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Based on interview and record review the facility failed to protect and promote the rights of two of 31 sampled patients (Patient 1 and Patient 18) to receive safe and dignified care when:

1. Patient 1 and Patient 18 were unnecessarily restrained without acceptable indications and required assessments per the hospital's policies and procedures for Patient Rights and Restraint and Seclusion (Refer to A0154),

2. Patient 1 and Patient 18 were restrained without attempting less restrictive interventions to protect the patient or others from harm (Refer to A0164),

3. Patient 1's was restrained without having an authorized order for restraints (Refer to A0168),

4. Patient 1 was restrained without physician notification (Refer to A0170), and

5. The hospital was not able to provide a log that tracked the reporting of Patient 10's death that occurred within 24 hours of the use of soft, non-rigid wrist restraints (a means to reduce the ability to move the arms freely) to the Centers for Medicare and Medicaid Services (Refer to A0214).

The cumulative effect of these failures resulted in the hospital's inability to protect and promote each patient's rights.

Based on interview and record review the facility failed to ensure two of 31 sampled patients (Patient 1 and Patient 18) that were restrained (any method, physical, or chemical [drug], that immobilizes or reduces the ability to move arms, legs, body or head freely) had necessary assessments and acceptable indications per hospital policies and procedures for Patient Rights and Restraint and Seclusion when:

1. Patient 1 was found to have mittens (glove devices to limit hand and finger movements) on both hands and Coban (self-adhering bandage commonly used as a wrap on a limb [arm or leg] that will stick to itself and not loosen) wrapped around Patient 1's wrists and tied to the bedside rails.

2. Patient 18 was found to be chemically restrained with both Olanzapine (a medicine that effects the brain and is Food and Drug Administration [FDA] approved in adults to treat both schizophrenia [a chronic mental illness that affects a person's thoughts, feelings and behaviors] and Tourette's syndrome [a chronic medical condition with repetitive body motions and vocal utterances) 5 mg (milligram, a unit of measure) intramuscularly (IM) and two doses of Haloperidol (a medicine that effects the brain and is FDA approved in adults to treat both schizophrenia and bipolar disorder [a chronic mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]) 2.5 mg IM.

These failures resulted in Patient 1 and Patient 18 being restrained in a manner not in accordance with regulatory requirements and facility policies and procedures, which violated their rights to receive care in a safe setting and their dignity, rights and well-being not being protected.

Findings:

1. Review of Patient 1's "Admission History and Physical (H&P)," dated 7/6/24, at 6:19 p.m., the H&P indicated Patient 1 was a 92-year-old, with a history which included significant dementia (loss of brain function such as thinking, remembering, reasoning), hypertension (high blood pressure), and had been brought via ambulance to the facility after a fall and that resulted in a left hip fracture. Patient 1's noted weight was 46 kilogram (equivalent to 101 pounds).

During a concurrent interview and record review on 9/10/24 at 11:16 a.m., with the Clinical Manager of Multi-Specialty (CMMS), CMMS indicated, on 7/10/24, Patient 1 had no active restraints orders, no documented restraint interventions, no documented nursing notes and no documented physician notification.

During an interview on 9/11/24 at 1:26 p.m., with the Chief Human Resources Officer (CHRO), CHRO indicated that a report had been received from a Respiratory Therapist (RT) that on 7/10/24 around 1 a.m., per CHRO Patient 1 had been found with mitten restraints, Coban stretched and wrapped around the wrists over the mittens and the Coban wrapped around the bed rails. RT reported that she could not find the assigned Registered Nurse (RN 7). RT notified another RN (RN 2) and the charge nurse (CN). RT reported that RN 2 reviewed Patient 1's orders, and found no current restraint orders. RT indicated that Patient 1 was not fussing or yelling and did not try to hit her (RT).

Continued concurrent interview and record review on 9/11/24 at 1:26 p.m., with CHRO, CHRO indicated she interviewed RN 7, and RN 7 initially denied having restrained Patient 1. RN 7 later admitted to restraining Patient 1. RN 7 alleged Patient 1 was hitting, punching, and calling him slurs. RN 7 had further stated he was overwhelmed with his assignment, never having had experienced this before. RN 7 saw the Coban in the room and acknowledged placing the hand mittens and wrapping Coban on Patient 1's wrists.

During a telephone interview on 9/11/24 at 3:02 p.m., with the CN, CN stated she was the CN on the night of 7/10/24, CN stated one of the RTs came to her with a concern that Patient 1's wrists were tied to the bedside rails. CN stated she then went to Patient 1's room and saw Patient 1 sleeping, Patient 1 had Coban wrapped around the wrists and Coban tied to the side rails. CN stated she spoke to RN 7 and RN 7 denied placing the Coban. CN stated she got scissors and removed the Coban.

During a telephone interview on 9/11/24 at 3:17 p.m., with RN 2, RN 2 stated she works in ICU (Intensive Care Unit). The night of 7/10/24, RN 2 was floating to the Medical Surgical Unit (MSU), the RT came and asked if it was a normal practice to tie Coban around a wrist and then around the siderails. RN 2 stated she told RT that this was "not a type of restraint we use, we use wrists restraints and mittens." RN 2 stated she went to Patient 1's room. Patient 1 was sleeping, saw Coban around Patient 1's wrists and Coban tied to the bed side rails. RN 2 indicated that she notified the CN and both the CN and RN2 went to Patient 1's room.

During a telephone interview on 9/11/24 at 3:25 p.m., with RT, RT stated she was the night shift RT on 7/10/24, while giving Patient 1's second breathing treatment on 7/10/24 around 01:00 a.m., she saw Patient 1 with hand mittens and Coban wrapped over the velcro in the wrist area, and the Coban wrapped around the bedside rail. RT stated that when she saw the Coban wrapped around the wrist and the Coban tied to the bedside rail, she (RT) went to find the CN, saw the Resource Nurse (RN 2) and told RN 2 about finding Patient 1 in mittens with Coban wrapped around wrists and tied to bed siderails. RT further stated RN 2 reviewed the Restraints Orders and Patient 1 had no current restraints orders. RT indicated that she and RN 2 notified the CN. The CN, RN 2 and RT went to Patient 1's room to assess Patient 1 and then RT left the unit.

During a telephone interview on 9/11/24 at 4:05 p.m., with RN 8, RN 8 stated she works day shift. RN 8 indicated she was the assigned nurse for Patient 1 on 7/10/24 and 7/11/24. RN 8 stated Patient 1 had a fractured hip, was a little confused, pleasant and easily re-directed. RN 8 futher stated that on one of the days (could not recall which day), Patient 1 was found with mittens and she (RN 8) removed the mittens. RN 8 stated when the mittens were removed, she observed new bruises on Patient 1's one hand and wrists, the hand was swollen, her skin was fragile, and her right arm had bruising. RN 8 indicated there were no orders for restraints.

2. During concurrent interview and review of Patient 18's Electronic Medical Record (EMR) on 9/10/24 at 3:15 p.m. with the Chief Nursing Officer (CNO), the Emergency Department Triage record, dated 8/26/24, indicated Patient 18 was a 98-year-old brought in by ambulance from an assisted living facility on 8/26/24 and per the Facesheet, Patient 18 was admitted to the hospital on 8/27/2024 at 5:17 a.m. Review of the EMR indicated that on 8/28/24 at 0:11 a.m. a physician was notified the patient's condition was "very agitated and combative," for which the physician ordered one dose of Olanzapine 5 mg IM. Review of the Medication Administration Record (MAR) indicated Olanzapine was injected at 1:45 a.m. The CNO stated that Olanzapine would be considered a restraint. The CNO stated she considered the message of the patient being "very agitated and combative" as a change of condition and thus required a reassessment, per Hospital Policy. The CNO reviewed Patient 18's EMR and stated there were no apparent documentation of attempts and failures of less restrictive interventions before the use of Olanzapine, no re-assessment of the patient's condition by nursing, no modified Nursing Care Plan (NCP) that included restraints, no post-medication assessment including documentation of the response to the chemical restraint, and no doctor's assessment related to the patient's then current condition. The CNO stated the missing nursing documentation was all required by the Restraint & Seclusion policy.

During continued concurrent interview and record review of Patient 18's EMR on 9/10/24 at 3:15 p.m. with the CNO, Patient 18's MAR indicated on 8/28/24 at 4:21 a.m., Patient 18 received Haloperidol 2.5 mg IM once. The CNO stated that Haloperidol would be considered a restraint per the hospital policy. The CNO could not find documentation of attempts and failures of less restrictive interventions, communication to the Physician, a nursing re-assessment, the response to the chemical restraint, a physician's assessment, a revised care plan that included restraints, and/or a post-medication assessment. The CNO stated the missing nursing documentation was all required by the Restraint & Seclusion policy. The MAR indicated on 8/28/24 at 7:53 a.m., Patient 18 received a second dose of Haloperidol 2.5 mg IM once, for which the CNO stated the nursing documentation was consistent with the hospital policy Restraints & Seclusions.

During a concurrent interview and review of Patient 18's MAR and nursing assessments dated 8/28/24 with the Emergency and Intensive Care Unit Director (ED/ICUD) on 9/11/24 at 10:13 a.m., ED/ICUD stated, on 8/28/24 Patient 18 received Olanzapine 5mg IM at 1:45 a.m. and Haloperidol 2.5 mg IM at 4:21 a.m., for which there was no documentation of any nursing assessment before or after the medication administrations. ED/ICUD stated the lack of nursing assessments was not consistent with hospital policy.

During a concurrent interview and review of Patient 18's MAR on 8/28/24 with a hospital Pharmacist (Ph), on 9/12/24 at 2:45 p.m., Ph stated that Patient 18's dose of Olanzapine 5 mg IM at 1:45 a.m. and subsequent doses of Haloperidol 2.5 mg IM at 4:21 a.m. and 7:53 a.m. would have led her to question whether the patient needed the additional doses of Haloperidol.

Review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 9/21/22, the P&P indicated, "Receive care in a safe setting, free from verbal, mental, sexual, or physical abuse, neglect ...Be free from restraints and seclusion of any form used as means of coercion, discipline, convenience, or retaliation by staff."

Review of the facility's P&P titled, "Restraint and Seclusion," dated 6/9/15, the P&P indicated: "Purpose: The purpose of this policy is to define the Hospital's approach to the application of restraint and seclusion for patients in a way that protects the patient's health and safety, and preserves his or her dignity, rights and well-being. Definitions: Restraint means any method, physical or chemical, or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, leg, body or head freely."

Based on interview, patient record review and facility document review the hospital failed to ensure 2 of 31 sampled patients (Patient 1 and Patient 18), who were ordered and placed in restraints (any method, physical, or chemical [drug], that immobilizes or reduces the ability to move arms, legs, body or head freely), had previously had less restrictive interventions attempted and failed when:

1. Patient 1 was found to have mitten restraints (glove devices to limit hand and finger movements) and Coban (self-adhering bandage commonly used as a wrap on a limb [arm or leg] that will stick to itself and not loosen) wrapped around Patient 1's wrists and tied to the bedside rails.

2. Patient 18 received Olanzapine (a medicine that affects the brain and is Food and Drug Administration (FDA) approved in adults to treat both schizophrenia [a chronic mental illness that affects a person's thoughts, feelings and behaviors] and Tourette's syndrome [a chronic medical condition with repetitive body motions and vocal utterances]) 5 mg (milligram, a unit of measure) intramuscularly (IM) and two doses of Haloperidol (a medicine that affects the brain and is FDA approved in adults to treat both schizophrenia and bipolar disorder (a chronic mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) 2.5 mg IM.

These failures resulted in the hospital neither protecting the patients' health and safety, nor preserving their dignity, rights, and well-being.

Findings:

1. Review of Patient 1's "Admission History and Physical (H&P)," dated 7/6/24, at 6:19 p.m., the H&P indicated Patient 1 was a 92-year-old with a history, which included significant dementia (loss of brain function such as thinking, remembering, reasoning), hypertension (high blood pressure), and had been brought by ambulance to the facility after a fall with complaints of hip pain resulting on a left hip fracture.

During a telephone interview on 9/11/24 at 3:25 p.m., with the Respiratory Therapist (RT), RT stated she was the night shift RT on 7/10/24. RT stated, while giving Patient 1's breathing treatment on 7/10/24 around 01:00 a.m., RT saw Patient 1 had mittens on her hands and Coban wrapped around the wrists, and around the bedside rails.

During a concurrent interview and record review on 9/10/24 at 11:16 a.m., with the Clinical Manager Multi-Specialty (CMMS), Patient 1's "Restraint Flowsheet," dated 7/10/2024, was reviewed. CMMS confirmed that, the Restraint Flowsheet indicated, on 7/10/24 from midnight to 8 a.m., no documented interventions to demonstrate restraint usage and rationale including the use of less restrictive interventions done prior to the application of the restraint.

2. During concurrent interview and review of Patient 18's Electronic Medical Record (EMR) on 9/10/24 at 3:15 p.m. with the Chief Nursing Officer (CNO), the Emergency Department Triage record, dated 8/26/24, indicated Patient 18 was a 98-year-old brought in by ambulance from an assisted living facility on 8/26/24, and, per the Facesheet, Patient 18 was admitted to the hospital on 8/27/2024 at 5:17 a.m. Review of a "Communication" note, dated 8/28/24, indicated that on 8/28/24 at 0:11 a.m. a physician was notified the patient's condition was "very agitated and combative," for which the physician ordered one dose of Olanzapine (a medicine that effects the brain and is Food and Drug Administration (FDA) approved in adults to treat both schizophrenia (a chronic mental illness that affects a person's thoughts, feelings and behaviors) and Tourette's syndrome (a chronic medical condition with repetitive body motions and vocal utterances) 5 mg (milligram, a unit of measure) intramuscularly (IM). Review of the Medication Administration Record (MAR), dated 8/28/24, indicated that Patient 18 received the injection of Olanzapine at 1:45 a.m. The CNO stated Olanzapine would be considered a restraint and that, according to Patient 18's EMR, there was neither documentation of less restrictive interventions having been tried and failed before Patient 18's restraint was administered nor was there documentation of a nursing assessment.

During continued concurrent interview and review of Patient 18's EMR with the CNO on 9/10/24 at 3:15 p.m., the MAR indicated that, on 8/28/24 at 4:21 a.m., Patient 18 received Haloperidol (a medicine that effects the brain and is FDA approved in adults to treat both schizophrenia and bipolar disorder (a chronic mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) 2.5 mg IM, once. On 8/28/24 at 7:53 a.m., Patient 18 received Haloperidol 2.5 mg IM, once. The CNO stated that Haloperidol would be considered a restraint per hospital policy and procedure. The CNO could not find documentation of attempts and failures of less restrictive interventions before Patient 18's restraint was administered.

During a review of the facility's policy and procedure (P&P) titled, "Restraint & Seclusion," dated 6/9/15, the P&P indicated: "The purpose of this policy is to define the Hospital's approach to the application of restraint and seclusion for patients in a way that protects the patient's health and safety, and preserves his or her dignity, rights and well-being. Definitions: Restraint means any method, physical or chemical, or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, leg, body or head freely ...The hospital uses restraint or seclusion only when it can be clinically justified or when warranted by patient behavior that threatens physical safety of the patient, staff, or others...Relevant orders for use of restraints, including least restrictive intervention... Assessment:...Determination of least restrictive intervention and rationale selection... Consideration of less restrictive alternatives tried and/or failed in the past, including failure of non-physical interventions (ineffective methods) ..."

Based on interview and record review the facility failed to ensure one (Patient 1) of 31 sampled patients on restraints had a restraint initiated only upon the order of a physician or other licensed independent practitioner (LIP- health care provider who is legally permitted to provide care and services without supervision or direction) when Patient 1 was found to have mittens restraints (glove devices to limit hand movements) and Coban (self-adhering bandage commonly used as a wrap on a limb (arm or leg) will stick to itself and not loosen) wrapped around Patient 1's wrists and tied to the bedside rails.

This failure resulted in Patient 1's being restrained without having an authorized order for restraints.

Findings:

Review of Patient 1's "Admission History and Physical (H&P)," dated 7/6/2024, at 6:19 p.m., the "H&P" indicated Patient 1 was a 92-year-old with a history which included significant dementia (loss of brain function such as thinking, remembering, reasoning), hypertension (high blood pressure), and had been brought via ambulance to the facility after a fall with complaints of hip pain resulting on a left hip fracture.

During a concurrent interview and record review on 9/10/24 at 11:16 a.m., with the Clinical Manager Multi Specialty (CMMS), Patient 1's "Restraint Order Sheet," dated 7/8/24 and 7/11/24 were reviewed. CMMS indicated there was no physician restraints orders for 7/10/24. The CMMS further indicated that restraint orders are required and last for 24 hours.

During a concurrent interview and record review with the Chief Nursing Officer (CNO) on 9/11/24 at 2:05 p.m., Patient 1's physician orders, dated 7/10/24, were reviewed. The CNO stated there was no restraint order for 7/10/24. The CNO stated Registered Nurse (RN 7) was not practicing within his scope of practice when RN 7 applied restraints (mittens and Coban) to Patient 1 on 7/10/24 without a physician's orders. The CNO stated Coban was not an acceptable use for restraints.

Review of the facility's policy and procedure (P&P) titled "Restraint and Seclusion," dated 6/9/15, the P&P indicated, " ...Restraint is initiated only upon the order of a physician or other licensed independent practitioner (LIP). The order is time-limited not to exceed 24 hours and includes the specific reason for the intervention."

Based on interview and record review the facility failed to ensure one (Patient 1) of 31 sampled patients had a physician consultation before or soon after the initiation of restraints when Patient 1 was found to have mittens restraints (glove devices to limit hand movements) and Coban (self-adhering bandage commonly used as a wrap on a limb (arm or leg) will stick to itself and not loosen) wrapped around Patient 1's wrists and tied to the bedside rails.

This failure resulted in Patient 1 being restrained without physician notification, potential psychosocial injury and the failure to be provided with a more appropriate intervention and treatment.

Findings:

Review of Patient 1's "Admission History and Physical (H&P)," dated 7/6/2024, at 6:19 p.m., the "H&P" indicated Patient 1 was a 92-year-old with a history which included significant dementia (loss of brain function such as thinking, remembering, reasoning), hypertension (high blood pressure), and had been brought via ambulance to the facility after a fall and complaints of hip pain resulting on a left hip fracture.

During a telephone interview on 9/11/24 at 3:25 p.m., with the Respiratory Therapist (RT), RT stated she was the night shift RT on 7/10/24, RT saw Patient 1 with hand mittens and Coban wrapped over the velcro in the wrist area, and the Coban wrapped around the bedside rail.

Continued telephone interview on 9/11/24 at 3:25 p.m., with the RT, RT stated RN 2 reviewed the Restraints Orders and Patient 1 had no current restraints orders.

During a concurrent interview and record review on 9/10/24 at 11:16 a.m., with the Clinical Manager of Multi-Specialty (CMMS), Patient 1's physician orders for 7/10/24 were reviewed. The CMMS verified that Patient 1 had no active restraints orders for 7/10/24 and there was no documentation of physician notification of Patient 1's change of condition.

Review of the facility's policy and procedure (P&P) titled, "Restraint & Seclusion," dated 6/9/15, the P&P indicated ... "Restraint is initiated only upon the order of a physician or other licensed independent practitioner (LIP). ... If the ordering physician is not the attending, the attending physician must be consulted as soon as possible. The attending physician may have information regarding if the patient's history significantly impacts the use of selection of the restraint."

Additional review of the facility's policy and procedure (P&P) titled, "Restraint & Seclusion," dated 6/9/15, the P&P indicated ... "If the need for restraint is based on a significant change in the patient's condition, the Registered Nurse must immediately notify the physician or licensed independent practitioner."

Based on interview and patient record review the hospital was not able to provide a report of deaths associated with the use of soft, non-rigid wrist restraints (a means to reduce the ability to move the arms freely) for 1 of 31 sampled patients (Patient 10).

This failure resulted in the hospital not meeting the federal regulations for the death reporting requirements associated with the use of soft, non-rigid wrist restraints.

Findings:

During an interview on 9/11/24 at 8:30 a.m. with Chief Nursing Officer (CNO), CNO stated, when a patient death occurs an incident report is completed, submitted, and put on a spreadsheet by the quality manager. The CNO stated there is no documentation made in a patient's medical record regarding restraints at the time of death. A death report is run monthly from the electronic medical record system and reviewed. The spreadsheet or some other tracking mechanism of patient deaths while in restraints or 24 hours after a patient has been removed from restraints was requested, and the CNO did not provide one.

During a concurrent interview and record review on 9/11/24 at 9 a.m. with Clinical Manager Multi Specialty (CMMS), Patient 10's "Interactive View Print Request" dated 8/13/24 indicated Patient 10's "2 point soft restraints left and right upper limb" restraints were discontinued on 8/13/24 at 7:00 a.m., and Patient 10's "Notification of Death" record indicated Patient 10 expired on 8/13/24 at 1:59 p.m. CMMS confirmed the documentation of death and restraints.

During an interview on 9/12/24 at 10:25 a.m. with CNO, the spreadsheet or some other tracking system for reporting deaths associated with the use of soft, non-rigid wrist restraints was requested and was not provided. CNO stated, "there is nothing in the quality folder for a death reporting log ...I don't think this spreadsheet has been started."

A review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion", dated 6/9/15, the P&P indicated, "4.0 Death Reporting Requirement: ...the hospital staff must record in an internal log or other system ...each entry must be made no later than seven days after the date of death of the patient ... each entry must document the patient's name, date of birth, date of death, name of attending physician or other licensed independent practitioner who is responsible for the care of the patient, medical record number, and primary diagnosis ...The information must be made available in either written or electronic form to CMS [Centers for Medicare and Medicaid Services] immediately upon request."

Based on interview, patient record review and facility document review the hospital failed to ensure nursing staff developed and maintained a nursing care plan (NCP) which accurately reflected the needs of 10 out of 31 sampled patients (Patients 2, 5, 6, 7, 12, 15, 16, 18, 23, and 31) who were restrained.

These failures had the potential to negatively impact the care of these patients.

Findings:

During a current interview and record review on 9/10/24 at 10:50 a.m., with the Director of Accreditation (DOA) Patient 2's medical record was reviewed. Patient 2's facesheet indicated Patient 2 was admitted to the hospital on 6/11/24 at 1:38 a.m., and a physician's order was written to place Patient 2 in 2-point soft wrist restraints (a means to reduce the ability to move freely) on 6/11/24 at 10:12 a.m. DOA confirmed the order for restraints and indicated a NCP was not initiated when the patient was placed in restraints.

During a concurrent interview and record review on 9/10/24 at 11 a.m., with the DOA, Patient 5's medical record was reviewed. Patient 5's facesheet indicated Patient 5 was admitted to the hospital on 6/20/24 at 2:45 p.m. A physician's order was written to place Patient 5 in 2-point soft limb wrist restraints on 6/25/2024 at 3:30 a.m. DOA confirmed the order for restraints and indicated a NCP was not initiated when Patient 5 was placed in restraints.

During a concurrent interview and record review on 9/10/24 at 8:47 a.m., with the Clinical Manager Multi Specialty (CMMS), Patient 6's medical record was reviewed. Patient 6's facesheet indicated Patient 6 was admitted to the hospital on 6/11/24, and a physician's order was written to place Patient 6 in 2-point soft wrist restraints. CMMS confirmed the physicians order and that a NCP was not initiated when Patient 6 was placed in restraints.

During a current interview and record review on 9/10/24 at 8:47 a.m., with CMMS, Patient 7's medical record was reviewed. Patient 7's facesheet indicated Patient 7 was admitted to the hospital on 6/20/24 and a physician's order was written to place Patient 7 in 2-point soft wrist restraints. CMMS confirmed the physician's order and indicated a NCP was not initiated when Patient 7 was placed in restraints.

During an interview on 9/11/24 at 8:00 a.m., with the Chief Nursing Officer (CNO) indicated a NCP should have been initiated when restraints were applied to Patients 2,5,6, and 7.

During a concurrent interview and record review on 9/10/24 at 11:30 a.m., with Director of Quality (DOQ), Patient 12's "Order Sheet", dated 8/15/24 was reviewed. The Order Sheet indicated Patient 12 was admitted on 8/15/24 and "Soft limb, Restraint Points: 2 Point Restraint, Bilateral (both sides) Upper Extremity," were ordered on that date. Review of Patient 12's "Document in Plan" did not indicate any NCP for restraints. DOQ confirmed the order for restraints and stated if a patient has restraints ordered, there should be a NCP for restraints in place.

During a concurrent interview and record review on 9/10/24 at 11 a.m., with Emergency Department/Intensive Care Unit Director (ED/ICU D), Patient 15's "Order Sheet," dated 8/12/24 was reviewed. The Order Sheet indicated Patient 15 was admitted 8/8/24 and "Soft limb, Restraint Points: 2 Point Restraint, Bilateral (both sides) Upper Extremity," were ordered on 8/12/24. Review of Patient 15's "Document in Plan" did not indicate any plan of care for restraints. ED/ICU D confirmed the order for restraints and stated if a patient has restraints ordered, there should be a NCP in place.

During a concurrent interview and record review on 9/10/24 at 11:15 a.m., with ED/ICU D, Patient 16's "Order Sheet", dated 8/23/24 was reviewed. The Order Sheet indicated Patient 16 was admitted 8/23/24 and "Soft limb, Restraint Points: 2 Point Restraint, Bilateral (both sides) Upper Extremity," were ordered on that date. Review of Patient 16's "Document in Plan" did not indicate any NCP for restraints. ED/ICU D confirmed the order for restraints and stated if a patient has restraints ordered, there should be a NCP for restraints in place.

During a concurrent interview and record review on 9/10/24 at 2:22 p.m., with the CMMS, Patient 23's "Order Sheet" was reviewed. The Order Sheet indicated Patient 23 was admitted on 7/4/24 and "Soft limb, Restraint Points: 2 Point Restraint, Bilateral Upper Extremity," were ordered on 7/12/24. Review of Patient 23's "Document in Plan" did not indicate any NCP for restraints. CMMS confirmed the orders for restraints and stated Patient 23 should have had a restraint NCP.

During a concurrent interview and record review on 9/10/24, at 11 a.m., with ED/ICU D Patient 31's "Order Sheet", dated 8/31/24 was reviewed. The Order Sheet indicated Patient 31 was admitted 8/30/24 and "Soft limb, Restraint Points: 2 Point Restraint, Bilateral (both sides) Upper Extremity," were ordered on 8/31/24. Review of Patient 31's "Document in Plan" did not indicate any NCP for restraints. ED/ICU D confirmed the order for restraints and stated if a patient has restraints ordered, there should be a care plan for restraints in place.

During a concurrent interview and record review on 9/10/24 at 3:15 p.m. with the CNO, Patient 18's "Order Sheet," dated 8/28/24 was reviewed. The Order Sheet indicated Olanzapine (a medicine that effects the brain and is Food and Drug Administration approved in adults to treat both schizophrenia [a serious mental health condition that affects the way a person thinks, feels, and behaves] and Tourette's syndrome [a condition with frequent repetitive body movements and vocal utterances]) 5 mg (milligram, a unit of measure) to be given intramuscularly (injected into a muscle) on 8/28/24 at 1:15 a.m. The CNO stated Olanzapine would be considered a restraint. The CNO verified Patient 18's chart did not indicate any NCP for restraints.

During a review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion", dated 6/9/15, the P&P indicated, "1.7 When a restraint is implemented, the patient's plan of care [NCP] must be modified to reflect this change."

During a review of the facility's P&P titled, "Patient Care Planning", dated 3/17/21, the P&P indicated, "The plan of care [NCP] will be based on assessment of the patient/family and identification of needs and problems ...an assessment is made of what is necessary to ensure the patient's safety."