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Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined the facility failed to use restraints in accordance with the order of a physician for three of three medical records reviewed (MR7, MR8, and MR9).

Findings include:

Review of facility "Policy and Procedure for Patient Restraint and Seclusion" last revised April, 2017, revealed "1. Physical Restraint: Any manual method or physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely ... B. Non-violent, non-self-destructive patient's restrain use: ... All orders for restraint/seclusion must include: Type of restraint utilized based upon patients' assessed needs and least restrictive modality."

Review of facility documentation revealed MR7 had a physician order dated January 6, 7, 8, and 9, 2019, for "mittens". Further review revealed the physician order failed to include left or right mitten or both. Review of MR7 revealed documentation that left and right mittens where applied.

Review of facility documentation revealed MR8 had a physician order dated January 17, 18, and 19, 2019, for "soft wrist". Further review revealed the physician order failed to include left or right soft wrist or both. Review of MR8 revealed documentation that left and right soft wrist restraints were applied.

Review of facility documentation revealed MR9 had a physician order dated January 23, 2019, for "soft wrist". Further review revealed the physician order failed to include left or right soft wrist or both. Review of MR9 revealed documentation that left and right soft wrist restraints were applied.

Interview with EMP2 on January 20, 2019, at 11:15 AM confirmed the above findings and revealed "You're right, the order doesn't include right or left."

Based on a review of medical records (MR), facility documentation and staff interviews (EMP), it was determined the facility failed to update an interdisciplinary plan of care to reflect changes in the patient's wound treatment for one of 16 medical records reviewed. (MR1).

Findings include:

Review of facility policy "Care Plan Documentation" revised April 2016 revealed "...Purpose...Interddisciplinary plans of care (IPOCs) are developed in order to direct the patient's nursing care from admission to discharge... ."

Review of MR1's History and Physical dated October 16, 2018, revealed the patient was admitted to the facility on October 16, 208 with a chief complaint of altered mental status and diagnoses that included quadriplegia with paralysis, acute on-chronic kidney disease, chronic anemia and pressure ulcers.

Review of Progress Note-Nurse dated and documented by EMP4 on October 16, 2018, at 11:09 AM revealed treatment orders for colostomy care, a stage 3 buttocks pressure injury, and a left ankle unstageable wound.

A review of MR1's IPOC initiated on October 17, 2018, revealed no documentation regarding the treatment orders documented by EMPX on October 16, 2018, at 11:09 AM.

During interview on January 31, 2019, at approximately 11:00 AM EMP4 confirmed the above findings and failure to document the treatment orders anywhere else but the progress note on October 16, 2018, at 11:09 AM.