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Based on interview, record review and review of the facility's policy, it was determined the facility failed to identify two (2) of the facility's approved "restraint alternatives" as meeting the definition of a restraint. The facility failed to identify the use of non anchored mittens which were bulky in size that significantly reduced the patient's ability to use their hands and elbow immobilizers that restricted and prohibited movement of the arms, as meeting the definition of a restraint.

The findings include:

Review of the facility's policy titled "Restraints and Seclusion", Policy A08-120, revealed the definition for a restraint to be any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely. Further review revealed, a restraint alternative is a method for redirecting unsafe behavior, serving as a reminder to maintain ongoing medical treatments and preventing accidental patient harm.

Review of a facility provided list of patients in "restraint alternatives" for the date 04/19/13, revealed three (3) patients in non-anchored mittens and an additional three (3) patients that were not specific as to what alternative was in use but listed "Yes" on the alternative list. For the date of 04/22/13, two (2) patients were documented as having elbow immobilizers in use, four (4) patients with non-anchored mittens in use and an additional five (5) patients that were not specific as to the alternative in use.

1. Review of the medical record revealed, the facility admitted Patient #1 to the facility on 04/15/13 at 12:55 PM with diagnoses which included an Altered Level of Consciousness. Record review revealed on 04/19/13 at 8:00 PM, Patient #1 had non-anchored mittens applied. There was no evidence found documenting a Physician's order for the application or when the mittens were applied and why the patient's hands were restricted and prohibited from normal movement.

2. Review of the medical record revealed, the facility admitted Patient #4 to the facility on 04/14/13 at 12:43 with diagnoses which included Cerebral Vascular Accident. Further record review revealed documentation of non-anchored mittens in use with no documentation when these were applied.

3. Review of the medical record revealed, the facility admitted Patient #9 to the facility on 11/22/12 at 10:51 AM with diagnoses which included weakness and leg pain. Review of the medical record revealed the patient was admitted with a diagnoses which included a positive blood culture obtained on 11/22/12. Further review, on 12/02/13 at 1:00 PM, revealed documentation of mittens removed; however, there was no documentation of the mitten application.

Interview with Registered Nurse (RN) #4, on 04/19/13 at 2:50 PM, revealed the use of elbow immobilizers and bulky mittens were not restraints but restraint alternatives. RN #4 further stated the restraint alternatives were not tied to the bed, therefore were not restraints. Further interview revealed the "restraint alternatives" did restrict movement.

Interview with Charge Nurse #10, on 04/19/13 at 3:15 PM, revealed the "restraint alternatives" did restrict movement and motion of the patient. Further interview revealed, a Physician's order was not necessary to use the alternatives.

Interview with Unit Manager #11, on 04/19/13 at 3:15 PM, revealed the mittens did limit the range of motion for the fingers and hands and the elbow immobilizer did restrict movement at the elbow. Unit Manager #11 further stated that these were restraint alternatives because they were not attached to the bed.

Interview with Educational Registered Nurse #12, on 04/19/13 at 3:15 PM, revealed "the hospital did not view them as a restraint and Physician's order was not needed".

Interview with Charge Nurse #17, on 04/23/13 at 12:45 PM, revealed the elbow immobilizers were restrictive to the patient but less restrictive than being restrained to the bed.

Interview with Registered Nurse #10, on 04/23/13 at 1:00 PM, revealed the mittens prohibit the fine motor movement of the fingers and prohibit the use of the hands but was less restrictive than other methods.

Interview with the Director of the Enterprise, on 04/22/13 at 12:45 PM, revealed the mittens and the elbow immobilizer were restricting the patient's movement; however, stated the facility consulted a Consultant for clarification and thought it was acceptable to use the mittens and elbow immobilizer as a "restraint alternative".

Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to ensure implementation of restraints in accordance with safe and appropriate techniques for four (4) of ten (10) sampled patients (Patient #1, Patient #3, Patient #4 and Patient #9). The facility failed to ensure restraints were applied in a consistent and safe manner. The facility failed to notify the Attending Physician related to the restraint applications. The facility had approved the use of non-anchored mittens, which were bulky in size and restricted normal patient activity; and approved the use of elbow immobilizers that restricted upper extremity movement, as a restraint "alternative", which the facility determined did not require a physician's order or any restraint documentation for the safety of the patient.

The findings include:

Review of the facility's policy titled, Restraints and Seclusion, Policy A08-120, revealed a restraint was any manual method, physical or mechanical device, material, or equipment that immobilized or reduced the ability of the patient to move his or her arms, legs, body, or head freely (a "physical restraint"). Further review revealed any use of restraints and/or seclusion should include a written modification to the patient's plan of care, be based on an individual order, include evaluation and monitoring of the patient's condition and ordered by the treating health care provider.

1. Review of the medical record revealed the facility admitted Patient #1, on 04/15/13, with a diagnosis of Altered Level of Consciousness. Further review of Patient #1's medical record revealed restraints were applied, on 04/16/13, with no documented evidence a physician's order was obtained for the use of the restraint. Continued review of the medical record revealed there was no documented evidence as to when the restraint was removed or reason the restraint was removed.

Review of Physician's orders, dated 04/17/13, revealed non-anchored mittens were to be applied to Patient #1's hands. Further review of the medical record revealed, the non-anchored mitten were discontinued, on 04/19/13, due to the patient was "calm". Continued record review revealed, on 04/19/13, Patient #1 had non-anchored mittens applied; however, there was no documented evidence that a physician's order for the application was obtained or documentation as to why the mittens were applied. Further review of Patient #1's medical record revealed, the mittens were applied, on 04/20/13, with no documented evidence a Physician's order was obtained. Additionally, there was no documented evidence a restraint care plan was developed per the facility's policy. There was no documentation found that Patient #1's Attending Physician's was notified of any restraint application, per the facility's policy.

2. Review of the medical record revealed the facility admitted Patient #3, on 04/16/13, with diagnoses which included Altered Mental Status and to Rule Out Aspiration. Further review of Patient #3's medical record revealed restraints were applied, on 04/17/13 at 10:00 AM; however, there was no documentation a Physician's order was immediately obtained until 04/1713 at 3:29 PM. Further review revealed, restraints were discontinued on 04/17/13 at 19:30 PM; however, there was no documentation as to the reason of discontinuation of the restraint per facility's policy.

3. Review of the medical record revealed the facility admitted Patient #4, on 04/14/13, with diagnoses which included Cerebral Vascular Accident. Further review of Patient #4's medical record revealed, on 04/16/13 at 8:00 PM, non-anchored mittens were in use with no documentation found for a physician's order or the reason for the use of the mittens. Further review of the medical record revealed the non anchored mittens were again applied, on 04/18/13 at 2:00 AM with no documentation a Physician's order was obtained. Further review of the record revealed the mittens remained on Patient #4 until an order was written on 04/19/13 at 9:43 AM. there was no documented evidence Patient #4's Attending Physician's was notified of any restraint application, per the facility's policy.

4. Review of the medical record revealed the facility admitted Patient #9, on 11/22/12, with diagnoses which included Weakness and Leg Pain. Further record review revealed a physician's order was obtained for use of restraints, on 11/26/12. Further review revealed, on 11/28/12 at 8:00 AM, there was no documented evidence the patient remained in restraints nor when the restraints were discontinued or rationale as to why the restraints were removed. Further review, on 12/02/12 at 1:00 PM, revealed documentation of mittens removed; however, no documentation of the mitten application. Further review of Patient #9's medical record revealed a Physician's order for restraints, on 12/10/12 at 6:17 AM, with no documentation that restraints were applied or documentation of a change in the patient condition. Further review revealed a nursing note, dated 12/10/12 at 12:00 PM, documenting "restraints remain on patient". Additionally, there was no consistent evidence found identifying a restraint flow nursing flow sheet, nor safe consistent restraint documentation. There was no documented evidence that Patient #9's Attending Physician's was notified of the restraint application, per the facility's policy.

Interview with Registered Nurse (RN) #1, on 04/19/13 at 1:50 PM, revealed he thought the Attending Physician notification was with the order set and that notifying the Attending Physician was not a routine practice.

Interview with Registered Nurse (RN) #3, on 04/19/13 at 1:50 PM, revealed the practice was to call the Physician Resident for the order. RN #3 stated the nursing staff did not notify the Attending Physicians of the restraints.

Interview with Registered Nurse (RN) #4, on 04/19/13 at 2:50 PM, revealed the use of elbow immobilizers and non-anchored mittens were not restraints but restraint alternatives. RN #4 further stated the restraint alternatives were not tied to the bed, therefore were not restraints. Further interview revealed the "restraint alternatives" did restrict movement.

Interview with Charge Nurse #10, on 04/19/13 at 3:15 PM, revealed the "restraint alternatives" did restrict movement and motion of the patient. Further interview revealed, a Physician's order was not necessary for the use of alternative restraints.

Interview with the Director of the Enterprise, on 04/22/13 at 12:45 PM, revealed the Attending Physician should be notified when restraints were initiated per the facility's policy. Further interview revealed, the "restraint alternatives" were restricting to the patient and even reduced the patient's mobility; however, the facility consulted with a Consultant for clarification. Additional interview, on 04/23/13 at 12:00 PM, revealed any application of a restraint should have a Physician's order, nursing restraint flow sheet and care plan per the facility's policy.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure the use of restraint or seclusion be in accordance with the order of a Physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. The facility failed to obtain a Physician's order for restraints for four (4) of ten (10) sampled patients (Patient #1, Patient #3, Patient #4 and Patient #9).

The findings include:

Review of the facility's policy titled "Restraints and Seclusion", Policy A08-120, revised 11/09/12, revealed all restraint usage required an order from the treating health care provider.

1. Review of the medical record revealed, the facility admitted Patient #1 to the facility on 04/15/13 at 12:55 PM with diagnoses which included an Altered Level of Consciousness. Further review of Patient #1's medical record revealed, restraints were applied on 04/16/13 at 1:35 PM with no documented evidence a Physician's order was obtained. Restraints were again initiated on 04/17/13 at 3:07 AM. The Physician's order was not obtain immediately after the application of the restraints, per Federal Regulation A-0168, but documented on 04/17/13 at 6:41 AM. Record review revealed on 04/19/13 at 8:00 PM, Patient #1 had non-anchored mittens applied; however, there was no documented evidence of a Physician's order for the application or when the mittens were applied and why the patient's hands were restricted and prohibited from normal movement. Further review of Patient #1's medical record revealed, restraints were applied on 04/20/13 at 1:00 AM with no documented evidence a Physician's order was obtained. Further review of Patient #1's medical record revealed, restraints were again initiated on 04/20/13 at 9:00 AM with no Physician's order obtained until 04/20/13 at 10:20 AM.

2. Review of the medical record revealed, the facility admitted Patient #3 to the facility on 04/16/13 at 12:17 PM, with diagnoses which included Altered Mental Status and to Rule Out Aspiration. Further review of Patient #3's medical record revealed restraints were applied on 04/17/13 at 10:00 AM. Documentation of a Physician's order was not immediately obtained per Federal Regulations, but was dated 04/17/13 at 3:29 PM.

3. Review of the medical record revealed, the facility admitted Patient #4 to the facility on 04/14/13 at 12:43 with diagnoses which included Cerebral Vascular Accident. Further review of Patient #4's medical record revealed, on 04/16/13 at 8:00 PM, non-anchored mittens were in use with no documentation found for a Physician's order, when they were applied or why the restrictions were implemented. Further review of the medical record revealed, restraints were initiated on 04/18/13 at 2:00 AM with no documentation that a Physician's order was obtained. Documented evidence further revealed the restraints remained on Patient #4 until an order was written on 04/19/13 at 9:43 AM.

4. Review of the medical record revealed, the facility admitted Patient #9 to the facility on 11/22/12 at 10:51 AM with diagnoses which included weakness and leg pain. Review of the medical record revealed the patient was discharged from the Emergency Department and later notified by a Physician to return to the Emergency Department for admit with a diagnoses which included a positive blood culture obtained on 11/22/12. Further review, on 12/02/12 at 1:00 PM, revealed documentation of mittens removed; however, there was no documentation of a Physician's order for the application of the mittens.

Interview with the Director of the Enterprise, on 04/23/13 at 12:00 PM, revealed any application of a restraint should have a Physician's order.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure the Attending Physician was consulted as soon as possible after an order was obtained for a restraint for four (4) of ten (10) sampled patients (Patient #1, Patient #3, Patient #4 and Patient #9).

The findings include:

Review of the facility's policy titled "Restraints and Seclusion" Policy A08-120, revealed the Attending Physician should be consulted as soon as possible if he/she did not order the restraint or seclusion.

1. Review of the medical record revealed, the facility admitted Patient #1 to the facility on 04/15/13 at 12:55 PM with diagnoses which included an Altered Level of Consciousness. Further review of the medical record revealed the patient had been placed in restraints with no documentation found the Attending Physician had been consulted or notified.

2. Review of the medical record revealed, the facility admitted Patient #3 to the facility on 04/16/13 at 12:17 PM, with diagnoses which included Altered Mental Status and to Rule Out Aspiration. Further review of the medical record revealed the patient had been placed in restraints with no documentation found the Attending Physician had been consulted or notified.

3. Review of the medical record revealed, the facility admitted Patient #4 to the facility on 04/14/13 at 12:43 with diagnoses which included Cerebral Vascular Accident. Further review of the medical record revealed the patient had been placed in restraints with no documentation found the Attending Physician had been consulted or notified.

4. Review of the medical record revealed, the facility admitted Patient #9 to the facility on 11/22/12 at 10:51 AM with diagnoses which included weakness and leg pain. Review of the medical record revealed the patient was discharged from the Emergency Department and later notified by a physician to return to the Emergency Department for admit with a diagnoses which included a positive blood culture obtained on 11/22/12. Further review of the medical record revealed the patient had been placed in restraints with no documentation found the Attending Physician had been consulted or notified.

Interview with Recruiting Registered Nurse #18, on 04/22/13 at 3:30 PM, revealed the Attending Physician should be notified of the patient being placed in restraints. Further interview revealed she was unable to locate documentation of the Attending Physician's notification of the restraint applications.

Interview with the Director of the Enterprise, on 04/22/13 at 12:45 PM, revealed the Attending Physician should be notified when restraints were initiated per the facility's policy. Further interview revealed, the facility's restraint policy did not designate who was responsible to do this.

Based on interview and record review, it was determined the facility failed to ensure all patient's medical record entries were complete and contained sufficient information to promote continuity of care among providers for one (1) of ten (10) sampled patients (Patient #3). Patient #3's medical record contained another patient's information in the Emergency Department's History and Physical.

The findings include:

Record review revealed, Patient #3 was an eighty-eight (88) year old male, admitted by the facility to the Emergency Department on 04/16/13 at 12:17 PM, with the chief complaint of Altered Mental Status Changes and Rule out Aspiration. Further review revealed, Patient #3 was intubated and placed on a ventilator (mechanical breathing device) in the Emergency Department on 04/17/13 at 9:15 AM.

Review of Patient #3's History and Physical completed by the Emergency Department's Resident Physician and authenticated by the Emergency Department's Attending Physician, dated 04/16/13 at 11:38 PM, revealed Patient #3 to be a twenty-two (22) year old female involved in a Motor Vehicle Collision.

Interview with Resident Physicians #14 and #15, on 04/22/13 at 1:45 PM, revealed the electronic system would not allow charting on multiple patients. Further interview revealed once documentation on a patient was complete, the resident would save the information and exit out of the patient's file. After exiting out, the Resident Physician would then be able to open another patient's information. Further interview revealed, the attending received computer notification to authenticate the document when the Resident Physician completed the record.

Interview with Attending Physician #16, on 04/22/13 at 1:55 PM, revealed he could sign multiple patient orders at a time; however, to authenticate or "sign off" on a patient's record the system required him to do every patient individually. He further stated that "it would be easy to click on the wrong patient". Additionally, Attending Physician #16 stated if he were a surveyor, this would be a minor documentation error that should not even be cited.

Interview with Patient Care Manager #9 and the Director of the Enterprise, on 04/18/13 at 1:15 PM, revealed the facility's Emergency Department process was the Resident Physician would enter the patient's information into the facility's electronic charting systems and the Emergency Department's Attending Physician would check the information for correctness and then authenticate the document. Further interview revealed, the Resident Physician and Attending Physician did not fully exit out of Patient #3's medical record prior to documenting the information for the other patient and that information was collected into Patient #3's medical record. Further interview revealed the expectation would be to confirm the correct information for the correct patient.