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Based on record review and staff interview, it was determined that the facility failed to protect and promote the rights of each patient in 3 of 5 patients in restraints sampled (#1, #6, #9) from a total sample of 10 patients, resulting in the potential for poor outcomes for all patients. See Citations A131, and A178.

Based on interview and record review the facility failed to obtain informed consent for the administration of a restraint for 3 of 5 patients (#1, 6 and 9) reviewed for restraints, from a total sample of 10 patients, resulting in the withholding of information required by the patient's legal representative to make informed decisions regarding care. Findings include:

Review of Patient #1's medical record, revealed he was a 73-year-old male who was admitted to the hospital on 04/11/2022 with a history of lung cancer, post right upper lobectomy (right upper lobe of lung removed) on 2/7/2022, was having shortness of breath and dizziness, and now had a diagnosis of deep vein thrombosis (clot in the vein), of his left subclavian and internal jugular. History and Physical dated 4/11/2022 revealed he was alert; oriented and neurological exam was within normal limits. Physician progress note dated 4/12/2022 indicated Patient #1 was forgetful, neurology was consulted. Review of physician orders for Patient #1 revealed a physician order for restraint violent or self-destructive adult dated 4/21/2022 at 1718, which was discontinued on 4/21/2022 at 1910. Review of the medical record for Patient #1 could not locate any face-to-face assessment of Patient #1 from 1718 through 1910. Review of Patient #1's medical record did not reveal any documentation that the family/representative of Patient #1 was notified of the restraint on 4/21/2022.

Review of Patient #6's medical record revealed he was an 80-year-old male who was admitted to the hospital on 06/11/2022 with a diagnosis to include encephalopathy. Physician's order dated 6/24/2022 at 0737 revealed an order for Right and Left Mitt restraints (mitts over the hands). Nursing note dated 6/24/2022 indicated nursing was unable to contact family but would try again. No other documentation was found in Patient #6's medical record regarding communication with the family about restraints.

Review of Patient #9's medical record, revealed she was a 70-year-old female who was admitted to the hospital on 06/27/2022 with a diagnosis to include encephalopathy. Physician's order dated 6/28/2022 at 0312 revealed an order for Right and Left Mitt restraints (mitts over the hands). Review of Patient #9's medical record did not reveal any documentation that the family/representative of Patient #9 was notified of the restraint on 6/28/2022.

In an interview on 6/29/2022 at 1050, Staff A, Manager of Accreditation reviewed the records of Patient #1, Patient #6 and Patient #9's and stated there was no documented notification of Patient #1, #6 or #9's family/representative of the restraints. Staff A stated it is the facility policy to notify family when a patient is placed in restraints, whether it be violent or non-violent.

Review of facility policy, "Restraints: Care of Patients in Restraints" dated 09/02/2021, on 06/28/2022 at 1330 revealed under section IV.A.2.d., A face-to-face assessment is required by a provider within one hour after restraint initiation. Also, under section IV.B.1.b., The patient, the patient's legal guardian, and the patient's family (as appropriate) will be notified of the reason for restraint and other possible alternatives, and the criteria for removal.

Based on interview and record review, the facility failed to ensure that a physician performed a face to face assessment within one hour of the initiation of a physical restraint for one (Patient #1) of five patients reviewed for physical restraints out of a total sample of 10, resulting in the potential for poor outcomes. Findings include:

Review of Patient #1's medical record, revealed he was a 73-year-old male who was admitted to the hospital on 04/11/2022 with a history of lung cancer, post right upper lobectomy (right upper lobe of lung removed) on 2/7/2022, was having shortness of breath and dizziness, and now had a diagnosis of deep vein thrombosis (clot in the vein), of his left subclavian and internal jugular. History and Physical dated 4/11/2022 revealed he was alert; oriented and neurological exam was within normal limits. Physician progress note dated 4/12/2022 indicated Patient #1 was forgetful, neurology was consulted. Physician progress note dated 4/20/2022 indicated Patient #1 was forgetful, but hopeful for discharge soon. Nurse Practitioner note dated 4/21/2022 indicated Patient #1 had sustained a fall while being under constant video surveillance. Physicians note on 4/24/2022 indicated Patient #1 had pushed a staff member who was attempting to assist him and sustained a fall. Review of physician orders for Patient #1 revealed a physician order for restraint violent or self-destructive adult dated 4/21/2022 at 1718, which was discontinued on 4/21/2022 at 1910. Review of the medical record for Patient #1 could not locate any face-to-face assessment of Patient #1 from 1718 through 1910.

In an interview on 6/29/2022 at 1050, Staff A, Manager of Accreditation reviewed the record of Patient #1 and stated there was no documented face to face assessment of Patient #1 on 4/21/2022 after the initiation of the violent restraint.

Review of facility policy, "Restraints: Care of Patients in Restraints" dated 09/02/2021, on 06/28/2022 at 1330 revealed under section IV.A.2.d., A face-to-face assessment is required by a provider within one hour after restraint initiation. Also, under section IV.B.1.b., The patient, the patient's legal guardian, and the patient's family (as appropriate) will be notified of the reason for restraint and other possible alternatives, and the criteria for removal.