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Based on review of facility policies and procedures, medical records (MR), and interview with staff (EMP), it was determined the facility failed to protect and promote the rights of each patient; by failing (A-0168); to use restraints in accordance with the order of a physician, (A-0169); ensuring orders were never written as a standing order or on an as needed basis(PRN); (A-0174); discontinue the restraints at the earliest possible time, regardless of the length of time identified in the order, (A-0187); document in the patient's medical record the patient's condition or symptom(s) that warranted the use of the restraints, and (A-0214); report deaths associated with the use of restraints.


Cross Reference:
482.13(e)(5) Patient Rights: Restraint or Seclusion
482.13(e)(6) Patient Rights: Restraint or Seclusion
482.13(e)(9) Patient Rights: Restraint or Seclusion
482.13(e)(16)(iv) Patient Rights: Restraint or Seclusion
482.13(g)(2)(i) Patient Rights: Restraint or Seclusion

Based on review of facility policy, medical records (MR), and interview with staff (EMP), it was determined the facility failed to use restraints in accordance with the order of a physician for two of ten medical records reviewed (MR1 and MR6.)

Findings include:

Review of facility policy, "Restraint and Seclusion, dated June 23, 2017, revealed, "... VIII. Use of Restraint for Non Violent/Non Self-Destructive Behavior. A. Order (Written/Computerized provider order entry or CPOE). A physician order, order of a CRNP or order of a PA is required for restraint use. ..."

1. Review of MR1 revealed a restraint assessment on February 10, 2018, that left and right upper extremity restraints were discontinued on February 10, 2018, at 1408. Further review of MR1 revealed restraint assessments on February 10, 2018 at 1600, 1800, 2000, 2200, February 11, 2018 at 0200, 0400, and 0600, documenting MR1 was in right and left upper extremity soft restraints. No physician order was observed for left and right upper extremity restraints until February 11, 2018 at 7:39 AM.

2. Interview with EMP1 on March 22, 2018 at 2:00 pm confirmed the above, and revealed, "Yes there is no order".

3. Review of MR1 revealed a restraint assessments on February 21, 2018, at 1200 and 1400, and February 23, 2018 at 0000, documenting the use of full siderails. Further review of MR1 revealed no physician order for full siderails.

4. Interview with EMP2 on March 22, 2018 at 2:00 pm, revealed, "There are no orders."

5. Review of MR6 revealed restraint assessments on March 5, 2018 at 1600 and 1800 documenting the use of full siderails. Further review of MR2 revealed no physician order for full siderails.

6. Interview with EMP1 on March 23, 2018 at 11 am, revealed , "It [physcian order for full siderails] should have been reordered."

Based on review of facility documentation, medical records(MR), and staff(EMP) interview revealed the facility failed to ensure an order for the use of restraint or seclusion was not written as an as needed basis (PRN) for one of eight medical records reviewed (MR3).

Findings include:

Review of facility policy and procedure "Restraint and Seclusion" dated June 23, 2017, revealed "... 3. STANDING OR PRN (as needed) ORDERS FOR ANY RESTRAINT ARE NOT ACCEPTED. ..."

1. Review of MR3 revealed physician orders dated January 22 through January 23, 2018 revealed "left and right upper extremity as needed at night for line pulling" Further review revealed physician orders dated January 20 & 21, 2018 "Mitt(s) secured as needed"

Interview with EMP2 on March 22, 2018 at approximately 11:30 AM confirmed the above findings and revealed "That should not have been written like that."

Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to discontinue restraints at the earliest possible time for three of ten medical records reviewed (MR1, MR6, and MR8.)

Findings include:

Review of facility policy dated June 23, 2017, revealed, " ... Use of Restraint for Non Violent/Non self-destructive Behavior A. Order (written/computerized provider order entry or 'CPOE') ... 2. Restraint use is to be discontinued at the earliest possible time, based on individualized assessment that the individuals needs can be addressed using less restrictive methods, regardless of the length of time identified in the order. ..."

1. Review of MR1 revealed restraint assessments for left and right upper extremity soft restraints on February 10, 2018, at 1600 and 1800, the patient was sleeping and no longer attempts to discontinue therapeutic interventions. Further review of the February 10, 2018 1600 and 1800 assessments revealed the restraints were reapplied after both assessments. Further review of MR1 revealed restraint assessments for vest and left and right upper extremity restraints on February 26, 2018, at 2000, 2200, and February 27, 2018, 0000, 0200, 0400, and 0600 revealed the patient no longer attempts to discontinue therapeutic interventions and no longer demonstrates actions that could impede recovery/healing" Further review of the above restraint assessments revealed the restraints were reapplied after all these assessments.

2. Interview with EMP1 on March 22, 2018 at approximately 1:00 pm, confirmed the above and revealed, "The nurses must not understand what they are documenting."

3. Review of MR6 revealed a restraint assessment for full siderails on March 5, 2018, at 1600, the patient was quiet/calm, sleeping, no longer demonstrates actions that could impede recovery/healing. Further review of the assessment revealed the restraints were reapplied after the assessment.

4. Interview with EMP1 on March 23, 2018, at approximately 11 am revealed, "yes, they (restraints) should have been removed."

5. Review of MR8 revealed a restraint assessment for left and right upper extremity soft restraints on January 8, 2018, at 2000, 2200, and January 9, 2018, at 0000, 0200, and 0400, the patient was quiet/calm. Further review of the above restraint assessments revealed the restraints were reapplied after all these assessments.

6. Interview with EMP on March 23, 2018, at 2:00 pm confirmed the above and revealed, "Those are newer nurses, it looks like they need more education."

Based on review of facility documentation, medical records (MR) and staff (EMP) interview revealed the physician order failed to include documentation the patient ' s condition or symptoms that warranted the use of full side rails for four of four medical records reviewed (MR3, MR5, MR8 and MR10).

Findings include:

Review of facility policy "Restraint and Seclusion" dated June 23, 2017, revealed "B. PHYSICIAN'S ORDER (WRITTEN/COMPUTERIZED PROVIDER ORDER ENTRY OR "COPE" ... 1. The order will include: ... b. reason for use"

1. Review of MR3 revealed a physician order "Full Side Rails ... 01/20/18 13:35:00" further review revealed no documentation of the condition or symptoms that warranted the use.

2. Review of MR5 revealed a physician order "Full Side Rails ... 02/04/18 11:24:00" further review revealed no documentation of the condition or symptoms that warranted the use.

3. Review of MR8 revealed a physician order "Full Side Rails ... 01/08/18 0:31:00" further review revealed no documentation of the condition or symptoms that warranted the use.

4. Review of MR10 revealed a physician order "Full Side Rails ... 02/15/18 14:50" further review revealed no documentation of the condition or symptoms that warranted the use.

Interview with EMP1 on March 23, 2018, at approximately 11:45 AM confirmed the above findings and revealed, "No they [orders] do not."

Based on review of facility documentation, medical records(MR) and staff(EMP) interview revealed the facility failed to document in the patient's medical record the date and time each reportable death associated with the use of restraints was reported to the CMS Regional Office for four of six medical records reviewed (MR2, MR3, MR4, and MR7).
Findings include:
Review of facility policy and procedure "Restraint and Seclusion" dated February 12, 2018, revealed "E. For each death ... hospital staff will document in the patient's medical record, the date and time the death was reported to CMS."

1. Review of facility documentation "Restraint Log" with MR2, MR3, MR4, and MR7 name recorded on it. Further review of the medical records revealed no documentation the facility documented the date and time the death was reported to CMS.

Interview with EMP1 and EMP2 on March 23, 2018 at 1:00 PM confirmed the above findings and revealed "right there was four out of six that didn't have it[documentation in the medical record when their death was reported to CMS]. "