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Based on record review and interview the facility failed to assess restrained patients every two hours to ensure their safety five of eight restrained patients included in the survey sample. (Patients #9, #11, #18, #20 and #21)

The findings included:

1. Review of Patient #9's active medical record revealed the patient had restraints for medical and non-behavior reasons. Review of the nursing documentation for every two-hour assessments revealed nursing staff did not document restraint assessments:
? From January 31, 2013 at 2:00 p.m. through February 1, 2013 at 6:00 a.m.; the last assessment for January 31, 2013 had been performed at 12:00 p.m. and the next documented assessment was February 1, 2013 at 8:00 a.m. an eighteen (18) hour span without safety assessments.
? For February 1, 2013, there was no documentation Patient #9 had been assessed at the scheduled every two hours at 10:00 a.m., 6:00 p.m., or 10:00 p.m.
? For February 2, 2013, there was no documentation Patient #9 had been assessed at the scheduled every two hours at Midnight, 4:00 a.m., 6:00 a.m., 6:00 p.m., and 10:00 p.m.
? For February 3, 2013, there was no documentation Patient #9 had been assessed at the scheduled every two hours from Midnight until 6:00 a.m.
? For February 4, 2013, there was no documentation Patient #9 had been assessed at the scheduled every two hours from 8:00 a.m. through 6:00 p.m. A nursing notation revealed Patient #9 was not in restraints on February 4, 2013 at 8:00 p.m., however documentation revealed Patient #9 had a restraint assessment for 10:00 p.m.
? For February 5, 2013, Patient #9's medical record did not have documented restraint assessments. Patient #9 was in bilateral wrist restraints, according to Staff # 10.

An interview was conducted on February 5, 2013 at 11:35 a.m., with Staff #4 during the review of Patient #9's medical record. Staff #4 confirmed Patient #9 had missing assessment documentation.

An interview was conducted on February 5, 2012 at 11:46 a.m., with Staff #10. Staff #10 reported Patient #9 did not have bilateral wrist restraints at the start of his/her shift. Staff #10 reported he/she was not aware when the restraints had been removed. Staff #10 reported Patient #9 had bilateral wrist restraints re-applied after the physician called the morning of February 5, 2013. Staff #10 reported Patient #10 had left the unit in bilateral wrist restraints for a scheduled test. Staff #10 reported he/she had not performed the re-assessment for restraint application.


2. Review of Patient #18's medical record revealed nursing staff failed to document every two-hour restraint assessments for January 28, 2013 at 8:00 a.m. and January 29, 2013.

An interview was conducted on February 6, 2013 at 8:36 a.m., with Staff # 17 during the review of Patient #18 medical record. Staff #17 confirmed Patient #18 did not have the required every two-hour restraint safety assessments.


3. Review of Patient #20's medical record revealed nursing staff failed to document every two-hour restraint assessments for January 3, 2013 at 4:00 p.m. Patient #20's medical record did not reveal restraint safety assessments for 6:00 a.m., and for eight (8) hours, from 12:00 p.m. through 8:00 p.m., on January 5, 2013.

An interview was conducted on February 6, 2013 at 11:58 a.m., with Staff #17. Staff #17 reviewed the nursing restraint assessments and confirmed Patient #20's medical record did not have evidence of every two-hour restraint safety assessments for the above dates.

4. Review of Patient #21's medical record revealed the nursing staff failed to document every two-hours restraint safety assessments for:
? September 28, 2012, for 2:00 p.m., 4:00 p.m., and 6:00 p.m.
? September 30, 2012, for 6:00 a.m., and for seven assessments from 8:00 a.m. through 8:00 p.m.
? October 1, 2012, for 8:00 a.m., 2:00 p.m., and 6:00 p.m.

An interview was conducted on February 7, 2013 at 10:45 a.m., with Staff #28. Staff #28 reviewed the nursing restraint documentation and confirmed the above listed missing safety assessments.


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5. Patient #11 was admitted on 10/8/12 with the diagnoses of small bowel obstruction and dehydration. On 10/15/12 per the EMR (Electronic Medical Record) Patient #10's physician placed an order at 08:21 for soft UE (upper extremity) right and left restraints. The nursing assessment for the restraints is not documented until 10:00 and notes the type of restraint as "soft, Third and Forth Siderail." On 10/16/12 at 00:01 Patient #11 is assessed. Patient #11's restraints is not assessed per the documentation in the EMR until 06:00.

The facility policy #266 notes all Restraint-Non-Behavior Mgt is to be assessed every 2 hours. The policy also notes Attachment C which indicates the ordering physician has the ability to select Third and Forth Siderails as a restraint type.

Employee #4 stated, "I am assume the patient was assessed because the nurse was in the room with the patient frequently."

Based on record review and interview the facility failed to modify the care plans for seven of eight restrained patients included in the survey sample. (Patients #9, #10, #12, #18, #19, #20 and #21)

The findings included:

1. Review of Patient #9's electronic medical record did not include a care plan for restraints.

An interview was conducted on February 5, 2013 at 11:38 a.m. with Staff #7 in the presence of Staff #4. Staff #7 retrieved and reviewed Patient #9's care plan. Staff #7 reported the care plan for restraint was a free text entry. Staff #7 stated, "There isn't a plan of care documented for [name of Patient #9]'s restraints. Staff #7 reviewed each problem listed and again reported "[Patient #9's name] does not have a care plan for restraints."

2. Review of Patient #18's electronic medical record did not include a care plan for restraints.

An interview was conducted on February 6, 2013 at 10:45 a.m., with Staff #25. Staff #25 reviewed Patient #18's medical record for a restraint plan of care. Staff #25 stated, "Restraints are planned under risk of injury. I do not see that staff care planned [name of Patient #18]'s restraints."

3. Review of Patient #20's electronic medical record did not reveal a care plan for restraints.

An interview was conducted on at 11:58 a.m., with Staff # 17. Staff #17 reviewed Patient # 20's medical record and reported it did not contain a plan of care for restraints.

4. Review of Patient #21's electronic medical record did not reveal a care plan for restraints

An interview was conducted on February 7, 2013 at 10:45 a.m., with Staff #28. Staff #28 reported nursing staff were to utilize the risk for injury plan of care for restraints. Staff #28 reviewed Patient #21's medical record. Staff #28 stated, "I cannot find a care plan for restraints." Staff #28 reported if the restraints had been discontinued the plan of care would remain and documented as resolved or discontinued.


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5. On 2/5 and 6/13 Patients #10, 12 and 19's medical records were reviewed and revealed all had been placed in restraints of some type at various dates and times. There was no evidence in the medical records of Patient #10, 12 or 19 that the of the use of restraints had been noted in their respective care plans. The specifics of Patient #10, 12 and 19's medical records noted the following:
Patient #10 was admitted on 1/24/13 with the diagnoses of abdominal pain and impressions of Urinary tract infection (UTI), Abdominal pain, Encephalopathy, Hepatitis C, Anemia, Acute or chronic kidney injury, Leukocytosis, Diabetes mellitus, Hypertension, Hypothyroidism, Thrombocytopenia.
On 1/25/13 per the EMR (Electronic Medical Record) Patient #10's physician placed an order at 09:14 for Restraint-Non-Behavior Mgt the type is not indicated. The nursing assessment for the restraints is documented 10:00 and notes the type of restraint as "Vest." The medical record review revealed the use of restraints was not documented on the nursing care plan.

6. Patient #12 was admitted on 1/19/13 with the diagnoses of Subdural intracranial hemorrhage, ETOH (alcohol) withdrawal, Hypertension, Diabetes mellitus and Raynaud's Disease. On 1/20/13 per the EMR at 08:15 Patient #12's physician ordered soft left and right UE and Vest restraints.
The nursing assessment for the restraints is documented at 09:18 and notes the type of restraint as "Soft, Third and Forth Siderail and Vest." The medical record review revealed the use of restraints was not documented on the nursing care plan.

7. Patient #19 was admitted on 10/22/12 withe the diagnoses of Abscess of the left buttock perianal area. On 10/25/12 at 11:34 per the EMR the physician ordered "soft left and right UE" restraints and remained in restraints until 10/28/12. The medical record review revealed the use of restraints was not documented on the nursing care plan.

Based on record review and interview the facility failed to use restraint in accord with the physician's orders for five of eight restrained patients included in the survey sample (Patients #11, #12, #18, #20 and #21)

The findings included:

1. Review of physician ordered restraints for Patient#18, included "soft wrist restraints, 3rd and 4th side rails." Review of nursing documentation for January 28 and 29, 2013 reveal Patient #18 had been placed in a vest restraint. Review of the electronic orders from January 27, 2013 through January 30, 2013 did not indicate the inclusion of a vest restraint for Patient #18.

An interview was conducted on February 7, 2013 at 10:45 a.m., with Staff #28. Staff #28 reviewed the nursing documentation and the physician orders. Staff #28 confirmed the physician had not indicated by order that Patient #18 should be placed in a vest restraint. Staff #28 confirmed Patient #18's medical record did not have an order for a vest restraint.

2. Review of Patient #20's medical record revealed the restraint safety assessments for January 3, 2013 and January 4, 2013 described the "Restraint Type" as "medication, soft (wrist), Third and Fourth side rails." Review of nursing documentation for January 3, 2013 and January 4, 2013 revealed "...bilateral wrist rest (restraints) intact side rails up x (times) 4 ..."

An interview was conducted on February 7, 2013 at 10:50 a.m., with Staff #28. Staff #28 reviewed the nursing documentation and the physician orders. Staff #28 confirmed the physician's orders included the the third and fourth side rails. Staff #28 confirmed Patient #20's medical record did not have documentation for the use of all four side rails.

3. Review of Patient #21's medical record revealed nursing restraint assessments for "09/30/2012" with an order date of "09/28/2012" timed at "1600 (4:00 p.m.)." Review of Patient #21's medical record did not reveal a physician's order for restraints dated "09/28/2012" at "1600."

An interview was conducted on February 7, 2013 at approximately 3:33 p.m., with Staff #28. Staff #28 had reviewed the physician orders and reported not being able to find a physician's order for restraints on September 28, 2012.




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4. Patient #11 was admitted on 10/8/12 with the diagnoses of small bowel obstruction and dehydration. On 10/15/12 per the EMR (Electronic Medical Record) Patient #10's physician placed an order at 08:21 for soft UE (upper extremity) right and left restraints. The nursing assessment for the restraints is not documented until 10:00 and notes the type of restraint as "soft, Third and Forth Siderail."

5. Patient #12 was admitted on 1/19/13 with the diagnoses of Subdural intracranial hemorrhage, ETOH (alcohol) withdrawal, Hypertension, Diabetes mellitus and Raynaud's Disease. On 1/20/13 per the EMR at 08:15 Patient #12's physician ordered soft left and right UE and Vest restraints.
The nursing assessment for the restraints is documented at 09:18 and notes the type of restraint as "Soft, Third and Forth Siderail and Vest."

The facility policy #266 Attachment C indicated the ordering physician has the ability to select Third and Forth Siderails as a restraint type.

2. Review of Patient #9's active medical record revealed the patient had restraints for medical and non-behavior reasons. Review of the nursing documentation for every two-hour assessments revealed nursing staff did not document restraint assessments:
? From January 31, 2013 at 2:00 p.m. through February 1, 2013 at 6:00 a.m.; the last assessment for January 31, 2013 had been performed at 12:00 p.m. and the next documented assessment was February 1, 2013 at 8:00 a.m. an eighteen (18) hour span without safety assessments.
? For February 1, 2013, there was no documentation Patient #9 had been assessed at the scheduled every two hours at 10:00 a.m., 6:00 p.m., or 10:00 p.m.
? For February 2, 2013, there was no documentation Patient #9 had been assessed at the scheduled every two hours at Midnight, 4:00 a.m., 6:00 a.m., 6:00 p.m., and 10:00 p.m.
? For February 3, 2013, there was no documentation Patient #9 had been assessed at the scheduled every two hours from Midnight until 6:00 a.m.
? For February 4, 2013, there was no documentation Patient #9 had been assessed at the scheduled every two hours from 8:00 a.m. through 6:00 p.m. A nursing notation revealed Patient #9 was not in restraints on February 4, 2013 at 8:00 p.m., however documentation revealed Patient #9 had a restraint assessment for 10:00 p.m.
? For February 5, 2013, Patient #9's medical record did not have documented restraint assessments. Patient #9 was in bilateral wrist restraints, according to Staff # 10.

An interview was conducted on February 5, 2013 at 11:35 a.m., with Staff #4 during the review of Patient #9's medical record. Staff #4 confirmed Patient #9 had missing assessment documentation.

An interview was conducted on February 5, 2012 at 11:46 a.m., with Staff #10. Staff #10 reported Patient #9 did not have bilateral wrist restraints at the start of his/her shift. Staff #10 reported he/she was not aware when the restraints had been removed. Staff #10 reported Patient #9 had bilateral wrist restraints re-applied after the physician called the morning of February 5, 2013. Staff #10 reported Patient #10 had left the unit in bilateral wrist restraints for a scheduled test. Staff #10 reported he/she had not performed the re-assessment for restraint application.


3. Review of Patient #18's medical record revealed nursing staff failed to document every two-hour restraint assessments for January 28, 2013 at 8:00 a.m. and January 29, 2013.

An interview was conducted on February 6, 2013 at 8:36 a.m., with Staff # 17 during the review of Patient #18 medical record. Staff #17 confirmed Patient #18 did not have the required every two-hour restraint safety assessments.


4. Review of Patient #20's medical record revealed nursing staff failed to document every two-hour restraint assessments for January 3, 2013 at 4:00 p.m. Patient #20's medical record did not reveal restraint safety assessments for 6:00 a.m., and for eight (8) hours, from 12:00 p.m. through 8:00 p.m., on January 5, 2013.

An interview was conducted on February 6, 2013 at 11:58 a.m., with Staff #17. Staff #17 reviewed the nursing restraint assessments and confirmed Patient #20's medical record did not have evidence of every two-hour restraint safety assessments for the above dates.

5. Review of Patient #21's medical record revealed the nursing staff failed to document every two-hours restraint safety assessments for:
? September 28, 2012, for 2:00 p.m., 4:00 p.m., and 6:00 p.m.
? September 30, 2012, for 6:00 a.m., and for seven assessments from 8:00 a.m. through 8:00 p.m.
? October 1, 2012, for 8:00 a.m., 2:00 p.m., and 6:00 p.m.

An interview was conducted on February 7, 2013 at 10:45 a.m., with Staff #25. Staff #25 reviewed the nursing restraint documentation and confirmed the above listed missing safety assessments.






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Based on document review and interviews the facility staff failed to ensure each patient placed in restraints was assessed every 2 hours per the facility's policy for 5 of 8 patients whose medical records were reviewed due to restraints, Patients #11, 9 18, 20 and 21.

The findings include:

1. Patient #11 was admitted on 10/8/12 with the diagnoses of small bowel obstruction and dehydration. On 10/15/12 per the EMR (Electronic Medical Record) Patient #10's physician placed an order at 08:21 for soft UE (upper extremity) right and left restraints. The nursing assessment for the restraints is not documented until 10:00 and notes the type of restraint as "soft, Third and Forth Siderail." On 10/16/12 at 00:01 Patient #11 is assessed. Patient #11's restraints is not assessed per the documentation in the EMR until 06:00.

The facility policy #266 notes all Restraint-Non-Behavior Mgt is to be assessed every 2 hours. The policy also notes Attachment C which indicates the ordering physician has the ability to select Third and Forth Siderails as a restraint type.

Employee #4 stated, "I am assume the patient was assessed because the nurse was in the room with the patient frequently."

The facility's performance improvement committee failed to identify an opportunity to analyze data collected from a high risk area. The facility's quality committee failed to use data collected from it's restraint committee, which indicated the intensive care units did not reduce their use of restraints to meet the established goal for the twelve (12) months of 2012.

The findings included::

Review of the quality data, quality records and interviews were conducted on February 7, 2013 from 3:15 p.m. to 4:35 p.m., with Staff #24, Staff #17 and Staff #20. Staff #24 initially presented the dashboard data for the facility's restraint usage. Staff #24 reported the data had been gathered by the restraint committee. Review of the data presented to the surveyor displayed the percentage of restraint usage for the intensive care units was above the established goal of "12%" for the twelve months of 2012. The percentages ranged from the lowest reported 15.6 % in January 2012 to the highest of 30.5 % in May of 2012. Staff #24 deferred the interview to Staff #20.

Staff #20 reported he/she chaired the restraint committee and reported the findings to leadership. Staff #20 was asked what actions had been initiated for the intensive care units, which had been above their established goal for the twelve months of 2012. Staff #20 reported the changes that had been established to bring the other facility units within their goal. Staff #20 reported the "...intensive care units have a difficult population, what works for other units doesn't work with their population." Staff #20 reported Staff #17 collected the restraint data for the intensive care units.

Staff #17 reported he/she performs one hundred percent audit of restraint charts to ensure each chart had current restraint orders, the patients had been assessed for safety every two-hours, that staff documented the alternatives that had been tried prior to placing the patient in restraints and that the reason fro restraints was "legitimate." Staff #17, Staff #20 and Staff #24 were informed of the current survey finding of restraint safety assessment not being performed every two-hours and a lack of modification to the restrained patient's care plan. Staff # 17, Staff #20 and Staff #24 were asked how the data collected by Staff #17 had been analyzed and employed for the reduction of restraint usage on the intensive care units.

Staff #24 reported the data he/she received reflected only the percentage of restraint use. Staff #24 reported no action had been taken to bring the intensive care units' restraint usage closer to their established goal. Staff #24 reported not being aware of the data collected by Staff #17. Staff #20 reported the data collected by Staff #17 did not go further than the unit; the restraint committee did not report the data to the quality committee or leadership committee. Staff #17 confirmed his/her monthly audit data was analyzed and placed in the front of the folder for each month, but had not been forwarded to the quality committee. Staff #24 stated, "I think we have missed an opportunity to utilize data in the area of restraints."

Staff #17, Staff #20 and Staff #24 confirmed the facility had missed an opportunity to assess a high risk area, the use of restraints in the intensive care units. Staff #20 and Staff #24 confirmed the quality committee had failed to consider the prevalence and severity of the intensive care units' failure to reach their goal to reduce the use of restraints for the twelve months of 2012.