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Based on medical record review, staff interview and review of facility policy and procedures it was determined the facility failed to ensure patients had the right to be free from restraints, of any form, for one (#2) of fourteen patients sampled. This does not ensure patients rights and safety are provided in a safe setting.

Findings include:

Patient #2 was admitted on 9/11/2012 with complaints of chest pain. Review of the patient's history revealed the patient was mentally challenged. On 9/12/2012 a discharge order was written by the physician.

Review of nursing documentation revealed discharge instructions were signed and given to the caregiver from the patient's group home. The RN (Registered Nurse) documented on 9/12/2012 at 11:45 a.m. the patient left the unit via wheelchair with an improved condition.

An interview was conducted via telephone on 12/6/2012 at 1:30 p.m. with the RN in charge of the patient's care at the time of discharge. The RN stated a volunteer came to escort the patient out.

On 12/6/2012 at 1:50 p.m. an interview was conducted via telephone with the volunteer who assisted the patient in the wheelchair at the time of discharge on 9/12/2012. The volunteer stated the patient kept bending over as if she was going to get up or possibly fall out of the wheelchair. The volunteer stated she asked a nurse for a blanket or sheet to use for the patient. She stated the nurse gave her a sheet. She proceeded to tie the sheet in front of the patient to the arms of the wheelchair for the patient's safety. The volunteer stated she was afraid the patient was going to fall and possibly get hurt. She stated she pushed the patient in the wheelchair to the exit and the caregiver escorted the patient into the van.

Review of the facility policy, "Restraint Management", stated under Direction for Restraint Use #7 only trained qualified staff will apply, monitor, reassess or remove restraints.

Review of the record and staff interview revealed no comprehensive patient assessment by the RN to determine if the use of a restraint was required to ensure patient safety.

Interview with the risk manager and director of quality on 12/6/2012 at 2:15 p.m. confirmed the above findings.

Based on record review, staff interview, and review of facility policy and procedure it was determined the facility failed to ensure restraints were implemented by a trained staff member for one (#2) of fourteen patients sampled. This practice does not ensure patient safety.

Findings include:

Patient #2 was admitted to the facility on 9/11/2012 with complaints of chest pain. Review of the patient's history revealed the patient was mentally challenged. The physician discharged the patient on 9/12/2012.

Review of the nursing documentation revealed the RN (Registered Nurse) discharged the patient on 9/12/2012 at 11:45 a.m.

An interview was conducted via telephone on 12/6/2012 at 1:30 p.m. with the RN in charge of the patient's care at the time of discharge. The RN stated a volunteer escorted the patient out via wheelchair.

On 12/6/2012 at 1:50 p.m. an interview was conducted via telephone with the volunteer who assisted the patient in the wheelchair at the time of discharge on 9/12/2012. The volunteer stated the patient kept bending over as if she was going to get up or possibly fall out of the wheelchair. The volunteer stated she asked a nurse for a blanket or sheet to use for the patient. She stated the nurse gave her a sheet. She proceeded to tie the sheet in front of the patient to the arms of the wheelchair for the patient's safety. The volunteer stated she was afraid the patient was going to fall and possibly get hurt. She stated she pushed the patient in the wheelchair to the exit and the caregiver escorted the patient into the van.

Interview with the volunteer coordinator, risk manager and director of quality on 12/6/2012 at 1:55 p.m. confirmed that volunteers are not provided training or competency in the safe implementation of restraints.

Review of the facility policy, "Restraint Management", stated staff members who have direct patient care contact will have education and training regarding the use of restraints and seclusion at orientation before participating in the use of restraints and seclusion and on a periodic basis thereafter.

Interview with the risk manager and director of quality on 12/6/2012 at 2:15 p.m. confirmed the above findings.