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Based on observations, interviews and records review, the facility failed to ensure safe application of restraints in 2 of 5 (#s 1 and 5) patients.

Refer to Tag A0167

Based on observations, interviews and records review, the facility failed to ensure that physician orders were obtained and renewed for restraint usage in 2 of 5 (#s 1 and 4) patients reviewed for restraints.

Refer to Tags A0168 and A0173

Based on interviews and records review, the facility failed to ensure that patients who were restrained were monitored for restraint release at the earliest possible time in 4 of 5 (#s 4, 5, 6, and 7) patients.

Refer to Tag A0175

Based on interviews and records review, the facility failed to ensure that there were alternative interventions done so patients can be realesed from restarints at the earliest possible time in 3 of 5 (#s 4, 6, and 7) patients.

Refer to Tag A0185

Based on observation, interview and record review, the facilty failed to ensure safe application of restraints in 2 of 5 (#s 1 and 5) patients reviewed for restraint usage.

This deficient practice had the potential to cause harm to 5 patients in restraints.


1.) Review of a facility's "Restraint" policy dated December 2011 revealed the following:

" Requires monitoring at least every two hours" for the following:
"Signs of injury associated with restraint application."
"Whether the restraint is correctly applied."

Review of an ambulance record dated 06/20/12 revealed Patient #1 was a 51 year old male admitted to the hospital with a chief complaint of Motor Vehicle Accident (MVA) with multi trauma.

Review of a surgical checklist revealed Patient #1 had the following surgeries:

*On 06/20/12 an open reduction internal fixation (ORIF) of the right femur and an external fixation of the right ankle with an ORIF.

*On 06/24/12 an ORIF of the left humerus, radius and ulna.

* On 06/27/12 an ORIF of the right metacarpal and right distal radius.

Review of the nursing "assessment report" dated 06/22-07/03/12 revealed restraints were used on Patient #1.

Review of nursing clinical notes revealed the following about Patient #1's restraints:

*On 06/24/12 at 10:23 p.m. soft restraints were applied to the left ankle.

*On 07/03/12 at 6:27 p.m. the patient was resting in bed with a posey vest.

*On 07/03/12 at 9:22 p.m. a note revealed a report was received at 7:00 p.m., indicating the patient was placed on a bedpan by a nurse tech. One side of the vest restraint was untied and she left him in the room alone with the privacy curtain pulled. The patient attempted to exit the bed alone and fell to the floor landing directly on his buttock.

Review of a physician's order dated 07/01/12 revealed all restraints were discontinued.
There was no order dated 07/03/12 for a Posey restraint and it was applied incorrectly.

During an interview on 01/04/13 at 2:30 p.m., Staff #3 confirmed Patient #1 did not have a physician order for restraints on 07/03/12.

2.) Review of a consultation report dated 12/23/12 revealed Patient #5 was a 27 year old male admitted on 12/22/12 for a MVA.

Review of the nursing "assessment report" dated 01/03/13 at 7:00 a.m. revealed Patient #5 had orders for bilateral wrist/hand restraints and staff verified correct application. At 9:00 a.m. there was no documentation of staff verifying for correct application.

During an observation on 01/03/13 at 9:12 a.m., Patient #5 was lying in bed with a wrist restraint on the left arm. The restraint was tied to a raised bedrail. Staff #2 reported the restraint was suppose to be tied to the bed frame and instructed staff to tie it correctly.

Based on observation, interview and record review, the facilty failed to ensure physician orders were obtained for restraint usage in 2 of 5 (#s 1 and 4) patients reviewed for restraints.

This deficient practice had the potential to cause harm to 5 patients in restraints.


1.) Review of a facility's "Restraint" policy dated December 2011 revealed the following:

*Initial restraint orders "Requires an order by a Physician only."
*"Requires an in-person evaluation by the physician and a new order for restraint each calendar day by the Physician."

Review of an ambulance record dated 06/20/12 revealed Patient #1 was a 51 year old male admitted to the hospital with a chief complaint of Motor Vehicle Accident (MVA) with multi trauma.

Review of a surgical checklists revealed Patient #1 had the following surgeries:

*On 06/20/12 an open reduction internal fixation (ORIF) of the right femur and an external fixation of the right ankle with an ORIF.

*On 06/24/12 an ORIF of the left humerus, radius and ulna.

* On 06/27/12 an ORIF of the right metacarpal and right distal radius.

Review of the nursing "assessment report" dated 06/22-07/03/12 revealed restraints were used on Patient #1.

Review of nursing clinical notes revealed the following about Patient #1's restraints:

*On 06/24/12 at 10:23 p.m. soft restraints were applied to the left ankle.

*On 07/03/12 at 6:27 p.m. the patient was resting in bed with a posey vest.

*On 07/03/12 at 9:22 p.m. a note revealed a report was received at 7:00 p.m., indicating the patient was placed on a bedpan by a nurse tech. One side of the vest restraint was untied and she left him in the room alone with the privacy curtain pulled. The patient attempted to exit the bed alone and fell to the floor landing directly on his buttock.

Review of a physician's order dated 07/01/12 revealed all restraints were discontinued.
There was no physician order dated 07/03/12 for a posey vest restraint.

During an interview on 01/04/13 at 2:30 p.m., Staff #3 confirmed Patient #1 did not have a physician order for restraints on 07/03/12.


2.) Review of a history and physical dated 12/16/12 revealed Patient #4 was a 25 year old male patient admitted on 12/16/12 with a gunshot wound to the head.

Review of the nursing "assessment report" dated 12/16/12-01/13/13 revealed restraint usage on Patient #4.

Review of physician orders revealed there were no updates to continue restraint usage on 12/21/12, 12/24/12, 12/25/12, 12/29/12, 12/30/12, 12/31/12, and 01/02/13.

During an interview on 01/14/12 at 2:35 p.m., Staff #3 confirmed there were no physician orders for restraint usage on these days.

Based on observation, interview and record review the facilty failed to ensure physician orders were obtained or renewed for restraint usage in 2 of 5 (#s 1 and 4) patients reviewed for restraints.

This deficient practice had the potential to cause harm to 5 patients in restraints.


1.) Review of a facility's "Restraint" policy dated December 2011 revealed the following:

*Initial restraint orders "Requires an order by a Physician only."
*"Requires an in-person evaluation by the physician and a new order for restraint each calendar day by the Physician."


Review of an ambulance record dated 06/20/12 revealed Patient #1 was a 51 year old male admitted to the hospital with a chief complaint of Motor Vehicle Accident (MVA) with multi trauma.

Review of a surgical checklists revealed Patient #1 had the following surgeries:

*On 06/20/12 an open reduction internal fixation (ORIF) of the right femur and an external fixation of the right ankle with an ORIF.

*On 06/24/12 an ORIF of the left humerus, radius and ulna.

* On 06/27/12 an ORIF of the right metacarpal and right distal radius.

Review of nursing clinical notes revealed the following about Patient #1's restraints:

*On 06/24/12 at 10:23 p.m. soft restraints were applied to the left ankle.

*On 07/03/12 at 6:27 p.m. the patient was resting in bed with a posey vest.

*On 07/03/12 at 9:22 p.m. a note revealed a report was received at 7:00 p.m., indicating the patient was placed on a bedpan by a nurse tech. One side of the vest restraint was untied and she left him in the room alone with the privacy curtain pulled. The patient attempted to exit the bed alone and fell to the floor landing directly on his buttock.

Review of a physician's order dated 07/01/12 revealed all restraints were discontinued.
There was no physician order dated 07/03/12 for a posey restraint.

During an interview on 01/04/13 at 2:30 p.m., Staff #3 confirmed Patient #1 did not have a physician order for restraints on 07/03/12.


2.) Review of a history and physical dated 12/16/12 revealed Patient #4 was a 25 year old male patient admitted on 12/16/12 with a gunshot wound to the head.

Review of the nursing "assessment report" dated 12/16/12-01/13/13 revealed restraint usage on Patient #4.

Review of physician orders revealed there were no updates to continue restraint usage on 12/21/12, 12/24/12, 12/25/12, 12/29/12, 12/30/12, 12/31/12, and 01/02/13.

During an interview on 01/14/12 at 2:35 p.m., Staff #3 confirmed there were no physician orders for restraint usage on these days.

Based on interviews and records review, the facility failed to ensure patients who were restrained were monitored consistently in regards to restraint release in 4 of 5 (#s 4, 5, 6, and 7) patients reviewed for restraints.

This deficient practice had the potential to cause harm to 5 patients in restraints.


1.) Review of a facility's "Restraint" policy dated December 2011 revealed the following:

"Requires monitoring at least every two" for criteria for release.

Review of a history and physical dated 12/16/12 revealed Patient #4 was a 25 year old male patient admitted on 12/16/12 with a gunshot wound to the head.

Review of the nursing "assessment report" dated 12/16/12-01/03/13 revealed restraints being used on Patient #4.

Review of the nursing "assessment report" revealed no documentation of restraint release on the following days:

*On 12/17/12 at 7:00 p.m -11:00 p.m.;

* On 12/18/12 at 1:00 a.m.- 5:00 a.m., 7:00 p.m.-11:00 p.m.;

* On 12/19/12 at 1:00 a.m. - 5:00 a.m., 8:00 p.m., and 10:00 p.m.;

* On 12/20/12 at 12:00 a.m.- 6:00 a.m.;

* On 12/22/12 at 8:00 p.m;

* On 12/24/12 at 8:00 a.m. - 11:00 p.m.;

* On 12/25/12 at 1:00 a.m., 3:00 a.m., 5:00 a.m., 10:00 a.m., 12:00 p.m. - 11:00 p.m.;

* On 12/26/12 at 1:00 a.m., 3:00 a.m., 5:00 a.m.;

* On 12/27/12 at 2:00 p.m., 4:00 p.m., and 7:00 p.m.;

* On 12/28/12 at 6:47 a.m.;

* On 12/29/12 at 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m, 3:00 p.m.-10:00 p.m;

* On 12/30/12 at 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m.- 6:06 p.m.;

* On 01/01/13 at 2:00 a.m., 6:00 a.m., and 11:15 p.m.;

* On 01/02/13 at 7:00 a.m., 9:00 a.m. - 6: 07 p.m.;

* On 01/03/12 at 7:00 a.m., 8:54 a.m., 9:00 a.m., 10:52 a.m., 12:00 p.m., 1:00 p.m., and 3:12 p.m..

2.) Review of a consultation report dated 12/23/12 revealed Patient #5 was a 27 year old male admitted on 12/22/12 for a MVA.

Review of the nursing "assessment report" dated 12/23/12-01/104/13 revealed wrist/ankle/mittens or siderail restraints being used on Patient #5.

Review of the nursing "assessment report" revealed no documentation of restraint release on the following days:

* On 12/23/12 at 4:00 a.m. and 6:00 a.m.;

*On 12/24/12 at 7:00 p.m., 9:00 p.m., and 11:00 p.m.;

* On 12/25/12 from 1:00 a.m - 11:00 p.m.;

* On 12/26/12 at 1:00 a.m., 3:00 p.m. - 11:00 p.m.;

*On 12/27/12 from 1:00 a.m. - 11:00 p.m.;

*On 12/28/12 from 1:00 a.m. - 11:00 p.m.;

*On 12/29/12 from 1:00 a.m. - 8:00 p.m.. After 8:00 p.m. there was no documentation on restraints at all.

*On 12/30/12 at 2:00 a.m., 4:00 a.m., and nothing from 7:00 a.m.- 10 p.m.;

* On 12/31/12 at 12:00 a.m. there was no documentation. The next documentation about restraints was 4 hours later at 4:00 a.m. and there was no documented restraint release.
From 4:00 a.m. - 6:00 p.m. there was no documented restraint release.

* On 01/01/13 from 7:00 a.m.-10 p.m.;

* On 01/02/13 from 12:00 a.m.- 11:00 p.m.

* On 01/03/13 from 1:00 a.m.- 9:00 a.m. and 3:00 p.m.- 11:00 p.m.;

* On 01/04/13 from 1:00 a.m. - 5:00 a.m..

3.) Review of a physician consultation report dated 12/30/12 revealed Patient #6 was a 64 year old female admitted on 12/30/12 with a headache, confusion, and chronic subdural hematoma.

Review of physician's orders dated 01/01/13 and 01/03/13 revealed Patient #6 had orders for bedrails x 4 and wrist restraints.

Review of the nursing "assessment report" revealed no documentation of restraint release on the following:

On 01/01/13 at 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., 7:00p.m., 9:00 p.m., and 11:00 p.m.


During an interview on 01/04/13 at 2:35 p.m., Staff #3 confirmed there was no documentation of restraint release on Patient #4, #5 and #6. Staff #3 reported nursing was supposed to check the areas underneath "assessed for release" section on the "assessment report" indicating what interventions they used on the patient.


4.) Review of a history and physical dated 12/31/12 revealed Patient #7 was a 74 year old female admitted on 12/31/12 with diagnoses of ground level fall, bilateral subdural hematomas, coagulation defect and multiple extremity bruising.

Review of a physician's order dated 01/03/13, 2:17 a.m. and 9:29 a.m. revealed Patient #7 had bedrails x 4, wrist and mittens for restraint usage.

Review of the nursing "assessment report" revealed there was no documentation of staff releasing restraints on Patient #7 on 01/03/12 at 4:00 a.m, 6:00 a.m., and 07:00 a.m., 11:01 a.m., 3:00 p.m., and 5:00 p.m.. There was no other documentation of interventions tried in regards to the restraint release until 12 hours later on 01/04/13 at 5:31 a.m.

During an interview on 01/4/13 at 10:00 a.m., Staff #3 confirmed the restraints had not been released on Patient #7. Staff #3 reported nursing was suppose to check the areas underneath "assessed for release" section on the "assessment report" indicating what interventions they used on the patient.

Based on interviews and records review, the facility failed to ensure a description of the intervention of restraint release in 3 of 5 (#s 4, 6, and 7) patients.

This deficient practice had the potential to cause harm to 5 patients in restraints.


1.) Review of a facility's "Restraint" policy dated December 2011 revealed the following:

"Requires monitoring at least every two" for criteria for release

" A description of the patient's behavior and the intervention used."


Review of a history and physical dated 12/16/12 revealed Patient #4 was a 25 year old male patient admitted on 12/16/12 with a gunshot wound to the head.

Review of the nursing "assessment report" dated 12/16/12-01/03/13 revealed restraints being used on Patient #4.

Review of the nursing "assessment report" revealed no documentation of restraint release on the following days:

*On 12/17/12 at 7:00 p.m -11:00 p.m.;

* On 12/18/12 at 1:00 a.m.- 5:00 a.m., 7:00 p.m.-11:00 p.m.;

* On 12/19/12 at 1:00 a.m. - 5:00 a.m., 8:00 p.m., and 10:00 p.m.;

* On 12/20/12 at 12:00 a.m.- 6:00 a.m.;

* On 12/22/12 at 8:00 p.m;

* On 12/24/12 at 8:00 a.m. - 11:00 p.m.;

* On 12/25/12 at 1:00 a.m., 3:00 a.m., 5:00 a.m., 10:00 a.m., 12:00 p.m. - 11:00 p.m.;

* On 12/26/12 at 1:00 a.m., 3:00 a.m., 5:00 a.m.;

* On 12/27/12 at 2:00 p.m., 4:00 p.m., and 7:00 p.m.;

* On 12/28/12 at 6:47 a.m.;

* On 12/29/12 at 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m, 3:00 p.m.-10:00 p.m;

* On 12/30/12 at 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m.- 6:06 p.m.;

* On 01/01/13 at 2:00 a.m., 6:00 a.m., and 11:15 p.m.;

* On 01/02/13 at 7:00 a.m., 9:00 a.m. - 6: 07 p.m.;

* On 01/03/12 at 7:00 a.m., 8:54 a.m., 9:00 a.m., 10:52 a.m., 12:00 p.m., 1:00 p.m., and 3:12 p.m..


2.) Review of a consultation report dated 12/23/12 revealed Patient #5 was a 27 year old male admitted on 12/22/12 for a MVA.

Review of the nursing "assessment report" dated 12/23/12-01/104/13 revealed wrist/ankle/mittens or siderail restraints being used on Patient #5.

Review of the nursing "assessment report" revealed no documentation of restraint release on the following days:

* On 12/23/12 at 4:00 a.m. and 6:00 a.m.;

*On 12/24/12 at 7:00 p.m., 9:00 p.m., and 11:00 p.m.;

* On 12/25/12 from 1:00 a.m - 11:00 p.m.;

* On 12/26/12 at 1:00 a.m., 3:00 p.m. - 11:00 p.m.;

*On 12/27/12 from 1:00 a.m. - 11:00 p.m.;

*On 12/28/12 from 1:00 a.m. - 11:00 p.m.;

*On 12/29/12 from 1:00 a.m. - 8:00 p.m.. After 8:00 p.m. there was no documentation on restraints at all.

*On 12/30/12 at 2:00 a.m., 4:00 a.m., and nothing from 7:00 a.m.- 10 p.m.;

* On 12/31/12 at 12:00 a.m. there was no documentation. The next documentation about restraints was 4 hours later at 4:00 a.m. and there was no documented restraint release.
From 4:00 a.m. - 6:00 p.m. there was no documented restraint release.

* On 01/01/13 from 7:00 a.m.-10 p.m.;

* On 01/02/13 from 12:00 a.m.- 11:00 p.m.

* On 01/03/13 from 1:00 a.m.- 9:00 a.m. and 3:00 p.m.- 11:00 p.m.;

* On 01/04/13 from 1:00 a.m. - 5:00 a.m..

3.) Review of a physician consultation report dated 12/30/12 revealed Patient #6 was a 64 year old female admitted on 12/30/12 with a headache, confusion, and chronic subdural hematoma.

Review of physician's orders dated 01/01/13 and 01/03/13 revealed Patient #6 had orders for bedrails x 4 and wrist restraints.

Review of the nursing "assessment report" revealed no documentation of restraint release on the following:

On 01/01/13 at 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., 7:00p.m., 9:00 p.m., and 11:00 p.m.


During an interview on 01/04/13 at 2:35 p.m., Staff #3 confirmed there was no documentation of restraint release on Patient #4 and #6. Staff #3 reported nursing was supposed to check the areas underneath "assessed for release" section on the "assessment report" indicating what interventions they used on the patient.


4.) Review of a history and physical dated 12/31/12 revealed Patient #7 was a 74 year old female admitted on 12/31/12 with diagnoses of ground level fall, bilateral subdural hematomas, coagulation defect and multiple extremity bruising.

Review of a physician's order dated 01/03/13, 2:17 a.m. and 9:29 a.m. revealed Patient #7 had bedrails x 4, wrist and mittens for restraint usage.

Review of the nursing "assessment report" revealed there was no documentation of staff releasing restraints on Patient #7 on 01/03/12 at 4:00 a.m, 6:00 a.m., and 07:00 a.m., 11:01 a.m., 3:00 p.m., and 5:00 p.m.. There was no other documentation of interventions tried in regards to the restraint release until 12 hours later on 01/04/13 at 5:31 a.m.

During an interview on 01/4/13 at 10:00 a.m., Staff #3 confirmed the restraints had not been released on Patient #7. Staff #3 reported nursing was suppose to check the areas underneath "assessed for release" section on the "assessment report" indicating what interventions they used on the patient.

Based on records review and interview, the facility failed to assure medical record entries had appropriate signatures. 6 of 10 (#1, 4, 5, 6, 7, and 10) charts had consent forms that were not signed by the physician.

Findings include:

Review of patient charts revealed the following with consents not signed by the physician:
-Chart #1 with 2 unsigned consents

-Chart #4 with 2 unsigned consents

-Chart #5 with 3 unsigned consents

-Chart #6 with 1 unsigned consent

-Chart #7 with 1 unsigned consent

-Chart #10 with 1 unsigned consent

During an interview on 1/04/13 at 2:00pm in the Administration Conference Room, staff #3 confirmed these findings.

Based on record review and interview, the facility failed to assure consent forms were properly executed and complete with the signature of the physician. 6 of 10 (#1, 4, 5, 6, 7, and 10) charts had consent forms that were not signed by the physician.

Findings include:

Review of patient charts revealed the following with consents not signed by the physician:

-Chart #1 with 2 unsigned consents

-Chart #4 with 2 unsigned consents

-Chart #5 with 3 unsigned consents

-Chart #6 with 1 unsigned consent

-Chart #7 with 1 unsigned consent

-Chart #10 with 1 unsigned consent

During an interview on 1/04/13 at 2:00pm in the Administration Conference Room, staff #3 confirmed these findings.