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Based on observation, interview, and record review the facility restrained (restraint, any physical or mechanical device used to reduce the ability of a patient to move his/her body) without an order from an authorized physician. This deficient practice had the potential for physical and emotional harm to the patient.

Findings:

During an observation on 4/16/2024 at 1:00 PM, there was a sign, 'Seizure Precautions' (measures taken to prevent injury during a seizure) posted along side the door to PT3's room. All (4) side rails to PT3's bed were in the up position, confining the patient to his bed. There was no padding on the 4 side rails. PT3 had a foley (urine collection device that has a tube that goes to a collection bag) and the collection bag was resting on the ground under the bed.

During an interview on 4/16/2024 at 1:10 PM, RN 4 stated that if a patient is on seizure precautions then there should be padding on all the rails in order to prevent injury during a possible seizure (sudden, uncontrolled burst of electrical activity in the brain that can trigger uncontrolled body movement).

During an interview on 4/16/2024 at 1:15 PM, RN 4 clarified that PT4 was not actually on seizure precautions; the signage outside PT3's door was intended for a patient that was previously in this room. Subsequently RN 4 stated that 4 rails up means a patient is under restraint and that PT3 did not have an order for restraint.

A review of PT3's medical record did not indicate there was an order for restraint.

During a review of 'Restraints: Non Violent Behavior', (dated 6/15/2022) this policy indicted: All patients have the right to be free from any form of restraint that is imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraints must be implemented through order from a physician or authorized care provider who is responsible for the patient's care.

Based on observation, interview, and record review the facility failed to ensure PT3's foley (urine collection device that has a tube that leads to a reservoir) bag did not come into contact with the floor under his bed. This deficient practice has the potential for infection.

Findings:

During an observation on 4/16/2024 at 1:00 PM, there was a sign, 'Seizure Precautions' (measures taken to prevent injury during a seizure) posted along side the door to PT3's room. All (4) side rails to PT3's bed were in the up position, confining the patient to his bed. There was no padding on the 4 side rails. PT3 had a foley catheter (urine collection device that has a tube that goes to a collection bag) and the collection bag was resting on the ground under the bed.

During an interview on 4/16/2024 at 1:10 PM, RN 4 stated sometimes the urine collection bag comes to rest on the ground upon lowering the bed so the patient can get out of bed. RN 4 subsequently stated that leaving the bag on the floor can possibly lead to a urinary tract infection (condition in bacteria invades the urinary tract, body system producing and expelling urine).

During a review of the 'Infection Prevention 2023 Program Assessment and 2024 Annual Plan' indicated part of the facility's 2024 Surveillance Plan included reducing and eliminating CAUTI (catheter associated urinary tract infection) through the following measures (not all inclusive): Limiting use of indwelling (insertion of catheter through the urinary tract) catheters to acceptable indications; Use of a maintenance bundle (closed drainage system, bag located below the bladder and off the floor, catheter securement, no dependent loops of catheter line leading to collection bag, routine hygiene); Daily review of need for catheter.