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Based on clinical record review and staff interview, it was determined the facility staff failed to ensure for one (1) of three (3) patients who had orders for the use of non-violent restraints (Patient # 9), that the restraint was discontinued at the earliest possible time.

Patient #9 was documented to be asleep in the restraints for well over 8 (eight) hours.

The findings included:

Patient #9 was admitted to the facility on 8/31/19 with diagnoses that included, but were not limited to: dementia and fall with fracture. Patient #9 had an order on 9/1/19 at 6:37 p.m. for the use of non-violent soft bilateral wrist restraints, due to "interference with medical treatment". Patient #9 was being monitored via camera with a remote "telesitter". According to the "Telesitter Remote Visual Log", on 9/1/19 from 2300 (11:00 p.m.) through 0700 (7:00 a.m.) on 9/2/19, Patient #9's "behavior" was documented as "#10- asleep". The "Patient Safety Associate-Shift Activity Communication" (fifteen minute documentation log)
evidenced from 7:45 p.m. 9/1/19 through 7:15 a.m. on 9/2/19 the activity code was "2" which was "sleeping".

The facility policy and procedure "Restraints and Restraint Alternatives" evidenced, in part: "...A. Discontinuation/Termination of Restraint/Seclusion: 1. Restraint and/or seclusion is removed at the earliest possible time...5. Restraints are removed as soon as the patient demonstrates desired behaviors..."

On 10/10/19 Staff Member #3 (Regulatory) was navigating the clinical record for the surveyor and was aware of the documentation that the patient had been asleep in the restraints for an extended period of time. Staff Member #3 stated, "Yes I see that."

Based on clinical record review, staff interview and review of facility documentation, it was determined the facility staff failed to ensure one (1) of (3) three patients, (Patient #11) who expired within twenty-four hours of being in restraints, was included on the facility internal log of patient restraints.

The findings included:

Patient #11 was admitted to the facility on 9/22/19 with diagnoses that included but were not limited to: Stroke, seizures and asthma. According to documentation in the clinical record, Patient #11 was ordered non-violent bilateral soft wrist restraints on 9/22/19 at 1758 (5:58 p.m.) after requiring intubation (placed on a mechanical ventilator). At 2120 (9:20 p.m.) Patient #11 was taken off the ventilator and the restraints were removed. On 9/23/19 the patient was transferred into hospice for end of life care. Patient #11 was pronounced deceased at 1651 (4:51 p.m.) on 9/23/19. There was no documentation in the patient's record of the patient being included on the facility log.

A review of the facility policy and procedure "Restraints and Restraint Alternatives" evidenced, in part: "...E. Mandatory Death Reporting Requirements:...EXCEPTION: 2. When no seclusion has been used and when the only restraints used on the patient are those composed solely of soft, non-rigid, cloth-like materials applied exclusively to the patients wrist(s), the hospital does not need to notify CMS (Centers for Medicare and Medicaid Services)...but must maintain records of these cases by recording them in a log or other system for review upon request by CMS. Entry into that log/system must occur within seven (7) days of the death. Quality Leadership, with the assistance of the Administrative Supervisors maintains the log. Also, staff must document in the patient's medical record the date and time the entry was made into the log/system..."

On 10/10/19 at (9:15 a.m., the surveyor reviewed the clinical record with the assistance of Staff Member #3 (Regulatory). Staff Member #3 stated, "Yes, (Patient #11) expired within twenty-four hours of being in restraints and it was not documented in the log and I cannot find anything in the record."