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Based on medical record review, staff interview, document review, and policy review, the facility failed to ensure each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy (A173) and failed to ensure the condition of the patient who is restrained must be monitored by a physician, other licensed practitioner or trained staff at an interval determined by hospital policy (A175).

Based on medical record review, facility document review, and staff interview, the facility failed to ensure each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy for one of four patients reviewed with restraints (Patient #3). The total sample was ten records. The facility's census was 636.

Findings include:

Review of the medical record of Patient #3 revealed the patient was admitted to the facility on 01/23/23 for a planned two part back surgery. According to the attending physician's History and Physical, the patient had a history of severe cervical stenosis and myelopathy with wheelchair dependence, prostate cancer with recent prostatectomy, hypertension, a transient ischemic attack, prediabetes, and a gastrointestinal bleed. C4-C5 cervical corpectomy (removing the front part of the vertebra) and C3-C6 anterior cervical fixation and fusion was performed the morning of 01/23/23.

A nurse practitioner's progress note on 01/25/23 stated the patient became agitated, threatening to leave against medical advice (AMA), removing the c-collar. According to the progress note, Patent #3 stated he had a very vivid dream that the surgery didn't go well and he died causing extreme anxiety.

The patient continued to exhibit agitation and verbal aggression toward staff and the decision was made to initiate restraints for non-violent, non-self destructive behavior. Bilateral soft wrist restraints were initiated on 01/28/23. The restraints were removed and then reapplied on 01/31/23 and remained on intermittently until 03/29/23.

Further review of the patient's record revealed there was no physician order to renew the patient's restraints on 02/17/23 for the bilateral soft wrist restraints that were in place on that date.

Review of the undated document titled, A Quick Review of Practice Pointers for 5 Areas of Care, revealed restraint orders must be renewed daily while the patient requires restraints.

Staff A was interviewed on 05/26/23 at 1:00 PM. It was confirmed that the patient remained in restraints intermittently from 01/31/23 until 03/29/23, approximately two months. It was confirmed that the medical record lacked documentation of a physician's order for a day in which the patient remained in restraints.

This deficiency represents non-compliance investigated under Substantial Allegation OH00142010.

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure the condition of the patient who is restrained must be monitored by a physician, other licensed practitioner or trained staff at an interval determined by hospital policy for one of four patients reviewed for restraints (Patient #3). The total sample was ten records. The facility's census was 636.

Findings include:

Review of the medical record of Patient #3 revealed the patient was admitted to the facility on 01/23/23 for a planned two part back surgery. According to the attending physician's History and Physical, the patient had a history of severe cervical stenosis and myelopathy with wheelchair dependence, prostate cancer with recent prostatectomy, hypertension, a transient ischemic attack, prediabetes, and a gastrointestinal bleed. C4-C5 cervical corpectomy (removing the front part of the vertebra) and C3-C6 anterior cervical fixation and fusion was performed the morning of 01/23/23.

A nurse practitioner's progress note on 01/25/23 stated the patient became agitated, threatening to leave against medical advice (AMA), removing the c-collar. According to the progress note, the patient stated he had a very vivid dream that the surgery didn't go well and he died causing extreme anxiety.

The patient continued to exhibit agitation and verbal aggression toward staff and the decision was made to initiate restraints for non-violent, non-self destructive behavior. Bilateral soft wrist restraints were initiated on 01/28/23 at 12:51 AM. Documentation of safety checks were noted every two hours through 2:00 PM. There was no documentation of safety checks again until 7:50 PM, more than five hours after the previous safety check. The restraints were discontinued at 8:00 PM as the patient's family member was at the bedside and he was much calmer.

The patient became increasingly confused, agitated, and combative on 01/31/23. Bilateral wrist restraints were again initiated at 3:29 AM. Safety checks, alternatives and effectiveness were documented every two hours as required until 02/04/23. Safety checks were documented as within normal limits at 6:00 AM. The medical record lacked safety checks again until 7:36 PM, more than 12 hours later. On 02/05/23 at 4:00 AM, the restraint flowsheet revealed a registered nurse assessed the restraints for effectiveness and alternatives. The medical record lacked documentation of another assessment until 8:00 AM. On 02/08/23 at 2:04 PM, a registered nurse assessed the bilateral wrist restraints for alternatives and effectiveness. The medical record lacked documentation of the restraint assessment until 02/09/23 at 8:00 AM, more than 17 hours later. On 02/09/23 at 10:00 PM, the restraint flowsheet noted a registered nurse assessed the restraints for alternatives and effectiveness. The medical record lacked documentation a registered nurse assessed the restraints for alternatives and effectiveness until 8:00 AM the next morning. On 02/10/23, the restraint flowsheet lacked documentation a registered nurse assessed the restraints for effectiveness and alternatives from 10:00 AM until 6:00 PM that day. On 02/11/23 and 02/12/23, the medical record lacked documentation a registered nurse assessed the restraints for alternatives or effectiveness from 10:00 AM to 6:00 PM. On 02/13/23, the medical record lacked documentation a registered nurse assessed restraints for alternatives and effectiveness from 8:00 AM until 6:00 PM. On 02/14/23, again the medical record lacked documentation a registered nurse assessed the restraints for alternatives and effectiveness from 8:00 AM until 6:00 PM. On 02/15/23, the medical record lacked documentation a registered nurse assessed restraints for effectiveness and alternatives from 12:02 PM until 6:00 AM on 02/16/23. On 03/08/23, the medical record lacked documentation a registered nurse assessed the restraints for effectiveness and alternatives from 10:00 AM until 12:00 AM on 03/09/23, more than 13 hours. The restraints remained on the patient until 03/29/23.

The facility policy titled, Use of Restraints, effective 03/10/22, was reviewed on 05/25/23 at 5:00 PM. According to the policy, the patient in restraints for physical safety should be evaluated by the Registered Nurse or Licensed Practical Nurse every two hours and this evaluation should be documented in the medical record.

Staff A was interviewed on 05/26/23 at 1:00 PM. The gaps where the medical record lacked documentation every two hour safety checks, and a nurse's assessment for effectiveness and alternatives for restraints were confirmed.

This deficiency represents non-compliance investigated under Substantial Allegation OH00142010.