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Based on clinical record review and review of policy and procedure it was determined the nursing staff did not comprehensively assess six of six (#1-#6) patients as to the condition or symptom that warranted the use of more than one (side rails up times four, soft limb, vest, etc.) restraint at a time. The nursing staff failed to adhere to the written policy " Restraints and Seclusion, effective 04/25/12, in that side rails up times four and another restraint device was used which was i8n conflict with the policy. The failed practice did not assure the least restrictive and appropriate device was in use for the patient ' s condition which warranted the use of a restraint. The failed practice had the likelihood to affect patients who were restrained. The findings were:
A. Patient #1: Review of the physician ' s order on 06/14/13 at 1055 and 06/15/08 at 1108 revealed the type of restraint was side rails up times four and a vest restraint. The reason was | " disoriented, confused, attempting to get up/unsafe " . Review of the Adult Assessment and Intervention nursing notes from 06/14/13 to 06/15/13 revealed there was no descriptive assessment of the patient ' s physical ability to ambulate or transfer with or without assistance. In fact the Nursing Admission Assessment-Adult Patient Profile dated 06/13/13 at 0120 revealed, under Activity-Exercise/Self Care, the patient was independent with ambulation, transfer, toileting, bathing dressing and eating. Review of the Restraints Non-Violent/Non-Self Destructive records for 06/14/13 and 06/15/13 revealed there was no descriptive assessment of the patient ' s physical ability to ambulate or transfer which made it unsafe for the patient to do so; there was no separate assessment for the side rails up times four and vest restraint to determine the necessity for the use of each restraint at the same time and which was the least restrictive device to use.
B. Patient #2: Review of the physician ' s orders 06/19/13 at 1616, 06/24/13 at 1613 and 06/26/13 at 1318 revealed the type of restraint was side rails up times four and bilateral upper extremity soft limb restraints. The reason was " disoriented, attempting to get up/unsafe ambulation " of " disoriented, confused, and removing medical devices " . Review of the Restraints Non-Violent/Non-Self Destructive records from 06/19/13 at 1500 at 06/26/13 at 1000 revealed there was no descriptive assessment of the patient ' s physical ability to ambulate or transfer which made it unsafe for the patient to do so; there was no separate assessment for the side rails up times four and bilateral upper extremity soft limb restraints to determine the necessity for the use of each restraint at the same time and which was the least restrictive device to use. Observation on 06/26/13 at 1320 revealed all four side rails were up and bilateral upper extremity soft limb restraints were applied. During interview of Registered Nurse (RN) #2, the Surveyor questioned why the side rails times four were up and soft limb restraints used. RN #2 stated for the patient ' s protection as the patient was pulling at lines and tubes and the patient ' s legs were flailing over the side of the bed.

C. Patient #3: Review of the physician ' s orders 06/20/13 at 1422, 06/21/13 at 1351, 06/22/13 at 1150, 06/23/13 at 1345, 06/24/13 at 1300, 06/25/13 at 1241, 06/25/13 at 1549 and 06/26/13 at 1336 revealed the type of restraint was side rails up times four, bilateral upper extremity soft limb restraints and vest restraint. The reason was " disoriented, confused, attempting to get up/unsafe ambulation " or " disoriented, confused, inability to follow directions " . Review of the Restraints Non-Violent/Non-Self Destructive records from 06/20/13 at 1300 to 06/26/13 at 1000 revealed there was no descriptive assessment of the patient ' s physical ability t ambulate or transfer which made it unsafe for the patient to do so. There was no separate assessment for the side rails up times four, bilateral upper extremity soft limb restraints and vest restraint to determine the necessity for the use of each restraint at the same time and which was the least restrictive device to use. Review of the Restraints Non-Violent/Non-Self Destructive records for 06/20/13 from 2000 to 06/21/13 at 1320 revealed the RN recorded a bed enclosure restraint was used; there was no order to use a bed enclosure restraint. Observation on 06/26/13 at 1320 revealed a vest restraint was applied and the top two side rails were up. During the exit conference on 06/26/13 at 1430, the Vice President of Patient Care Services/Chief Nursing Officer stated the facility did not have bed enclosure restraint devices in the building for use.

D. Patient #4: Review of the physician ' s orders 06/12/13 at 0225, 06/13/13 at 1242, 06/15/13 at 1318, 06/16/13 at 1724, 06/07/13 at 1957, 06/18/13 at 1754, 06/20/13 at 1009, 06/21/13 at 0916, 06/22/13 at 0412, 06/24/13 at 0643, 06/25/13 at 0157 and 1308 and 06/26/13 at 0814 and 1308 revealed the type of restraint was side rails up times four and left upper extremity soft limb restraints. The reason was " inability to follow directions and removing medical devices " , " removing medical devices " and " disoriented " . Review of the Restraints Non-Violent/Self Destructive records from 06/12/13 at 0230 to 06/26/13 at 1145 revealed there was no descriptive assessment of the patient condition or symptom that warranted the use of side rails up times four; there was no separate assessment for the side rails up times four and bilateral upper extremity soft limb restraints to determine the necessity for the use of each restraint at the same time and which was the least restrictive device to use.

E. Patient #5: Review of the physician ' s orders 06/04/13 at 1222, 06/06/13 at 2151, 06/10/13 at 2130, 06/12/13 at 0153 and 1931, 06/13/13 at 1257, 06/14/13 at 1923, 06/15/13 at 1838, 06/16/13 at 1831, 06/17/13 at 1839, 06/18/13 at 1901, 06/20/13 at 1548, 06/21/13 at 1529, 06/22/13 at 1032, 06/23/13 at 1134, 06/24/13 at 2019 and 06/25/13 at 2010 revealed the type of restraint was side rails up times four, bilateral upper extremity soft limb restraints and vest restraint. The reason was " Inability to follow directions, removing medical devices " and " Disoriented, confused, attempting to get up/unsafe " . Review of the Restraints Non-Violent/Non-Self Destructive records from 06/04/13 at 1200 to 06/26/13 at 1200 revealed there was no separate assessment for the ride rails up times four and bilateral upper extremity soft limb restraints to determine the necessity for the use of each restraint at the same time and which was the least restrictive device to use.

F. Patient #6: Review of the physician ' s orders 06/22/13 at 0904, 06/23/13 at 0821, 06/24/13 at 0757 and 06/25/13 at 0802 revealed the type of restraint was side rails up times four and vest restraint. The reason was " Attempting to get up/unsafe " and " Disoriented, Confused, Attempting to get up/unsafe " . Review of the Restraints Non-Violent/Non-Self Destructive records from 06/22/13 at 1000 to 06/26/13 at 1200 revealed there was no descriptive assessment of the patient ' s physical ability to ambulate or transfer which made it unsafe for the patient to do so; there was no separate assessment for the side rails up times four and vest restraint to determine the necessity for the use of each restraint at the same time and which was the least restrictive device to use.
G. Review of the written policy " Restraints and Seclusion, effective 04/25/12 " , revealed under E. Side Rails, Key Points, " Top two (2) side rails up at all times with the above restraints " . The above restraints were vest, soft limb holders, mittens, leather limb restraints. The staff failed to adhere to the written policy in that Patient #1-#6 had orders for side rails up times four plus a vest or soft limb restraint applied and was verified in review of the Restraints Non-Violent/Non-Self Destructive records as above.

H. On 07/26/13 at 0907 via electronic mail, the Regulatory Specialist confirmed the above findings.