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Based on review of the medical record, review of the policy and procedures and interview and confirmation with staff it was determined the facility failed to protect and promote each patient's rights in respect to restraint and seclusion. The hospital did not ensure that the least restrictive interventions were exhausted prior to the placement of restraints; that an order was obtained and followed for the use of restraints and that no standing orders or as needed orders were utilized for restraints. This was noted in five out of 10 medical records and affected Patient's #1, 4, 5, 7 and 8. The hospital census was 174.

Findings include:

The hospital failed to ensure that least restrictive measures were utilized prior to the placement of restraints. See A-0164

The hospital failed to ensure that the use of, restraints was in accordance with a physician's order. See A-0168.

The hospital failed to ensure that the orders for the use of restraints must not be written as a standing order or an as needed (PRN) order. See A-0169.

Based on review of the medical record, A hospital policy and interview and confirmation with staff it was determined that the facility failed to ensure that the least restrictive interventions were used prior to placing a patient in restraints. This was noted in four out of 10 medical records reviewed and affected Patient #s 1, 4, 7 and 8. The hospital census was 174.
Findings include:
The medical record review for Patient #1 was conducted on 09/22/10. Patient #1 was admitted on 07/24/10 with end stage chronic obstructive pulmonary disease, pleural effusion (fluid around the lungs) and hypertension. On 07/25/10 at 8:45 AM Patient #1 was found lying on the floor next to his/her bed. A post fall assessment was completed and at 9:15 AM an order was obtained to restrain the patient with soft wrist restraints and a soft vest. Documentation reflected that only the soft vest was used to secure Patient #1 to the bed. The nursing documentation reflected that Patient #1 was alert and oriented to name, time and place following the fall at 9:00 AM. Further documentation by the staff nurse described Patient #1's mental status as inappropriate. The restraint assessment completed on 07/25/10 at 9:00 AM listed the interventions completed by staff prior to initiation of the vest restraint. The interventions listed included one-to-one contact with staff to maintain safe behavior and assign staff to increased observations. There was no documentation in the medical record as evidence Patient #1 had received one-to-one contact with staff or that staff had been assigned to increased observations prior to Patient #1's fall and prior to his/her placement in restraints.
The type of restraint used for Patient #1 was a vest restraint. A review of the manufacturer's recommendations for the use of vest restraints was completed on 09/23/10. The manufacturer's recommendations listed medical conditions in which the use of the vest restraint would be contraindicated and included severe chronic obstructive pulmonary disease (COPD). The use of the vest restraint was contraindicated for use on Patient #1 as Patient #1 was diagnosed with End Stage COPD.
The hospital policy and procedure entitled "Restraints and Seclusion" was reviewed on 09/23/10. The policy stated that restraints or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm.
On 09/23/10 at 10:00 AM an interview was conducted with Staff A. Staff A was questioned regarding the documentation for Patient #1 and was asked why a sitter was not utilized prior to Patient #1's placement in restraints. Staff A related that a sitter is utilized only as a last resort and that they can't bring in a sitter every time a patient gets confused.
There was no evidence that all less restrictive interventions had been utilized prior to Patient #1 being placed in restraints.



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The medical record review for Patient #4 was completed on 09/23/10. The clinical record review revealed the 80-year-old female was admitted to the hospital on 09/09/10 for ulcers on her lower extremities. A review of the history and physical dated 09/10/10 indicated the patient was a diabetic. The history and physical stated the patient had a past medical history of bilateral knee replacements and a heart attack. The medical record revealed a physician's order dated 09/21/10 at 10:00 A.M. for bilateral soft wrist restraints. A nursing note dated 09/21/10 at 10:00 A.M. stated the nurse placed a tube through the patient's nose for nutritional purposes. The medical record revealed a nursing restraint assessment form that stated the bilateral soft wrist restraints were applied on 09/21/10 at 10:00 A.M. because the patient was unable to make decisions for herself or follow simple instructions and because the patient attempted to remove her intravenous line. The assessment form stated a minimum of two alternative interventions were required prior to initiation of the use of restraints. The assessment stated the only alternative interventions attempted prior to placement of the restraints for this patient was reality reorientation and redirection.
In the morning of 09/23/10, during an interview Staff BA and BB confirmed the medical record did not indicate the patient had attempted to remove the nasal feeding tube or that another less restrictive device had been attempted.


The medical record review for Patient #8 was completed on 09/23/10. The medical record revealed the 63-year-old patient was admitted to the facility on 08/13/10. A review of the history and physical dated 08/14/10 was completed on 09/23/10. The review revealed the patient was diagnosed with hepatic encephalopathy and cirrhosis of the liver. The medical record revealed a physician's order dated 08/20/10 at 7:00 A.M. to restrain the patient with a vest so that the patient would be unable to get out of a chair because the patient would not call for assistance before ambulation. A nursing note dated 08/20/10 at 4:00 P.M. stated the patient was found on "hands and knees and (right) side on floor ...vested to bedside chair ... chair on top of patient .... Returned to bed .... No injury apparent .... Disoriented place and time. Uncooperative. Posey vest continued. Soft limb restraints applied." The medical record lacked evidence of an order for the use of soft limb restraints.

On 09/23/10 at 1:30 P.M. during an interview, Staff BD revealed she was unable to find evidence as to why a staff member (i.e., a sitter) was not assigned to provide continuous one-to-one observations of the patient prior to the use of the vest and the use of the vest and soft limb restraints. She said she didn't think it would be appropriate to use a sitter, but was unable to explain why. She said the sitter would be used as a last resort.


The medical record review for Patient #7 was completed on 09/23/10. The medical record revealed the 75-year-old patient was admitted to the hospital on 09/19/10 with diagnoses of chest pain, rule out coronary artery disease, headache, and low sodium. The medical record revealed a nursing note dated 09/21/10 at 7:35 P.M. that stated the patient was having increased confusion and hallucinations stating, "Look what they done to my house". A nursing note dated 09/21/10 at 8:15 P.M. stated the patient was agitated and the physician was paged. The medical record revealed a physician's order dated 09/21/10 at 8:15 P.M. that directed the staff to apply a soft vest restraint because the patient was agitated, confused, not following simple directions and was ambulating unassisted. The medical record revealed a restraint assessment form that stated the patient was placed into a vest restraint on 09/21/10 at 8:15 P.M. and that an alternative intervention of one-to-one contact with staff to maintain behavior was attempted.

On 09/22/10 in the afternoon during an interview, the surveyor asked Staff BE what one-to-one contact with staff meant. He said a sitter, i.e. a staff member who stays with the patient at all times. The surveyor asked since the restraint assessment form stated the patient had one-to-one contact marked, who was the sitter? Staff BE said that one-to-one contact had been inadvertently checked and the patient had not had a sitter prior to being placed in a vest restraint.

Based on review of the medical record, review of the hospital's policies and procedures and interview and confirmation with staff it was determined that the hospital failed to ensure that an order was written and followed prior to the placement of patient's in restraints. This was noted in three out of 10 medical records reviewed and affected Patient #s 1, 5 and 8. The hospital census is 174.
Findings include:

The medical record for Patient #1 was reviewed on 09/23/10. Patient #1 was admitted on 07/24/10 for chronic obstructive pulmonary disease, pleural effusion (accumulated fluid around the lungs) and hypertension. On 07/24/10 at 8:45 AM Patient #1 was found by staff lying on the floor. A post fall assessment was completed and at 9:15 AM an order was obtained from the physician for soft wrist restraints and a soft vest restraint to be applied. There was no documentation the order was followed or that the soft wrist restraint was applied. An interview was conducted on 09/23/10 at 10:00 AM. with Staff A who confirmed there was no documentation the soft wrist restraints were utilized. Staff A stated that the staff must have felt they did not need them. There was no documentation the physician was contacted for clarification of the order or notified that the soft wrist restraints were not going to be utilized.



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The medical record review for Patient #5 was completed on 09/23/10. The medical record revealed the 70-year-old patient was admitted to the hospital on 09/22/10 for agitation and aggressive behavior. The clinical record revealed a history and physical dated 09/22/10 that stated the patient had diagnoses of Alzheimer's dementia and depression. The medical record lacked evidence of a physician order for use of a lap belt to prevent the patient from getting out of his chair. The medical record did not identify when a lap belt had been applied to the patient.

On 09/23/10 at 9:50 A.M., the surveyor observed Patient #5 in a geri-chair with a black belt applied across his waist that secured him to the chair. The belt did not require a key for release. The surveyor and Staff BA asked the patient if he could remove the belt. The patient was unable to do so.

On 09/23/10 at 10:00 A.M. Staff BC explained that the nursing aide had applied the lap belt between 6:00 A.M. and 6:45 A.M. Staff BC said the aide did this when she got the patient up from bed. She said the aide applied the belt because she was instructed to do so. Staff BC said she was not aware the belt was considered a restraint if the patient didn't know how to release himself from it.

The medical record review for Patient #8 was completed on 09/23/10. The medical record revealed the 63-year-old patient was admitted to the facility on 08/13/10. A review of the history and physical dated 08/14/10 was completed on 09/23/10. The review revealed the patient was diagnosed with hepatic encephalopathy and cirrhosis of the liver. The medical record revealed a physician's order dated 08/20/10 at 7:00 A.M. to restrain the patient with a vest so the patient would be unable to get out of a chair because the patient would not call for assistance before ambulation. The medical record revealed a nursing note dated 08/20/10 at 4:00 P.M. that stated the patient was found on "hands and knees and (right) side on floor ...vested to bedside chair ... chair on top of patient .... Returned to bed .... No injury apparent .... Disoriented place and time. Uncooperative. Posey vest continued. Soft limb restraints applied." The medical record lacked evidence of a physician's order for the soft limb restraints.

On 09/23/10 at 1:30 P.M. during an interview, Staff BD confirmed he/she was unable to find documentation of a physician's order for the soft limb restraints.

Based on interview, policy and medical record review, the facility failed to obtain a physician's order to place Patient #8 back into restraints after having been released from them. The sample size was ten patients.

Findings:

The medical record review for Patient #8 was completed on 09/23/10. The medical record revealed the 63-year-old patient was admitted to the facility on 08/13/10. A review of the history and physical dated 08/14/10 was completed on 09/23/10. The review revealed the patient was diagnosed with hepatic encephalopathy and cirrhosis of the liver.

The medical record review revealed a physician's order dated 08/18/10 at 8:00 A.M. to have the patient restrained with soft limb restraints. The medical record revealed nursing notes dated 08/18/10 that stated the patient was out of restraints between 4:00 P.M. and 6:00 P.M. The notes indicated the patient was placed back into restraints at 8:00 P.M. The medical record lacked evidence a physician's order was obtained to place the patient back into restraints.

A review of the facility's restraint and seclusion policy as revised in May, 2009, was completed on 09/23/10. The policy stated a physician's order for each episode of the use of restraints is to be obtained and as needed or standing orders are not permissible.

On 09/23/10 at 12:30 P.M. during an interview, Staff BA confirmed the above findings.

On 09/23/10 at 1:30 P.M. during an interview Staff BD was unable to give an account of the patient's behavior while the patient was out of restraints, and was unable to locate a physician's order to place the patient back into restraints.