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Based on interview and document review, the facility failed to ensure patients who were placed in physical restraints were monitored and assessed, per facility policy, to ensure the physical and emotional safety of the patients in 2 of 3 restraint records reviewed (Patients #1 and #6).

This failure created the potential for an unsafe patient care environment, in which the physical and emotional safety needs of patients were not met.

FINDINGS

POLICY

According to the policy, Restraint Use in Non-Violent and Violent Situations, for Behavioral Restraints, monitor the patient for appropriateness and necessity of Restraints, restraint safely applied, risks associated with the intervention, level of distress or agitation, cognitive status and vitals signs if able to obtain. If the patient is in Behavioral Restraint, monitor the patient a minimum of every 15 minutes, more frequent or continuously depending on assessment of patient. Documentation of 15 minutes checks to include circulation checks (within the scope of the observer), general status, patient comfort, offer of : nutrition/hydration, elimination; VS as ordered; hygiene as needed.

For Medical/Nonviolent Restraint, re-assess the patient every 2 hours or more frequently based on the individual needs of the patient. Include in the assessment: physical/psychological status and readiness for discontinuation of restraints. Document the following, reassessment of patient every two hours, at minimum, including readiness for discontinuation of restraints.

1. The facility failed to provide evidence which showed how nursing staff determined the patients' restraints needed to be continued.

a) Review of Patient #6's medical record showed the patient was admitted to the facility on 06/09/17. From 06/11/17 through 06/20/17, the patient was in soft limb restraints.

According to the Restraint Initiation documentation dated, 06/11/17 at 9:15 a.m., soft limb restraints were applied to the patient's upper extremities. The documented behaviors leading to restraint use included: removing lines, dressings, or equipment. The patient's nurse documented the patient was on a ventilator (a machine that helps a patient to breathe).

From 12:00 p.m. until 8:00 a.m., the next day, the patient continued to be in restraints. Ten assessments were completed. However, there was no documented evidence which showed why the patient continued to require the restraints.

Similar findings were found on 06/12/17, 06/13/17, 06/14/17, 06/15/17, 06/16/17, 06/17/17, 06/19/17 and 06/20/17, a total of 8 days.

b) Review of Patient #1's History and Physical, dated 08/31/17, showed the patient was admitted to the facility for dementia and agitation.

According to the Restraint Initiation documentation, dated 09/07/17, non-violent restraints were applied at 6:15 a.m. for impulsive behavior.

At 7:00 a.m., Registered Nurse (RN) #1 documented soft limb restraints were continued to Patient #1's upper extremities. However, there was no documented evidence which showed why the patient continued to require the restraints.

At 7:46 a.m., a different nurse (RN #2) documented a Restraint/Seclusion Assessment for Patient #1. RN #2 documented the restraints needed to be continued but there was no evidence which showed what behaviors required the continued use of the restraints.

From 6:15 a.m. to 10:00 a.m., almost 4 hours, there was no evidence which indicated how both RN #1 and RN #2, determined the continued necessity of the non-violent restraints. This was in contrast to facility policy.

c) On 11/02/17 at 3:50 p.m., an interview was conducted the Director of Inpatient Units (Director #3) and the Chief Nursing Officer (CNO #4). Director #3 stated continued use of restraints was determined by patient's behavior and if the patient was pulling at things. S/he stated the assessment of the behaviors should be documented every 2 hours, including patients who were intubated and on a ventilator. Director #3 stated the behavior would show why the restraint was required to be continued.

Director #3 reviewed the Patient #1 and Patient #6's medical record and confirmed the missing restraint documentation.

2. The facility failed to ensure staff conducted required assessments every 15 minutes while a patient was in violent 4 point restraints.

a) Review of Patient #1's History and Physical, dated 08/31/17, showed the patient was admitted to the hospital for dementia and agitation.

Review of Patient #1's restraint documentation showed on 09/05/17 at 3:30 p.m., violent restraints were applied to the patient's upper and lower extremities. RN #7 documented the patient was agitated, restless, climbing out of bed, impulsive, removing lines, dressings or equipment.

RN #7 documented at 5:15 p.m. the restraints were discontinued. There was no evidence which showed the patient was assessed, every 15 minutes, for circulation to extremities, general status, patient comfort, hydration and elimination needs. This was in direct contrast to facility policy.

b) On 11/02/17 at 3:50 p.m., an interview was conducted with Director #3 and CNO #4. After review of Patient #1's restraint documentation, dated 09/05/17, Director #3 confirmed there were no documented 15 minutes checks in the patient's medical record. S/he stated patients in violent restraints were at high risk of injury due to being in the restraints. Director #3 stated staff were expected to ensure patients in violent restraints had circulation checks to the extremities, was offered activities of daily living and if the patient continued to need restraints.