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Based on policy review, medical record review, and staff interview, the facility failed to ensure the patient or his or representative had the right to request or refuse treatment (A131). The facility failed to ensure a physician order was obtained for non-violent restraints according to policy and procedure (A168). The facility failed to ensure restrained patients were monitored by trained staff (A175). The facility failed to ensure all deaths that occur within 24 hours after removal of restraints were recorded on the log (A214).

Based on policy review, medical record review, and staff interview, the facility failed to ensure the patient or his or representative had the right to request or refuse treatment for two of ten medical records reviewed (Patient #2 and #3). The facility census was 261.

Findings include:

Review of the policy titled, "Consent for Treatment, Payment and Healthcare Operations," approved 01/01/19, revealed "each patient, or the patient's authorized representative, will receive and be asked to sign the 'Consent for Treatment, Payment and Healthcare Operations'. This is the document first giving" the facility "permission to render care." "For emergent situations, treatment should begin without delay, even if the consent has not been signed yet. Attempts should be made as quickly as possible to obtain consent when appropriate given the clinical status of the patient and/or when an authorized representative is available."

1. Review of the medical record for Patient #2 revealed an admission date 12/14/2020 and a discharge date of 12/26/2020. The medical record lacked documentation of consent for treatment, or the "Consent for Treatment, Payment and Healthcare Operations" document. This was verified on 02/09/21 at 2:55 PM by Staff A. Staff A stated the registration staff had notes that they attempted twice to reach Patient #2 who was in isolation with no success.

2. Review of the medical record for Patient #3 revealed a "Consent for Treatment, Payment and Healthcare Operations" dated 01/20/21. The signature box on this form noted verbal consent from the patient's spouse and listed the spouse's name. The "Health Care Power of Attorney" form listed the spouse as the primary agent and the adult child as the first alternate agent. The adult child provided consent for all procedural consents. The medical record contained documentation Patient #3's spouse died the previous week and the funeral was on 01/21/21. This was verified on 02/09/21 at 2:55 PM by Staff A. Staff A stated the registration staff had notes that the adult child who was the Power of Attorney was contacted and gave verbal consent to treat and mentioned that the spouse died recently. The registration staff documented the consent was from the spouse when it was from the adult child.

Based on policy review, medical record review, and staff interview, the facility failed to ensure a physician order was obtained for non-violent restraints according to policy and procedure for three of seven medical records reviewed with restraints (Patient #7, #9, and #3). A total of ten medical records were reviewed. The facility census was 261.

Findings include:

Review of the policy titled, "Use of Restraints for Nonviolent, Non-Self Destructive Patient Situations: Medical Use of Restraints," approved 01/09/18, revealed an order from a physician or authorized practitioner is required for all instances of restraint every calendar day.

1. Review of the medical record for Patient #7 revealed an admission date of 01/25/21 for diagnoses to include pneumonia secondary to COVID-19, acute encephalopathy, and sepsis. Review of the nursing flowsheets noted monitoring and documentation of the non-violent restraints from 01/26/21 at 1:30 AM through 01/29/21 at 2:45 PM. The medical record lacked evidence of a physician order for bilateral soft wrist restraints for 01/28/21 and 01/29/21. Staff A confirmed these findings during a phone interview on 02/10/21 at 10:33 AM.

2. Review of the medical record for Patient #9 revealed an admission date of 01/26/21 following a COVID-19 diagnosis on 01/14/21. The medical record noted the patient was transferred to the facility due to a deteriorating respiratory status which required mechanical ventilation and an increased level of monitoring. Review of the nursing flowsheets from 01/27/21 through 02/04/21 noted monitoring and documentation of the bilateral soft wrist restraints. The medical record lacked evidence of a physician order for bilateral soft wrist restraints for 01/28/21 and 02/04/21. Staff A confirmed these findings during a phone interview on 02/10/21 at 10:04 AM.


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3. Review of the medical record for Patient #3 revealed an admission date of 01/20/21. The medical record contained documentation of restraints applied on 01/20/21 at 6:14 PM due to pulling at lines and agitation. The medical record lacked an order or monitoring of restraints until 01/21/21 at 6:34 AM when an order was obtained and the medical record contained documentation of restraints applied at 6:00 AM. This was verified on 02/09/21 at 2:55 PM in an interview with Staff A.

This substantiates Substantial Allegation OH00119696.

Based on policy review, medical record review, and staff interview, the facility failed to ensure restrained patients were monitored by trained staff for three of seven medical records reviewed with restraints (Patient #1, #3, and #4). A total of ten medical records were reviewed. The facility census was 261.

Findings include

Review of the policy titled, "Use of Restraints for Nonviolent, Non-Self Destructive Patient Situations: Medical Use of Restraints," approved 01/09/18, revealed face to face observation or direct examination of the patient every 60 minutes by qualified staff was required to ensure the restraint has been properly applied and the patient's rights, dignity, and safety are maintained. Assessment was required every two hours to assess the physical needs of the patient, remove restraints for circulation evaluation and range of motion, food and fluid needs, toileting needs, and to determine if the clinical condition may allow a least restrictive method or termination of restraints.

1. Review of the medical record for Patient #1 revealed an admission date of 12/17/2020. The medical record contained an order dated 12/20/2020 at 8:45 PM for bilateral soft wrist restraints for 24 hours. The medical record contained documentation of bilateral soft wrist restraints from 12/20/2020 at 8:30 PM to 12/21/2020 at 11:00 AM. The medical record lacked documentation of restraint monitoring or discontinuation after 11:00 AM. This was verified on 02/09/21 at 2:55 PM in an interview with Staff A.

2. Review of the medical record for Patient #3 revealed an admission date of 01/20/21. The medical record contained documentation of restraints applied on 01/20/21 at 6:14 PM due to pulling at lines and agitation. The medical record lacked an order or monitoring of restraints until 01/21/21 at 6:34 AM when an order was obtained and the medical record contained documentation of restraints applied at 6:00 AM. This was verified on 02/09/21 at 2:55 PM in an interview with Staff A.

3. Review of the medical record for Patient #4 revealed an admission date of 01/12/21. The medical record contained an order for bilateral soft wrist restraints dated 01/14/21 at 10:35 AM. The medical record lacked documentation of restraints applied, monitored or discontinued on 01/14/21. This was verified on 02/09/21 at 2:55 PM by Staff A.

This substantiates Substantial Allegation OH00119696.

Based on medical record review and staff interview, the facility failed to ensure all deaths that occur within 24 hours after removal of restraints were recorded on the log for one of one medical record of a patient who died within 24 hours of being restrained (Patient #1). A total of ten medical records were reviewed, of which seven had restraints. The facility census was 261.

Findings include:

Review of the medical record for Patient #1 revealed an admission date of 12/17/2020. The medical record contained documentation of bilateral soft wrist restraints from 12/20/2020 at 8:30 PM to 12/21/2020 at 11:00 AM. Patient #1 died on 12/22/2020 at 12:15 AM. The "Expiration Summary/Release of Body" form was marked no restraints on at time of death or within 24 hours of death and Quality not notified.

On 02/09/21 at 11:35 AM, Staff A and Staff H verified Patient #1 was not on the restraint log as required. Staff A and Staff H stated because the patient had bilateral soft wrist restraints this was not required to be reported but was required to be logged.