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Based on observations, interviews and record review the facility failed to ensure each patient using a restraint had a physician's order for the restraint within the timeframe outlined in the facility's policy and procedure for restraint use for 1 of 5 sampled residents identified by the facility with restraints (#28).

The findings include:

Record review for patient #28 revealed she was admitted to the hospital's intensive care unit (ICU) on 04/19/11 at 11:30 a.m. with a diagnosis of respiratory failure and on ventilator assisted breathing. She had a endotracheal (breathing) tube in place and had 2-point soft wrists in place to prevent the patient from removing her tube. Documentation on the nurses' flowsheets indicated staff was monitoring the application of soft wrist restraints from the time of admission. Further documentation revealed a physician's order for the application of the restraint was not obtained until 4/20/11 at 8:30 a.m., 21 hours after the initial application of the restraint. During the initial tour of the unit on 4/20/11 at 10 a.m., the patient was observed lying in bed with soft wrist restraints in place and the resident was intubated.

A review of the facility's policy and procedure titled "Utilization of Restraints" effective 2/01/05 and revised 3/15/11 showed "the qualified registered nurse may initiate a restraint but an order must be obtained as soon as possible, but no longer than 12 hours after initiation of a medical/surgical restraint."

During an interview with the ICU charge nurse at 3:45 p.m., she stated she could not find an initial order for the restraint on the resident's medical record. She later produced a physician's order written on 4/20/11 at 4 p.m. During an interview with the Vice President of Nursing Services (VPNS) at the same time, she stated she was unable to find the initial order. She stated she was told an order had been written and signed 4/20/11 at 8:30 a.m. by the Physician's Assistant which was not on the current chart. During further interview with the VPNS on 4/20/11 at 5:30 p.m., she produced the order signed 4/20/11 at 8:30 a.m. She also stated staff was unable to find initial restraint orders written within the 12 hour window. She agreed an order should have been written within the 12 hour time frame as outlined in the facility's policy and procedure, if not sooner.

Based on observation and interview, the facility failed to maintain the plumbing to ensure that traps were able to function, and failed to ensure that clean water was available upon activating water flow in the overflow areas of the facility affecting 4 rooms (259, 260, 262 & 278).

Findings:

1. On 4/20/11 around 4 p.m., a tour of the rooms in the overflow area revealed that the current level of water in the commode in the bathroom of room 260 was one inch below the freshly flushed level. This was measured by the director of maintenance. The water that flowed into the commode, upon flushing, was brown in color initially. The water had receded due to the vaporization of water from the commode since it's last occupation by a patient.

2. On 4/20/11 around 4:05 p.m., observation of room 259 revealed an odor in the bathroom that was identified by the maintenance director as coming from the shower. An interview at that time confirmed that the odor was due to a dry trap. Water from the hot side of the sink in this room initially ran brown upon activation.

3. On 4/20/11 around 4:10 p.m., observation of room 278 revealed that the commode had no water visible. The cold water in this room ran brown when first activated.

4. On 4/20/11 around 4:15 p.m., the commode in room 262 had brown water at a low level.

In an interview with the maintenance director around 4:15 p.m., he indicated that the facility needed to make changes to their policy for maintenance of the water traps and water quality in the overflow areas.