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Based on observations, interview, medical record review and review of policies and procedures the facility failed to provide evidence their system for restraint use, assessment, care planning, delivery of care to a patient in restraints, and monitoring of the system was being implemented. The facility failed to ensure the completion of the staff training which had been identified as needed by an administrative team evaluation of a patient death in which restraints were in use. The team determined the staff member's lack of knowledge of the facility's restraint protocol, the difference between restraint usage with patients with violent versus non violent behaviors led the staff member to incorrectly identify the reason for the restraint usage and thereby failed to follow the facility's restraint protocols (A196). The facility staff failed to place the correct size restraint on Patient #1 (A167) failed to ensure the physicians' orders for restraints were timely (A168), failed to ensure the required face-to-face meetings by physicians with violent behavior patients were conducted (A178), failed to document restraint usage for violent behaviors (A187) and failed to ensure plans of care were initiated and updated timely for patients with non-violent restraints (A166). The cumulative effect of these sytemic practices resulted in the facility's inability to ensure the rights of eight of 10 patients reviewed with restraints were protected. (Patients #1, #2, #3, #4, #5, #6, #7, and #9)

Based on medical record reviews, and staff interviews, the hospital failed to ensure the plans of care were initiated or updated for 4 of 10 patients reviewed with non-violent restraints (patients #5, #6, #7, and #9)per facility policy.The census on the first day of survey was 244 patients.

Findings include:

Medical record reviews were conducted for Patients #5, #6, #7, and #9 on 01/23/13 and 01/24/13. The reviews revealed the plans of care were not initiated, or updated as instructed by the facility policy for the usage of restraints with patients with non-violent behaviors.

In interview,Staff B verified on 01/24/13 at 9:27 AM these patients' plans of care should have been updated at least daily.

Patient #5 was placed in soft wrist restraints with side rails in the upright position on 01/18/13 at 9:39 PM. The restraints were continued to be used through 01/21/13 at 10:54 PM. The plan of care was not initiated until 01/20/12 at 11:23 PM for the use of these restraints. This was 49 hours and 44 minutes after the initiation of the restraints.

Patient #6's plan of care for restraints was initiated on 01/23/13 at 6:06 AM. However, the patient was placed in non-violent restraints (soft wrist and four side rails) on 01/05/13, and continued to be restrained in this manner from that date though 01/24/13. On 01/22/13 at 3:40 PM, this patient was observed lying in bed with bilateral wrist restraints in place and four split siderails in the upright position. The care plan was not initiated until 17 days after the restraints were in use.

Patient #7's medical record revealed, on 01/19/13 at 9:42 PM, the patient was placed in side wrist restraints with side rails in the upright position when in bed. These restraints continued to be uses until discontinued on 01/22/13 at 8:00 AM. A review of the medical record on 01/24/13 at 8:58 AM revealed there was no plan of care in place for these restraints.

Patient #9's medical record revealed on 01/20/13 at 2:39 PM, the patient was placed in soft wrist restraints with four split side rails in the upright position when in bed. The restraints continued to be used until 01/24/13.
A review of the medical record on 01/24/13 at 9:27 AM revealed there was no plan of care in place for these restraints. This was 90 hours and 46 minutes after the initiation of the restraints.

On 01/22/12 at 1:30 PM, a review was conducted of the facility's policies regarding the development of plans of care for restraint usage. The policy titled "General Documentation Policy" stated the following: Staff shall initiate an individualized plan of care within 24 hours of admission. Review the plan every shift. Update and address patient response to nursing interventions every shift and upon discharge. The instructions of this policy was verified as current with Staff B and Staff K on 01/24/13 at 11:30 AM.

Based on medical record review, staff interviews, and observation, the facility failed to ensure one of 10 patients (patient #1) reviewed was in the correct size vest restraint. The census on the first day of survey was 244 patients.

Findings include:

A medical record review was conducted for patient #1 on 01/23/13. The patient was admitted to the facility on 01/05/13 with diagnosis of traumatic subarachnoid hemorrhage (bleeding in the brain).

On 01/22/13, at 3:06 PM, a tour was conducted with Staff B and C. Patient #1 was observed lying in bed with the following restraints in place: four split side rails (which were padded with bolsters), bilateral hand mitts, bilateral ankle restraints, and a vest restraint. The color of the vest restraint was white with red edging. This was verified with staff C at the time of observation. The vest restraint was observed tied appropriately, and did not restrict the patient's breathing. The surveyor was unable to view the manufacturer ' s label on the vest restraint patient #1 was wearing at the time of the observation.

After observing patient #1 in the red edged mesh vest restraint, Staff C was interviewed whether the red-edged white mesh vest restraint was the appropriate size vest for patient #1. Staff C stated the facility follows the manufacturer's label for weight and chest circumference measurements, listed on the inside of the vest restraints, in order to determine appropriate vest restraint sizes to use on patients. Staff C then proceeded to take the surveyor across the hall into the storage room, revealing the shelf where these mesh vests were stored.


While standing in the storage room, Staff C verified these vest restraints were manufactured by the Posey Company, and verified the manufacturer ' s label inside the vests. Observations of the red edged and yellow edged mesh vests, on this shelf, revealed they were manufactured by the Posey Company. The inside label on the red edged mesh vest stated it should be used for patients who weigh 80-120 pounds, and who have a chest circumference of 32-39 pounds. The yellow edged vest restraint contained a label stating it should be used on patients who weigh 145-190 pounds, and who have a chest circumference of 43-49 inches. Staff C verified the red edged Posey vest worn by patient #1, and the red edged Posy vests stored in the storage room, were the same size and type of vest restraint manufactured by Posey. Staff C stated the red edged mesh vest size was smaller than the yellow edged mesh Posey vest.

Upon leaving the storage room a few minutes later, Staff C was questioned as to patient #1's weight and chest circumference. Staff C went to the nursing station and reviewed patient #1's medical record. After this review, Staff C stated patient #1 weighed 157 pounds, and verified the patients chest circumference measurement was not documented in the patient's medical record. Staff C stated to the surveyor the patient was in the wrong size vest restraint. Staff C stated the vest restraint the patient was currently wearing (red edged mesh Posey vest) was too small, and would be changed immediately to the larger yellow edged vest restraint, in accordance with the patient's weight. Staff B was present during the observations and medical record review of patient #1, and during the interviews with Staff C.

Based on staff interview, medical record review and policy review for restraint use, the facility failed to ensure all restraint use was followed with appropriate written and signed physician orders according to policy. This affected seven patients (#2, #3, #4, #5, #6. #7, #9) from the total of ten patients reviewed. The patient census at the first day of survey was 244.

Findings include:


On 01/24/13, a review of the policy titled "Restraint Alternatives/Use of Restraints" stated the following: For restraints for violent/self destructive behavior, an order shall be obtained from the MD/DO/LIP within 1 hour of the restraint application. The physician or MD/DO/LIP or a specially trained RN (Restraint Assessment Personnel) shall conduct a face-to-face evaluation for the need to continue the restraint or seclusion within one hour after initiation of the restraint. When the in-person evaluation (performed within one hour of the initiation of restraint or seclusion) is done by a trained registered nurse or trained physician assistant, he or she consults with the attending physician, clinical psychologist, or other licensed independent practitioner responsible for the care of the patient within one hour. This assessment/evaluation shall be documented in the medical record. A restraint order shall be renewed every 4 hours for adults 18 years and older and for no longer than 24 hours.

An interview with Staff B, on 01/24/13 at 9:40 AM, revealed all verbal orders for restraints should be cosigned by the MD/DO/LIP who gave the orders, unless specified in the policy to be done sooner than 24 hours.

Medical record reviews conducted on 01/23/13 and 01/24/13, with Staff B, revealed the following patients' physician's orders were either not signed timely or not signed in accordance with facility policy as follows:

Patient #2 was placed in bilateral splints, four side rails, and soft wrist restraints to prevent pulling on tubes. The date the physician's verbal order was obtained was on 01/09/13 at 8:09 PM. The physician did not cosign the verbal order until 01/11/13 at 6:50 AM (over 24 hours later). On 01/11/13 at 12:54 PM, a physician's verbal order was received for a vest restraint, soft wrist restraints, and four split side rails. As of 01/24/13, there was no physician's signature for this verbal order. This was greater than 12 days after the addition of the vest restraint.

Patient #4 was placed in soft wrist restraints on 01/06/13 at 7:08 PM, to prevent pulling on tubes. As of 01/24/13, this verbal order had not been cosigned by the physician. This was 17 days after the initiation of the wrist restraints. On 01/08/13 at 6:19 AM, a physician's verbal order was obtained for these same restraints; however, the physician did not cosign the verbal order until 01/10/13 at 6:48 AM (over 24 hours later).

Patient #5 was placed in soft wrist restraints with side rails in the upright position on 01/18/13 at 9:39 PM. As of 01/24/13, this verbal order was not cosigned by the physician as required per facility policy. This was greater than six days after the initiation of the wrist restraints and the side rail restraints.

Patient #6 was placed in soft wrist restraints on 01/22/13 at 12:44 PM to prevent pulling on tubes. As of 01/24/13, greater than 24 hours, this verbal order had not been cosigned by the physician.

Patient #7 was placed in soft wrist restraints on 01/21/13 at 1:39 PM to prevent pulling on tubes and airway. The physician cosigned the verbal order on 01/23/13 at 9:23 AM, (greater than 43 hours later).

Patient #9 was placed in soft wrist restraints and four split side rails in the upright position on 01/20/12 at 2:39 PM to prevent pulling on airway. This verbal order was not cosigned by the physician until 01/24/13 at 2:55 PM. This was greater than 96 hours after the initiation of the restraints.

Review of the medical record for Patient #3 was completed on 01/23/13. The patient was admitted to the emergency department on 01/12/2013 at 4:17 PM . The emergency department physician status order dated 1/12/2013 at 5:25 PM, indicated the patient's diagnosis as NSTEMI (Non-ST-Segment Myocardial Infarction).
On 01/14/13 at 12:20 AM the nursing progress notes stated " Dr. notified of patient's increasing agitation . Patient has become combative. Continues to remove oxygen, and pull at monitor and became combative, continues to remove oxygen, and pull at monitor and IV line. Patient is verbally and physically abusive with staff. Patient has started hitting, kicking and spitting at RNs. Order received for vest restraint, mitts and Haldol IV (an anti-anxiety medication) ".
The vest restraint and hand mitts were applied as ordered on 1/14/13 at midnight. The physician's signature for this order was documented on 01/16/13 at 4:10 PM, greater than 64 hours after the initiation of the restraints .

On 01/24/13 at 1:00 PM, Staff B verified these physicians' orders had not been signed as required by the facility's policy for the aforementioned patients.

Based on staff interview, review of the facility's restraint use policy, and medical record review, the facility failed to ensure physicians' orders were signed and face to face assessment was conducted on Patient #1 and #3 for violent restraint use within in one hour of application. A total of 10 patients were reviewed with restraint use.The census on the first day of the survey was 244.

Findings include:

On 01/22/13, a review of the facility's policy titled "Restraint Alternatives/Use of Restraints" stated the following: An order shall be obtained from the MD/DO/LIP within 1 hour of the restraint application. The physician or MD/DO/LIP or specially trained RN (Restraint Assessment Personnel) shall conduct a face-to-face evaluation for the need to continue the restraint or seclusion within one hour after initiation of the restraint. When the in-person evaluation (performed within one hour of the initiation of restraint or seclusion) is done by a trained registered nurse or trained physician assistant, he or she consults with the attending physician, clinical psychologist, or other licensed independent practitioner responsible for the care of the patient within one hour. This assessment/evaluation shall be documented in the medical record.

A medical record review was conducted for Patient #1 on 01/23/13. The patient was admitted to the facility on 01/05/13 with a diagnosis of traumatic subarachnoid hemorrhage (bleeding in the brain). On 01/06/13 at 12:21 AM, a verbal order was obtained from the physician for locked wrist restraints, and had been applied at midnight that same date. There was no documentation of a face-to-face meeting by the physician for these locked wrist restraints even though the restraints were used greater than one hour after being applied. These restraints were re-ordered on 01/07/13 at 7:37 AM.

An interview with Staff B, on 01/24/13 at 11:35 AM, confirmed the medical record lacked documentation of a face-to-face meeting with Patient #1, by the physician.

Review of the medical record for Patient #3 was completed on 01/23/13.The patient was admitted to the emergency department on 01/12/2013 at 4:17 PM . The patient's diagnosis was documented as NSTEMI (Non-ST-Segment Myocardial Infarction). The patient was admitted as an inpatient with transfer to the step-down with monitor unit (cardiac monitoring). The patient status was documented by the nurses on the cardiac monitoring unit every hour until 1/13/13 at 7:00 PM.

The nursing progress notes on 9:00 PM on 01/13/13 revealed "Dr. (cardiologist) notified that patient is agitated and confused. Patient having visual hallucinations.

On 01/14/13 at 12:20 AM the nursing progress notes stated "Dr. notified of patient's increasing agitation . Patient has become combative. Continues to remove oxygen, and pull at monitor and became combative, continues to remove oxygen, and pull at monitor and IV line. Patient is verbally and physically abusive with staff. Patient has started hitting, kicking and spitting at RNs. Order received for vest restraint, mitts and Haldol IV (an anti-anxiety medication). "
The vest restraint and hand mitts were applied as ordered on 1/14/13 at midnight. The medical record lacked documentation of a face -to -face assessment of Patient #3 by the physician in the hour after the restraint use was initiated.

Review of the hospital's policy for the face to face assessment required for the use of restraint with a patient with violent behaviors revealed the timeframe for the face to face assessment is 1 hour after the order is received.

An interview with Staff B, on 01/24/13 at 11:35 AM, confirmed the medical record lacked documentation of a face-to-face meeting with Patient #3, by the physician.

Based on medical record and staff interview, the facility failed to document the reason for the use of locked wrist restraints Patient 1 of 10 patients reviewed.The census on the first day of survey was 244 patients.

Findings include:

A medical record review was conducted for Patient #1 on 01/23/13. The patient was admitted to the facility on 01/05/13, with diagnosis of traumatic subarachnoid hemorrhage (bleeding in the brain). On 01/06/13 at 12:21 AM, a verbal order was obtained from the physician for the use of locked wrist restraints, which were applied at midnight that same date. On 01/07/13, at 7:37 AM, a verbal order was again received from the physician for locked wrist restraints.

Patient #1's medical record lacked documentation of the reason(s)/behavior for the use of the locked wrist restraints on 01/06/13 and 01/07/13.


An interview with Staff B, on 01/24/13 at 11:35 AM, confirmed the medical record lacked documentation of the reason for the use of the locked wrist restraints.

Staff B stated this restraint is used for patients who are exhibiting violent behaviors, and verified staff should have documented the patient's behaviors which warranted the use of the restraints.

Based on staff interview and medical record review the facility failed to in-service all staff on the definition and protocol for violent versus non violent restraint use after the need for education was identified by the facility's administrative team. This affected all nursing staff and one patient (Patient #3). A total of ten patients were reviewed with restraint use.

Findings include:

Review of the medical record for Patient #3 was completed on 01/23/13. The patient was admitted to the emergency department on 01/12/2013 at 4:17 PM, and was assessed by triage as having abdominal cramping and vomiting for four days.
The emergency department physician's status order dated 1/12/2013 at 5:25 PM, indicated the patient's diagnosis as NSTEMI (Non-ST-Segment Myocardial Infarction). The physician ordered the patient to be admitted as an inpatient with transfer to the step-down with monitor unit (cardiac monitoring).

On 01/14/13 at 12:20 AM the nursing progress notes stated " Dr. notified of patient's increasing agitation. Patient has become combative. Continues to remove oxygen, and pull at monitor and became combative, continues to remove oxygen, and pull at monitor and IV line. Patient is verbally and physically abusive with staff. Patient has started hitting, kicking and spitting at RNs. Hallucinating that he is in his home and calling staff by his grandchildren's names. Multiple attempts to reorient patient. Reposition in bed. Bed alarm reactivated. Order received for vest restraint, mitts and Haldol IV. " The medical record indicated Staff M documented the reason for the restraint as non violent when the order was taken.

An interview was conducted on 01/23/13 at 9:00 AM, with Staff B (RN, Project Manager), Staff K ( Manager of Quality/Accreditation and Prevention and Staff L (team leader for Quality/Accreditation and Prevention.) It was verified by Staff B, Staff K, and Staff L at this time, Staff M should have entered the patient's restraint as a violent restraint.

An interview was conducted with Staff N and Staff B on 01/22/13 between 3:05 PM and 3:48 PM, regarding staff training related to restraint usage. Staff N stated the administrative team, including Staff N, had met on Wednesday, 01/16/13, to discuss Patient #3's death, which occurred on 01/14/13, while in bilateral mitts and vest restraints.
Staff N stated, during that meeting administrative staff determined an educational need for staff in regard to the definition and protocol for violent versus non-violent restraints. On 01/22/13, Staff N said this in-service has not been completed for all staff members. However, Staff N said, after the 01/16/13 administrative meeting, the nurse (Staff M), who placed Patient #3 in restraints, was in-serviced about the definition and protocol of violent versus non-violent restraints.
On 01/23/13 at 9:33 AM, Staff B stated the in-service to update all nursing staff on the restraint protocol has been planned but not yet started.
On 01/23/13 at 1:00 PM, an interview was conducted with Staff A to identify who is responsible to perform the face-to-face assessments one hour after a violent type restraint is applied. Staff A said the physician who ordered the restraint is responsible for this assessment; however, if not available at night, then it should be conducted by the nursing supervisor on the night shift.
On 01/22/13 at 3:30 PM, an interview with Staff B revealed the facility lacked documentation nursing supervisors had been trained to conduct face to face assessments for violent type restraints.