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Based on staff interviews and review of clinical records and policy and procedures it was determined the facility did not ensure chemical or physical restraints were provided according to physician order for one (#4) of five sampled records. This practice does not ensure restraints are safely and necessarily applied.

Findings include:

Patient #4 was admitted on 11/23/11. Review of the History and Physical revealed an attempted suicide and depression. The documentation noted the patient had a tracheotomy and ventilator dependent.

Review of physician orders for restraints from 11/23/11 to 12/5/11 revealed soft wrist restrains, but the right and/or left were not indicated. Review of nursing documentation noted the patient had right and left soft wrist restraints.

Review of physician orders dated 12/6/11 at 4:13 a.m. instructed to transfer the patient to the Intensive Care Unit and initiate a Propofol drip. The order did not show the Propofol was being used as a chemical restraint.

Physician/Advanced Registered Nurse Practitioner (ARNP) progress note dated 12/6/11 at 9:53 a.m. revealed the patient was transferred to the Intensive Care Unit and required the use of Propofol for severe agitation. Review of physician progress notes dated 12/7/11 revealed the Propofol was discontinued.

Review of nursing documentation dated 12/6/11 at 4:20 a.m. revealed the patient was transferred to the Intensive Care Unit (ICU). The note indicated the patient was combative and kept trying to get out of bed. The patient remained ventilated. The documentation noted a Propofol drip was initiated.

Review of policy and procedure Propofol Infusion #H-MM dated 11/09 revealed the physician must include in the progress notes indicators for use, expected outcome and estimated duration. Review of the medication lists: Mediations that May Be considered a Chemical Restraint #H-PC F05-010C included Propofol under Misc.

Review of policy and procedure "Use of Physical and Chemical Restraints" H-PC- 05-010 dated 6/11 indicated a physician order for chemical or physical restraints must be obtained.

Interview with the Chief Nursing Officer on 12/19/11 at approximately 3:20 p.m. confirmed the Propofol was used as a chemical restraint for the agitation and that there was no physician order indicating the Propofol was used as a chemical restraint.

Based on staff interviews and review of clinical records, policy and procedures it was determined the facility did not ensure patients with chemical or physical restraints were monitored according to facility policy for one (#4) of five sampled records. This practice does not ensure patients receive needed care and are safe during restraint usage.

Findings include:

Patient #4 was admitted on 11/23/11. Review of the History and Physical revealed an attempted suicide and depression. The documentation noted the patient had a tracheotomy and ventilator dependent.

Review of physician orders for restraints from 11/23/11 to 12/5/11 revealed soft wrist restraints, but the right and/or left were not indicated. Review of nursing documentation noted the patient had right and left soft wrist restraints. Review of the restraint monitoring sheet dated 12/3/11 revealed there was no monitoring from midnight to 8:00 a.m. Review of physician orders dated 12/6/11 at 4:13 a.m. instructed to transfer the patient to the Intensive Care Unit and initiate a Propofol drip. Review of nursing documentation and restraint monitoring sheets did not reveal evidence of restraint monitoring.

Physician/ARNP progress note dated 12/6/11 at 9:53 a.m. revealed the patient was transferred to the Intensive Care Unit and required the use of Propofol for severe agitation. The Propofol was discontinued on 12/7/11.

Review of nursing documentation dated 12/6/11 at 4:20 a.m. revealed the patient was transferred to the Intensive Care Unit (ICU). The note indicated the patient was combative and kept trying to get out of bed. The documentation noted a Propofol drip was initiated. Review of nursing documentation did not reveal evidence of the patient's behavior prior to transfer to the Intensive Care Unit for the chemical restraint.

Review of policy and procedure Use of Physical and Chemical Restraints H-PC- 05-010 dated 6/11 indicated a registered nurse will assess the patient for the actual behavior observed. The patient will be assessed for mental status, fluid needs, toileting at a minimum of every two hours.

Interview with the Chief Nursing Officer on 12/19/11 at approximately 3:20 p.m. confirmed the Propofol was used as a chemical restraint for the agitation. She confirmed there was no evidence of restraint monitoring while on the Propofol. The interview also confirmed the findings related to the bilateral wrist restraints without monitoring.

Based on staff interviews and review of clinical records, policy and procedures it was determined the facility did not ensure the patient's behavior or intervention used related to restraints were documented for one (#4) of five sampled records. This practice does not ensure the least restrictive restraint is used.

Findings include:

Patient #4 was admitted on 11/23/11. Review of the History and Physical revealed an attempted suicide and depression. The documentation noted the patient had a tracheotomy and was ventilator dependent.

Review of physician orders dated 12/6/11 at 4:13 a.m. instructed to transfer the patient to the Intensive Care Unit and initiate a Propofol drip.

Physician/ARNP progress note dated 12/6/11 at 9:53 a.m. revealed the patient was transferred to the Intensive Care Unit and required the use of Propofol for severe agitation.

Review of Intensive Care Unit nursing documentation dated 12/6/11 at 4:20 a.m. revealed the patient was transferred to the ICU. The note indicated the patient was combative and kept trying to get out of bed. The documentation noted a Propofol drip was initiated. The documentation noted the patient was calm and cooperative at the time of transfer.

Review of nursing documentation and restraint monitoring sheets did not reveal evidence of the patient's behavior prior to the transfer or interventions used on the medical surgical unit

Review of policy and procedure Use of Physical and Chemical Restraints H-PC- 05-010 dated 6/11 indicated a registered nurse will assess the patient for the actual behavior observed and the reason for initiating the restraint. The document noted that alternatives and interventions tried must be documented for chemical and physical restraints.

Interview with the Chief Nursing Officer on 12/19/11 at approximately 3:20 p.m. confirmed the Propofol was used as a chemical restraint for the agitation and that there was no evidence of documentation from the nursing unit, and no evidence of interventions that were tried.

Based on staff interviews and review of clinical records, policy and procedures it was determined the facility did not ensure alternatives or the least restrictive intervention was used for one (#4) of five sampled records. This practice does not ensure patients are free from unnecessary restraints.

Findings include:

Patient #4 was admitted on 11/23/11. Review of the History and Physical revealed an attempted suicide and depression. The documentation noted the patient had a tracheotomy and ventilator dependent.

Review of physician orders dated 12/6/11 at 4:13 a.m. instructed to transfer the patient to the Intensive Care Unit and initiate a Propofol drip.

Review of physician progress notes dated 12/5/11 revealed the patient was seen by the physician's Advanced Registered Nurse Practitioner (ARNP). The note indicated the patient had anxiety and agitation and a plan for neurology to see the patient. Physician/ARNP progress note dated 12/6/11 at 9:53 a.m. revealed the patient was transferred to the Intensive Care Unit and required the use of Propofol for severe agitation. The plan included for neurology to see the patient. Review of physician/ARNP progress notes dated 12/7/11 revealed the patient was no longer on Propofol.

Review of Intensive Care Unit (ICU) nursing documentation dated 12/6/11 at 4:20 a.m. revealed the patient was transferred to the ICU. The note indicated the patient was combative and kept trying to get out of bed. The documentation noted a Propofol drip was initiated. The documentation noted the patient was calm and cooperative at the time of transfer.

Review of the medical surgical unit nursing documentation did not reveal evidence of the patient's behavior prior to transfer to the ICU or alternatives tried to ensure the least restrictive restraint was utilized prior to the transfer to the ICU for the chemical restraint.

Review of psychologist progress notes dated 12/1/11 showed the patient had been seen twice before. The documentation indicated she was not able to perform an evaluation at that time due to his cognitive status and would return if he improves.

Review of neurology consult dated 12/5/11 at 10:10 a.m. revealed the patient had improved neurologically and wanted to be able to get up and walk. He remained ventilator dependent. Neurology progress notes dated 12/7/11 revealed medications were adjusted the day before and the medications appeared to be controlling his agitation.

Review of policy and procedure "Propofol Infusion" #H-MM dated 11/09 revealed the physician must include in the progress notes indicators for use, expected outcome and estimated duration. Review of the medication list: Mediations that May Be considered a Chemical Restraint #H-PC F05-010C included Propofol under Misc.

Review of policy and procedure Use of Physical and Chemical Restraints H-PC- 05-010 dated 6/11 indicated a registered nurse will assess the patient for the actual behavior observed and the reason for initiating the restraint. The document noted that alternatives and interventions tried must be documented for chemical and physical restraints.

Interview with the Chief Nursing Officer on 12/19/11 at approximately 3:20 p.m. confirmed the Propofol was used as a chemical restraint for the agitation. There was no evidence of alternatives attempted prior to the use of Propofol as a chemical restraint by the physician or nurse.