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Based on interviews and document review, it was determined the facility staff failed to ensure the care plan for restraints was updated for 1 of 4 patients sampled for restraint use (Patient #1).

The findings include:

On 2/28/17 at 9:30AM Patient #1 was observed by the surveyor in bed with four-point soft limb restraints in use.

An initial restraint order (for a non-violent/non-self-destructive patient) dated 2/27/17 at 9:45PM for four (4) point soft limb restraints was found in Patient #1's clinical record. The 'patient behavior' documented on the restraint order was "pulling at tubes (IV, NG, Feeding, Catheter, drains, etc.)".

The following nurse's note was documented as occurring on 2/27/17 at 9:40PM: "(patient) confused, agigtated [sic], trying to get out of bed, combative and hitting staff, pulling at IV and catheter. (physician's name omitted) notified. IM Haldol will be given per order and (patient) will be placed back in restraints at this time."

Documentation indicated the restraints were applied on 2/27/17 at 9:45PM and the patient was observed to still have the restraints in use on 2/28/17 at 9:30AM.

On 2/28/17 at 9:40AM, the surveyor requested a copy of Patient #1's restraint care plan. The surveyor was provided a piece of paper with the heading of 'View Document Activity View Only - Care Plan Review'; this documentation included "Restraints" as a "problem" with the goal of "Restraint free and without injury." (The "goal time frame" was documented as "This shift". The "Goal Status" was documented as "In Progress".) The "problem" was documented as "Restraints" and marked with a status of "C". Staff Member (SM) #8 explained that a "C" indicated the "problem" was complete. SM #8 explained that when the restraints was applied on 2/27/17 at 9:45PM the 'care plan' was not able to be activated because it had previously been marked as completed at the end of an earlier restraint episode. (Later that same morning someone was able to update the restraint care plan to show it was currently active.)

The following information was found in the facility's policy and procedure entitled 'Restraint & Seclusion Management' (this policy and procedure had a revision date of 11/2015): "The RN should review the plan of care and modify as appropriate: 1. the alternatives attempted and their lack of effectiveness 2. cause of patient behavior 3. consideration for vulnerable patient population 4. reason for restraint 5. least restrictive type of restraint planned".

The failure to update Patient #1's Care Plan when restraints were reapplied on 2/27/17 at 9:45PM was discussed for a final time during a survey team meeting with the facility's Director of Quality and Risk Manager on 3/2/17 at 4:30PM; no additional information related to this issue was provided to the survey team.

Please see the following deficiencies in this report for more information related to this issue: Tags #171, #175, #176, and #178.

Based on observations, interviews, and document review, it was determined the facility staff failed to ensure appropriate use of restraints for the management of violent and/or aggressive behavior for 1 of 4 patients selected for restraint review (Patient #1).

The findings include:

On 2/28/17 at 9:30AM Patient #1 was observed by the surveyor in bed with four-point soft limb restraints in use.

Patient #1's clinical record contained an initial restraint order dated 2/27/17 at 9:45PM for four (4) point soft limb restraints; this order was written as restraints for a non-violent/non-self-destructive patient. The 'patient behavior' documented on the restraint order was "pulling at tubes (IV, NG, Feeding, Catheter, drains, etc.)".

The following nurse's note was documented as occurring on 2/27/17 at 9:40PM: "(patient) confused, agigtated [sic], trying to get out of bed, combative and hitting staff, pulling at IV and catheter. (physician's name omitted) notified. IM Haldol will be given per order and (patient) will be placed back in restraints at this time." (IM is the abbreviation for an intramuscular injection.)

Documentation indicated these restraints were applied on 2/27/17 at 9:45PM and the patient was observed to still have the restraints in use on 2/28/17 at 9:30AM. The order had not been renewed since given on 2/27/17 at 9:45PM.

The following information was found in a Progress Note that was dictated on 2/27/17 at 11:42PM: " ...Patient is little more awake and alert today. Patient denies any acute complaints. However, during the day, the patient became little [sic] more combative and agitated. The patient is currently on restraints ..." The surveyor was unable to find a date and time for when the interaction documented in this Progress Note occurred. On 2/28/17 at 10:50AM, Staff Member (SM) #8 (a registered nurse) was asked about physician documentation. SM #8 reported the aforementioned progress note was documented by a physician seeing Patient #1 during dayshift rounds on 2/27/17. SM #8 stated there was no progress note from the nightshift physician and that the patient had not yet been seen by the dayshift physician.

The following information was found in the facility's policy and procedure entitled 'Restraint & Seclusion Management' (this policy and procedure had a revision date of 11/2015): "Violent or Self-Destructive Behavior Restraint - is the use of restraint or seclusion in those patients who require management of violent and self-destructive behavior toward themselves or others (including caregivers or other patients) or, who require physical restraint to manage suicidal or homicidal behaviors in ANY setting."

Patient #1's non-violent restraint order being given for aggressive behaviors was discussed for a final time during a survey team meeting with the facility's Director of Quality and Risk Manager on 3/2/17 at 4:30PM; no additional information related to this issue was provided to the survey team.

Please see the following deficiencies in this report for more information related to this issue: Tags #166, #175, #176, and #178.

Based on interviews and document review, it was determined the facility staff failed to have documentation to indicate a patient with restraints was consistently monitored for 1 of 4 patients selected for restraint review (Patient #1).

The findings include:

On 2/28/17 at 9:30AM Patient #1 was observed by the surveyor in bed with four-point soft limb restraints in use.

Patient #1's clinical record contained an initial restraint order dated 2/27/17 at 9:45PM for four (4) point soft limb restraints ; this order was written as restraints for a non-violent/non-self-destructive patient. The 'patient behavior' documented on the restraint order was "pulling at tubes (IV, NG, Feeding, Catheter, drains, etc.)".

The following nurse's note was documented as occurring on 2/27/17 at 9:40PM: "(patient) confused, agigtated [sic], trying to get out of bed, combative and hitting staff, pulling at IV and catheter. (physician's name omitted) notified. IM Haldol will be given per order and (patient) will be placed back in restraints at this time." (IM is the abbreviation for an intramuscular injection.)

Documentation indicated these restraints were applied on 2/27/17 at 9:45PM. Patient #1's "24 Hour Restraint Record" document was reviewed on 2/28/17 at 9:38AM. Patient #1 had entries documented at 12:00 Midnight, 2:00AM, 4:00AM, 6:00AM, and 8:00AM for the morning of 2/28/17. This form was being completed for a patient having restraints for nonviolent purposes. The following information was found on this form: "Assess Safety/Comfort & Need for Continued Use Every 2 hours (Nonviolent) Every 15 (minutes) Violent".

The following information was found in the facility's policy and procedure entitled 'Restraint & Seclusion Management' (this policy and procedure had a revision date of 11/2015): "VIOLENT / SELF DESTRUCTIVE RESTRAINT OR SECLUSION INITIATION: ... F. The RN will assess the continued need of restraint or seclusion against established criteria at a minimum of every 15 minutes in order to release the patient from restraints / seclusion at the earliest possible time."

Patient #1's non-violent restraint order being given for aggressive behaviors was discussed for a final time during a survey team meeting with the facility's Director of Quality and Risk Manager on 3/2/17 at 4:30PM.

Please see the following deficiencies in this report for more information related to this issue: Tags #166, #171, #176, and #178.

Based on interviews and document review, it was determined the facility staff failed to ensure physicians writing restraint orders (for a patient who was or who had exhibited violent and/or aggressive behaviors) had evidence of education related to the facility's restraint policy and procedure for 2 of 5 physicians (Personnel File (PF) #1 and PF #2). (The training/education of these five physicians was reviewed because they had written restraint orders at this facility.)

The findings include:

On 2/28/17 at 9:30AM Patient #1 was observed by the surveyor in bed with four-point soft limb restraints in use.

Patient #1's clinical record contained an initial restraint order dated 2/27/17 at 9:45PM for four (4) point soft limb restraints; this order was written as restraints for a non-violent/non-self-destructive patient. The 'patient behavior' documented on the restraint order was "pulling at tubes (IV, NG, Feeding, Catheter, drains, etc.)".

The following nurse's note was documented as occurring on 2/27/17 at 9:40PM: "(patient) confused, agigtated [sic], trying to get out of bed, combative and hitting staff, pulling at IV and catheter. (physician's name omitted) notified. IM Haldol will be given per order and (patient) will be placed back in restraints at this time." (IM is the abbreviation for an intramuscular injection.)

Documentation indicated these restraints were applied on 2/27/17 at 9:45PM and the patient was observed to still have the restraints in use on 2/28/17 at 9:30AM. The order for the restraints was given by a physician (PF #1) on 2/27/17 at 9:45PM. On the morning 2/28/17, with the surveyor present, the restraint order was renewed with changes by a different physician (PF #2). The surveyor asked Staff Member (SM) #9 for evidence of restraint training for both the physician who gave the initial order on 2/27/17 at 9:45PM and the physician who renewed the order on the morning of 2/28/17. No evidence of restraint training for these two physicians was provided to the survey team. (The surveyor requested evidence of restraint training for three additional physicians who had ordered restraints at the facility. Documentation of restraint training for the three additional physicians was provided to the survey team.)

The following information was found in the facility's policy and procedure entitled 'Restraint & Seclusion Management' (this policy and procedure had a revision date of 11/2015): "PHYSICIAN AND STAFF TRAINING A. During orientation, physicians/LIPs are provided a working knowledge of the Restraint and Seclusion Management Policy and trained on their specific responsibilities specific to restraint/seclusion including: 1. Initial order requirements 2. Evaluation and reevaluation requirements of the patient's condition, timing, of evaluation, and documentation requirements 3. Renewal intervals for orders 4. Discontinuation of restraints in accordance with Hospital policy 5. Forms used for the process B. Evidence of physician orientation and training will be maintained in the medical staff credentials file."

The absence of documentation of restraint training for two physicians who had ordered restraints was discussed for a final time during a survey team meeting with the facility's Director of Quality and Risk Manager on 3/2/17 at 4:30PM; the Director of Quality acknowledged evidence of restraint training was not found for the two (2) aforementioned physicians.

Please see the following deficiencies in this report for more information related to this issue: Tags #166, #171, #175, and #178.

Based on interviews and document review, it was determined the facility staff failed to ensure a patient, who had restraints ordered due to violent and/or aggressive behaviors, had documentation indicating the patient was assessed by a LIP (licensed independent practitioner) within an hour of the application of the restraints for 1 of 4 patients selected for restraint review (Patient #1).

The findings include:

On 2/28/17 at 9:30AM Patient #1 was observed by the surveyor in bed with four-point soft limb restraints in use.

Patient #1's clinical record contained an initial restraint order dated 2/27/17 at 9:45PM for four (4) point soft limb restraints; this order was written as restraints for a non-violent/non-self-destructive patient. The 'patient behavior' documented on the restraint order was "pulling at tubes (IV, NG, Feeding, Catheter, drains, etc.)".

The following nurse's note was documented as occurring on 2/27/17 at 9:40PM: "(patient) confused, agigtated [sic], trying to get out of bed, combative and hitting staff, pulling at IV and catheter. (physician's name omitted) notified. IM Haldol will be given per order and (patient) will be placed back in restraints at this time." (IM is the abbreviation for a intramuscular injection.)

The following information was found in a Progress Note that was dictated on 2/27/17 at 11:42PM: " ...Patient is little more awake and alert today. Patient denies any acute complaints. However, during the day, the patient became little [sic] more combative and agitated. The patient is currently on restraints ..." The surveyor was unable to find a date and time for when the interaction documented in this Progress Note occurred. On 2/28/17 at 10:50AM, Staff Member (SM) #8 (a registered nurse) was asked about this physician documentation. SM #8 reported the aforementioned progress note was documented by a physician who saw Patient #1 during dayshift rounds on 2/27/17. SM #8 stated there was no progress note from the nightshift physician and that the patient had not yet been seen by the dayshift physician.

The following information was found in the facility's policy and procedure entitled 'Restraint & Seclusion Management' (this policy and procedure had a revision date of 11/2015): "A face to face evaluation of the patient by a physician/LIP must be conducted within one hour of the initiation of restraint or seclusion for the management of violent or self-destructive behavior that jeopardized the physical safety of the patient, staff or others." No evidence was found or provided to the survey team to indicate that Patient #1 had a face-to-face assessment completed within one hour of the initiation of the aforementioned restraints.

The absence of documentation of a face-to-face assessment occurring when restraints was used for Patient #1 on 2/27/17 at 9:45PM was discussed for a final time during a survey team meeting with the facility's Director of Quality and Risk Manager on 3/2/17 at 4:30PM; no additional information related to this issue was provided to the survey team.

On 3/3/17 at 9:40AM, the facility's Director of Quality was asked what types of employees were allowed to do the face-to-face assessment for a patient who was having restraints used for a reason requiring a face-to-face assessment. The Director of Quality stated that a physician, nurse practitioner, or physician assessment would be allowed to do the face-to-face assessment for these patients.

Please see the following deficiencies in this report for more information related to this issue: Tags #166, #171, #175, and #176.

Based on interviews and document review, it was determined the facility staff failed to ensure clinical documentation contained information detailing the care provided for 3 of 20 patients sampled for clinical record review (Patient #2, Patient #3, and Patient #13).

The findings include:

1. The facility staff failed to document Patient #3's response to and potential need for physician ordered medications.

Patient #3 had physician telephone orders dated 2/17/17 at 5:00PM for:
-"Benadryl 50mg IM now"
-"Zyprexa 5mg IM now"
-"if (pt) does not calm down (after) 30 minutes my give Ativan 2mg IM."
(IM is the abbreviation for an intramuscular injection.)

The following nursing documentation was included in Patient #3's clinical record:
-On 2/17/17 at 5:15PM - "(patient) continues to be yelling and cursing. (he/she) continues kicking seclusion door and wall. (he/she) is given IM benadryl 50 mg and IM Zyprexa 5 mg."
-On 2/17/17 at 8:00PM - "Assessed alert offer bathroom and something to eat. Yelled at writer and said get out. Also refuse (vital signs). Irritable saying (he/she) is leaving."

Reassessment of Patient #3 thirty (30) minutes after the administration of the Benadryl and Zyprexa was not found in the clinical documentation. Without a reassessment it is impossible to know if Patient #3's response to the administered medications was such that the Ativan was not needed.

The failure of the facility staff to document Patient #3's response to medications therefore failing to address if a physician ordered medication, Ativan, was needed was discussed for a final time during a survey team meeting with the facility's Director of Quality and Risk Manager on 3/2/17 at 4:30PM; no additional information related to this issue was provided to the survey team.

2. Patient #2 was administered a STAT medication greater than two hours after the medication was ordered. Patient #2's clinical documentation failed to address the delay in the administration of this medication. (STAT is a medical abbreviation indicating 'immediately'.)

Patient #2's clinical record included an order for Haldol 2mg to be given IM (intramuscular) STAT (immediately); this order was documented on 2/27/17 at 2:53AM. This medication was documented as being acknowledged by nursing staff on 2/27/17 at 4:46AM and administered on 2/27/17 at 5:01AM.

The following nurse notes were found in the clinical record:
- 2/27/17 at 2:00AM - "I called (doctors name omitted) and informed (him/her) of this (patient) confused and uncoopertative [sic], (patient) has pulled (nasogastric tube) out and is trying to remove (his/her) IV (intravenous access), (patient) given morphine 1 mg IV for (complaint of) pain in (his/her) abdomen, (patient) remains restless and continues trying to get (out of bed) alone and pulling at IV tubing and tape on (right) forearm. Bedrails raised (times) 3. Wrist restraints applied on both wrist [sic] per (doctor) order."
- 2/27/17 at 2:09AM - "(patient) yelling outloud [sic], restless, pulling against the restraints. I called (doctors name omitted) to come see (patient) and order something to calm (him/her). (He/She) states (he/she) is coming to see this (patient)."
- 2/27/17 at 8:17AM - "Patient awake, confused, very loud yelling, uncooperative, remains in wrist restraints, I called (his/her) doctor for today's team (doctor name omitted) and informed (him/her) of patient's behaviour [sic] during night shift and currently now, doctor gave order to hold NG tube insertion and encourage oral intake and stated (he/she) will be up to see patient soon."

The facility policy and procedure entitled 'Medication Orders' (last revised 3/2015) included the following information: "The prescriber must communicate "STAT" or "NOW" medication orders to the unit secretary or nurse. 1. "STAT" orders are written for drugs and procedures that may alleviate life-threatening conditions or jeopardize his or her immediate well-being. They must be carried out immediately 2. "NOW" orders are written for drugs and procedures and should start in less than one hour from the time the prescriber notifies the healthcare practitioners."

The delay in the administration of Patient #2's STAT medication was discussed for a final time during a survey team meeting with the facility's Director of Quality and Risk Manager on 3/2/17 at 4:30PM; no additional information related to this issue was provided to the survey team.

3. The facility staff failed to document the implementation of the "Alcohol Withdrawal Protocol Orders (Non-CCU)" for Patient #13.

Patient #13's clinical record included a physician order dated 2/28/17 at 9:55AM for Ativan 1 mg by mouth now. The patient was also ordered to have the Alcohol Withdrawal Protocol implemented.

Patient #13 was documented as receiving the Ativan 1mg by mouth on 2/28/17 at 10:09.

On 2/28/17 at 10:15AM Patient #13 had a Severity Assessment Scale (SAS) completed, as directed by the Alcohol Withdrawal Protocol, with a result of "6". This result according to the protocol indicated the patient was to receive Ativan 2 mg by mouth and have the SAS completed again in four (4) hours. No documentation was found to indicate the Ativan 2mg had been given or the physician was consulted related to the SAS results for medication administration guidance. No documentation was found to indicate the SAS was repeated in four (4) hours.

The next documented SAS assessment for Patient #13 was dated 2/28/17 at 10:34PM; the result was a "9" which indicated the patient was to receive Ativan 3mg by mouth. Documentation indicated the patient was administered the Ativan 3mg by mouth on 2/28/17 at 10:48PM.

A physician progress note for Patient #13 dictated on 2/28/17 at 3:34PM included the following "Treatment Plan": "History of alcohol dependence: Patient's current confusion and agitation overnight is likely related to alcohol withdrawal. I will proceed and give (him/her) 1 milligram p.o. Ativan as well as initiation of CIWA protocol."

The failure of the facility staff to document Patient #13's progress and/or response to the alcohol withdrawal protocol was discussed for a final time during a survey team meeting with the facility's Director of Quality and Risk Manager on 3/2/17 at 4:30PM; no additional information related to this issue was provided to the survey team.

Based on interviews and document review, it was determined the facility staff failed to ensure complete and accurate clinical records for 2 of 20 patients sampled for clinical record review (Patient #1 and Patient #16).

The findings include:

1. Patient #1's clinical record contained a physician progress note that failed to include the date and time of when the assessment/interaction occurred.

The following information was found in a Progress Note dictated on 2/27/17 at 11:42PM: " ...Patient is little more awake and alert today. Patient denies any acute complaints. However, during the day, the patient became little [sic] more combative and agitated. The patient is currently on restraints ..." The surveyor was unable to find a date and time for when the interaction documented in this Progress Note occurred. On 2/28/17 at 10:50AM, Staff Member (SM) #8 (a registered nurse) was asked about this physician documentation. SM #8 reported the aforementioned progress note was documented by a physician who saw Patient #1 during dayshift rounds on 2/27/17.

The following statement was found in the 'Medical Staff Executive Committee Rules and Regulations' approved by the Board of Directors on 12/28/16: "All entries in the medical record must be dated, timed, and authenticated."

The absence of a date and time identifying when the physician completed the assessment for a 2/27/17 interaction with Patient #1 was discussed for a final time during a survey team meeting with the facility's Director of Quality and Risk Manager on 3/2/17 at 4:30PM; no additional information related to this specific note was provided.

2. Patient #16's clinical documentation failed to consistently include the date and time of physician assessments/interactions.

Patient #16's clinical record included a History and Physical (H&P) dictated by a resident on 1/18/17 at 10:46AM; this did not include documentation of the date and time the patient was seen by the resident. This H&P had an "Attestation Statement", documented by the attending physician, which read in part: "I saw and evaluated the patient. I personally obtained the key and critical portions of the history and physical exam. I reviewed (doctor's name omitted) documentation and discussed the patient with the resident. I agree with the resident's medical decision making as documented in the resident's note, and I agree with the resident's assessment of care ..." This attestation statement did not document the date and time the attending physician assessed and/or interacted with Patient #16.

Patient #16's clinical record included a progress note by a resident which documented the patient was seen on 1/19/17 at 10:00AM. This note had an "Attestation Statement", documented by the attending physician, which read in part: "I saw and evaluated the patient. I personally obtained the key and critical portions of the history and physical exam. I reviewed (doctor's name omitted) documentation and discussed the patient with the resident. I agree with the resident's medical decision making as documented in the resident's note, and I agree with the resident's assessment of care ..." This attestation statement did not document the date and time the attending physician assessed and/or interacted with Patient #16.

The absence of a date and time identify when the attending physician and/or the resident assessed Patient #16 was discussed for a final time during a survey team meeting with the facility's Director of Quality and Risk Manager on 3/2/17 at 4:30PM; no additional information related to these specific assessments was provided to the survey team.

Based on interviews and document review, it was determined verbal and/or telephone orders had not been co-signed by a provider for 1 of 20 patients sampled for clinical record review (Patient #3).

The findings include:

Patient #3's clinical record was reviewed by a surveyor on 3/1/17 at 9:15AM. Patient #3's clinical record contained two telephone orders (TOs) which had not yet been cosigned by the physician giving the order.

A telephone order was documented by a nurse on 2/17/17 at 4:30PM for "Seclusion for up to four hours for aggression and physical violence. Release when calm, cooperative & redirectable." At the time of the chart review by the surveyor on the morning of 3/1/17, the order had not been cosigned by the physician.

A telephone order was documented by a nurse on 2/16/17 at 4:00PM for "Seclude for up to 4 hours for verbal and/or physical aggression, escape risk." At the time of the chart review by the surveyor on the morning of 3/1/17, the order had not been cosigned by the physician.

The following statement was found in the 'Medical Staff Executive Committee Rules and Regulations' approved by the Board of Directors on 12/28/16: " ... All verbal orders for medication or treatment shall be reduced to writing in the patient's chart and dated, timed, and signed by such attending, consulting, or substitute physician, within seventy-two (72) hours after such verbal orders are made."

The failure to ensure Patient #3's aforementioned telephone orders was signed by the prescriber was discussed for a final time during a survey team meeting with the facility's Director of Quality and Risk Manager on 3/2/17 at 4:30PM; no additional information related to this issue was provided to the survey team.