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Based on document reviews, and staff interview, it was determined that for 1 of 2 (Pt. #3) clinical records reviewed, the hospital failed to ensure an order was written for the use of restraints.

Findings include:

1. The Hospital policy titled, "Restraint Application, Use and Monitoring" (approved 11/15/12) required, " Restraint Usage for the Non-Violent /Medical Patient... Physician order is required for initial use and renewal of restraints for non-violent patients and must include...."

2. The clinical record for Pt. #3 was reviewed on 1/16/13 at 10:00 AM. Pt. #3 was a 70 year old female admitted on 12/21/13 with diagnoses of shortness of breath, lung mass, non-ST elevation, Cardiac Artery Disease and Hypertension. The clinical record contained documentation of soft wrist restraints being applied for restlessness and pulling on medical devices, on 1/12/14, and 1/13/14. Documentation indicated that Pt. #1 remained in restraints during this record review (1/16/14 at 10:00 AM). The record contained physician orders for the restraints dated 1/14/14, 1/15/14, and 1/16/14. However, there were no orders found for the initial application of restraints on 1/12/14 through 1/13/14.

3. The above findings were discussed with the Divisional Director of Critical Care Nursing on 1/16/14 at approximately 10:00 AM who stated there should be Physician orders for use of restraints.

Based on document review and interview, it was determined that for 2 of 2 (Pt. #2 and #3), clinical records reviewed for restraints, the Hospital failed to ensure a face to face evaluation of the patient was completed within 12 hours of restraints, according to Hospital policy.

Findings include:

1. The Hospital policy titled, "restraint Application, use and Monitoring" (approved 11/15/12) required, "6. A face to face physician evaluation of the patient is completed within 12 hours of initiation of restraints for the non-violent patient and before renewal of the order."

2. The clinical record for Pt. #2 was reviewed on 1/14/14 . Pt. #2 was a 44 year old female admitted on 1/11/14 with diagnosis of acute pyelonephritis and seizure. The clinical record contained a physician order for soft bilateral wrist restraints dated 1/12/14 at 9:46 AM,and discontinued on 1/13/14 at 9:12 PM. The clinical record lacked a face to face physician evaluation within 12 hours of initiation of restraints.

3. The clinical record for Pt. #3 was reviewed on 1/16/13 at 10:00 AM. Pt. #3 was a 70 year old female admitted on 12/21/13 with diagnoses of shortness of breath, lung mass, non-ST elevation, Cardiac Artery Disease and Hypertension. The clinical record contained documentation of soft wrist restraints being applied for restlessness and pulling on medical devices, on 1/12/14, and 1/13/14, without an order. The record contained 3 physician orders dated 1/14/14, 1/15/14, and 1/16/14 for soft wrist restraints due to Pt. #3 pulling on medical devices. However, the record lacked a face to face physician evaluation within 12 hours of initiation of restraints and before renewal of the orders.

4. The above findings were discussed with the Chief Nurse Officer and the MICU Manager during interview on 1/17/13 at approximately 9:00 AM who stated that they could not find the required face to face physician evaluation after initiation of restraints..

Based on documents review, interview and stated practice, it was determined that for 2 of 7 (Pt. #1 and #4) records reviewed, the Hospital failed to ensure all care rendered were documental.

Findings include:

1. The Hospital policy titled, "Nursing Documenting Requirements for In-Patient Care" (Effective June 2011) required, "Policy-A. Accurate and timely documentation is essential for quality of care and outcomes as it: ...provides a record of all care rendered... B. Documentation of care occurs at the time care is given or as soon thereafter as possible. D. Documentation occurs primarily in the electronic medical record with some components on paper."

2. The clinical record for Pt. #1 was reviewed on 1/15/13. Pt. #1 was a 49 year year old female admitted on 10/1/13 with history of embolitic stroke, lupus nephritis, subdural hematoma, and a complaints of fatigue, leg swelling, headaches, and concern for subdural hemorrhage on admission. Daily nursing flowsheet reviewed for ADLs indicated that peri-care was provided frequently due to frequent episodes of stool incontinence, with moisture barrier ointment applied. The flowsheet documentation indicated a bath was done on 11/24/13 at 10:04 AM. However on subsequent days (11-25/13-11/30/13) the record lacked documentation of staff providing baths to Pt#1, until 12/1/13 at 7:00 PM, a total of 6 days without a bath. The Nursing assessments documented Pt#1 unable to provide self-care and required complete to maximum assistance from staff due to deterioration in health. Documentation did not reflect that Pt#1 or family resisted or refused bathing

3. The clinical record of Pt. #4 was reviewed on 1/14/13 at approximately 10:50 AM. Pt. #4 was a 49 year old female admitted on 12/23/13 with diagnoses of shortness of breath, hypertension and rule out pulmonary embolism. Nursing admission notes dated 11/24/13 documented Pt.#4's skin as "not intact...excoriation". Subsequent notes indicated Pt. #4 on on complete bedrest, complete assist with activities of daily living (ADL) including bathing and daily wound precaution activities such as turning and repositioning. The personal care flowhseet documentation indicated Pt. #4 provided/assisted with baths on 12/24, 12/25, and 12/27/13. However there were no documentation of bath assists or provision from 12/28/13 through 1/9/14.

4. The above findings were discussed with the Divisional Director of Critical Care Nursing on 1/14/14 at approximately 11:00 AM who stated that it is standard practice in MICU for all patients to receive a Chlorohexedine bath daily, and should be documented in the record

Based on documents review and interview, it was determined that for 1 of 2 (Pt. #2) records reviewed, the Hospital failed to ensure the care plan was updated and reflected the use of restraints.

Findings include:

1. The Hospital policy titled, "Nursing Documenting Requirements for In-Patient Care" (Effective June 2011) required, "Nursing Care Plan: A Documented individualized care plan organizes and prioritizes patient/family needs and nursing intervention...The care plan is: ...reviewed at least daily and updated as indicated based on diagnosis of new problems...."

2. The Hospital policy titled, "Restraints Application, Use and Monitoring" (approved 11/15/12), required, "The patient's documented plan of care must reflect the use of restraints."

3. The clinical record for Pt. #2 was reviewed on 1/14/14 . Pt. #2 was a 44 year old female admitted on 1/11/14 with diagnosis of acute pyelonephritis and seizure. The clinical record contained a physician order for soft bilateral wrist restraints dated 1/12/14 at 9:46 AM and was discontinued on 1/13/14 at 9:12 PM. On review of the care plan on 1/14/14, the care plan was not updated to reflect the use of restraints.

4. The above findings were discussed with the the MICU Nurse Educator during an interview on 1/14/14 at approximately 11:30 AM who indicated that care plans should be updated.