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Based on facility document and medical record review and staff interviews, the facility failed to ensure that restraints were used only with the order of a physician or other licensed independent practitioner.

This failure resulted in the restraint of a patient without the required physician or licensed independent practitioner orders.

FINDINGS:

1. The facility did not have documentation of a physician order for restraints that were applied to 1 (Sample Patient #2) of the 4 (Sample Patients #2, 3, 7 and 16) patients that were restrained.

a) On 05/21/13 through 05/22/13, a review of Sample Patient #2's medical record was conducted. Sample Patient #2's medical record contained documentation by a Registered Nurse (RN) that the patient was restrained with restrictive mittens on 03/12/13. The RN's documentation from 03/12/13 at 6:33 a.m. stated,"Mittens in use for line/tube integrity". There were no physician orders for the use of mittens.

b) On 05/21/13, the facility's Patient Safety Manager provided the surveyors with a pair of mittens that were described in Sample Patient #2's medical record. The mittens covered the entire hand of the surveyor, contained padding that decreased the surveyor's ability to move his/her fingers, and were secured to the surveyor's wrist through the use of a Velcro strap. The mittens also contained a flap that allowed the fingers to be either exposed or enclosed in the mitten. When the fingers were enclosed, the surveyor's ability to grab items was greatly diminished and the surveyor's hands and fingers were not able to be viewed by staff members.

c) On 05/21/13, the facility's policy,"Restraint Non-Behavioral", revised 04/09/13, was reviewed. The policy stated,"If the mitts are so bulky that the patient's ability to use their hands is significantly reduced, this would be considered restraint and the requirements would apply." The facility's Director of Nursing (DON) verified this was the current policy.

d) On 05/22/13 at 9:00 a.m., an interview was conducted with the facility's Medical Surgical Assistant Nurse Manager. The Medical Surgical Assistant Nurse Manager stated that the mittens described in Sample Patient #2's medical record were not considered a restraint, as they could easily be removed by patients using their mouths to undo the mitten's Velcro strap.

The Medical Surgical Assistant Nurse Manager stated nursing used the mittens, "as more of a distraction" and "to keep patients from pulling at their lines," and that the mittens were applied to patients without a physician order.

e) On 05/22/13, the facility's policy,"Restraint Non-Behavioral", revised 04/09/13, was reviewed. The policy stated, "Each episode of restraint or seclusion requires an order by a physician or other license independent practitioner (LIP) primarily responsible for the patient's ongoing care'. The facility's Director of Nursing (DON) verified this was the current policy.

Based on facility medical record and document review and staff interviews, the facility failed to ensure that patients in restraints were monitored.

This failure had the potential for patient harm due to staff not monitoring patient's while immobilized in restraints.

FINDINGS:

1. The facility did not have documentation of monitoring of restraints for 1 (Sample patient #2) of the 4 (Sample Patients #2, 3, 7 and 16) Patients that were restrained.

a) On 05/21/13 through 05/22/13, a review of Sample Patient #2's medical record was conducted. Sample Patient #2's medical record contained documentation by a Registered Nurse (RN) that the patient was restrained with restrictive mittens on 03/12/13. The RN's documentation from 03/12/13 at 6:33 a.m. stated,"Mittens in use for line/tube integrity". The medical record contained no documentation that the patient was monitored while in restraints.

b) On 05/21/13, the facility's policy, "Restraint Non-Behavioral", last revised on 04/09/13, was reviewed. The policy listed items for documentation that included,"Every 2 hour requirements: (1)Restraint type; (2)location of properly applied restraint; (3) Psychological status/orientation/level of consciousness; (4) Behaviors displayed; (5) Circulation airway; (6) Activity/position; (7) Comfort care; (8) Performance of vital signs; (9) Nutrition and hydration; (10) Personal hygiene; (11) Elimination." The facility's Director of Nursing (DON) verified this was the facility's current policy.

None of these items were documented in Sample Patient #2's medical record. The facility's Patient Safety Manager verified Sample Patient #2's medical record contained no documentation of the patient being monitored while in restraints.

c) On 05/22/13 at 9:00 a.m., an interview was conducted with the facility's Medical Surgical Assistant Nurse Manager. The Medical Surgical Assistant Nurse Manager stated the staff on his/her unit did not consider the mittens placed on Sample Patient #2 to be a restraint, and therefore did not monitor the patient according to the restraint policy.