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Based on record reviews, facility policy reviews, and staff interviews, the facility failed to protect and promote patient rights for 2 (#s 17 and 19) of 9 patients in restraints reviewed. Findings include:


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The facility failed to:

-Ensure that the medical record included evidence that the least restrictive interventions were tried before placing the patient in restraints for 1 (#19) of 9 medical records reviewed. (See A164);

-Ensure that the care or treatment plan included documentation of restraint usage for 2 (#s 17 and 19) of 9 medical records reviewed. (See A166);

-Ensure that the physician renewed restraints orders used for patients with violent behavior every four hours for 1 (#17) of 9 medical records reviewed. (See A171);

-Ensure that after 24 hours the provider performed an assessment of the patient before writing a new restraint order for 1 (#17) of 9 sampled patients. (See tag A172);

-Ensure that each restraint order followed the hospital policy for 1 (#17) of 9 medical records reviewed. (See tag A173);

-Ensure that a face-to-face evaluation by a practitioner was done with in one hour after the initiation of the restraint for 1 (#17) of 9 medical record reviewed. (See tag A178);

-Ensure that the face-to-face re-evaluation included a physical and behavioral assessment by the practitioner for 1 (#17) of 9 medical record reviewed. (See tag A179); and

-Ensure that the documentation on the 1 hour face-to-face medical and behavioral assessment form was included in the patient's medical record for 1 (#17) of 9 medical records reviewed. (See A184).

Based on record review, policy review, and staff interview, the facility failed to assess 1 (#19) of 9 sampled patients to determine if least restrictive interventions would have been effective to protect the patient prior to restraint use. Findings include:

1. Review of the facility restraint policies and procedures began on 5/20/13 at 12:00 p.m. The facility policy labeled "Restraints: Non-Violent & Violent/Self Destructive included under the heading "Definitions" the following, "The use of restraints poses inherent risks to the physical safety and psychological well being of the patient and staff. We must always evaluate through a comprehensive assessment of the patient that the risks associated with the use of the restraint is outweighed by the risks of not using the restraints. Alternatives attempted or the rationale for not trying alternatives or less restrictive interventions are documented."

2. Patient #19 was admitted to the facility on 1/6/13 with diagnoses of acute pancreatitis and septicemia. Per physician orders and nursing assessments on 1/8/13 at 12:30 p.m., patient #19 was placed in bilateral soft wrist restraints and a full set of side rails.

On 1/8/13 at 12:30 p.m., 2:00 p.m., 4:30 p.m., and 6:00 p.m., the facility nurse documented on the Patient Assessment Non-Violent Restraints form that no alternative measures were attempted or used before placing the patient in the restraints. The Patient Notes form lacked documentation of alternative measures tried by the nurse.

The medical record lacked documentation from 1/8/13 at 12:30 p.m. to 7:00 p.m., of the least restrictive alternatives attempted/tried before placing the patient in restraints.

3. During an interview with staff member A, the Director of Quality Management, on 5/22/13 at 8:08 a.m., she stated staff members needed to try alternatives before applying restraints.

4. During an interview with staff member I, on 5/22/13 at 8:08 a.m., stated the staff needs to try alternatives before applying restraints. Staff member I stated facility staff members need more training on alternative measure.

Based on record review and staff interview, the facility failed to document the use of restraints in the patient's plan of care for 2 (#s 17 and 19) of 19 sampled patients.

1. Patient #19 was admitted to the facility on 1/6/13 with diagnoses of acute pancreatitis and septicemia.

According to physician orders and nursing assessments documented on 1/8/13 at 12:30 p.m., patient #19 was placed in bilateral soft wrist restraints and a full set of side rails.

Patient #19's medical record lacked documentation that the care plan was updated when staff initiated the use of restraints for patient #19.


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2. Patient #17 was admitted to the hospital on 1/17/13 with diagnoses including hypoxia, chronic obstructive pulmonary disease exacerbation, pubic ramus fracture and Vitamin B12 deficiency.

According to physician orders and nursing assessments documented on 1/17/13 at 11:00 p.m., patient #17 was placed in bilateral soft wrist restraints and a full set of side rails.

Patient #17's medical record lacked documentation that the care plan was updated when the staff put the patient into restraints.

3. Staff member I stated at 10:00 a.m., the care plan was to be updated when there was a new intervention put in place for patients.

4. During an interview with staff member I and K, on 5/22/13 at 11:00 a.m., stated unit managers were aware of issues with updating patient care plans. The staff members stated, they were not aware of issues with restraints being added to the care plan.

Based on medical record review, policy review, and staff interview, the facility failed to renew restraints for violent/self-destructive behaviors every fours hours, up to a total of 24 hours, for 1 (#17) of 9 sampled patients.


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Patient #17 was admitted to the hospital on 1/17/13 with diagnoses including hypoxia, chronic obstructive pulmonary disease exacerbation, pubic ramus fracture, and B12 deficiency.

The closed EHR was reviewed on 5/21/13 at 1:00 p.m. On 1/17/13 at 10:45 p.m., a nurse documented that patient #17 was yelling, combative, attempting to grab nurses and refused to put the oxygen on her. Patient #17 was a violent patient. According to the entry on the Violent/Self Destruction Assessment form at 11:00 p.m., patient #17 was a danger to self and others. According to the physician's restraint order, patient #17's behaviors were "confusion and unable to follow directions, persistent efforts to disconnect medical equipment." However, documented on 1/17/13 at 11:00 p.m., in the patient notes, patient #17 was placed in bilateral wrist restraints and full length bed rails due to her being violent. The initial order on 1/17/13 at 11:00 p.m., was for a non-violent patient.

According to the restraint order form a violent restraint required;
-a face-to face with in one hour after the initiation of the restraint;
-a face-to-face assessment with in 24 hours to renew the restraint orders; and
-a renewal order within 4 hours of the initiation of the restraint.
The EHR and hard copy record lacked documentation of the above requirements.

Staff member I stated on 5/22/13 at 10:00 a.m., the order for a non-violent restraint was incorrect. The patient needed a violent restraint order. The medical record had no documentation of a physician assessing and renewing the restraint order every four hours.

During review of the facility's policies on 5/20/13 at 2:00 p.m., the surveyors noted that within the policy for Restraints: Non-Violent & Violent/Self-Destructive, under the section labeled Restraints for Violent or Self-Destructive Behaviors the following, "...III...C. Initiated in accordance with the order of a Physician/APRN/PA- orders are written and limited to a maximum of four hours for adults..."

Based on record review, policy review, and staff interviews, the facility failed to ensure that after 24 hours the provider performed an assessment of the patient before writing a new restraint order for 1 (#17) of 9 sampled patients. Findings include:


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Patient #17 was admitted to the hospital on 1/17/13 with diagnoses including hypoxia, chronic obstructive pulmonary disease exacerbation, pubic ramus fracture, and B12 deficiency.

The closed EHR and the hard copy record were reviewed on 5/21/13 at 1:00 p.m. According to the entry on the Violent/Self Destruction Assessment form on 1/17/13 at 11:00 p.m., patient #17 was a danger to self and others. The medical record lacked documentation of a physician completing an assessment after 24 hours to renew the restraint order.

Staff member I stated at 10:00 a.m., a physician should have documented seeing the patient after 24 hours, completed an assessment, and ordered a renewal or a discontinuation order for the restraint.

During review of the facility's policies on 5/20/13 at 2:00 p.m., the surveyors noted that within the policy for Restraints: Non-Violent & Violent/Self-Destructive, under the section labeled Restraints for Violent or Self-Destructive Behaviors the following, "...III...D. A face to face assessment must be completed by a Physician/APRN/PA every 24 hours to renew orders for violent/self-destructive restraints."

Based on record review, facility policy review, and staff interview, the facility failed to renew restraint orders as stated in facility policy for 1 (#17) of 9 sampled patients. Findings include:

During the review of the facility restraint policies on 5/20/13 at 2:00 p.m., the surveyors noted that the policy labeled for Restraints: Non-Violent & Violent/Self-Destructive included under the Definitions section the following statement; "...4. A restraint for violent/self-destructive behavior refers to application of a restraint for the protection of the patient against injury to self or others because of an emotional or behavioral disorder; it also refers to an emergency situation in which the intervention is used to handle sudden violent, aggressive or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff or that of other and non-physical interventions would not be effective. The use of restraint for violent/self destructive behavior is not based on a patient's restraint history or solely on a history of dangerous behavior."


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Patient #17 was admitted to the hospital on 1/17/13 with diagnoses including hypoxia, chronic obstructive pulmonary disease exacerbation, pubic ramus fracture, and B12 deficiency.

The closed EHR was reviewed on 5/21/13 at 1:00 p.m. According to the entry on the Violent /Self Destruction Assessment form on 1/17/13 at 11:00 p.m., patient #17 was a danger to self and others. On 1/17/13 at 11:00 p.m., the soft wrist restraints and a full length bed rails were applied.

Staff member I and J reviewed patient #17's medical record with the surveyors on 5/22/13 at 10:00 a.m. Staff member I and J stated the restraint order should have been for violent restraints not non-violent restraints. The patient met the facility's definition of a violent patient.

The violent restraint order required the following;
-a face-to face with in hone hour after the initiation of the restraint;
-a face-to-face assessment with in 24 hours to renew the restraint orders;
-a renewal order within 4 hours of the initiation of the restraint.
The EHR lacked documentation of a face-to-face within 1 hour after the initiation of the restraint, a 4 hour assessment and renewal, a 24 hour assessment, and a renewal order or discontinuation order.

Staff member I stated at 10:00 a.m., that a practitioner was required to assess a violent patient in restraints after 1 hour of being in the restraints and then again at 4 hours for a renewal order. The EHR and hard copy record lacked documentation that the physician assessed patient #17 according to the required time frames for a violent patient.

Based on record review, policy review, and staff interview, the facility failed to ensure the physician performed, and documented, a 1 hour face-to-face assessment after the resident was placed in restraints for violent behavior for 1 (#17) of 9 patients reviewed. Findings include:

During the review of the facility restraint policies on 5/20/13 at 2:00 p.m., the surveyors noted that the policy labeled for Restraints: Non-Violent & Violent/Self-Destructive included under the Definitions section the following statement; "...III...One (1) Hour face to face evaluation: A Physician/APRN/PA must conduct a face to face evaluation of the patient's medical and behavioral condition within one hour of initiation of the intervention. The medical and behavioral assessment includes:
A. A description of the patient's behavior and interventions used;
B. Patients physical and psychological status;
C. Alternatives or less restrictive interventions attempted (as applicable);
D. The patient's condition or symptom(s) that warranted the use of the restraint; and
E. The patient's response to the intervention used, including the need for continued use of the intervention..."


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Patient #17 was admitted to the hospital on 1/17/13 with diagnoses including hypoxia, chronic obstructive pulmonary disease exacerbation, pubic ramus fracture, and B12 deficiency.

The closed EHR was reviewed on 5/21/13 at 1:00 p.m. On 1/17/13 at 11:00 p.m., the Violent/Self Destruction Assessment form revealed patient #17 was a danger to self and others. According to the entry in the patient's notes on 1/17/13 at 10:45 p.m., patient #17 was yelling, combative, trying to hit and grab the nurses, and would not keep the oxygen on her face. On 1/17/13 at 2100, "MD arrives orders received, PT restrained bilat [sic] wrist restraints..." Violent behavior was not documented on the restraint order form. The initial restraint order was for confusion and persistent efforts to pull out medical equipment.

Per the description of the patient's behavior above the order should have been for violent restraints. The EHR and hard copy medical record lacked documentation that a physician completed a 1 hour assessment after the initial application of the restraint.

Staff member I stated on 5/22/13 at 10:00 a.m., that the physician should have documented seeing the patient with in one hour after he signed the order. "The physician did not assess the patient because the order was incorrect. The order was for a non-violent restraint."

Based on medical record review, policy review, and staff interview, the facility failed to assess and document the patient's physical and behavioral response(s) to being placed in restraints during the 1 hour face-to-face evaluation for #1 (#17) of 9 sample patients. Findings include:

During review of the facility's policies on 5/20/13 at 2:00 p.m., the surveyors noted the policy for Restraints: Non-Violent & Violent/Self-Destructive. Under the section labeled Definitions the surveyors noted the following, "...D. A face to face assessment must be completed by a Physician/APRN/PA every 24 hours to renew orders for violent/self-destructive restraints."


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Patient #17 was admitted to the hospital on 1/17/13 with diagnoses including hypoxia, chronic obstructive pulmonary disease exacerbation, pubic ramus fracture, and B12 deficiency.

The closed EHR was reviewed on 5/21/13 at 1:00 p.m. The Violent /Self Destruction Assessment form was completed on 1/17/13 at 11:00 p.m., patient #17 was a danger to self and others. Documented on the patient's notes on 1/17/13 at 10:45 p.m., "patient #17 was yelling, combative, trying to hit and grab the nurses, and would not keep the oxygen on her face." On 1/17/13 at 11:00 p.m., the nurse documented, "MD arrives orders received, PT restrained bilat [sic] wrist restraints..." Violent behavior was not documented on the restraint order form. The initial restraint order was for confusion and persistent efforts to pull out medical equipment.

The initial order should have been for a violent restraint which required;
-a face-to face with in hone hour after the initiation of the restraint;
-a face-to-face assessment with in 24 hours to renew the restraint orders;
-a renewal order within 4 hours of the initiation of the restraint.

The EHR and hard copy medical record lacked documentation of a face-to-face with in 1 hour after the initiation of the restraint. The physician did not complete an evaluation to determine if the situation for the restraint was appropriate, how the patient reacted to the restraint, if the medical and behavioral condition of the patient changed while in the restraint, and if the restraint was to be continued or discontinued.

Staff member I stated at 10:00 a.m., that the restraint order form was marked for non-violent and should have been marked for violent restraint. The restraint order was for a non-violent restraint. The physician should have documented seeing the patient with in one hour after he signed the order. The medical records did not occur.

Based on medical record review, policy review and staff interview, the facility failed to document a 1 hour face-to-face medical and behavioral evaluation of the patient for use of restraints used to manage a violent or self-destructive behaviors for 1 (#17) of 9 sampled patients. Findings include:

During review of the facility's policies on 5/20/13 at 2:00 p.m., the surveyors noted the policy for Restraints: Non-Violent & Violent/Self-Destructive under the section labeled Definitions the following statement, "One (1) Hour face to face evaluation: A Physician/APRN/PA must conduct a face to face evaluation of the patient's medical and behavioral condition within one hour of initiation of the intervention. The medical and behavioral assessment includes:
A. A description of the patient's behavior and interventions used;
B. Patients physical and psychological status;
C. Alternatives or less restrictive interventions attempted (as applicable);
D. The patient's condition or symptom(s) that warranted the use of the restraint; and
E. The patient's response to the intervention used, including the need for continued use of the intervention..."


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Patient #17 was admitted to the hospital on 1/17/13 with diagnoses including hypoxia, chronic obstructive pulmonary disease exacerbation, pubic ramus fracture, and B12 deficiency.

The closed EHR was reviewed on 5/21/13 at 1:00 p.m. According to the entry on the Violent /Self Destruction Assessment form completed on 1/17/13 at 2100, patient #17 was a danger to self and others. A nurse documented on the patient's notes on 1/17/13 at 10:45 p.m., "patient #17 was yelling, combative, trying to hit and grab the nurses, and would not keep the oxygen on her face." On 1/17/13 at 11:00 p.m. "MD arrives orders received, PT restrained bilat [sic] wrist restraints..." Violent behavior was not documented on the restraint order form. The initial restraint order was for confusion and persistent efforts to pull out medical equipment.
The initial order was for non-violent restraint.

The EHR and hard copy medical record lacked documentation of a face-to-face within 1 hour after the initiation of the restraint. The physician did not complete an evaluation to determine if the situation for the restraint was appropriate, and, if the medical and behavioral condition of the patient changed while in the restraint.

Staff member I stated at 10:00 a.m., that the restraint order form was marked for non-violent and should have been marked for violent restraint. The restraint order was for a non-violent restraint. The physician should have documented seeing the patient with in one hour after he signed the order. This did not occur.

Based on record review and staff interviews, the facility failed to initiated care plans for patients as soon as possible after admission for 5 (#s 14, 16, 19, 20, and 24) of 24 patients reviewed. Findings include:

1. Patient #19 was admitted to the facility on 1/6/13 at 9:30 p.m., with diagnoses of acute pancreatitis and septicemia.

During the review of patient #19's medical record, the surveyor noted the patient's care plan was started on 1/7/13 at 4:30 p.m., nineteen hours after the patient was admitted.

2. Patient #20 was admitted to the facility on 5/15/13 at 3:02 a.m., with diagnoses of dorsal thoracic vertebra fractures, dental fractures, and abrasions.

During the review of patient #20's medical record, the surveyor noted the patient's care plan was started on 5/16/13 at 2:34 p.m., eleven and half hours after the patient was admitted.

3. Patient #24 was admitted to the facility on 1/19/13 at 1:00 a.m.

During review of the patient #24's medical record, the surveyor noted the patient's care plan was started on 1/21/13 at 11:04 p.m., forty six hours after the patient was admitted.


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4. Patient #14 was admitted to the facility on 5/10/13 at 11:59 a.m. with a drug overdose.

During review of the patient #14's medical record, the surveyor noted the patient's care plan was started on 5/11/13 at 7:32 a.m., 7 hours after the patient was admitted.

5. Patient #16 was admitted to the facility on 12/30/12 at 9:29 a.m. with suicide ideation.

During review of the patient #16's medical record, the surveyor noted the patient's care plan was started on 12/31/12 at 10:29 a.m., 25 hours after the patient was admitted.

6. Staff member I and J reviewed medical records for patient #s 14, 16, 19, 20, and 24, with the surveyors on 5/22/13 at 10:00 a.m. Staff member I and J stated the care plan should be initiated within 24 hours of the patient admission.

7. During an interview with staff member K on 5/22/13 at 11:00 a.m., the staff member stated the facility's policy for care plans was 24 hours after admission. Staff member K stated in March of 2013, the facility realized they were having issues with initiating care plans within 24 hours of the patient's admit. The facility also realized there was an issue with updating care plans. The management staff was reviewing a percentage of patient's medical records for care plans. The facility was not aware the care plans should be initiated as soon as the patient was admitted.