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Based on observation, interview and record review, the hospital failed to specify the least restrictive restraint intervention for 3 of 3 sampled restrained patients, (#15, 16 and 17).

The findings:

1. An observation of Patient #15 was conducted with the Unit Manager on 11/9/11 at approximately 1:57 pm. Patient #15 had three observed restraints, one on the right arm and two on the left arm (double restraint). Patient #15 was wearing a right wrist restraint, a left wrist restraint and a mitten on the left hand. (The left hand mitten was a bulky mitten to prevent grabbing. The wrist restraints were soft straps that wrap around the wrist and were tied to the bed-frame). The Unit Manager stated that double restraint was needed on the left arm because Patient #15 could still grab things even though he was restrained. Patient #15 had a severe contracture of the right arm, which limited its range of motion.

A record review was conducted for Patient #15. Patient #15 was admitted on 11/1/11. Restraints were first ordered on 11/4/11, three days after admission. On 11/4/11 at 9:00 am a physician ordered "Restrain with least restrictive device" for "Attempting to pull out tubes and lines."

The nurses notes were reviewed. On 11/5/11 at 5:00 am a nurse documented a left mitten and left wrist restraint (double restraint). There was no nursing documentation regarding what behavior necessitated the use of restraints. There was no documentation regarding how a double restraint on the left arm was determined to be the 'least restrictive'.

Further nurses notes were reviewed: The notes of 11/5/11 3:00 pm, 11/6/11 5:00 am and 6:39 pm, and 11/7/11 5:00 am, all stated double restraint on the left arm with a mitten and wrist restraints. On 11/7/11 at 5:02 pm a third restraint was added. The nurse documented left mitten, left wrist and right wrist. There was no documentation as to why the right wrist restraint was added. On 11/8/11 at 5:00 pm the restraints had been decreased to the left wrist and left mitten. The right wrist restraint was not documented, nor was there a reason why it was discontinued. On 11/9/11 at 5:00 am there were again three restraints, the left wrist, left mitten and right wrist. There was no documentation indicating why the right wrist was re-initiated. No documentation was found in any nursing notes regarding the rationale for double restraint on the left arm, or how the restraints were determined to be the least restrictive. There was no documentation to show that usage of just one left arm restraint was ever attempted and/or ineffective.

2. An observation of Patient #16 was conducted with the Unit Manager on 11/9/11 at approximately 1:56 pm. Patient #16 was restrained with a left mitten restraint. (A bulky mitten that prevents grabbing. This type of restraint was not tied to the bed-frame).

Physician orders were reviewed. The initial restraint order occurred in the emergency room on 11/7/11. The restraints were re-ordered on 11/8/11 and 11/9/11. The orders did not specify the type of restraint, stating "Restrain with least restrictive device."

The nurses notes were reviewed. There were three nurses notes on restraints. Each note documented a different restraint. There was no documentation regarding patient behavior necessitating restraint, or how it was determined that the least restrictive device was utilized. Nurses notes stated:
11/8/11 5:00 am: Both left and right wrist restraints. 11/8/11 5:00 pm: Left mitten restraint.
11/9/11 5:00 am: Left ankle restraint.

3. An observation of Patient #17 was conducted with the Unit Manager on 11/9/11 at approximately 2:10 pm.
Patient #17 was restrained with a roll belt (strap going across his chest).

Physician orders were reviewed. There was no physician order for restraints.

Nurses notes were reviewed. On 11/9/11 at 5:00 am a nurse documented that Patient #17 had non-behavioral restraints. Restraints used were a Roll belt, and both left and right wrist restraints. There was no documentation that the nurse notified the physician either before the restraint application, or immediately thereafter. There was no documentation as to how it was determined that these three restraints constituted the 'least restrictive'. There was no documentation as to why this particular patient needed a restraint.

An interview was conducted with the Performance Improvement Advisor (PI) and the Unit Manager on 11/9/11 at approximately 1:15 pm. The staff reviewed the medical record and were unable to determine when restraints were initiated, the patient-specific behavior necessitating restraints, or how it was determined that a roll belt and bilateral wrist restraints were the least restrictive. The PI Advisor stated that the physician does not document what medical restraint to use, just to use the least restrictive. It is up to nursing to determine the least restrictive. The PI Advisor confirmed that there was no documentation regarding patient-specific behaviors necessitating restraint nor was there documentation on how the 'least restrictive restraint' was determined.

The hospital policy and procedure for 'Restraint of a Patient in the Acute Care Hospital, Bixler Emergency Center or Behavioral Health Center' was reviewed. The policy was approved in May 1991, revised most recently in August 2011, and reviewed in February 2003.

The procedure for the 'Use of restraints for nonviolent or non-self destructive patients' was reviewed. Section 1 part D stated, "Application includes the least restrictive restraint, as determined by the physician or RN, and as appropriate for the situation and will be applied and removed by a trained, qualified caregiver: "

Section 1 part D7 stated, "To ensure correct documentation of restraint orders, the physician should use the appropriate restraint order form which outlines the requirements:
a. Date and time of order
b. Renewal is issued every calendar day
c. Clinical justification (reason restraints are needed)"

Section 1 part H5 Care and monitoring stated, "The RN must frequently assess/reassess the patient for:
a. The continued need for restraints
b. A less restrictive method of restraint if possible"

The section for the "Procedure for Training of Staff" was reviewed. Part 2 of this section stated, "Hospital staff members who assess patients for restraints or who apply restraints shall receive training in the following":
"C. Choosing the least restrictive intervention based on an individualized assessment of the patient's medical or behavioral status or condition".

The 2011 Nursing Skills Fair training on restraints was reviewed. The module did not include training in how to choose the least restrictive restraint.

Based on observation, interview and record review, the hospital failed to include restraint usage in the plan of care for 3 of 3 sampled restrained patients (#15, 16 and 17).

The findings:

1. An observation of Patient #15 was conducted with the Unit Manager on 11/9/11 at approximately 1:57 pm. Patient #15 had three observed restraints, one on the right arm and two on the left arm (double restraint). Patient #15 was wearing a right wrist restraint, a left wrist restraint and a mitten on the left hand. (The left hand mitten was a bulky mitten to prevent grabbing. The wrist restraints were soft straps that wrap around the wrist and were tied to the bed-frame). The Unit Manager stated that double restraint was needed on the left arm because Patient #15 could still grab things even though he was restrained. Patient #15 had a severe contracture of the right arm, which limited its range of motion.

A record review of the Plan of Care was conducted for Patient #15. The restraints were not mentioned in the Plan of Care.

2. An observation of Patient #16 was conducted with the Unit Manager on 11/9/11 at approximately 1:56 pm. Patient #16 was restrained with a left mitten restraint. (A bulky mitten that prevents grabbing. This type of restraint was not tied to the bed-frame).

The nurses notes were reviewed. There were three nurses notes documenting restraints. Each note documented a different restraint. There was no documentation regarding patient behavior necessitating restraint, or how it was determined that the least restrictive device was utilized. Nurses notes stated:
11/8/11 5:00 am: Both left and right wrist restraints. 11/8/11 5:00 pm: Left mitten restraint.
11/9/11 5:00 am: Left ankle restraint.

A record review of the Plan of Care was conducted for Patient #15. The restraints were not mentioned in the Plan of Care.

3. An observation of Patient #17 was conducted with the Unit Manager on 11/9/11 at approximately 2:10 pm.
Patient #17 was restrained with a roll belt (strap going across his chest).

A record review of the Plan of Care was conducted for Patient #17. The restraint was not mentioned in the Plan of Care.

On 11/9/11 at approximately 2:30 pm, an interview was conducted with the Performance Improvement (PI) Advisor. The PI Advisor stated that patients in restraints would have Plan of Care (POC) interventions such as 'patient safety' and 'patient will remain free from injury'. The PI Advisor confirmed that the POC did not specifically include restraint usage.

Based on observation, interview and record review, the hospital failed to apply restraints in a safe manner for 1 of 3 sampled restrained patients (#17).

The findings:

On 11/9/11 at approximately 2:10 pm, an observation of Patient #17 was conducted with the Unit Manager. Patient #17 was restrained with a roll belt (strap going across his chest). The roll belt was tied securely to the bed frame on both sides of the bed. There was no quick release knot. An interview was conducted with the Unit Manager during the observation. The Unit Manager was asked how this restraint would be released in an emergency? The Unit Manager stated "probably with scissors".

Immediately following the observation, the Unit Manager instructed staff to fix the restraint to be tied utilizing quick release knots.

A record review was conducted for staff training on the application of restraints. The 2011 Nursing Skills Fair training on Restraints was reviewed. The training on restraint application stated, "Make sure that the Restraint is tied to an immobile part of the bed with a slip knot." A picture of a quick-release knot was included in the training.

The hospital policy and procedure for 'Restraint of a Patient in the Acute Care Hospital, Bixler Emergency Center or Behavioral Health Center' was reviewed. The policy was approved in May 1991, revised most recently in August 2011, and reviewed in February 2003. The procedure for the 'Use of restraints for nonviolent or non-self destructive patients' was reviewed. Section D stated, "Application includes the least restrictive restraint, as determined by the physician or RN, and as appropriate for the situation and will be applied and removed by a trained, qualified caregiver: " The application section did not state how to tie the restraint to the bed-frame. There was no mention of using a slip knot or a quick-release knot.

An interview was conducted with the Performance Improvement Advisor (PI) on 11/9/11 at approximately 2:30 pm. The PI Advisor confirmed that restraints should be secured to the bed-frame with a quick-release knot.

Based on observation, interview and record review, the hospital failed to utilize restraints in accordance with the order of a physician or other licensed independent practitioner. Physician orders did not specify the type of restraint but instead stated, "Restrain with least restrictive device". The hospital failed to specify how the least restrictive restraint was determined for 2 of 3 sampled restrained patients (#15 and #16). The hospital failed to obtain physician order for restraints for 1 of 3 sampled restrained patients (#17).

The findings:

1. There were no physician orders for restraints for Patient #17.

An observation of Patient #17 was conducted with the Unit Manager on 11/9/11 at approximately 2:10 pm.
Patient #17 was restrained with a roll belt (strap going across his chest).

Physician orders were reviewed. There were no signed physician orders for restraints. There were no verbal orders for restraints.

Nurses notes were reviewed. The only assessment and note regarding restraints found was on the routine shift assessment dated 11/9/11 at 5:00 am. On this shift assessment, the nurse documented that Patient #17 had non-behavioral restraints. Restraints used were a roll belt belt (strap going across his chest), and both left and right wrist restraints. There was no documentation that stated at what time the restraints were initially applied. There was no documentation that the nurse notified the physician either before the restraint application, or immediately thereafter. There was no documentation as to how it was determined that these three restraints constituted the 'least restrictive'. There was no documentation as to why this particular patient needed a restraint.

An interview was conducted with the Performance Improvement Advisor (PI) and the Unit Manager on 11/9/11 at approximately 1:15 pm. The staff reviewed the medical record for restraint documentation. They were unable to determine from record review when the restraints were initiated, the patient-specific behavior necessitating restraints, or how it was determined that a roll belt and bilateral wrist restraints were the least restrictive. The staff confirmed that there was no physician order for the restraints. Based on the nurses note at 5:00 am, it was determined that the patient had been in restraints for a minimum of 8 hours without a physician order. The Unit Manager stated that the nurse practitioner was aware of the restraints, but had not written an order.

The hospital policy and procedure for 'Restraint of a Patient in the Acute Care Hospital, Bixler Emergency Center or Behavioral Health Center' was reviewed. The policy was approved in May 1991, revised most recently in August 2011, and reviewed in February 2003.

The procedure for the 'Use of restraints for nonviolent or non-self destructive patients' was reviewed. Section 1 part G for Restraint Orders stated:
1. Restraints are used upon the order of a physician.
2. If a physician is not available to issue the restraint order, an RN may initiate restraint used based on an appropriate assessment.
3. The physician should be notified before the end of the shift, not to exceed 12 hours, of the initiation of restraints.
a. A telephone or written order will be obtained and recorded on the appropriate restraint order form.

This policy was not written in accordance with the Center for Medicare and Medicaid (CMS). CMS guidance stated that the physician should be notified prior to the application of restraints, or in an emergency, immediately afterwards.

On 11/9/11 at approximately 10:00 am, an interview was conducted with the Risk Manager regarding the restraint policy. The Risk Manager referred me to the Performance Improvement (PI) Advisor.

On 11/9/11 at approximately 10:18 am, an interview was conducted with the PI Advisor. The PI advisor confirmed that the statement "The physician should be notified before the end of the shift, not to exceed 12 hours" was an error, and that the restraint policy was currently under revision.

The 2011 Nursing Skills Fair training on restraints was reviewed. Under the section for "Non-Behavioral restraints" the module stated that the Doctor needed to be notified within 12 hours and must see the patient within 24 hours.

A follow-up interview was conducted with the PI Advisor on 11/9/11 at approximately 2:30 pm. The PI advisor stated that the hospital was aware that the the physician needed to be notified of restraint application immediately, and not to wait up to 12 hours as the policy stated. The PI Advisor was asked why this was not fixed in the training currently being provided. The PI Advisor stated that they could not update the training until the policy was fixed, and policy revisions typically took several months.

2. Physician orders did not specify the type of restraint but instead stated, "Restrain with least restrictive device". There was no nursing documentation regarding how the 'least restrictive device' was determined.

An observation of Patient #15 was conducted with the Unit Manager on 11/9/11 at approximately 1:57 pm. Patient #15 had three observed restraints, one on the right arm and two on the left arm (double restraint). Patient #15 was wearing a right wrist restraint, a left wrist restraint and a mitten on the left hand. (The left hand mitten was a bulky mitten to prevent grabbing. The wrist restraints were soft straps that wrap around the wrist and were tied to the bed-frame). The Unit Manager stated that double restraint was needed on the left arm because Patient #15 could still grab things even though he was restrained. Patient #15 had a severe contracture of the right arm, which limited its range of motion.

A record review was conducted for Patient #15. Patient #15 was admitted on 11/1/11. Restraints were first ordered on 11/4/11, three days after admission. On 11/4/11 at 9:00 am a physician ordered "Restrain with least restrictive device" for "Attempting to pull out tubes and lines." The restraint orders were renewed every 24 hours. In none of the orders did the physician specify the 'least restrictive restraint'. There was no physician documentation indicating that the physician was aware of what type of restraint was being used.

The nurses notes were reviewed. On 11/5/11 at 5:00 am, a nurse documented a left mitten and left wrist restraint (double restraint of the left arm). There was no nursing documentation regarding what behavior necessitated the use of restraints. There was no documentation regarding how a double restraint on the left arm was determined to be the 'least restrictive'. There was no documentation to show that usage of just one left arm restraint was attempted prior to utilizing a double restraint.

Further nurses notes were reviewed: The notes of 11/5/11 3:00 pm, 11/6/11 5:00 am and 6:39 pm, and 11/7/11 5:00 am, all stated double restraint of the left arm with both a mitten and wrist restraint. On 11/7/11 at 5:02 pm a third restraint was added. The nurse documented left mitten, left wrist and right wrist. There was no documentation as to why the right wrist restraint was added. On 11/8/11 at 5:00 pm the restraints had been decreased to the left wrist and left mitten. The right wrist restraint was not documented, nor was there a reason why it was discontinued. On 11/9/11 at 5:00 am there were again three restraints, the left wrist, left mitten and right wrist. There was no documentation indicating why the right wrist was re-initiated. No documentation was found in any nursing notes regarding the rationale for double restraint on the left arm, or how the restraints were determined to be the least restrictive. There was no documentation to show that usage of just one left arm restraint was ever attempted.

3. An observation of Patient #16 was conducted with the Unit Manager on 11/9/11 at approximately 1:56 pm. Patient #16 was restrained with a left mitten restraint. (A bulky mitten that prevents grabbing. This type of restraint was not tied to the bed-frame).

Physician orders were reviewed. The initial restraint order occurred in the emergency room on 11/7/11. The restraints were re-ordered on 11/8/11 and 11/9/11. The orders did not specify the type of restraint, stating "Restrain with least restrictive device."

The nurses notes were reviewed. There were three nurses notes on restraints. Each note documented a different restraint. There was no documentation regarding patient behavior necessitating restraint, or how it was determined that the least restrictive device was utilized. Nurses notes stated:
11/8/11 5:00 am: Both left and right wrist restraints. 11/8/11 5:00 pm: Left mitten restraint.
11/9/11 5:00 am: Left ankle restraint.

There was no physician documentation indicating that they were aware of the multiple different restraints being utilized.

An interview was conducted with the Performance Improvement Advisor (PI) and the Unit Manager on 11/9/11 at approximately 1:15 pm. The PI Advisor stated that the physician does not document what medical restraint to use, just to use the least restrictive. It is up to nursing to determine the least restrictive. The PI Advisor confirmed that there was no documentation regarding patient-specific behaviors necessitating restraint nor was there documentation on how the 'least restrictive restraint' was determined.

The hospital policy and procedure for 'Restraint of a Patient in the Acute Care Hospital, Bixler Emergency Center or Behavioral Health Center' was reviewed. The policy was approved in May 1991, revised most recently in August 2011, and reviewed in February 2003.

The procedure for the 'Use of restraints for nonviolent or non-self destructive patients' was reviewed. Section 1 part D stated, "Application includes the least restrictive restraint, as determined by the physician or RN, and as appropriate for the situation and will be applied and removed by a trained, qualified caregiver: "

Section 1 part D7 stated, "To ensure correct documentation of restraint orders, the physician should use the appropriate restraint order form which outlines the requirements:
a. Date and time of order
b. Renewal is issued every calendar day
c. Clinical justification (reason restraints are needed)"

Section 1 part H5 Care and monitoring stated, "The RN must frequently assess/reassess the patient for:
a. The continued need for restraints
b. A less restrictive method of restraint if possible"

The section for the "Procedure for Training of Staff" was reviewed. Part 2 of this section stated, "Hospital staff members who assess patients for restraints or who apply restraints shall receive training in the following":
"C. Choosing the least restrictive intervention based on an individualized assessment of the patient's medical or behavioral status or condition".

The 2011 Nursing Skills Fair training on restraints was reviewed. The module did not include training on how to choose the least restrictive restraint.