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Based on record review and interview the facility failed to protect and promote patient rights by obtaining orders for restraints, failed to assess and monitor the use of restraints every 2 hours per facility policy, and failed to chart restraints on patient care plans as per facility policy in 2 of 2 (Patient #'s 1 & 2) medical records reviewed for the use of restraints in a total universe of 10 medical records reviewed.

Findings:

The facility failed to chart restraints on patient care plans every 24 hours as per facility policy. See Tag A-0166.

The facility failed to ensure that a new order was written by the physician for restraint every 24 hours. See Tag A-0173.

The facility failed to assess and monitor patients in restraints every 2 hours per facility policy. See Tag A-0175.

Based on record review and interview the facility staff failed to follow their policy to ensure that the care plan problem for restraints was reviewed daily in 2 (Patient #'s 1 and 2) out of 2 medical records reviewed for the use of restraints out of a total universe of 10 medical records reviewed.

Findings include:

The facility document titled "Restraints and Seclusion, GL-6014" #1005920 last revised 5/3/2021 was reviewed. This document revealed, "Implementation:...E. Plan of Care: The use of restraint or seclusion must be done with a written modification to the patient's plan of care which may include:...c. Nursing Care Plan."

The facility document titled "Nursing Care Plan, Nsg-6730" #10085386 last revised 5/10/2019 was reviewed. This document revealed "EVALUATE (REASSESS):...Inpatient: Assessments are completed and documented at minimum once a shift for patients under observation and inpatient status or if no timeline is defined by other treatment order or standards of care/standard operation procedures...Inpatient Nursing Care Plan Visual:...Evaluate: Care plans are reviewed, revised as needed and documented to at minimum every shift (2x/24 hours)...Inpatient Assessment & Reassessment Grid:...Care Plans:...5. Evaluate each goal (Met/ongoing/progressing/not progressing/unable to meet plan of care) or revised. 6. Evaluate goals, overall progress (improving, declining, no change) and write discipline summary...Due (per policy/reg) Within 24 hours and documented to daily."

Patient #1's medical record was reviewed on 1/11/2022 at 11:30 AM. Patient #1 was admitted to the Heritage (medical unit that maintains patients waiting to be admitted to skilled nursing facilities) unit on 10/21/2021 for an "acute mental status change" with a medical history of dementia, chronic obstructive pulmonary disease (COPD) and tongue cancer. After admission and evaluation Patient #1 was placed on palliative care on 11/4/2021 and Hospice related to "natural progression of dementia" and expired on the Heritage unit on 11/24/2021. After multiple falls and multiple interventions by facility staff to prevent Patient #1 from falling a "Posey" bed (enclosed bed) was ordered to prevent Patient #1 from attempting to get up alone and prevent falls and injury.

There was a restraint problem area documented on Patient #1's care plan. There was no documented restraint problem care plan charting for the following dates: 11/16/2021, 11/18,/2021 11/20/2021, 11/21/2021 and 11/23/2021 and Patient #1 was documented as being in enclosed bed.

Patient #2's medical record was reviewed on 1/11/2022 at 1:30 PM. Patient #2 was admitted to the Heritage unit (medical unit that maintains patients waiting to be admitted to skilled nursing home facilities) on 9/19/2021 after a fall outside of a group home of unknown down time with resulting hypothermia (low body temperature) and hypoglycemia (low blood sugar). After multiple falls and multiple interventions tried by facility staff to prevent Patient #2 from falling an enclosed bed was ordered. A "Progress Note" completed by a physician on 10/5/2021 documented "He (Patient #2) is impulsive and has obvious gait issues, which are a perfect combination for falls." Patient #2 was discharged to a nursing home on 12/29/2021.

There was a restraint problem area documented on Patient #2's care plan. There was no documented restraint problem care plan charting for 11/5-12/28/2021 and Patient #2 was documented as being in an enclosed bed.

An interview was conducted with Registered Nurse (RN) F during the medical record review for Patient #'s 1 and 2 on 1/11/2022 at 12:00 PM. When asked the facility's expectation for charting on care plan problems for restraints RN F stated "It is supposed to be done every 24 hours and it wasn't."

Based on record review and interview the facility failed to ensure that a physician's order was present for every calendar day that there was a restraint (bed enclosure) in use as per facility policy in 2 (Patient #'s 1 and 2) out of 2 medical records reviewed for the use of restraints out of a total universe of 10 medical records reviewed.

Findings include:

The facility document titled "Restraints and Seclusion, GL-6014" #1005920 last revised 5/3/2021 was reviewed. This document revealed "PROTECTIVE AND FOUR SIDE RAIL RESTRAINT" A. Orders:...4. The order for restraint must be renewed daily after the patient has been reassessed by the qualified provider."

Patient #1 was admitted to the Heritage unit (medical unit that maintains patients waiting to be admitted to skilled nursing facilities) on 10/21/2021 for an "acute mental status change" and a medical history of dementia, chronic obstructive pulmonary disease (COPD) and tongue cancer. After admission and evaluation Patient #1 was placed on palliative care on 11/4/2021 and Hospice related to "natural progression of dementia". After multiple falls and multiple interventions tried to prevent Patient #1 from falling a "Posey" bed (enclosed bed) was ordered. Patient #1 expired on Heritage unit on 11/24/2021.

There was no documented physician order for the use of the enclosed bed on 11/8/2021, 11/11/2021 and 11/13/2021 and Patient #1 was documented as being in an enclosed bed on the restraint flowsheet. There was a documented physician visit on the above dates but he/she did not write an order for the enclosed (restraint) bed.

Patient #2's medical record was reviewed on 1/11/2022 at 1:30 PM. Patient #2 was admitted to the Heritage unit (medical unit that maintains patients waiting to be admitted to skilled nursing home facilities) on 9/19/2021 after a fall outside of a group home with unknown down time with resulting hypothermia (low body temperature) and hypoglycemia (low blood sugar). After multiple falls and multiple intervention attempts to prevent falls Patient #2 was ordered an enclosed bed. Patient #2 was discharged to a nursing home on 12/29/2021.

There was no documented physician order for the use of the enclosed bed on 11/14/2021, 11/18 /2021or 11/25/2021 and Patient #2 was documented as being in an enclosed bed on the restraint flowsheet. There was documented physician visit on the above dates but he/she did not write an order for the enclosed (restraint) bed.

An interview was conducted with Registered Nurse (RN) F during the medical record review for Patient #'s 1 and 2 on 1/11/2022 at 12:00 PM. When asked the facility's expectation of a physician order for restraints RN F stated "It should be done every calendar day and these are missing some."

Based on record review and interview the facility failed to ensure that a restraint assessment was completed every 2 hours per facility policy for patients in a restraint (bed enclosure) in 2 (Patient #'s 1 & 2) out of 2 medical records reviewed for the use of restraints out of a total universe of 10 medical records reviewed.

Findings include:

The facility document titled "Restraints and Seclusion, GL-6014" #1005920 last revised 5/3/2021 was reviewed. This document revealed "PROTECTIVE AND FOUR SIDE RAIL RESTRAINT:...C. Monitoring and assessment: 1. Nursing...b. At these time frames:...ii. Every two hours until discontinued."

Patient #1's medical record was reviewed on 1/11/2021 at 11:45 AM. Patient #1 was admitted to the Heritage unit (medical unit that maintains patients waiting to be admitted to skilled nursing facilities) on 10/21/2021 for an "acute mental status change" and a medical history of dementia, chronic obstructive pulmonary disease (COPD) and tongue cancer. After admission and evaluation Patient #1 was placed on palliative care on 11/4/2021 and Hospice related to "natural progression of dementia". After multiple falls and interventions tried to prevent Patient #1 from falling a "Posey" bed (enclosed bed) was ordered to prevent Patient #1 from attempting to get up alone.

The "Restraint Flowsheet" for Patient #1 documented that on the following dates there were no restraint assessments completed every 2 hours as per facility policy: 11/8/2021 assessment completed at 1:43 PM and then at 4:30 PM (2 hours and 45 min later). On 11/10/2021 assessment was completed at 3:33 AM and then at 6:00 AM (2 hours and 27 minutes later) and at 12:00 PM and then at 3:00 PM (3 hours later). On 11/11/2021 assessment was completed at 12:17 PM and then at 4:43 PM (4 hours and 26 minutes later). On 11/13/2021 assessment was completed at 2:00 PM and then again at 6:56 PM (4 hours and 56 minutes later). On 11/14/2021 assessment was completed at 9:20 AM and then at 7:00 PM (9 hours and 40 minutes later). On 11/15/2021 assessment was completed at 2:00 AM and then again at 5:02 AM (3 hours and 2 minutes later), again at 8:31 AM (3 hours and 29 minutes later), at 2:18 PM and then again at 8:12 PM (3 hours and 54 minutes later) and then at 11:51 PM (3 hours and 39 minutes later). On 11/16/2021 assessment was completed at 3:41 PM and then again at 6:04 PM (2 hours and 43 minutes later). On 11/17/2021 assessment was completed at 4:00 PM then again at 8:00 PM (4 hours later). On 11/18/2021 assessment was completed at 12:00 PM and then 9:49 PM (9 hours and 49 minutes later). On 11/22/2021 assessment was completed at 8:00 AM and then again at 12:00 PM (4 hours later).

Patient #2's medical record was reviewed on 1/11/2022 at 1:30 PM. Patient #2 was admitted to the Heritage unit (medical unit that maintains patients waiting to be admitted to skilled nursing facilities) on 9/19/2021 after a fall outside of a group home with unknown down time resulting in hypothermia (low body temperature) and hypoglycemia (low blood sugar). After multiple falls and multiple intervention attempts to prevent falls Patient #2 was ordered an enclosed bed. Patient #2 was discharged to a nursing home on 12/29/2021.

The "Restraint Flowsheet" for Patient #2 documented that on the following dates there were no restraint assessments completed every 2 hours as per facility policy: On 12/10/2021 assessment was completed at 8:00 AM and then again at 10:30 PM (14 hours and 30 minutes later). On 12/16/2021 assessment was completed at 5:00 AM and then again at 11:19 PM (18 hours and 19 minutes later). On 12/17/2021 assessment was completed at 5:40 AM and then again at 10:00 PM (17 hours and 20 minutes later). On 12/18/2021 assessment was completed at 5:47 AM and then again at 10:00 PM (16 hours and 13 minutes later). On 12/19/2021 assessment was completed at 6:07 AM and then again at 10:15 PM (16 hours and 8 minutes later). On 12/20/2021 assessment was completed at 6:07 AM and then again at 10:34 PM (16 hours and 28 minutes later). On 12/21/2021 assessment completed at 6:00 AM and there was no documented assessment for the rest of the day. On 12/22/2021 assessment completed at 9:51 PM and there was no documented assessment for the rest of the day. On 12/23/2021 the assessment was completed at 6:00 AM and again at 9:30 PM (15 hours and 30 minutes later).

An interview was conducted with Registered Nurse (RN) F during the medical record review for Patient #'s 1 and 2 on 1/11/2022 at 12:00 PM. When asked the facility's expectation of restraint assessments being completed RN F stated "It should be done every 2 hours while the restraint is on. It doesn't look like that is happening."