physician stated he would be in at 0600 to write the orders.


Review of Physician Orders dated 9/29/09 at 0606 revealed an order for restraints for Patient #2, but does not include reason for restraints, type of restraint or timeframe. There was no evidence of a patient assessment. Review of the Acute Medical Surgical Restraint Order form dated 9/29/09 at 0700 (different practitioner) revealed vest and wrist restraints for Patient #2 were ordered. At 0710 the transcribing nurse documented the application of restraints for the 11-7 shift, last shift. There is no evidence medical staff assessed and wrote restraint orders within the required timeframe.

Review of Nursing note dated 10/6/09 at 1855 revealed Patient #10 was pulling at lines, yelling, fighting and throwing things at staff. Ortho was called and 0.5mg of Ativan and wrist restraints were applied. There was no evidence of a physician assessment or written order for the restraint.

Based on medical record review and interview, the facility utilizes PRN orders for restraints in 5 of 7 medical patients. (Patient # 3, 4, 5, 6 and 9)

Findings include:

Review on 2/11/10 of the policy CLIN-002 entitled "Restraints: Acute Medical Surgical" last revised 11/09 revealed orders for restraints shall include the specific reason for the restraint, the type of restraint and specific limited prior of time for use. If the patient's behavior or type of restraint changes, a new order must be written. If restraint is terminated early and needs to be replaced the restraints can be reapplied. The policy does not provide accurate guidelines for restraint use according to regulations.

Review of Acute Medical Surgical Restraint orders for Patient #3 dated 2/1/10 - 2/10/10 revealed three different types of restraints (a canopy bed, lap and vest) were ordered for 24 hours.

Review of restraint order for Patient #3 dated 2/10/10 at 0815 revealed a canopy bed, lap and vest restraints were ordered for impulsive behavior and confusion/interfering with care. There was no evidence to support the need of restraint interventions at 0815 when the order was written.

Observation at 1200 revealed Patient #3 walking in the hallway with family without restraints. Review of the nursing note dated 2/10/10 at 1823 revealed the patient was restraint free from 0800 to 1430 with no issues. At 1430 Patient #3 was put into posey bed due to agitation at shift change. There was no evidence of an additional physician order at 1430 when the posey bed restraint was initiated.

Review of Acute Medical Surgical Restraint orders for Patient #4 dated 2/4/10 at 1100 revealed three different types of restraints (side rails x4, lap and vest) for 24 hours due to impulsive behavior, confusion interfering with care and cognitive impairment. Review of Physician Note dated 2/4/10 at 1100 revealed no evidence of behaviors which warranted restraint intervention at that time.

Review of Acute Medical Surgical Restraint orders for Patient #5 dated 2/8/10 at 1000 revealed an order for side rails x4, vest and wrist restraints. Reasons indicated for restraint are impulsive behavior, confusion/interfering with care, cognitive impairment, agitated movement directed towards device, lack of awareness of potential harm to self and imminent danger of injury to self and others. Review of Physician Note dated 2/8/10 at 1010 revealed Patient #5 was alert and awake in bed. There was no evidence to indicate Patient #5's behavior warranted restraint intervention at this time.

Review of Acute Medical Surgical Restraint order for Patient # 5 dated 2/9/10 at 1420 revealed an order for side rails x4 and vest restraints due to inability to follow instructions, impulsive behavior and lack of awareness of potential harm to self. Review of Physician Note dated 2/9/10 at 1410 revealed Patient #5 was alert and in bed with eyes closed. There was no evidence to indicate Patient #5's behavior warranted restraint intervention at this time.

Review of Acute Medical Surgical Restraint orders for Patient # 6 dated 2/1/10 - 2/10/10 revealed 5 different types of restraints were ordered (side rails x4, canopy bed, lap, vest and wrist) at the same time and can be utilized for 24 hours.

Review of the Acute Medical Surgical Restraint orders dated 2/3/10 at 1445 for Patient #6 revealed side rails x4, canopy bed, lap, vest and wrist restraints were ordered due to impulsive behavior, delirium, cognitive impairment and agitation movement directed towards device. Review of the Physician Note dated 2/3/10 at 1505 revealed Patient #6 is alert, awake with decreased agitation. There was no evidence to indicate Patient # 6's behavior warranted restraint intervention at this time.

Review of Acute Medical Surgical Restraint order for Patient # 9 dated 2/10/10 at 1130 revealed an order for a canopy bed due to impulsive behavior and confusion/interfering with care. Observation at 11:25 revealed Patient #9 lying in bed holding the TV remote. Review of Physician Notes dated 2/10/10 revealed no evidence indicating behaviors warranting restraint intervention at this time.

Interview on 2/10/10 at 1100 with Staff #3 revealed behaviors that would require a restraint would be harm to self, increased risk of falls, decreased orientation, attempting to get out of bed and pulling at lines. Orders are good for 24 hours. If a restraint is discontinued and reapplied, a note would be written with the rationale. There are no PRN orders for restraints.

Interview on 2/10/10 at 1130 with Staff #4 and #5 revealed behaviors which require restraint include harm to self or others and fall precautions such as with Patient #9 who has dementia and a head injury. Orders are good for 24 hours and a new order is not needed if restraints are discontinued and then reapplied.

Based on documentation review and interview, the facility failed to report a death associated with the use of restraints within the required timeframes.

Findings include:

Review of the Nursing Flow Sheets dated 09/19/09, 09/20/09 and 09/21/09 reveals that Patient #1 was in a vest restraint.

Review of Inpatient Consultation dated 09/21/09 at 1515 reveals "early this a.m. code blue called as pt. found pulseless and breathless by nurse with Posey vest tight around neck."

Review of Physician Progress Note dated 09/21/09 at 0450 reveals the patient was intubated, placed on a vent and transferred to MICU.

Review of the Physician Progress Note dated 09/25/09 at 1555 reveals that the family decided to withdraw Patient #1 from the vent. Patient #1 expired at 1655.

Review of the Medical Examiner's Report of Autopsy conducted 09/26/09 at 1100 reveals the cause of Patient #1's death as "Hypoxic encephalopathy due to Asphyxia due to Entanglement in Restrictive Medical restraint Device."

Interview on 2/11/10 at 1115 with Staff #1 revealed she was not aware of the requirement and has not reported the events of Patient #1's death to CMS.