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Based on the scope and severity of deficiencies related to patient restraints, the facility failed to substantially comply with this condition.

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A-0168 Based on staff interview and document review, it was determined the facility failed to ensure the use of restraints were in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient in five (5) of six (6) records of patients in restraints reviewed in the survey sample.

A-0175 Based on staff interview and document review, it was determined the facility failed to ensure the condition of each patient in restraints was adequately monitored in two (2) of six (6) medical records of patients with orders for restraints in the survey sample.

A-0186 Based on staff interview and document review, it was determined the facility failed to ensure it documented alternatives to restraints in one (1) of six (6) medical records of patients in restraints reviewed in the survey sample.

Based on staff interview and document review, it was determined the facility failed to ensure the use of restraints were in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient in five (5) of six (6) records of patients in restraints reviewed in the survey sample. Medical record #'s 1, 3-6.

Findings:

Six (6) medical records of patients in restraints were reviewed on 08/29/22 with a Nurse Clinician (staff member #3)assisting in the navigation of the electronic medical record (EMR).

The medical record for patient #1 contained documentation that the patient was in bilateral soft wrist restraints beginning on 08/24/22 at 7:40 PM. The physician order for the restraints expired on 08/25/22 and was not renewed until 08/27/22. The patient was in bilateral wrist restraints on 08/26/22 with no active physician order for the restraints.

The medical record for patient #3 contained documentation that the patient was in bilateral mitts with wrist restraints on 08/22/22. The physician order for the restraint expired on 08/21/22 and was not renewed, but the patient continued in the restraints.

The medical record for patient #4 contained documentation that the patient was placed in bilateral soft wrist restraints for pulling at lines and tubes 07/30/22 - 08/07/22. The medical record contained no physician order for the restraints on 08/01/22 despite the patient remaining in soft wrist restraints on 08/01/22.

The medical record for patient #5 contained documentation that all four (4) side rails were up on the patient's bed. The record did not contain documentation that the patient could independently put down the fourth side rail. The medical record failed to contain an order for the use of four (4) side rails.

The medical record for patient #6 contained an order for all four (4) side rails to be up dated and timed 08/17/22 at 8:00 PM. The nursing documentation indicated the four (4) side rails were utilized as a restraint on 08/17/22 and 08/18/22. The medical record did not contain a physician order for the use of (4) side rails on 08/18/22. The patient was also placed in bilateral soft wrist restraints on 08/16/22. The physician order for the restraints expired on 08/17/22. The patient continued in bilateral soft wrist restraints on 08/17/22 despite the absence of a new physician order.

During record review on 08/29/22 staff member #5 stated that a new physician order for restraints was required each calendar day and confirmed the absence of orders for restraints in the above noted records.

The facility's policy, Restraint and seclusion was reviewed and partially reads as follows: The use of four side rails are not considered a restraint when used in the following situations: At the request of a competent adult patient who can demonstrate lowering of a rail for safe exit .....Duration of orders. Non-violent/non-self-destructive restraint orders expire in the morning following a full calendar day. At that time, the order is considered to be complete/discontinued, and a new order is obtained if it becomes necessary to reapply or continue the restraints.

Based on staff interview and document review, it was determined the facility failed to ensure the condition of each patient in restraints was adequately monitored in two (2) of six (6) medical records of patients with orders for restraints in the survey sample. Medical records # 5 and 6.

Findings:

Six (6) medical records of patients in restraints were reviewed on 08/29/22 with a Nurse Clinician (staff member #3) assisting in the navigation of the electronic medical record (EMR).

The medical record for patient #5 indicated all four (4) side rails were up per the patient's request at approximately 7:50 AM on 08/21/22. The medical record contained no documentation that the patient was able to independently put down the fourth (4) side rail and contained no physician order for the side rails. The patient remained in restraints (four side rails up) for approximately an hour and 52 minutes according to facility documentation. After this time, when the nurse returned to assess the patient the patient was found on the floor after an apparent fall.

The medical record for patient #6 contained an order for all four (4) side rails to be up dated and timed 08/17/22 at 8:00 PM. The nursing documentation indicated the four (4) side rails were utilized as a restraint on 08/17/22 and 08/18/22. The medical record failed to contain any monitoring according to hospital policy while the patient was restrained on 08/17/22 and 08/18/22.

Staff member #3 confirmed the absence of documentation of monitoring of patients in restraints during record review.

The facility's policy, Restraint and seclusion was reviewed and partially reads as follows: Monitoring is performed according to the following standards by a team member who had completed the required restraint training and competency. This includes: ...Non-behavioral restraints: Observe patients frequently. Document monitoring and care in the patient's record by a trained RN at least every two (2) hours. Care is provided based on the assessed needs of the patient and includes: Offering liquids and nutrition, comfort measures, toileting, temporary release the occurs for the purpose of caring for a patient's needs (toileting, feeding, range of motion). This is not considered a trial release.

Based on staff interview and document review, it was determined the facility failed to ensure it documented alternatives to restraints in one (1) of six (6) medical records of patients in restraints reviewed in the survey sample. Medical record #6.

Findings:

Six (6) medical records of patients in restraints were reviewed on 08/29/22 with a Nurse Clinician (staff member #3)assisting in the navigation of the electronic medical record (EMR).

The medical record for patient #6 contained an order for all four (4) side rails to be up dated and timed 08/17/22 at 8:00 PM. The nursing documentation indicated the four (4) side rails were utilized as a restraint on 08/17/22 and 08/18/22. The patient was also placed in bilateral soft wrist restraints on 08/16/22. The physician order for the restraints expired on 08/17/22. The patient continued in bilateral soft wrist restraints on 08/17/22 despite the absence of a new physician. A new physician order was documented on 08/18/22 at 2:26 PM. The clinical record failed to contain documentation of alternatives to the restraints.

During record review staff member #3 confirmed the absence of alternatives to restraint use in the medical record for patent #6.

The facility's policy, Restraint and seclusion was reviewed and partially reads as follows: Restraint alternatives are attempted prior to the use of restraint or seclusion unless there is an immediate jeopardy of harm.