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Based on medical record review, Root Cause Analysis review, policy and procedure review, and staff interview, the facility failed to assure that less restrictive interventions were determined to be ineffective to protect patient #1 before physical restraining patient #1. One (1) of ten (10) patients was affected.

Findings include:

Patient #1: Medical record review revealed the patient had a right hip fracture surgically repaired on 7/13/2015. While in the Post Anesthesia Care Unit (PACU) following surgery on 7/13/15 at 3:18 p.m., the patient became combative and tried to get out of the bed. At that time the patient was physically restrained. Assessment Reports indicate the patient remained physically restrained until he was found without respirations on 7/14/15 at 6:03 a.m. A Code Blue was called at that time. The patient was pronounced dead at 6:52 a.m. There was no documented evidence that the patient was assessed for less restrictive interventions. The Root Cause Analysis stated: "There is no evidence that the patient was assessed for the restraints." Surveyor findings were discussed with the Chief Nursing Officer on 9/29/15 at 2:00 p.m. She indicated agreement with surveyor findings at that time.

Page three (3) of the facility's Nursing Service Restraint and Seclusion policy and procedures dated 8/15/14 contained the following requirements. 5. Alternatives to restraints use must be attempted and documented in the medical record prior to the initiation of a non-violent or violent episode. Less restrictive treatments and measures to prevent the use of restraints and seclusion must be attempted and determined to be ineffective to the application of restraints.

Based on medical record review, Root Cause Analysis review, policy and procedure review, and staff interview, the facility failed to ensure that an as needed order was used to physically that patient #1. One (1) of ten (10) patients was affected.

Findings include:

Patient #1: Medical record revealed the patient was physically restrained from 7/13/15 at 3:52 p.m. to 7/14/14 at 6:03 p.m. An order to restrain the patient as needed was written on 7/13/15 at 3:52 p.m. This was the only available physical restraint order. The Root Cause Analysis report stated the MD (medical physician) ordered a restraint PRN (as needed) against policy. Surveyor findings were discussed with the Chief Nursing Officer on 9/29/15 at 2:00 p.m. She indicated agreement with surveyor findings at that time.

Page four (4) of the facility's Nursing Service Restraint and Seclusion policy and procedure dated 8/15/14 contained the following requirement. D: Orders will not be accepted as a standing order or on an as needed (PRN) basis.

Based on medical record review, Root Cause Analysis review, staff interview, and policy and procedure review, the facility failed to report the death of patient #1 which occurred while the patient was physically restrained to the Centers for Medicare and Medicaid Services (CMS) within the close of the business on the next day following knowledge of the patient ' s death. One (1) of eight (8) patients was affected.

Findings include:

Patient #1: Medical record review revealed the patient had a right hip fracture surgically repaired on 7/13/2015. While in the Post Anesthesia Care Unit (PACU) following surgery on 7/13/15 at 3:18 p.m., the patient became combative and tried to get out of the bed. At that time the patient was physically restrained. A Clinical Nurse's Report on 7/14/15 at 6:13 a.m. stated "Upon arriving in patient's room to hang antibiotics, patient had no respirations. Code button was immediately pulled, code blue called, and chest compressions started." A Code/Death Note on 7/14/15 at 6:54 a.m. contained the following information. Staff was unable to resuscitate the patient after a long code. The time of death was 6:52 a.m. Cause of death likely MI (Myocardial Infarction) versus Pulmonary Embolism, Coronary Artery disease, Atrial fibrillation, Gastric Co-morbid with Liver metastasis, hip fracture. The facility ' s Root Cause Analysis report stated "Patient died while in 4 point restraint." Interview with the Director of Nursing on 9/28/15 at 1:30 p.m. revealed the death with associated physical restraints was not reported to the Centers for Medicare and Medicaid Services (CMS) no later than the close of business on the next day following knowledge of the patient ' s death.

Page ten (10) of the facility's Nursing Service Restraint and Seclusion policy and procedure dated 8/15/14 contained the following requirement. A. Death associated with the use of seclusion or restraint will be reported to the Centers for Medicaid and Medicaid (CMS). B. Each death must be reported to CMS by telephone no later than the close of the next business day following knowledge of the patient ' s death.