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Based on observation, medical record review, facility policy review and staff interview, the facility failed to generate a care plan or update the care plan in a timely manner according to facility policy (A166). The facility failed to ensure physician orders were obtained for applied restraints (A168). The facility failed to ensure restraint renewal orders were obtained as per facility policy (A173). The facility failed to monitor patients with restraints per facility policy (A175). The facility failed to ensure face to face evaluations were obtained when restraints were ordered for violent behaviors (A178). The cumulative effect of these systemic practices resulted in the facility's inability to ensure the provision of quality health care in a safe environment.

Based on policy review, medical record review, and staff interview, the facility failed to modify the patient care plan when restraints were initated for ten of ten medical records reviewed (Patients #1, #2, #3, #5, #7, #9, #8, #4, #6, and #10). The facility census was 213.

Findings include:

Review of the "Restraint and Seclusion" policy revealed a written modification of the plan of care must be documented.

1. Review of the medical record for Patient #1 revealed an admission date of 08/31/17. An order was obtained on 09/08/17 at 12:34 AM for a geri-chair with table top due to the patient's inability to comprehend the seriousness of his/her condition. The care plan lacked documentation of restraint usage. This was verified on 09/19/17 at 9:43 AM by Staff C.

2. Review of the medical record for Patient #2 revealed an admission date of 09/10/17. The patient was placed in bilateral soft wrist restraints on 09/10/17 through 09/11/17 and 09/16/17 through 09/18/17. The care plan lacked documentation of restraint usage. This was verified on 09/18/17 on 2:35 PM by Staff C.

3. Review of the medical record for Patient #3 revealed an admission date of 09/17/17. The medical record contained documentation the patient was placed in bilateral soft wrist restraints on 09/18/17 at 12:09 AM. The care plan lacked documentation of restraint usage. This was verified on 09/19/17 at 10:00 AM by Staff C.

4. Review of the medical record for Patient #5 revealed an admission date of 09/11/17. The medical record contained documentation the patient was placed in a geri-chair with table top at 3:40 PM through 7:16 PM on 09/15/17. The medical record contained documentation the patient was placed in a Geri-chair with tray from 2:00 PM to 3:30 PM and from 8:50 PM through 9:21 PM on 09/16/17. The care plan lacked documentation of restraint usage. This was verified on 09/19/17 at 11:50 AM by Staff C.

5. Review of the medical record for Patient #7 revealed an admission date of 09/13/17. The medical record contained documentation the patient was placed in bilateral soft wrist restraints on 09/15/17 at 4:00 PM and remained in place through 09/19/17. The care plan lacked documentation of restraint usage. This was verified on 09/19/17 at 11:14 AM by Staff C.

6. Review of the medical record for Patient #9 revealed an admission date of 09/15/17. The medical record contained an order dated 09/18/17 at 4:39 PM for bilateral soft wrist restraints and documentation this order was discontinued on 09/18/17 at 10:05 PM. The only restraint monitoring was documented at 2:00 PM on 09/18/17, two and a half hours prior to the order. The medical record lacked documentation of any additional monitoring notes or documentation of the exact time the restraints were applied or discontinued. The care plan lacked documentation of restraint usage. This was verified on 09/19/17 at 12:15 PM by Staff A.


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7. Patient #8 was admitted on 09/12/17. Review of the medical record on 09/19/17 revealed physician's orders on 09/13/17 for a geri-chair restraint and on 09/14/17 through 09/19/17 for bilateral soft upper extremity restraints. The bilateral wrist restraints were used on 09/14/17 through 09/19/17. The record review revealed there was no plan of care for these restraints.

This was confirmed with Staff C on 09/11/17 at 11:00 AM.

8. Medical record review was conducted on 09/19/17 for Patient #4. Physician's orders were received on 09/16/17, 09/17/17, and 09/18/17 for upper bilateral extremities due to the patient's inability to comprehend the seriousness of their condition.

On 09/18/17 at 12:02 PM and on 09/19/17 at 3:22 PM, the patient was observed with bilateral soft wrist restraints in place. The patient was observed with eyes closed and lying quietly during the two observations.

The record review revealed there was no plan of care for these restraints. This was confirmed with Staff C on 09/11/17 at 11:00 AM.

9. Medical record review of Patient #6 revealed the patient was admitted on 09/16/17. The patient had an intravenous site, a surgical drainage bag into the kidney, an indwelling urinary catheter, and oxygen. Physician orders received were for non violent bilateral soft wrist restraints due to the patient pulling the oxygen mask off. The orders were received on 09/16/17 and 09/18/17. Further review of the medical record revealed the restraints were used on 09/16/17 through 09/18/17; however, there was no plan of care for the restraints.

This was confirmed with Staff C on 09/11/17 at 11:00 AM.

10. On 09/19/17 a medical record review was conducted for Patient #10. Medical review revealed at 1:56 AM on 09/16/17 hard restraints were ordered by the physician when the patient was sitting up in bed, kicking his/her legs and swinging his/her arms, and attempting to get out of bed. Security was at the patient's bedside at 1:59 AM, at which time the patient was resting in bed. At 2:21 AM the patient was cooperative throughout a computed tomography scan, security was no longer on standby and restraints were not applied at that time.

The violent restraint was ordered on 09/16/17 at 1:57 AM by the physician for self - injurious behavior for four hours, and was discontinued at 2:17 AM on 09/16/17.

On 09/19/17 at 1:48 PM, Staff A confirmed there was no plan of care for the violent restraint.

Based on policy review, medical record review, and staff interview, the facility failed to ensure physician orders were obtained for applied restraints for three of ten medical records reviewed (Patients #2, #5, and #7). The facility census was 213.

Findings include:

Review of the "Restraint and Seclusion" policy revealed violent/self destructive restraint or seclusion was used for behavioral management. Non-Violent/Medical/Surgical restraints were used for a change in behavior or the inability to comprehend due to a clinical condition, not for aggressive or violent behavior. If restraints were removed for a period of time, then a new order was required, even if the previous order had not expired. When reducing from four point restraints to two point restraints, use opposite limbs and then discontinue restraints.

1. Review of the medical record for Patient #2 revealed an admission date of 09/10/17. The medical record contained an order on 09/10/17 at 6:01 PM for bilateral soft wrist restraints. Documentation in the medical record on 09/10/17 at 7:00 PM, 8:00 PM, and 9:00 PM noted right soft wrist, but lacked documentation of the left wrist being restrained. The medical record then lacked documentation of restraint usage or discontinuation until a new order was obtained at 6:24 AM on 09/11/17 for soft bilateral wrist restraints. An order for violent/behavioral restraints was obtained at 1:13 PM on 09/11/17 for keyed leather restraints times all four extremities for four hours. The medical record contained documentation the patient was in four point keyed leather restraints from 1:17 PM through 3:00 PM. The medical record contained two restraint monitoring notes on 09/11/17 at 3:00 PM, one stated the patient was in four point keyed restraints and the other stated the patient was in bilateral soft wrist restraints. The 3:15 PM restraint monitoring note stated the patient was in bilateral soft wrist restraints. The 3:34 PM restraint monitoring note on 09/11/17 stated the patient was in four point keyed restraints with the notation to continue restraints. No further monitoring notes for violent/behavioral restraints were noted.

On 09/11/17 at 3:11 PM the medical record contained non-violent restraint monitoring for bilateral soft wrist restraints through 09/11/17 at 9:15 PM when the restraints were discontinued. The medical record contained an order on 09/11/17 at 5:34 PM for bilateral soft wrist restraints, more than two hours after they were applied.

An order was obtained on 09/16/17 at 12:23 AM for soft bilateral wrists restraints. The medical record contained documentation on 09/11/17 at 6:58 PM and on 09/18/17 at 6:00 PM of the patient having left soft limb and right keyed hard and soft limb restraints. In addition, on 09/11/17 at 6:05 PM and 8:53 PM, the medical record lacked documentation as to what type of restraint was present. On 09/17/17 at 6:15 AM and 4:00 PM and on 09/18/17 at 1:00 PM, the restraint monitoring documentation noted bilateral soft wrist and left lower extremity restraints. This was verified on 09/18/17 at 2:35 PM by Staff C.

2. Review of the medical record for Patient #5 revealed an admission date of 09/11/17. The medical record contained an order on 09/15/17 at 3:46 PM for violent/self destructive restraint initiation of geri-chair with table top times four hours. The medical record then contained an order dated 09/15/17 at 4:00 PM for non-violent restraint of geri-chair with table top for one day. The medical record contained documentation the patient was placed in a geri-chair with table top at 3:40 PM through 7:16 PM on 09/15/17. The nurse's note on 09/15/17 stated the patient had grabbed a family member's hand and hit it on the table multiple times. After four minutes the family member was able to escape and the patient took two swings at the family member. The patient was ambulated and re-directed. The patient was placed in a large recliner at the table and then climbed over the side of the chair after ten minutes. At approximately 3:25 PM, the patient swung a fist at a staff member's head. The patient was placed in a geri-chair with table top and an order was obtained.

The nurse's note dated 09/16/17 stated the patient was attempting to push chairs that other patients were sitting in, became difficult to re-direct, agitated, and visibly annoyed. An order was obtained for a geri-chair with a tray to protect the patient from harming others and his/herself. The patient was in the geri-chair with the tray from 2:00 PM to 3:30 PM. An order was written at 2:00 PM on 09/16/17 for a non-violent restraint geri-chair with table top.

The nurse's note dated 09/16/17 at 8:25 PM revealed the patient was wandering the unit and became agitated when staff attempted to re-direct the patient. The patient became combative, hitting and squeezing the staffs' arms and punching at staff. The patient approached another patient and raised his/her fists. Staff attempted to re-direct the patient and the patient continued to hit and punch at the nurses. An order was obtained for a geri-chair with table top for the safety of the patient and others. At 9:21 PM, the patient's behavior improved and the table top was removed. On 09/16/17 at 8:48 PM an order was written for a non-violent restraint geri-chair with table top.

These restraints were ordered for patient safety and the safety of others due to violent and aggressive behaviors by the patient. This was verified on 09/19/17 at 11:50 AM by Staff C.

3. Review of the medical record for Patient #7 revealed an admission date of 09/13/17. The medical record contained documentation the patient was placed in bilateral soft wrist restraints on 09/15/17 at 4:00 PM and these remained in place through 09/19/17. The medical record lacked an order for restraints until 7:19 PM on 09/15/17 with a 24 hours time limit. The medical record lacked documentation of a restraint order for the time period of 7:19 PM on 09/16/17 through 7:39 PM on 09/17/17. This was verified on 09/19/17 at 11:14 AM by Staff C.

Based on policy review, medical record review, and staff interview, the facility failed to ensure restraint renewal orders were obtained per the facility policy for one of ten medical records reviewed (Patient #7). The facility census was 213.

Findings include:

Review of the "Restraint and Seclusion" policy revealed restraint orders would be time limited. Orders were required for all restraint/seclusion episodes.

Review of the medical record for Patient #7 revealed an admission date of 09/13/17. The medical record contained documentation the patient was placed in bilateral soft wrist restraints on 09/15/17 at 4:00 PM that remained in place through 09/19/17. The medical record lacked an order for restraints until 7:19 PM on 09/15/17 with a 24 hours time limit. The medical record lacked documentation of a restraint order for the time period of 7:19 PM on 09/16/17 through 7:39 PM on 09/17/17. This was verified on 09/19/17 at 11:14 AM by Staff C.

Based on policy review, medical record review, observation and staff interview, the facility failed to monitor restraints per facility policy for ten of ten medical records reviewed (Patients #1, #2, #3, #5, #7, #9, #8, #4, #6, and #10). The facility census was 213.

Findings include:

Review of the "Restraint and Seclusion" policy revealed non-violent restraint monitoring was to have hourly registered nurse assessment of continued need for restraints, mental status, circulatory status, and skin breakdown. Every two hours, restraints were to be removed for active or passive range of motion, to change the patient's position, to assess nutritional status, and to offer personal hygiene. For violent/behavioral restraints, the patient was to be monitored every 15 minutes for continued use of restraints and patient safety. Every two hours, a physical and mental assessment was to occur to determine if the restraints could be reduced and for nutritional and hygiene needs by an registered nurse.

1. Review of the medical record for Patient #1 revealed an admission date of 08/31/17. An order was obtained on 09/08/17 at 12:34 AM for a geri-chair with a table top due to the patient's inability to comprehend the seriousness of his/her condition. Restraint hourly monitoring on 09/08/17 was not documented between placing the patient into the geri-chair at 12:34 AM and 2:00 AM, between 6:00 AM and 7:15 AM, and between 8:15 AM and 9:45 AM when the patient expired.

This was verified on 09/19/17 at 9:43 AM by Staff C.

2. Review of the medical record for Patient #2 revealed an admission date of 09/10/17. The medical record contained an order on 09/10/17 at 6:01 PM for bilateral soft wrist restraints. Documentation in the medical record on 09/10/17 at 7:00 PM, 8:00 PM, and 9:00 PM noted a right soft wrist restraint, but lacked documentation of the left wrist being restrained. The medical record then lacked documentation of restraint usage or discontinuation until a new order was obtained at 6:24 AM on 09/11/17 for soft bilateral wrist restraints. The medical record lacked documentation of hourly monitoring from 6:26 AM until 8:08 AM. An order for violent/behavioral restraints was obtained at 1:13 PM on 09/11/17 for keyed leather restraints times all four extremities for four hours. The medical record contained documentation the patient was in four point keyed leather restraints from 1:17 PM through 3:00 PM. The medical record lacked documentation of monitoring every 15 minutes between 2:15 PM and 2:45 PM on 09/11/17. The medical record contained two restraint monitoring notes on 09/11/17 at 3:00 PM, one stated the patient was in four point keyed restraints and the other stated the patient was in bilateral soft wrist restraints. The 3:15 PM restraint monitoring note stated the patient was in bilateral soft wrist restraints. The 3:34 PM restraint monitoring note on 09/11/17 stated the patient was in four point keyed restraints with the notation to continue restraints. No further monitoring notes for violent/behavioral restraints were noted.

On 09/11/17 at 3:11 PM the medical record contained non-violent restraint monitoring for bilateral soft wrist restraints through 09/11/17 at 9:15 PM when the restraints were discontinued. The medical record contained an order on 09/11/17 at 5:34 PM for bilateral soft wrist restraints, more than two hours after they were applied. An order was obtained on 09/16/17 at 12:23 AM for soft bilateral wrists restraints. The medical record contained documentation of hourly monitoring except on 09/18/17 from 1:00 AM through 2:35 AM. The medical record contained documentation on 09/11/17 at 6:58 PM and on 09/18/17 at 6:00 PM of the patient having left soft limb and right keyed hard and soft limb restraints. In addition, on 09/11/17 at 6:05 PM and 8:53 PM, the medical record lacked documentation as to what type of restraint was present. On 09/17/17 at 6:15 AM and 4:00 PM and on 09/18/17 at 1:00 PM, the restraint monitoring documentation noted bilateral soft wrist and left lower extremity restraints.

This was verified on 09/18/17 on 2:35 PM by Staff C.

3. Review of the medical record for Patient #3 revealed an admission date of 09/17/17. The medical record contained documentation the patient was placed in bilateral soft wrist restraints on 09/18/17 at 12:09 AM. The medical record contained restraint monitoring notes on 09/18/17 at 1:51 AM, 5:21 AM, 5:24 AM, 5:26 AM, 7:41 AM, 7:42 AM, 8:00 AM, and when discontinued at 9:40 AM.

This was verified on 09/19/17 at 10:00 AM by Staff C.

4. Review of the medical record for Patient #5 revealed an admission date of 09/11/17. The medical record contained an order on 09/15/17 at 3:46 PM for violent/self destructive restraint initiation of a geri-chair with a table top times four hours. The medical record then contained an order dated 09/15/17 at 4:00 PM for a non-violent restraint of a geri-chair with table top for one day. The medical record contained documentation the patient was placed in a geri-chair with a table top at 3:40 PM through 7:16 PM on 09/15/17. The restraint monitoring checks were completed at 4:02 PM, 4:09 PM, 6:18 PM, and 6:40 PM. The nurse's note on 09/15/17 stated the patient had grabbed a family member's hand and hit it on the table multiple times. After four minutes the family member was able to escape and the patient took two swings at the family member. The patient was ambulated and re-directed. The patient was placed in a large recliner at the table and then the patient climbed over the side of the chair after ten minutes. At approximately 3:25 PM, the patient swung a fist at a staff member's head. The patient was placed in a geri-chair with a table top and an order was obtained.

The nurse's note dated 09/16/17 stated the patient was attempting to push chairs that other patients were sitting in, became difficult to re-direct, agitated, and visibly annoyed. An order was obtained for a geri-chair with a tray to protect the patient from harming others and his/herself. The patient was in the geri-chair with a tray from 2:00 PM to 3:30 PM. An order at 2:00 PM on 09/16/17 was written for a non-violent restraint geri-chair with table top. Restraint monitoring was documented on 09/16/17 at 2:00 PM, 3:00 PM, and discontinued at 3:35 PM.

The nurse's note dated 09/16/17 revealed at 8:25 PM the patient was wandering the unit and became agitated when staff attempted to re-direct the patient. The patient became combative, hitting and squeezing staffs' arms and punching at staff. The patient approached another patient and raised his/her fists. Staff attempted to re-direct the patient and the patient continued to hit and punch at the nurses. An order was obtained for a geri-chair with a table top for the safety of the patient and others. At 9:21 PM, the patient's behavior improved and the table top was removed. On 09/16/17 at 8:48 PM an order was documented for a non-violent restraint geri-chair with table top. The restraint monitoring on 09/16/17 was documented at 8:50 PM and the restraint was discontinued at 9:21 PM.

The restraint monitoring was not documented every 15 minutes as required by policy for violent restraint monitoring.

This was verified on 09/19/17 at 11:50 AM by Staff C.

5. Review of the medical record for Patient #7 revealed an admission date of 09/13/17. The medical record contained documentation the patient was placed in bilateral soft wrist restraints on 09/15/17 at 4:00 PM that remained in place through 09/19/17. The medical record lacked documentation of hourly monitoring on 09/17/17 from 4:00 PM to 5:34 PM and from 7:00 PM to 8:37 PM; on 09/18/17 from 2:00 AM to 3:41 AM, from 4:00 AM to 5:23 AM, from 6:00 AM to 7:25 AM, from 2:00 PM to 4:01 PM, from 7:00 PM to 8:33 PM, and from 11:00 PM to 12:26 AM; and on 09/19/17 from 6:09 AM to 7:27 AM.

This was verified on 09/19/17 at 11:14 AM by Staff C.

6. Review of the medical record for Patient #9 revealed an admission date of 09/15/17. The medical record contained an order dated 09/18/17 at 4:39 PM for bilateral soft wrist restraints and documentation this order was discontinued on 09/18/17 at 10:05 PM. The only restraint monitoring was documented at 2:00 PM on 09/18/17, two and a half hours prior to the order. The medical record lacked documentation of any additional monitoring notes or documentation of the exact time the restraints were applied or discontinued.

This was verified on 09/19/17 at 12:15 PM by Staff A.


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7. Patient #8 was admitted on 09/12/17 with diagnoses of confusion/weakness, sepsis, coccyx wound and had a nasogastric tube, a central intravenous line and a mechanical ventilator. The medical record review revealed a physician order on 09/13/17 at 10:04 AM for a geri-chair with table top for upper bilateral extremities due to being unable to comprehend the seriousness of his/her condition.

During an interview on 09/19/17 at 12:05 PM, Staff C was unable to explain why the geri-chair was ordered or if it had been used.

Further review of the patient's record revealed physician orders for upper bilateral extremity soft restraints for not being able to comprehend the seriousness of his/her condition. These restraints were ordered on 09/16/17, 09/17/17 and 09/18/17. The medical record review revealed the patient's bilateral soft wrist restraint monitoring was not completed every hour by staff per policy as follows: on 09/16/17 between 11:30 AM and 4:05 PM, on 09/17/17 between 3:31 PM and 5:00 PM, on 09/18/17 between 4:55 PM and 6:26 PM, and on 09/19/17 between 11:00 AM and 1:00 PM.

Further review of the patient's record revealed on 09/14/17 hourly monitoring occurred between 7:00 AM and 11:00 AM; however, the documentation was entered by the registered nurse (RN) between 11:32 AM and 11:35 AM, monitoring between 12:00 PM and 2:00 PM was documented from 3:52 PM to 3:57 PM, monitoring between 3:00 PM and 5:00 PM was documented from 5:37 PM to 5:39 PM, monitoring between 8:00 PM and 11:00 PM on 09/14/17 and 3:00 AM on 09/15/17 were all documented later on 09/15/17 from 3:23 PM to 3:35 PM. On 09/15/17 hourly monitoring between 8:00 AM and 10:00 AM was documented later between 10:14 AM and 11:00 AM, monitoring between 3:00 PM and 7:00 PM was documented later between 7:32 PM and 7:36 PM, and monitoring between 8:00 PM on 09/15/17 and 4:00 AM on 09/16/17 was documented later on 09/16/17 from 3:22 AM to 4:24 AM. On 09/16/17 hourly monitoring between 1:00 PM and 4:07 PM was documented later between 4:05 PM to 4:07 PM, monitoring between 8:00 PM on 09/16/17 and 5:00 AM (10 entries of monitoring) on 09/17/17 was documented from 5:35 AM and 5:44 AM on 09/17/17. On 09/17/17 hourly monitoring between 7:00 AM and 9:00 AM was documented later between 12:27 PM to 12:57 PM, monitoring between 10:00 AM and 1:46 PM was documented later between 1:43 PM and 1:46 PM, and monitoring between 7:00 PM on 09/17/17 and 12:00 AM on 09/18/17 was documented later from 1:37 AM to 1:45 AM on 09/18/17, and on 09/18/17 hourly monitoring between 8:05 AM and 10:16 AM was documented from 10:12 AM to 10:16 AM by Staff E.

Further record review revealed on 09/15/17 documentation was completed at 5:51 AM; however, the restraint monitoring was performed at 6:00 AM, on 09/16/17 documentation was completed at 11:09 AM; however the monitoring time was 11:30 AM, and on 09/17/17 documentation was completed at 5:51 AM and monitoring time was 6:00 AM.

The findings were confirmed with Staff C on 09/19/17 at 11:00 AM.

On 09/18/17 at 11:58 AM Patient #8 was observed lying in bed with bilateral soft wrist restraints intact. Staff E was providing care for the patient at that time. Staff E stated the facility policy was for restraint monitoring and documentation every hour.

8. On 09/19/17 a medical record review was conducted for Patient #4. The patient was admitted to the Critical Care unit on 09/12/17. The patient was intubated on 09/16/17, was receiving daily hemodialysis, was on intravenous antibiotics via a central line, and had a nasogastric feeding tube.

Physician orders were received on 09/16/17, 09/17/17, and 09/18/17 for upper bilateral extremities, due to the patient's inability to comprehend the seriousness of his/her condition. The medical record review revealed a lack of hourly monitoring by nursing staff on 09/17/17 from 10:30 PM through 2:00 AM on 09/18/17, on 09/18/17 from 6:18 PM to 10:42 PM, on 09/18/17 from 10:42 PM until 2:00 AM on 09/19/17, and on 09/19/17 from 5:00 AM and 8:00 AM.

On 09/16/17 hourly monitoring occurred between 6:00 PM and 7:04 PM; however, the documentation for the monitoring was entered by the RN at 7:04 PM, hourly monitoring from between 12:00 PM and 4:00 PM were all documented later between 4:39 PM and 4:42 PM by the RN, the monitoring at 7:00 PM was documented at 8:03 PM, the hourly monitoring between 8:00 PM on 09/16/17 and 12:00 AM on 09/17/17 was documented later at 12:21 AM on 09/17/17. On 09/17/17 hourly monitoring between 7:00 AM and 9:00 AM was documented by the RN between 8:57 AM and 8:59 AM. On 09/18/17 hourly monitoring between 1:00 PM and 2:00 PM was documented at 2:42 PM and 2:45 PM, and monitoring between 11:00 PM on 09/18/17 and 1:12 AM on 09/19/17 was documented from 1:11 AM and 1:12 AM on 09/19/17, and monitoring at 5:00 AM was documented at 7:30 AM. The documentation for hourly monitoring on 09/17/17 at 9:54 AM was earlier than the restraint monitoring at 10:00 AM, documentation at 1:42 PM was for the 2:00 PM monitoring, at 3:52 PM for the 4:00 PM monitoring, on 09/18/17 at 4:50 PM for the monitoring done at 5:00 PM and at 6:09 PM for the monitoring done at 7:00 PM.

The findings were confirmed with both Staff A and Staff C

Review of the medical record on 09/19/17 at 10:36 AM revealed the last restraint monitoring was documented for 6:00 AM on that same date. At the time of the medical record review, Staff C was informed of the lack of documentation for hourly restraint monitoring on 09/19/17 after 6:00 AM. At 1:23 PM on 09/19/17 further review of the patient's record revealed entries for hourly monitoring from 7:00 AM through 12:00 PM. However, all restraint monitoring entries from 7:00 AM through 11:00 AM were made by the RN between 10:56 AA and 11:05 AM. This was confirmed with Staff A on 09/19/17 at 1:23 PM.

9. Medical record review of Patient #6 revealed the patient was admitted on 09/16/17. The patient had an intravenous site, a surgical drainage bag into the kidney, and indwelling urinary catheter, and oxygen. Physician orders were for non violent bilateral soft wrist restraints due to having an oxygen mask and pulling it off. The orders were received on 09/16/17 and 09/18/17.

On 09/17/17 monitoring occurred at 1:00 AM and 2:00 AM; however, was not documented until 2:03 AM and 2:04 AM that same date. The 3:00 AM and 4:00 AM checks were not documented until 4:33 AM and 4:34 AM. On 09/17/17 the monitoring for 7:00 AM and 8:30 AM was not documented until 11:13 AM and 11:14 AM. On 09/17/17 at 8:30 AM the restraints were discontinued; however, the RN did not document the discontinuation until 1:14 PM that same date. The restraints were reapplied on 09/18/17 at 5:41 AM according to RN documentation. On 09/18/17 the 8:00 AM monitoring was not documented until 9:10 AM and the 11:00 AM monitoring was not documented until 12:59 PM. On 09/16/17 the documentation at 10:55 PM was earlier than the performed monitoring at 11:00 PM.

10. On 09/19/17 a medical record review was conducted for Patient #10. Medical review revealed at 1:56 AM on 09/16/17 hard restraints were ordered by the physician when the patient was sitting up in bed, kicking his legs and swinging his arms, and attempting to get out of bed. Security was at the patient's bedside at 1:59 AM, at which time the patient was resting in bed. At 2:21 AM the patient was cooperative throughout a computed tomography scan, security was no longer on standby and restraints were not applied at that time. The patient was moved to the observation unit at 4:49 AM and was transferred to the fourth floor unit at 5:51 AM and was discharged with the spouse on 09/17/17 at 12:29 PM. The violent restraint was ordered on 09/16/17 at 1:57 AM by the physician for self - injurious behavior for four hours, and was discontinued at 2:17 AM on 09/16/17.

It could not be determined per medical record review and interview with Staff A on 09/19/17 at 1:48 PM if the restraint had been applied as there was no documentation.

Based on policy review, medical record review, and staff interview, the facility failed to ensure face to face evaluations were obtained when restraints were ordered for violent behaviors for two of three medical records reviewed with restraints ordered for violent behaviors (Patients #2 and #5). A total of ten medical records were reviewed. The facility census was 213.

Findings include:

Review of the "Restraint and Seclusion" policy revealed within one hour of application of violent, self distructive restraints/seclusion, a face to face evaluation was to occur by a trained registered nurse or Licensed Independent Practitioner (physician, nurse practitioner, etc.). Documentation was to include a summary of the immediate situation, reaction to intervention, the behavior condition, a physical/behavioral assessment, and the need to continue or terminate the restraints.

1. Review of the medical record for Patient #2 revealed an admission date of 09/10/17. An order for violent/behavioral restraints was obtained at 1:13 PM on 09/11/17 for keyed leather restraints times all four extremities for four hours. The medical record contained documentation the patient was in four point keyed leather restraints from 1:17 PM through 3:00 PM. The medical record lacked documentation of a face to face evaluation.

This was verified on 09/18/17 on 2:35 PM by Staff C.

2. Review of the medical record for Patient #5 revealed an admission date of 09/11/17. The medical record contained an order on 09/15/17 at 3:46 PM for violent/self destructive restraint initiation of geri-chair with a table top times four hours. The medical record then contained an order dated 09/15/17 at 4:00 PM for non-violent restraint of a geri-chair with a table top for one day. The medical record contained documentation the patient was placed in a geri-chair with a table top at 3:40 PM through 7:16 PM on 09/15/17. The nurse's note on 09/15/17 stated the patient had grabbed a family member's hand and hit it on the table multiple times. After four minutes the family member was able to escape and the patient took two swings at the family member. the patient was ambulated and re-directed. The patient was placed in a large recliner at the table and then climbed over the side of the chair after ten minutes. At approximately 3:25 PM, the patient swung a fist at a staff member's head. Patient was placed in a geri-chair with a table top and an order was obtained.

The nurse's note dated 09/16/17 stated the patient was attempting to push chairs that other patients were sitting in, became difficult to re-direct, agitated, and visibly annoyed. An order was obtained for a geri-chair with a tray to protect the patient from harming others and his/herself. The patient was in the geri-chair with the tray from 2:00 PM to 3:30 PM. An order was written at 2:00 PM on 09/16/17 for a non-violent restraint geri-chair with table top.

The nurse's note dated 09/16/17 noted at 8:25 PM the patient was wandering the unit and became agitated when staff attempted to re-direct the patient. The patient became combative, hitting and squeezing staffs' arms and punching at staff. The patient approached another patient and raised his/her fists. Staff attempted to re-direct the patient and the patient continued to hit and punch at the nurses. An order was obtained for a geri-chair with table top for the safety of the patient and others. At 9:21 PM, the patient's behavior improved and the table top was removed. On 09/16/17 at 8:48 PM an order was documented for a non-violent restraint geri-chair with table top.

These restraints were ordered for patient safety and the safety of others due to violent and aggressive behaviors by the patient. The medical record lacked documentation of any face to face evaluations for the need for ordered restraints due to violence.

This was verified on 09/19/17 at 11:50 AM by Staff C.