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Based on record reviews, facility policy review, and staff interviews, the facility failed to protect and promote the rights of all patients admitted to the facility. Findings include:

During the course of the survey, the following concerns were identified. The facility staff did not: determine if less restrictive interventions would have been effective to protect the patient prior to restraint use (A164.); notify the physician immediately when restraints were applied (A168.); follow the facility's policy with the use of as needed orders for restraints (See A169.); assess the patient for the earliest possible time to remove the restraints (See A171.); renew restraint orders as stated in the facility's policy (A173.); renew restraints for violent/self-destructive behaviors every fours hours for up to a total of 24 hours (See A174.); document an 1-hour face-to-face assessment of the physical and behavioral response to being placed in restraints by the physician, licensed independent practitioner (LIP), or trained registered nurse (RN) (See A179 and A184.).

Based on medical record review, policy review, and staff interview, the facility failed to assess 1 (#7) of 7 sampled records to determine if less restrictive interventions would have been effective to protect the patient prior to the use of restraint. Findings include:

1. Patient #7, an 88-year-old-male, was admitted to medical floor on 3/20/10. The patient was admitted for dementia, agitation, and aggression.

During the medical record review on 3/24/10 at 3:46 p.m., the following information was noted:

Per the Safety/Fall Risk Assessment on 3/20/10 at 4:51 p.m. and 3/21/10 at 2:54 a.m., the patient was a high risk for falls.

On 3/21/10 at 5:30 a.m., the nurse documented the following, "Focus: Abrasion to forehead D [Data]: Bed alarm goes off the same time we hear a loud bang from PTs [Patient's] room; We find pt sitting on the floor at side of bed with abrasion to forehead bleeding; He has urinal in hand and had urine in it and on the floor A [Action]: Assisted back to bed; [Name of physician] called; He comes to exam pt and orders received to sent pt to ER [emergency room] for suturing; Pt taken per Gerichair [sic] to ER accomp [accompanied] by [Staff name], CNA [Certified Nursing Assistant] and [Physician's name]."

On 3/21/10 at 6:30 a.m., the nurse documented the patient was back from ER with steri-strips on his lacerations. The patient was in a Geri chair with his feet elevated. No evidence in the record of a physicians physicain order while he was in the Geri chair.

On 3/21/10 at 10:45 a.m., the nurse filled out the Non-Violent/Non-Self-Destructive Restraint Physician Orders. The nurse implemented the restraint order for the physical safety of the patient to support medical healing. The nurse chose the following devices: Enclosure Bed and Geri Chair, for use in the same time frame. The nurse did not fill out the telephone order section for the restraints. The physician signed the restraint order on 3/22/10 at 3:00 p.m., 28 hours later. When the physician signs the restraint order the physician was acknowledging that the patient has been examined or reassessed and documented on of the use of the restraints by the physician.

On 3/21/10 at 10:47 p.m., the nursing staff implemented the Restraint Documentation. The staff listed the following reasons for implementing the enclosure bed: "attempted to get up, confusion/disorientation, impulse, lack of judgement, protect for injury, unable to follow directions, and unsafe ambulation." The following less restrictive methods were tried: "bed alert, decreased environment stimuli, assist with transfers, increased observation, moved to a room closer to the nursing station, and reoriented." The staff placed the patient in an enclosed bed.

On 3/24/10 at 11:45 a.m., the surveyor observed the patient in a Geri chair. There was no evidence in the record of a physician's order while he was in the Geri chair. The enclosed bed had been removed on 3/22/10 during the day shift. The patient was placed in a low bed with a mat on the floor. The surveyor interviewed the patient's nurse at this time. The nurse stated the patient was claustrophobic, so she had removed the enclosed bed.

Record review showed no evidence of claustrophobia or behaviors described that led to the decision for the enclosed bed.

The chart lacked documentation about a low bed with mat being tried before the use of the enclosed bed.

2. On 3/25/10 starting at 10:20 a.m., the surveyor interviewed 3 staff nurses about restraints. The 3 staff nurses stated before placing a patient in restraints, the staff needed to try other diversions, such as closure to the nurse's station, pain medications, and taking the resident to the bathroom.

3. On 3/24/10 at 4:00 p.m., the clinical patient safety coordinator stated the staff should have tried a low bed with a mat on the floor before putting the patient in a enclosed bed.

4. On 3/24/10 at 5:00 p.m., the surveyor reviewed the facility's Restraints: Non-Violent & Violent/Self- Destructive policy. The surveyor noted the following statements documented under "Procedure/Responsibilities: Restraint for Non-Violent/Non-Self Destructive Care (medical) I. A non-violent/non-self destructive restraint can only be used based on the patient's clinical assessment if needed to improve the patient's well being and less restrictive interventions have been determined to be ineffective. Restraints are applied...."

Based on medical record review, policy review and staff interview, the facility failed to ensure that the restraint policy included the appropriate time interval for physician notification when restraints were applied to patients. The facility failed to notify the physician immediately when restraints were applied to 2 (#s 7 and 18) of 7 sampled residents. Findings include:

1. Patient #7, an 88-year-old-male, was admitted to medical floor on 3/20/10. The patient was admitted for dementia, agitation, and aggression.

During the medical record review on 3/24/10 at 3:46 p.m., the following information was noted:

On 3/21/10 at 6:30 a.m., the nurse documented the patient was back from ER with steri-strips on his lacerations. The patient was in a Geri chair with his feet elevated. No evidence in the record of a physicians order while he was in the Geri chair.

On 3/21/10 at 8:45 a.m., the nurse documented in the Safety/Fall Risk Assessment, the patient was in restraints. There was no evidence in the record of a physicians order while the staff was charting about the patient being in a restraint.

On 3/21/10 at 10:45 a.m., the nurse filled out the Non-Violent/Non-Self-Destructive Restraint Physician Orders. The nurse implemented the restraint order for the physical safety of the patient to support medical healing. The nurse chose the following devices: Enclosure Bed and Geri Chair, for use in the same time frames. The nurse did not fill out the telephone order section for the restraints. The physician signed the restraint order on 3/22/10 at 3:00 p.m., 28 hours later. When the physician signs the restraint order the physician stating the patient has been examined or reassessed and documented, the need for the use of restraints.

On 3/21/10 at 10:47 a.m., the nurse documented in the Restraint Documentation that the enclosed bed was implemented.

On 3/21/10 at 3:26 p.m., the nurse documented in the Nurse Notes, "...Posey bed used, no agitation or combativeness this shift."

Record review showed no evidence of the physician being notified when the patient was placed in restraints on 3/21/10 at 8:45 a.m. There was no evidence of the physician documenting about the restraint in the Progress Notes. The first acknowledgement of the restraint by the physician was when the order was signed on 3/22/10 at 3:00 p.m.

2. Patient #18, an 89-year-old-male, was admitted to the facility on 3/3/10. The patient was admitted for confusion, altered mental status, possible TIA (Transient Ischemic Attack) or "even stroke."

During the medical record review on 3/25/10 at 8:00 a.m., the following information was noted:

On 3/10/10 at 7:40 p.m., the nurse wrote the following telephone order, "[Enclosed] bed if seroquel and haldol do not help."

On 3/11/10 at 11:30 a.m., the nurse documented in the Patient's Notes, "Focus: Behavior D[Data]: Pt [patient] continues to be agitated and confused. Will not stay in bed or the chair. A [Action]: Placed in [Enclosed] bed for pt safety. Continue to monitor."

On 3/11/10 at 12:13 p.m., the nurse documented in the Safety/Fall Risk Assessment, the patient was in restraints. At this time, the nurse documented in the Restraint Documentation the patient was in an enclosed bed.

Per documentation, the patient was placed in an enclosed bed on 3/11/10 at 11:30 a.m. The nurse filled out the Non-Violent/Non-Self-Destructive Restraint Physician Order on 3/11/10 at 8:00 p.m., 8 and 1/2 hours later.

On 3/11/10 at 8:00 p.m., the nurse filled out the Non-Violent/Non-Self-Destructive Restraint Physician Orders. The nurse implemented the restraint order "for the physical safety of the patient to support medical healing and the safety risk to self, staff, and others." The following devices were selected: Enclosure Bed and Geri Chair, for use in the same time frames. Below the nurse's signature, she wrote the following "PRN [As Needed] 3/10/10 [Staff member initial]." The physician signed but did not indicate a time or date on the restraint order.

Record review showed no evidence of the physician being notified when the patient was placed in restraints on 3/11/10 at 11:30 a.m. There was no evidence of the physician documenting about the restraint in the Progress Notes. The first acknowledgement of the restraint by the physician was when the physician signed but did not indicate a time or date on the restraint order.

The patient's medical record lacked documentation of physician notification that the restraint was placed at 11:30 a.m.

3. On 3/2/10 at 4:30 p.m., the surveyor requested the facility's restraint policy.

On 3/24/10 at 5:00 p.m., the surveyor reviewed the facility's Restraints: Non-Violent & Violent/Self- Destructive policy. The surveyor noted the following statements documented under II. "A physician or other LIP (Licensed Independent Practitioner) orders restraints. This order is:...B. If a physician/LIP is not available to issue such an order, restraint use is initiated by a registered nurse based on an appropriate assessment of the patient. In this case, a physician/LIP is notified of the initiation of restraint and a verbal order or written order is obtained within 12 hours from that practitioner and entered into the patient's medical record. If the initiation of restraint is based on an unanticipated change in the patient's condition, the registered nurse immediately notifies a physician/licensed independent practitioner. A written order, based on a face-to-face examination of the patient by a physician/LIP, is entered into the patient's medical record within 24 hours of the initiation of restraint."

The policy did not include the requirement by the federal regulations that an order for restraint must be given and signed by the physician/LIP prior to initiating the use of restraint and if the situation is an emergency, the physician order may be obtained either during the emergency or immediately (within a few minutes) after the restraint was applied.

4. On 3/24/10 at 5:15 p.m., the surveyor asked the clinical patient safety coordinator about the policy. She stated the facility recently revised the restraint policy. She did not realize that the sentence about contacting the physician 12 hours after the restraints were applied was in the policy.

5. On 3/25/10 starting at 10:20 a.m., the surveyor interviewed 3 different staff nurses about restraints. The 3 staff nurses stated to place a restraint they would need a physician order. The staff could apply the restraint but the physician needed to be contacted immediately.

Based on medical record review, policy review, and staff interview, the facility failed to ensure orders for the use of restraints were not written as a standing order, or on an as needed (PRN) basis for 2 (#s 7 and 18) of 7 sampled residents. Findings include:

1. Patient #7, an 88-year-old, was admitted to medical floor on 3/20/10. The patient was admitted for dementia, agitation, and aggression.

During the medical record review on 3/24/10 at 3:46 p.m., the following information was noted:

On 3/20/10 at 5:40 p.m., the physical wrote the following order, "...7. Soft 4 pt [point] restraints if absolutely necessary."

On 3/20/10 at 5:59 p.m., the physician dictated the following in the history and physical, "Soft restraints as needed."

The staff did not place patient #7 in 4 point restraints.

On 3/24/10 at 4:00 p.m., the clinical patient safety coordinator stated the facility does not allow as needed restraint orders. The order for the 4 point restraints, if absolutely necessary, was not allowed by the facility.

2. Patient #18, an 89-year-old-male, was admitted to the facility on 3/3/10: with confusion, altered mental status, and possible TIA (Transient Ischemic Attack) or "even" stroke.

During the medical record review on 3/25/10 at 8:00 a.m., the following information was noted:

On 3/10/10 at 7:40 p.m., the nurse wrote the following telephone order, "[Enclosed bed] if seroquel and haldol do not help."

The staff placed the resident in an enclosed bed on 3/11/10 at 12:14 p.m. The staff used the PRN order for the enclosed bed.

On 3/11/10 at 8:00 p.m., the nurse filled out the Non-Violent/Non-Self-Destructive Restraint Physician Orders. The nurse implemented the restraint order "for the physical safety of the patient to support medical healing and the safety risk to self, staff, and others." The following devices were selected: Enclosure Bed and Geri Chair. Below the nurse's signature, she wrote the following "PRN [As Needed] 3/10/10 [Staff member initial]." The physician signed but did not indicate a time or date on the restraint order.

On 3/25/10 at 7:30 a.m., the clinical patient safety coordinator stated the facility does not allow as needed restraint orders. The nursing staff never should have written the telephone order, "[Enclosed] bed if seroquel and haldol do not help."

3. On 3/24/10 at 5:00 p.m., the surveyor reviewed the facility's Restraints: Non-Violent & Violent/Self- Destructive policy. The surveyor noted the following statements documented under, II. "A physician or other LIP (Licensed Independent Practitioner) orders restraints. This order is: ...PRN orders for restraints are not used at [Name of facility] Hospitals."

4. On 3/25/10 starting at 10:20 a.m., the surveyor interviewed 3 staff nurses about restraints. The 3 staff nurses stated the facility did not allow PRN restraint orders.

Based on medical record review, policy review, and staff interview, the facility failed to renew restraints for violent/self-destructive behaviors every fours hours for up to a total of 24 hours for 1 (#7) of 7 sampled resident.

1. On 3/24/10 at 11:45 a.m., the surveyor observed the patient in a Geri chair. The enclosed bed had been removed on 3/22/10 during the day shift. The patient was placed in a low bed with a mat on the floor. The surveyor interviewed the patient's nurse at this time. The nurse stated the patient was claustrophobic, so she had removed the enclosed bed.

On 3/25/10 at 11:10 a.m., the surveyor observed resident #7 in his room in a Geri chair. The low bed and mat on the floor observed on 3/24/10 was gone. The bed had been replaced with an enclosed bed.

2. At this time the chart was reviewed and the following documentation was noted:

* Patient #7, an 88-year-old-male, was admitted to the medical floor on 3/20/10. The patient was admitted for dementia, agitation, and aggression.

* On 3/24/10 at 10:12 p.m., nurse #27 documented the following in Patient Notes, "Focus: Aggressive Behavior D: Called to room [number] for report of aggressive behavior. Found the CNA [certified nursing assistant] with bite bark [sic] on inner arm, LPN [licensed practical nurse] kicked in chest and RN [registered nurse] punched in left jaw. Security in room attempting to calm patient, who at this time became withdrawn and not interacting or answering staff questions. A: Notified Dr. [doctor] and order received for restraints to include geri chair and [enclosed] bed. Service response notified re: need to set-up [enclosed] bed. Notified patient flow."

* On 3/24/10 at 10:45 p.m., nurse #27 wrote the following telephone order, "Initiate Restraints, geri chair and [enclosed] bed." The Geri chair and enclosed bed were ordered for the same time frame.

* On 3/24/10 at 11:00 p.m., nurse #26 documented the following in Patient Notes, " Focus: Skin Data: Patient bit himself on his left forearm when trying to place him Geri chair. Informed patient he was biting his own arm. Patient oriented x1. PT [patient] did not breakskin [sic]. He did bruise his left forearm."

* On 3/24/10 at 11:17 p.m., the nurse filled out the Non-Violent/Non-Self-Destructive Restraint Physician Orders. The nurse implemented the order for the physical safety of the patient to support medical healing and safety risk to self, staff, and others. The following devices were selected: Enclosure Bed and Geri Chair, for the same time frame. The physician signed the order on 3/24/10 at 11:00 p.m.

* On 3/25/10 at 12:56 a.m., nurse #26 documented the following in Patient Notes, "Focus: Behavior Data: PT was attempting to get out of bed. Patient unable to stand without assist. He is high fall risk. Had to call for assist from CNA. We assisted PT PT [sic] from the side of the bed and and [sic] had him lay down while explaining why. PT became angry. He kicked LPN in the chest. Patient continued to swing at staff and try to get out of bed without assist. Called another staff member to assist us in putting him into the Geri chair. While going to assist him to the chair he punched the RN in the chin. Then bit the CNA in the left forearm. Then bit himself on his leftforem [sic]. PT oriented x1. Response: Received orders for Geri chair from MD and [enclosed] bed. Placed patient in Geri chair. Soon relaxed after putting him in the Geri chair. Called security."

* At the end of record review, there was no evidence of a new restraint order since 11:00 p.m. on 3/24/10. There was no evidence of a physician progress note since 8:00 p.m. on 3/24/10.

3. The facility's restraint policy describes, "...4. A restraint for violent/self-destructive behavior refers to application of a restraint for the protection of the patient against injury to self or others because of an emotional or behavioral disorder; it also refers to an emergency situation in which the intervention is used to handle sudden violent, aggressive or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or that of others and non-physical interventions would not be effective. The use of restraint for violent/self-destructive behavior is not based on patient's restraint history or solely on a history of dangerous behavior.
"5. A restraint for non-violent/non-self destructive care refers to an intervention used to promote or restore the patient's health in the least restrictive manner possible and is to protect the physical safety of the patient. The primary reason for use directly supports medical healing...."

4. On 3/25/10 at 11:20 a.m., the third floor charge nurse stated, the third floor did not have any violent/self harm restraints order forms. The violent/self harm restraint order forms were only at the psychiatric unit. The charge nurse stated, "third floor can not have violent/self harm patients on the third floor." Those patients need to go to the psychiatric unit, not at the main hospital.

5. On 3/25/10 at 11:25 a.m., the third floor manager stated, the patient was crawling out of the bed. The staff were helping the patient back into bed. The patient did not want to be in bed. The staff were trying to help him back into the bed, so the patient got irritated and started swinging at the staff. The patient punched a nurse in the chin and bit a CNA. Once the patient was placed in the restraint, he calmed right down. The manager stated she did not believe the patient's actions were violent. If it had been a violent action, the patient would have been in four point restraints.

Based on observation record review, facility policy review, and staff interview, the facility failed to renew restraint orders as stated in the facility's policy for 1 (#18) of 7 sampled residents. Findings include:

1. On 3/24/10 at 5:00 p.m., the surveyor reviewed the facility's Restraints: Non-Violent & Violent/Self- Destructive policy. The surveyor noted the following statements documented under II. "A physician or other LIP [Licensed Independent Practitioner] orders restraints. This order is:...C. A physician/LIP issuing a new order does so when a change of status of restraint use is identified (i.e. stopping bilateral wrists restraints and beginning enclosure bed use; or stopping 4 point use and beginning bilateral wrists only) and the restraint use continues to be clinically justified."

2. During the medical record review on 3/25/10 at 8:00 a.m., the following information was noted:

Patient #18, an 89-year-old-male, was admitted to the medical floor on 3/3/10. The patient was admitted for confusion, altered mental status, possible TIA (Transient Ischemic Attack) or "even" stroke.

On 3/10/10 at 7:40 p.m., the nurse wrote the following telephone order, "[Enclosed bed] if seroquel and haldol do not help."

The staff placed the resident in an enclosed bed on 3/11/10 at 12:14 p.m. The staff used the PRN order for the enclosed bed.

On 3/11/10 at 8:00 p.m., the nurse filled out the Non-Violent/Non-Self-Destructive Restraint Physician Orders. The nurse implemented the restraint order "for the physical safety of the patient to support medical healing and the safety risk to self, staff, and others." The following devices were selected: Enclosure Bed and Geri Chair, for use in the same time frame. Below the nurse's signature, she wrote the following "PRN [As Needed] 3/10/10 [Staff member initial]." The physician signed but did not indicate a time or date on the restraint order.

On 3/13/10 at 10:00 p.m., the nurse charted on the Restraint Documentation form the type of restraints used for patient #18 were the modular rehab bed and Geri chair during the same time frame. The medical record lacked documentation of a new order for the modular rehab bed and Geri chair during the same time frame.

The nurses charted the use of the modular rehab bed on the Restraint Documentation form on 3/14/10 at 12:05 a.m., 2:00 a.m., 4:00 a.m., and 6:00 a.m.

On 3/14/10 at 8:00 a.m., the nurse charted on the Restraint Documentation form the type of restraint used for patient #18 were the enclosure bed and Geri chair during the same time frame. The medical record lacked documentation of a new order for the enclosure bed and Geri chair during the same time frame.

On 3/15/10 at 11:59 p.m., the nurse charted on the Restraint Documentation form the type of restraints used for patient #18 were the modular rehab bed. The medical record lacked documentation of a new order for the modular rehab bed and Geri chair during the same time frame.

The nurses charted the use of the modular rehab bed on the Restraint Documentation form on 3/16/10 at 8:15 a.m., and 8:11 p.m., and on 3/17/10 at 1:00 a.m.

On 3/25/10 at 11:30 p.m., the clinical patient safety coordinator stated, she went to the nursing floor to clarify with the nursing staff that the modular rehab bed was not in use at the main hospital east campus. The clinical patient safety coordinator stated, the modular rehab bed was used only in rehab on the west campus not at the main hospital on the east campus. The nurses who charted about the modular rehab bed really meant enclosure bed. The nurses on the above dates chart the wrong restraint. The device used was an enclosed bed.

On 3/25/10 starting at 10:20 a.m., the surveyor interviewed 3 staff nurses about restraints and the modular rehab bed. The 3 staff nurses did not know what a modular rehab bed was, or the use of the modular rehab bed.

Based on observation medical chart review, policy review, and staff interview, the facility failed to assess the patient for the earliest possible time to remove the restraints for 1 (#7) of 7 sampled residents. Findings included:

1. On 3/24/10 at 11:45 a.m., the surveyor observed the patient in a Geri chair. The enclosed bed had been removed on 3/22/10 during the day shift. The patient was placed in a low bed with a mat on the floor. The surveyor interviewed the patient's nurse at this time. The nurse stated the patient was claustrophobic, so she had removed the enclosed bed.

On 3/25/10 at 11:10 a.m., the surveyor observed resident #7 in his room in a Geri chair. The low bed and mat on the floor which was observed on 3/24/10 was gone. The bed had been replaced with an enclosed bed.

2. At this time the chart was reviewed and the following documentation was noted:

* Patient #7, an 88-year-old-male, was admitted to the medical floor on 3/20/10. The patient was admitted for dementia, agitation, and aggression.

* On 3/24/10 at 10:00 p.m., nurse #27 staff implemented the Restraint Documentation assessment. The following reasons listed for the implementation of the Geri chair and enclosed bed were: "Attempting to get up, confusion/disorientation, lack of judgement, protect form injury, unable to follow directions, and unsafe ambulation." The following were less restrictive alternatives used:" increased observation, bed alert, assist with ambulation, bed in low position fall mats and reorient." The nurse documented the following, "The Geri chair and closed bed are to protect him from falling hurting himself and staff."

* On 3/24/10 at 10:12 p.m., nurse #27 documented the following in Patient Notes, "Focus: Aggressive Behavior D: Called to room [number] for report of aggressive behavior. Found the CNA [certified nursing assistant] with bite bark [sic] on inner arm, LPN [licensed practical nurse] kicked in chest and RN [registered nurse] punched in left jaw. Security in room attempting to calm patient, who at this time became withdrawn and not interacting or answering staff questions. A: Notified Dr. [doctor] and order received for restraints to include geri chair and [enclosed] bed. Service response notified re: need to set-up [enclosed] bed. Notified patient flow."

* On 3/24/10 at 10:45 p.m., nurse #27 wrote the following telephone order, "Initiate Restraints, geri chair and [enclosed] bed." The Geri chair and enclosed bed were ordered for the same time frame.

* On 3/24/10 at 11:00 p.m., nurse #26 documented the following in Patient Notes, " Focus: Skin Data: Patient bit himself on his left forearm when trying to place him [sic] Geri chair. Informed patient he was biting his own arm. Patient oriented x1. PT [patient] did not breakskin [sic]. He did bruise his left forearm."

* On 3/24/10 at 11:00 p.m., nurse #26 charted in the Restraint Documentation the patient was in the Geri chair for the use of the independent patient. The Geri chair was being used for prevention of falls.

* On 3/24/10 at 11:17 p.m., the nurse filled out the Non-Violent/Non-Self-Destructive Restraint Physician Orders. The nurse implemented the order for the physical safety of the patient to support medical healing and safety risk to self, staff, and others. The following devices were selected: Enclosure Bed and Geri Chair, for use in the same time frame. The physician signed the order on 3/24/10 at 11:00 p.m.

* On 3/25/10 at 12:00 a.m., nurse #26 charted in the Restraint Documentation the patient was in the Geri chair for the use of the independent patient.

* On 3/25/10 at 12:56 a.m., nurse #26 documented the following in the Patient Notes, "Focus: Behavior Data: PT was attempting to get out of bed. Patient unable to stand without assist. He is high fall risk. Had to call for assist from CNA. We assisted PT PT [sic] from the side of the bed and and [sic] had him lay down while explaining why. PT became angry. He kicked LPN in the chest. Patient continued to swing at staff and try to get out of bed without assist. Called another staff member to assist us in putting him into the Geri chair. While going to assist him to the chair he punched the RN in the chin. Then bit the CNA in the left forearm. Then bit himself on his leftforem [sic]. PT oriented x1. Response: Received orders for Geri chair form MD and [enclosed] bed. Placed patient in Geri chair. Soon relaxed after putting him in the Geri chair. Called security."

* On 3/25/10 at 2:00 a.m., 4:00 a.m., and 6:00 a.m., nurse #26 charted in the Restraint Documentation the patient was in the enclosed bed.

* On 3/25/10 at 3:00 a.m., nurse #26 documented in patient #7's Patient Notes about the patient removing his telemetry wires and not keeping them on.

* On 3/25/10 at 8:30 a.m., the RN documented in patient #7's Patient Notes about the patient not being in pain or discomfort.

3. On 3/25/10 at 11:25 a.m., the third floor manager stated, the patient was crawling out of the bed. The staff were helping the patient back into bed. The patient did not want to be in bed. The staff were trying to help him back into the bed, so the patient got irritated and started swing at the staff. The patient punched a nurse in the chin and bit a CNA. Once the patient was placed in the restraint he calmed right down. The manager stated she did not believe the patient's actions were violent. If it had been a violent action, the patient would have been in four point restraints.

When the patient calmed down after being placed in the Geri chair or the enclosed bed the patient was no longer a risk to him self or others. The patient should have been removed from his Geri chair or enclosed bed.

4. The surveyor noted the following statements documented in the facility's restraint policy: "Discontinuing A Restraint (Non-Violent or Violent) I. Restraints are discontinued at the earliest possible time. Restraints may be discontinued by an RN or LPN when the patient no longer poses a threat of injury to himself or others, no longer poses a threat to interfere with medical intervention, or other criteria defined by the ordering LIP [Licensed Independent Practitioner] based on original behavior. Discontinuing a restraint does not require a physician's order."

Based on observation medical record review, policy review, and staff interviews, the facility failed to assess the patient's physical and behavioral response to being placed in restraints during the 1 hour face-to-face evaluation for 1 (#7) of 7 sample residents. Findings include:

1. The surveyor noted the following statement within the facility's restraint policy, "...IV. One (1) Hour face to face evaluation: A physician, LIP, or RN who has been trained in the restraints or seclusion requirements must conduct a face to face evaluation of the patient's medical and behavioral condition within one hour of initiation of the intervention. If a trained RN is conducting the face-to-face evaluation, the results of the evaluation must be relayed to the physician as soon as possible (within 30 minutes) after the completion of the evaluation. The medical and behavioral assessment includes:
A. A description of the patient's behavior and interventions used;
B. Patients physical and psychological status;
C. Alternatives or less restrictive interventions attempted (as applicable);
D. The patient's condition or symptom(s) that warranted the use of the restraint or seclusion; and
E. The patient's response to the intervention used, including the need for continued use of the intervention.
F. Physician Consultation when the RN preforms the face to face evaluation. The physician or LIP will review the staff, the patient's physical and psychological status, determined if restraint or seclusion should be continued and provide guidance on ways to help the patient regain control."

2. On 3/24/10 at 11:45 a.m., the surveyor observed the patient in a Geri chair. The enclosed bed had been removed on 3/22/10 during the day shift. The patient was placed in a low bed with a mat on the floor. The surveyor interviewed the patient's nurse at this time. The nurse stated the patient was claustrophobic, so she had removed the enclosed bed.

On 3/25/10 at 11:10 a.m., the surveyor observed resident #7 in his room in a Geri chair. The low bed and mat on the floor observed on 3/24/10 was gone. The bed had been replaced with an enclosed bed.

3. At this time the chart was reviewed and the following documentation was noted:

* Patient #7, an 88-year-old-male, was admitted to the medical floor on 3/20/10. The patient was admitted for dementia, agitation, and aggression.

* On 3/24/10 at 10:00 p.m., nurse #27 staff implemented the Restraint Documentation assessment. The following reasons listed for the implementation of the Geri chair and enclosed bed were: "Attempting to get up, confusion/disorientation, lack of judgement, protect form injury, unable to follow directions, and unsafe ambulation." The following were less restrictive alternatives used:" increased observation, bed alert, assist with ambulation, bed in low position fall mats and reorient." The nurse documented the following, "The Geri chair and closed bed are to protect him from falling hurting himself and staff."

* On 3/24/10 at 10:12 p.m., nurse #27 documented the following in Patient Notes, "Focus: Aggressive Behavior D: Called to room [number] for report of aggressive behavior. Found the CNA [certified nursing assistant] with bite bark [sic] on inner arm, LPN [licensed practical nurse] kicked in chest and RN punched in left jaw. Security in room attempting to calm patient, who at this time became withdrawn and not interacting or answering staff questions. A: Notified Dr. [doctor] and order received for restraints to include geri chair and [enclosed] bed. Service response notified re: need to set-up [enclosed] bed. Notified patient flow."

* On 3/24/10 at 10:45 p.m., nurse #27 wrote the following telephone order, "Initiate Restraints, geri chair and [enclosed] bed."

* On 3/24/10 at 11:00 p.m., nurse #26 documented the following in Patient Notes, " Focus: Skin Data: Patient bit himself on his left forearm when trying to place him Geri chair. Informed patient he was biting his own arm. Patient oriented x1. PT [patient] did not breakskin [sic]. He did bruise his left forearm."

* On 3/24/10 at 11:00 p.m., nurse #26 charted in the Restraint Documentation the patient was in the Geri chair for the use of the independent patient. The Geri chair was being used for prevention of falls. The nurse did not document the patient's behavioral and physical reaction to being placed in the restraints.

* On 3/24/10 at 11:17 p.m., the nurse filled out the Non-Violent/Non-Self-Destructive Restraint Physician Orders. The nurse implemented the order for the physical safety of the patient to support medical healing and safety risk to self, staff, and others. The following devices were selected: Enclosure Bed and Geri Chair for use during the same time frame. The physician signed the order on 3/24/10 at 11:00 p.m.

* On 3/25/10 at 12:00 a.m., nurse #26 charted in the Restraint Documentation the patient was in the Geri chair for the use of the independent patient. The nurse did not document the patient's behavioral and physical reaction to being placed in the restraints.

* On 3/25/10 at 12:56 a.m., nurse #26 documented the following, "Focus: Behavior Data: PT was attempting to get out of bed. Patient unable to stand without assist. He is high fall risk. Had to call for assist from CNA. We assisted PT PT [sic] from the side of the bed and and [sic] had him lay down while explaining why. PT became angry. He kicked LPN in the chest. Patient continued to swing at staff and try to get out of bed without assist. Called another staff member to assist us in putting him into the Geri chair. While going to assist him to the chair he punched the RN in the chin. Then bit the CNA in the left forearm. Then bit himself on his leftforem [sic]. PT oriented x1. Response: Received orders for Geri chair form MD and [enclosed] bed. Placed patient in Geri chair. Soon relaxed after putting him in the Geri chair. Called security."

On 3/25/10 at 11:10 a.m., the medical record lacked a documented assessment of the patient's physical and behavioral response to being placed in restraints during the 1 hour face-to-face evaluation.

4. On 3/25/10 at 11:20 a.m., the third floor charge nurse stated, the third floor did not have any violent/self harm restraints order forms. The violent/self harm restraint order forms were only at the psychiatric unit. The charge nurse stated, "third floor can not have violent/self harm patients on the third floor. Those patients need to go to the psychiatric unit, not at the main hospital."

5. On 3/25/10 at 11:25 a.m., the third floor manager stated, the patient was crawling out of the bed. The staff were helping the patient back into bed. The patient did not want to be in bed. The staff were trying to help him back into the bed, so the patient got irritated and started swing at the staff. The patient punched a nurse in the chin and bit a CNA. Once the patient was placed in the restraint he calmed right down. The manager stated she did not believe the patient's actions were violent. If it had been a violent action, the patient would have been in four point restraints.

Base on medical record review, policy review and staff interview, the facility failed to document an 1 hour face-to-face medical and behavioral evaluation of the restraints use to manage a violent or self-destructive behavior for 1 (#7) of 7 sampled residents. Findings include:

1. On 3/24/10 at 11:45 a.m., the surveyor observed the patient in a Geri chair. The enclosed bed had been removed on 3/22/10 during the day shift. The patient was placed in a low bed with a mat on the floor. The surveyor interviewed the patient's nurse at this time. The nurse stated the patient was claustrophobic, so she had removed the enclosed bed.

On 3/25/10 at 11:10 a.m., the surveyor observed resident #7 in his room in a Geri chair. The low bed and mat on the floor observed on 3/24/10 was gone. The bed had been replaced with an enclosed bed. During the observation the patient was sitting in a Geri chair, he presented to be calm, talking with family members.

2. At this time the chart was reviewed and the following documentation was noted:

* Patient #7, an 88-year-old-male, was admitted to the medical floor on 3/20/10. The patient was admitted for dementia, agitation, and aggression.

* On 3/24/10 at 10:00 p.m., nurse #27 staff implemented the Restraint Documentation assessment. The following reasons were listed for the implementation of the Geri chair and enclosed bed: "Attempting to get up, confusion/disorientation, lack of judgement, protect from injury, unable to follow directions, and unsafe ambulation." The following are less restrictive alternatives used:" increased observation, bed alert, assist with ambulation, bed in low position fall mats and reorient." The nurse documented the following, "The Geri chair and closed bed are to protect him from falling hurting himself and staff." The one hour face to face was not preformed at this time.

* On 3/24/10 at 10:12 p.m., nurse #27 documented the following in Patient Notes, "Focus: Aggressive Behavior D: Called to room [number] for report of aggressive behavior. Found the CNA [certified nursing assistant] with bite bark [sic] on inner arm, LPN [licensed practical nurse] kicked in chest and RN punched in left jaw. Security in room attempting to calm patient, who at this time became withdrawn and not interacting or answering staff questions. A: Notified Dr. [doctor] and order received for restraints to include geri chair and [enclosed] bed. Service response notified re: need to set-up [enclosed] bed. Notified patient flow."

* On 3/24/10 at 10:45 p.m., nurse #27 wrote the following telephone order, "Initiate Restraints, geri chair and [enclosed] bed." The Geri chair and enclosed bed were for the same time frame.

* On 3/24/10 at 11:00 p.m., nurse #26 documented the following in Patient Notes, " Focus: Skin Data: Patient bit himself on his left forearm when trying to place him Geri chair. Informed patient he was biting his own arm. Patient oriented x1. PT [patient] did not breakskin [sic]. He did bruise his left forearm."

* On 3/24/10 at 11:00 p.m., nurse #26 charted in the Restraint Documentation the patient was in the Geri chair for the use of the independent patient. The Geri chair was being used for prevention of falls. The nurse did not document the patients behavioral and physical reaction to being placed in the restraints. The one hour face to face was not preformed at this time.

* On 3/24/10 at 11:17 p.m., nurse #26 filled out the Non-Violent/Non-Self-Destructive Restraint Physician Orders. The nurse implemented the order for the physical safety of the patient to support medical healing and safety risk to self, staff, and others. The following devices were selected: Enclosure Bed and Geri Chair for the same time frame. The physician signed the order on 3/24/10 at 11:00 p.m. Yet the record lacked documentation of the one hour face to face being preformed.

* On 3/25/10 at 12:00 a.m., #26 charted in the Restraint Documentation the patient was in the Geri chair for the use of the independent patient.

* On 3/25/10 at 12:56 a.m., nurse #26 documented the following in Patient Notes, "Focus: Behavior Data: PT was attempting to get out of bed. Patient unable to stand without assist. He is high fall risk. Had to call for assist from CNA. We assisted PT PT [sic] from the side of the bed and and [sic] had him lay down while explaining why. PT became angry. He kicked LPN in the chest. Patient continued to swing at staff and try to get out of bed without assist. Called another staff member to assist us in putting him into the Geri chair. While going to assist him to the chair he punched the RN in the chin. Then bit the CNA in the left forearm. Then bit himself on his leftforem [sic]. PT oriented x1. Response: Received orders for Geri chair form MD and [enclosed] bed. Placed patient in Geri chair. Soon relaxed after putting him in the Geri chair. Called security."

* On 3/25/10 at 3:00 a.m., nurse #26 documented in patient #7's Patient Notes about the patient removing his telemetry wires and not keeping them on.

* On 3/25/10 at 8:30 a.m., the RN documented in patient #7's Patient Notes about the patient not being in pain or discomfort.

* On 3/25/10 at 11:10 a.m., the medical record lacked a documented assessment of the patient's physical and behavioral response to being placed in restraints during the 1 hour face-to-face evaluation. The last physician note was on 3/24/10 at 8:00 p.m.

2. The surveyor noted the following statement within the facility's restraint policy, "...IV. One (1) Hour face to face evaluation: A physician, LIP, or RN who has been trained in the restraints or seclusion requirements must conduct a face to face evaluation of the patient's medical and behavioral condition within one hour of initiation of the intervention. If a trained RN is conducting the face-to-face evaluation, the results of the evaluation must be relayed to the physician as soon as possible (within 30 minutes) after the completion of the evaluation. The medical and behavioral assessment includes:
A. A description of the patient's behavior and interventions used;
B. Patients physical and psychological status;
C. Alternatives or less restrictive interventions attempted (as applicable);
D. The patient's condition or symptom(s) that warranted the use of the restraint or seclusion; and
E. The patient's response to the intervention used, including the need for continued use of the intervention.
F. Physician Consultation when the RN preforms the face to face evaluation. The physician or LIP will review the staff, the patient's physical and psychological status, determined if restraint or seclusion should be continued and provide guidance on ways to help the patient regain control."

3. On 3/25/10 at 11:20 a.m., the third floor charge nurse stated, they did not have any violent/self harm restraints order forms. The violent/self harm restraint order forms were only at the psychiatric unit. The charge nurse stated, "third floor can not have violent/self harm patients on the third floor. Those patients need to go to the psychiatric unit, not at the main hospital."

4. On 3/25/10 at 11:25 a.m., the third floor manager stated, the patient was crawling out of the bed. The staff were helping the patient back into bed. The patient did not want to be in bed. The staff were trying to help him back into the bed, so the patient got irritated and started swing at the staff. The patient punched a nurse in the chin and bit a CNA. Once the patient was placed in the restraint he calmed right down. The manager stated she did not believe the patient's actions were violent. If it had been a violent action, the patient would have been in four point restraints.