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Based on interview and document review, the facility failed to ensure orders were obtained by a physician, or other Licensed Independent Practitioner (LIP), for patients who were placed in restraints. No physician or LIP order was found in 1 of 8 restraint records reviewed (Patient #1).

This failure created the potential for an unsafe patient care environment, in which the responsible ordering physician or LIP was not aware of the patient's medical needs and current health status.

FINDINGS:

POLICY

According to the policy, Restraint and Seclusion, the hospital initiates restraint or seclusion based on an individual order. In addition, the policy stated nursing and other staff who have documented training in restraint and seclusion use may apply restraints or seclusion on the order of a physician or nurse practitioner (NP).

According to the policy, Business Continuity Plan (Epic Downtime Process), paper forms will be used during downtime. The policy continued, commonly used order sets and any corresponding decision support guidelines can be obtained from BCA red binders or from designated BCA file drawers. A blank order form should be used when individual orders are written or when a particular order set is not available.

1. Nursing staff did not receive an order before restraints were initiated on Patient #1.

a) Review of Patient #1's History and Physical, dated 8/24/15, revealed the patient presented with altered mental status and a recent acute Cerebral Vascular Accident (CVA). A progress note, written by Physician #2, on 08/26/15 at 2:20 p.m., stated the patient was "doing OK, eating, very active walking in room although is 'fall risk' and wants to go and have a cigarette! In a posey bed since last p.m. as impulsive and repeatedly kept trying to get out of bed (oob)."

A Speech and Language Pathologist (SLP) Therapy Note, written on 08/26/15 at 2:50 p.m., stated, the "patient was lying with his/her head at the foot of the posey bed and had the mattress/extra cushion pulled partially on top of him/her. S/he was cooperative but somewhat confused and demonstrated a flat affect. Patient was secured in the posey bed after speech therapy with call light and phone in reach."

A Neurology Consult Follow-Up Note, written on 08/26/15 at 10:39 p.m. stated "patient required posey bed as s/he kept trying to get out of bed through the evening."

There was no restraint documentation of when the restraints were initiated, or to correlate with the aforementioned progress notes which stated the restraints were applied over the night of 08/25/15 to 08/26/15. No order had been placed for the use of non-violent restraints while Patient #1 was admitted on the inpatient floor. The first documentation of physical restraints was on 08/26/15 at 7:00 p.m., almost 4 hours and 40 minutes after Physician #2's progress note, which stated "continued" for use of the enclosed posey bed.

The patient was transferred to the acute inpatient rehabilitation floor on 08/27/15, where an order was placed for non-violent restraints.

During the review of Patient #1's electronic medical record (EMR), on 11/18/15 at 12:53 p.m., the Patient Safety Officer (Employee #13) and the Manager of Regulatory and Accessibility (Employee #9) discussed the possibility of a computer downtime, and stated the order might have been on paper, and wasn't entered electronically. The facility was unable to provide any supporting documentation of a restraint order for Patient #1.

b) On 11/18/15, at 3:47 p.m., an interview was conducted with Registered Nurse #3 (RN). RN #3 stated s/he thought orders for restraints occurred every 24 hours. RN #3 stated a signed order from a physician must be in the chart in order to initiate and continue restraints.

c) On 11/18/15, at 3:46 p.m., an interview was conducted with RN #4 who stated restraints were ordered every 3 days by a physician. RN #4 stated if a downtime occurred, s/he would get a paper order and then back chart it into the patient's EMR. RN #4 stated restraints shouldn't be initiated without an order.

d) On 11/18/15 at 4:52 p.m., an interview with Physician #2 revealed restraint use required an order. Physician #2 stated s/he probably didn't realize an order wasn't placed on Patient #1 when s/he wrote his/her progress note. Physician #2 stated the mention of restraints in a progress note did not substitute the need for a restraint order.

e) On 11/18/15, at 3:55 p.m., an interview was conducted with the Director of Rehabilitation. The Director stated restraints were not to be used without an order. The Director stated if a downtime occurred the expectation for staff was to follow the downtime procedure and obtain a paper order for the restraint.

f) On 11/19/15, at 10:16 a.m., an interview was conducted with the Medical Director of Rehabilitation (Physician #6), the Clinical Manager of Rehabilitation (RN #7), and the Case Manager (CM) of Rehabilitation (RN #8). The Medical Director stated orders were always required for restraints. Physician #6 stated in a downtime, the facility used paper orders, and once the computers worked, the orders were placed in the EMR.

g) On 11/19/15 at 11:48 a.m., an interview was conducted with Employee #9 who stated an order was required for restraint use. Employee #9 stated when computer downtime occurred, the expectation was for the nurse to write the order on paper and when the computer worked again, the order was placed in the EMR.

h) On 11/19/15 at 12:01 p.m., an interview with the Director of Clinical Quality (Employee #12) revealed the quality department wasn't reviewing restraint audits done on the floor. Employee #12 stated s/he didn't know if the units performed audits on restraint use and documentation. Employee #12 stated the quality department reviewed restraint audits in the past; however, the quality department "backed off" of their review because the facility had been compliant with documentation. Employee #12 stated that in the last 2 days, s/he realized they had room for improvement with the documentation of restraints.

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 8 restraint records reviewed (Patient #1 and #6).

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

FINDINGS:

POLICY

According to the policy, Restraint and Seclusion, restraint or seclusion is discontinued as soon as is safely possible; when the patient is no longer a threat to self or others (violent restraint), or when the medical need for restraint (non-violent restraint) is no longer present. Furthermore, the policy stated documentation of restraint and seclusion in the medical record includes the following: a description of the patient's behavior and the intervention used; the patient's condition or symptom(s) that warranted the use of the restraint or seclusion; the patients response to the interventions(s) used, including the rationale for continued use of the intervention; individual patient assessments and reassessments; and monitoring documentation every 2 hours for nonviolent or non-self destructive patients to protect their physical safety.

1. Staff did not document every 2 hours if the restraint was continued or if the least restrictive method was being used. Furthermore, staff did not document a change in patient condition to signify the simultaneous use of 4 point soft restraint and an enclosed bed.

a) Review of Patient #6's History and Physical, dated 09/30/15, showed the patient was admitted to the hospital on 09/30/15 for a Cerebral Vascular Accident (CVA) following a motorcycle accident with Traumatic Brain Injury (TBI). An enclosed bed (posey bed) was ordered on 09/30/15, and initiated at 4:00 p.m. for safety of the patient due to increased agitation following a TBI.

Review of the restraint documentation for the night of 09/30/15 and morning of 10/01/15, revealed documentation for 4:00 p.m., 6:00 p.m., 10:00 p.m., 12:00 a.m., 4:00 a.m., 8:00 a.m., which stated the enclosed bed was "continued." It is unclear why the enclosed bed was not documented at 8:00 p.m., 2:00 a.m., and 6:00 a.m., through the night of 09/30/15 and into the morning of 10/01/15, and if the patient remained in the enclosure bed during those hours.

During the same review of restraint documentation for the night 09/30/15, under the section titled "Less Restrictive Alternatives Attempted," the Registered Nurse (RN) did not document at 10:00 p.m. In addition, on 10/01/15, the RN did not document "Less Restrictive Alternatives Attempted" at 12:00 a.m., 4:00 a.m., and 10:00 p.m.

On 10/02/15, the RN did not document "Less Restrictive Alternatives Attempted" at 12:00 a.m. and 2:00 a.m.

On 10/01/15 at 8:00 a.m., RN #1 documented the patient was placed in soft restraints on the left and right ankle, in addition to an enclosed bed, and 1:1 monitoring, however RN #1 did not document a change in patient condition that required the increased restraint use. Furthermore, on 10/01/15, from 10:00 a.m. through 6:00 p.m., RN #1 documented the patient was placed in soft restraints on left and right ankles and left and right wrists, in addition to the enclosed bed and 1:1 monitoring. RN #1 did not document a change in patient condition that required increased restraint use.

There was no subsequent documentation to show why the patient was in the enclosed bed or if the patient had been evaluated for the continued necessity of physical restraints every 2 hours.

b) Review of Patient #1's History and Physical, dated 8/24/15, revealed the patient presented with altered mental status and a recent acute CVA. A progress note, written by Physician #2, on 08/26/15 at 2:20 p.m., stated the patient was "doing OK, eating, very active walking in room although is 'fall risk' and wants to go and have a cigarette! In a posey bed since last p.m. as impulsive and repeatedly kept trying to get out of bed (oob)."

A Speech and Language Pathologist (SLP) Therapy Note, written on 08/26/15 at 2:50 p.m., stated the "patient was lying with his/her head at the foot of the posey bed and had the mattress/extra cushion pulled partially on top of him/her. S/he was cooperative but somewhat confused and demonstrated a flat affect. Patient was secured in the posey bed after speech therapy with call light and phone in reach."

A Neurology Consult Follow-Up Note, written on 08/26/15 at 10:39 a.m. stated "patient required posey bed as s/he kept trying to get out of bed through the evening."

There was no restraint documentation of when the restraints were initiated, or to correlate with the aforementioned progress notes which stated the restraints were applied over the night of 08/25/15 to 08/26/15. The first documentation of physical restraints was on 08/26/15 at 1900, almost 4 hours and 40 minutes after Physician #2's progress note, which stated "continued" for the enclosed bed.

The facility was unable to provide supporting documentation for when the restraints were initiated or how frequently the patient was monitored while in restraints.

c) On 11/18/15, at 3:47 p.m., an interview was conducted with RN #3. RN #3 stated the expectation for restraints, like a posey bed, was they had to be charted when they were initiated and if the patient was taken out of the posey bed. RN #3 stated restraints, including posey beds, were charted on every 2 hours and included 15 minute monitoring.

d) On 11/18/15, at 3:46 p.m., an interview was conducted with RN #4 who stated patients in restraints were monitored every 15 minutes, and documented on every 2 hours. RN #4 stated s/he charted "initiated" when the restraints were applied, "continued" while restraints were present, and "discontinued" when the restraints were removed.

e) On 11/19/15, at 11:30 a.m., an interview with RN #10 was conducted. RN #10 stated RN's selected the least restrictive method once the non-violent restraint was ordered by an authorized provider. RN #10 stated they would begin with the least restrictive restraint and had the ability to increase the level of restraint if it was required for the patient's safety. RN #10 stated s/he was trained on restraints in his/her new graduate nurse program, on the floor, and annually through hospital training.

f) On 11/19/15 at 11:45 a.m., an interview with RN #11 was conducted. RN #11 stated the use of restraints depended on the patient's behavior, and the nurse selected the least restrictive restraint that kept the patient safe. RN #11 stated s/he had never used multiple types of restraints at one time. RN #11 stated s/he was trained on restraint use in orientation, through in-services, and from staff on the floor.

g) On 11/18/15, at 3:55 p.m., an interview was conducted with the Director of Rehabilitation. The Director stated restraints were documented every 2 hours. In addition, the Director stated therapists were suppose to document if the patient was removed from posey bed for therapy, and when they returned the patient to the posey bed.

h) On 11/19/15, at 10:16 a.m., an interview was conducted with the Medical Director of Rehabilitation (Physician #6), the Clinical Manager of Rehabilitation (RN #7), and the Case Manager (CM) of Rehabilitation (RN #8). The Medical Director stated a code gray was called on Patient #6, and security had to come up to assist with the patient's behavior. The Medical Director stated Patient #6 would not have been in 4 point soft restraints, and s/he didn't know why that was charted. The Medical Director stated Patient #6 was in a posey bed related to the behavioral component of his/her TBI.

g) On 11/19/15, at 10:46 a.m., and interview with RN #7 and the Manager of Regulatory and Accessibility (Employee #9) was conducted. RN #7 stated s/he was unclear why 4 point soft restraints were charted on Patient #6. RN #7 stated, "a lot of this just isn't making sense. I know it's what is documented and that is what you go by, but it isn't likely we did that." Employee #9 reviewed the documentation on the computer and stated the facility had opportunities to improve restraint documentation. RN #7 further stated that chart audits focused more on pain documentation, rather than restraint documentation.