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Based on staff interview, medical record review, facility policy review, and review of the facility's Risk Management investigation, it was determined the facility failed to ensure all patients were free from the use of a physical restraint of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff for one (1) of ten (10) sampled patients (Patient #4).

Patient #4 was placed in a restraint chair on 10/26/19. Patient #4 was on physician ordered 1:1 supervision for unpredictable behavior (UPB) however, review of the nurses notes revealed there was no documentation of Patient #4's behaviors to justify the use of a restraint chair. Additionally, there was no documentation of a Physician's Order for the use of the restraint chair, and/or documentation that Patient #4's physician was notified the restraint chair was used.

The findings include:

Review of the facility's policy titled, "Seclusion and Restraint" dated August 1977, and last revised April 2019, revealed seclusion and/or restraint are utilized only as emergency measures when all other less restrictive approaches/interventions have failed. Restraint is reserved for those occasions when severely aggressive or destructive behavior places the patients and/or others in imminent danger that outweighs the risk of physical interventions. All patients have the right to be free from seclusion or restraint, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Definition of restraint is any manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely.

Review of the medical record revealed the facility admitted Patient #4 on 02/28/19 with diagnoses which included Unspecified Neurocognitive Disorder, Insulin Dependent Diabetes Mellitus (IDDM), Hypertension, Vitamin D Deficiency, and Chronic Obstructive Pulmonary Disease (COPD).

Interview with Patient Support Aide (PSA) #1, on 12/09/19 at 2:40 PM, revealed she was involved with putting Patient #1 in a restraint chair on 10/26/19. PSA #1 stated Patient #1 was physically aggressive (hitting and spitting at) staff when Registered Nurse (RN) #2 instructed PSA #4 to get a restraint chair. PSA #1 stated at the direction of RN #2, himself and PSA's #4, #7, and RN #2 placed the patient in restraint chair while on Unit 563. PSA #1 stated Patient #4 was already on physician ordered one to one (1:1) supervision for UPB when the restraint chair was used. Further interview revealed Patient #4 was in restraint chair for approximately twenty (20) minutes.

However, review of Patient #1's Physician Orders, dated 10/26/19, revealed no order for the use of a restraint chair. In addition, review of the Nurses Progress Notes, dated 10/26/19, revealed there was no documented evidence the Patient had behaviors/actions that indicated the use of a restraint chair or that any less restrictive measure were attempted.

Interview with PSA #4, on 12/10/19 at 10:55 AM, revealed he was told by RN #2 to get a restraint chair on 10/26/19 for Patient #4. PSA #4 stated Patient #4 was on 1:1 supervision; however, was walking around Unit 563 spitting, hitting, and kicking staff and peers. Further interview revealed at directive given by RN #2, himself, PSA #1, #7, and RN #2, placed the patient in restraint chair. Further interview revealed Patient #4 was in restraint chair for approximately fifteen (15) to twenty (20) minutes.

Interview with PSA #7 attempted, on 12/10/19 at 9:59 AM, 12/11/19 at 1:48 PM, and 12/12/19 at 10:20 AM, without success. Facility's Nursing Coordinator revealed PSA #7 was on vacation and the only listed phone number was provided to Surveyor.

Review of a Witness Statement form, completed during the facility's Risk Management Investigation, on 10/29/19 at 3:15 PM, revealed PSA #7 was interviewed and stated he assisted in putting Patient #4 in restraint chair. PSA #7 revealed he placed band around Patient #4's waist to secure the patient in restraint chair. Further review revealed documentation by PSA #7, "I was just doing what I was told".

Interview with RN #2, on 12/10/19 at 2:29 PM, revealed on 10/26/19 she instructed PSA #4 to obtain a restraint chair due to Patient #4 pacing on Unit 563, banging on doors, yelling, kicking, and hitting at staff and peers. RN #2 stated, "Had the PSA to get the restraint chair because I considered using it but I didn't. I went into the office for approximately ten (10) to 15 minutes, and when I came out to the office, I noticed the Patient in the restraint chair. PSA #7 was sitting 1:1 with the patient. I asked who put the Patient in the restraint chair, and PSA #7 responded, "I don't know". I know PSA #7 could not have put the Patient in the restraint chair alone; however, no other staff would acknowledge assisting". RN #2 revealed she gave instruction to remove Patient #4 from the restraint chair. RN #2 revealed she failed to document the incident in Patient #4's medical record, notify the facility Supervisor, fill out an incident report, and failed to notify Patient #4's physician and family.

Interview with the Director of Nursing, on 12/12/19 at 1:50 PM, revealed RN #2 should have followed the facility's policy regarding Patient #4 being in restraint chair. The DON stated the patient's physician, family, and facility Supervisor. should have been notified and she expected the incident to be documented in Patient #4's medical record.

Based on staff interview, medical record review, and facility policy review, it was determined the facility failed to ensure the attending physician was consulted as soon as possible following the use of a restraint chair, if the attending physician did not order the restraint or seclusion, for one (1) of ten (10) sampled patients (Patient #4).

Patient #4 was placed in a restraint chair on 10/26/19; however, the licensed staff failed to notify the physician as soon as possible of the use of the restraint chair.

The findings include:

Review of the facility's policy titled, "Seclusion and Restraint" dated August 1977, and last revised April 2019, revealed seclusion and/or restraint are utilized only as emergency measures when all other less restrictive approaches/interventions have failed. Restraint is reserved for those occasions when severely aggressive or destructive behavior places the patients and/or others in imminent danger that outweighs the risk of physical interventions. The Registered Nurse (RN) has fifteen (15) minutes to obtain an order after implementing an emergency seclusion or restraint. An order must be obtained even if the seclusion or restraint has been discontinued, or if the total duration of the incident is less than 15 minutes. When a physician does not concur with the use of seclusion/restraints and the patient has already been secluded/ restrained, then the physician must come to the unit and document such on the one (1) hour face to face assessment.

Review of the medical record revealed the facility admitted Patient #4 on 02/28/19 with diagnoses of Unspecified Neurocognitive Disorder, Insulin Dependent Diabetes Mellitus (IDDM), Hypertension, Vitamin D Deficiency, and Chronic Obstructive Pulmonary Disease (COPD).

Interview with RN #2, on 12/10/19 at 2:29 PM, revealed on 10/26/19 she instructed PSA #4 to obtain a restraint chair due to Patient #4 pacing on Unit 563, banging on doors, yelling, kicking, and hitting at staff and peers. RN #2 stated she had considered using it and went into the office for approximately ten (10) to 15 minutes. She revealed when she came out of the office she noticed Patient #4 was in the restraint chair and PSA #7 was sitting 1:1 with the patient. However, review of Patient #4's Physician Orders, dated 10/26/19, revealed there was no order for restraint chair and review of the Nursing Progress Note, dated 10/26/19, revealed there was no documented evidence the resident was restrained.

Further interview with RN #2 on 12/10/19 at 2:29 PM revealed she failed to notify Patient #1's physician the restraint.

Interview with the Director of Nursing (DON), on 12/12/19 at 1:50 PM, revealed RN #2 should have followed the facility's restraint policy and notified the physician of the use of the restraint.