HospitalInspections.org

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Based on observations, interviews and record reviews the facility failed to ensure patients' rights were protected and promoted in accordance's to the Condition of Participation: CFR 482.13 Patient's Rights. Findings:


The facility failed to ensure a restraint was only used when less restrictive interventions had been determined to be ineffective. Referenced at citation A-164.


The facility failed to ensure the type of restraint used was the least restrictive intervention that would be effective to protect the patient and/or staff from harm. Referenced at citation A-165.


The facility failed to ensure the use of a restraint was in accordance with a written modification in the patient's plan of care. Reference at citation A-166.


The facility failed to ensure the use of a manual restraint was conducted in a manner that was approved and safe. Reference at citation A-167.


The facility failed to ensure an order by a physician or licensed practitioner was obtained for the use of the manual restraint. Reference at citation A-168.


The facility failed to ensure the attending physician was consulted as soon as possible for the use of a manual restraint when the physician did not order the restraint. Reference at citation A-170.


The facility failed to ensure a face-to-face evaluation was conducted after the use of a manual restraint. Reference at citation A-179.


The facility failed to ensure a manual restraint was documented in the patients' medical record when used. Reference at citation A-185.



The facility failed to ensure alternatives and less restrictive interventions that were not effective were documented in the patients' medical record before the manual restraint was used. Reference at citation A-186.


The facility failed to ensure the patients response to the manual restraint was documented in the medical record including the reasoning for the restraint. Reference at citation A-188.

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Based on record review, interview, and document review, the facility failed to ensure that less restrictive intervention was not effective before the use of manual restraint for 1 patient (#1) out of 11 sampled patients. This failed practice placed the Patient at risks of harm, inappropriate care and psychological effects. Findings:


Record review from 9/3-18/20 of the medical record dated 8/5/20, revealed Patient #1 was brought to Emergency Department (ED) from home due to pain after fall. Patient has history of "recurrent falls, recent left hip fracture with intramedullary nailing, dementia . . . depression and chronic pain."


The medical record also revealed Patient #1 was "fighting all cares, moaning and gesturing to left hip", prior to receiving 50 mcg Fentanyl. Patient #1 "speaks Korean only but due to [his/her] dementia [,] [he/she was] not able to communicate by speech."


Further review of the medical record revealed, Patient #1 "had an in-house hospital fall . . . which resulted in a distal femoral shaft fracture." Patient #1 had "cognitive deficits," "Hard of Hearing" and had a Dx [diagnosis] [of] "Dementia."


Review of Physician's "Operative Report" dated 8/14/20 revealed Patient #1 had open reduction and internal fixation (a surgical implementation of implants for the purpose of repairing a bone) on 8/14/20 and Hemovac drain (used to remove fluids that build up in an area of the body after surgery) was in place.


Review of Physician's "Progress Note" dated 8/15/20, revealed "It is difficult to assess [Patient's] true mental status . . . suspect [s] . . . some degree of AMS [altered mental status] or delirium postoperatively. . . daughter . . . concern for some altered behavior however agrees that it may be postoperative . . . state[s] that the patient has never had similar postoperative symptoms."


Review of "Progress Note" further revealed physician's "assessment and plan . . . E-sitter and judicious pain meds [medication] . . . altered mental status . . . likely from anesthesia and pain meds in the last day . . .supportive care . . . limit mind affecting pain meds as possible"

Record review of medical record on 9/13-18/20, revealed Nurse's "Plan of Care" dated 8/15/20 signed by Licensed Nurse (LN #1), stated Patient #1 "complaint of pain to LLE[left lower extremity], PRN[as needed] Norco (HYDROcodone-acetamenophen) 1 tab 5/325 mg given with relief and schedule Tylenol"


Record Review on 9/17/20 of Medication Administration Record (MAR) dated from 8/13-16/20, revealed HYDROcodone-acetamenophen (NORCO) 5-325 mg per tablet 1-2 tablet, frequency every 8 hours PRN for pain was given at 8/14/20 at "2200 (1 tablet)." There was no entry of NORCO being administered in the MAR thereafter.


Further review of medical record on 9/13-18/20, revealed Nurse's "Plan of Care" dated 8/15/20 signed by LN #2 at 1846, revealed "Pain managed with scheduled Tylenol and Lidocaine patch."


Record Review on 9/17/20 of Medication Administration Record (MAR) dated from 8/13-16/20, revealed Acetaminophen (TYLENOL) tablet 1,000 mg every 8 hours was given on 8/15/20 at "2106 (1,000 mg)." It further revealed Tylenol was not given on 8/16/20.


Further review of the MAR on 9/17/20, revealed Lidocaine (LIDODERM) 5% patch 1 patch daily. The instruction was to apply "for 12 hours, then remove for 12 hours." The patch was due at "2106 (1 patch)."


Review of medical record on 9/13-18/20, the "Esafety Aide Shift Note" dated 8/16/20 signed by Certified Nursing Assistant (CNA #1) at 0632, revealed "Throughout the shift: The patient was verbally redirected 16 times. The primary caregiver was called 6 times. The STAT alarm was activated 0 times."


Review of medical record on 9/13-18/20, the Nurse's "Plan of Care" dated 8/16/20 at 6:30 am signed by LN #3, revealed Patient #1 level of consciousness (LOC) was alert, orientation UTA [unable to assess] due to language barrier, confused, pulling out tubes and lines. Pt [patient] was calm and cooperative when . . . daughter was around at early shift. Slept for a while and wake up very restless, pt [patient] pulled out . . . purewick, and tried to remove . . . drain and dressings. Called daughter to asked [ask]. . . to translate what . . . [Patient #1] wants." Patient #1's daughter stated, "she is confused right now".


Review of plan of care further revealed "non-verbal cues for pain noted, scheduled Tylenol was given at HS".


Record Review on 9/17/20 of Medication Administration Record (MAR) dated from 8/13-16/20, revealed "acetaminophen (Tylenol) tablet 1,000 mg EVERY 8 HOURS Route PO ..." was given on 8/15/20 at 2106.


Record review of medical record on 9/13-18/20, revealed the Nurse's "Plan of Care" dated 8/16/20 signed by LN (#3), stated at "0630: pt [patient] was combative, kicking, biting, staff while changing her brief, needed 3 staff to attend . . . in changing."


Record review on 9/11/20 at 3:40 pm of Providence Quality/Risk Event Reviewer Form dated 8/18/20, revealed CNA #1 emailed his/her supervisor on 8/16/20 which stated the incident happened on 8/15/20 at 06:30 am. "[LN #3] entered patient's room and attempted to change . . . [Patient #1's] brief. Pt. [Patient #1] is non-English speaking . . . and staff were not using interpreter. Pt [Patient #1] was confused and started to combat due to not understanding what was happening. [LN #3] called the second RN [registered nurse], unknown and the PCT [primary care technician] to help hold the patient down. Pt. [Patient #1] tried to fight [LN #3]. [LN #3] pushed the pt.'s [Patient #1] own wrists into . . . [his/her] mouth and told . . . [his/her] to bite it instead. The pt. was still fighting and [LN #3] continued to push the pt's [Patient #1] wrist into . . . [his/her] mouth. The second RN (unknown name) used her knee to hold the pt's [Patient #1] right leg down. The RN (unknown name) continued pinning pt [Patient #1] Down to change. . . [his/her] and climbed on the bed to pin the pt's [Patient #1] arm down to . . . [his/her] chest. The whole time, they started speaking Tagolog and laughing as pt. struggled to be free. [Patient #1] started to yell 'don't do that' in English. The staff refused to acknowledge her and continued to force her down and reapply dressing onto her hemo-vac site. No one seemed to call the interpreter to explain what was happening to pt. [Patient #1]. The RN (LN #3] noted that the interpreter was not called all shift. After they finished changing . . . [his/her], they left the room. At 7:03 am, pt. [Patient #1] Started to yell . . . They made fun of . . . [him/her] and mock . . . [him/her] outside . . . [him/her] room. They continued to laugh . . . The pt. is hard of hearing and confused."


Record review on 9/16-17/20 of the Nurse Manager's (NM) investigation with CNA #1 dated 8/21/20, revealed CNA #1 stated "The Patient needed brief changed and had a hemo-vac . . ." LN #3 called her [for] help due to patient's agitation. The patient became very agitated and tried to hit LN #3, he/she then took the patient's wrist and put the wrist in the patient's mouth . . . then . . . LN #1 had her knee on the patient's leg, then . . . grabbed patient's arms on . . . [his/her] chest . . ."


During an interview with the facility's Program Manager Regulatory Compliance (PMRC) on 9/11/20, she stated that the incident happened on 8/16/20, the telesitter must have wrote the wrong date in the report.


During an interview with CNA #1 on 9/14/20 at 10:50 am, about the incident that happened on 8/16/20, CNA #1 stated on 8/16/20 at 6:30 am he/she was watching the monitor for Patient #1 for fall prevention. He/she had watched patient (Patient #1) couple of times. Patient #1 "had moments being confused". The incident happened after surgery. Staff tried to "change the patient". Patient #1 had been upset.


CNA #1 further stated LN #3 "put hand over patient mouth and stayed there." LN #3 told the patient to bite his/her hand. LN #1 "put her knee" to "put patient down" and continue to "pin" him/her down. LN #1 was holding patient's wrist, while holding down patient's knee. LNs #1 and #3 were speaking Tagalog and laughing. Patient #1 was screaming while changing his/her brief and dressing. The LNs (#1 and #3) were yelling and so was Patient #1. CNA # 3 came in right at the end of it. CNA #1 also stated that Patient #1 had difficulty hearing.


When asked if changing brief was an urgent care need, she responded "No", if patient was aggressive, they could "wing it" then "go back" after 30 minutes to 1 hour.


During an interview with CNA #2 on 9/14/20 at 11:22 am, about the incident that happened on 8/16/20, CNA #2 stated he/she was working with CNA #1 at the monitor studio [Telemetry]. He/she was watching a patient next to Patient #1's room. CNA #2 stated that he/she could hear Patient #1 "screaming all throughout the night", "confused", and "in pain not getting medicine."


CNA #2 further stated, CNA #1 pointed out to her and said, "look at this". They were changing him/her in the "middle of screaming." CNA #2 described that nurses were "frustrated." There were two nurses [LN #1 and #3] helping out and tech [CNA #3] went to room. They were trying to change him/her "holding down." Both nurses were "aggressive". The Primary nurse [LN #3] was "frustrated trying to get her job done."


During an interview with LN #3 on 9/14/20 at 1:59 pm, when asked what to do if patient refused care, LN #3 stated "we don't argue." "We go out and return after few minutes." He/she added if the patient was confused and care was necessary, "we do it for them." He/she further explained they need to do it so pressure ulcer would not develop especially when patient is soiled of stool or urine.


LN #3 gave a scenario when patient refused care by the technician and the patient tried to hit the technician, LN #3 told technician to leave patient alone. Then, LN #3 tried to approach the patient with a low tone, the patient allowed her to change [the brief]. He/she further explained that with the proper tone of voice the patient will participate. Patient would not participate if the tone is high pitched or loud.


When asked about the incident on 8/16/20, LN #3 stated the patient [Patient #1] was Korean and not speaking English. That night Patient #1 was yelling. LN #3 stated he/she did not use narcotic because it makes Patient #1 lethargic. LN #3 further explained that prior to that incident, a nurse [not identified] from surgery gave Patient #1 narcotic which made the patient lethargic.


LN #3 added that on his/her shift, Patient # 1 was alert, confused and yelling. The incident happened at 6:30 am. As per hospital policy, if the patient was confused, they need "to change" [the brief of] the patient because he/she was "soaked with urine." According to LN #3, Patient #1 tried to bite LN #3 and was kicking the technician. So, LN #3 asked the technician to call for help. There were three of them who tried to help Patient #1 to not break Patient #1's bone.


LN #3 further explained "it was a busy night," Patient #1 was yelling, pulling IV, drain and dressing so they were preventing the Patient #1 from doing it. LN #3 also stated he/she needed to change the dressing but had run out of medipore tape. LN #3 asked the other nurse [LN #1] to help so he/she could go get the tape. LN # 1 was holding Patient #1 while LN #3 was "out not even a minute." When LN #3 was changing the brief and dressing, LN #1 was on the right side.


When asked if changing patient's brief was an urgent care need, LN #3 stated it was urgent because it was end of shift. LN #3 explained that a good team was to finish the task and not to pass it on to the next shift. Patient # 1 was soaked so LN #3 was preventing the development of pressure sore, dressing to get soaked, and infection so they made sure the patient was cleaned. LN #3 considered changing the brief as an emergency care need.


LN #3 further explained that if the care was not done, patient would not be happy, they could report them, and other people would think they are abusing the patient.


During the interview with LN #3 on 9/14/20 at 1:59 pm, when asked about pain medication, LN #3 stated he/she followed doctor's order of "no narcotic." There was an order of Tylenol but Patient #1 tried not to take medication. Patient #1 could recognize Tylenol and took it out of the medicine cap. LN #3 stated he/she did not give medication because narcotic can escalate consciousness. When asked if Patient #1 might be in pain the whole night, LN #3 replied "yes."


On 9/14/20 at 1:59 pm, when asked about definition of restraint, LN #3 stated holding the patient to prevent him/her from doing what he/she wants to do. LN #3 stated that they did not meant any harm to the patient. He/she explained that Patient #1 was hard of hearing and didn't understand so use of low tone would not work. If the Patient #1 was able to understand, they would not have had any issue.


During an interview with LN #1 on 9/15/20 at 9:05 am, when asked if they had ever had a patient who refused care and what they would do if a patient refused care, LN #1 stated "yes", if patient refused care, she would "explain type of care" to the patient and "reorient the patient . . ." LN #1 further explained that if the patient was still refusing care, "it is not a big deal" if it will not compromise the condition of the patient, LN #1 would "wait for few hours, then asked the patient again."


During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about the incident with Patient #1 on 8/16/20, LN #1 stated Patient #1 was not his/her patient at that time. LN #1 described that Patient #1 "was combative, confused and hard of hearing." LN #1 stated LN #3 asked for her help because Patient #1 urinated and they were changing her brief. CNA #3 was not there, CNA #3 was with other patient. LNs (#1 and #3) waited for CNA #3 for few minutes but CNA #3 was still with other patient. Patient #1's brief was already removed so they changed the brief. Patient #1 "was combative," so LN #1 told LN #3 they would "hold" Patient #1's hand while LN #3 cleaned Patient #1. LN #1 also stated that Patient #1 was "soaked with [urine] up the back." LN #3 also changed the dressing. LN #1 stated if the dressing was not changed, the patient would be prone to infection and they don't want that to happen.


LN #1 stated they always log roll the patient with broken leg or hip using bedsheet or pad. LN #3 was on Patient #'s left side. They turned the patient towards LN #1 first but not all the way about "35 degrees" angle to "insert [brief]," then they turned Patient #1 towards LN #3 but not all the way about '"20 degrees" angle to "pull [brief]." They don't want to break Patient #1's bone and go to surgery because of wrong turn.


LN #1 stated he/she was "holding" Patient #1's two arms "with her left hand but not really tight" because Patient #1 was "old and bones are fragile."

When asked if he/she was in the room the whole time, LN #1 stated "Yes." He/she came in at the middle of the process and was in the room the whole time, LN #3 left the room for "not even a minute" to get supplies. CNA #3 came back when they were done.



During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about definition of restraint, LN #1 stated . . . physical was for violent and non-violent. Violent restraint is used when patient was pulling IV (intravenous), NGT (nasogastric tube), and catheter . . . LN #1 also stated they "use wrist restraint" so patient could "not harm himself" and "other" or "pull catheter and IV." They use device . . . for wrist and ankle so patient will not get hurt. For non-violent restraint, LN #1 stated they "use mitten so patients could not scratch themselves."


Surveyor asked LN #1 if holding needs to be done when patient wants to get out of bed, hit a nurse or hurt others, LN #1 stated he/she would "redirect" the patient. If the patient was confused or combative he/she would asked for help, stay with the patient but not to put down the patient.


When asked about holding Patient #1, LN #1 stated they were "just doing the right acceptable pressure, . . . it was done very quickly because they need to log roll" Patient (#1). LN #1 taught it was the "best thing to do" that time. He/she "did not consider it as a restraint" because "they did it to keep the patient from hurting them."


Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA # 2 dated on 8/20/20, revealed CNA #2 stated "The patient arms were on . . . [his/her] chest they had use physical force, yeah it was a little aggressive, it was rough, the patient was unable to move, the patient was so agitated, they were trying to change . . . [Patient #1] and get the job done."


Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA #3 dated on 8/20/20, revealed CNA #3 stated "Yes, we changed her . . . We wanted to change the patient's brief, but she's kicking and biting . . . very combative . . . LN #3 was on one side of bed, LN #1 on the other side. . . We had to hold her down, we hold her like this, LN #1 put her leg on the bed so that the patient
wouldn't kick us . . ., but didn't put her leg on the patient. . . LN #3 and LN #1 were holding . . . [Patient #1] arms and legs while we were changing . . ."


Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #1 dated on 8/21/20, revealed LN #1 stated LN #3 asked her help to change Patient's brief because he/she was soaked. Patient #1 was combative and hitting them both. LN #1 stated he/she "could not hold both patient's arm with one hand". LN #3 was "holding one hand" and LN #1 was "holding the right leg". LN #1 put her "knee on the bed for self-defense" so they "could change . . . [Patient]".


Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #3 dated on 8/21/20, revealed LN #3 stated he/she and CNA #3 were "changing . . . [Patient's brief]" and asked LN #1 to help. He/she was holding the . . . [Patient's] hands. Patient was kicking CNA #3 while he/she was "trying to take Patient's brief." LN #1 was "holding the Patient's leg." When asked by Nurse Manager if LN #3 used excessive physical force to restrain the patient while providing care, LN #3 replied "Just enough for patient not to hurt me or bite my hand."


During an interview with the Nurse Manager (NM) on 9/10/20 at 2:45 pm, when asked about managing dementia patients, he stated they were concerned about safety and risk for fall. If the patient became violent, caregiver leaves the room. Caregivers also should ensure their own safety, protect themselves and recognize their vulnerability then return to the patient when he/she is no longer violent.


During an interview on 9/15/20 from 4:15- 5:00 pm, with NM, stated he investigated the incident with Patient #1. During the investigation the NM stated the Patient was hard of hearing, spoke Korean as the primary language, and was confused. The NM further stated any patient has the right to refuse care. The NM stated during the investigation he found no translator was used by staff when working with the patient that shift. The NM, when asked if a wet undergarment was an emergency that would require a manual hold, he stated it was not an emergency. He further stated holding the patient as LN #1 and 3 did would be a restraint no matter the length of time of the hold without the consent of the patient.


The NM stated the expectations would be the staff step back, ask for help, have other staff approach the patient, see what needs the patient might have that aren't being met to cause the behaviors.


Record review of the medical record from 9/3-18/20, revealed there was no documentation showing a least restrictive intervention had been tried and was not effective.


Review of the facility's "Restraint Management" policy on 9/4/20 at 9:45 am, revealed restraint is defined as "any manual method, physical or mechanical device . . . that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely."


The policy also defined "Non-violent, Non self-destructive Restraint: Restraint used when the patient is demonstrating behavior that is interfering with treatment (pulling on or reaching for lines, tubes, drains, dressings . . .)" and "Violent or Self-Destructive Restraint: Restraint used to restrict patient movement due to severely aggressive, destructive, violent . . . that places the patient or others in imminent danger when non-physical interventions are not effective. The goal of the restraint is to keep the patient and others physically safe in an emergent situation."


Document review on 9/4/20 at 9:45 am of the facility's "Restraint Management" policy dated 12/2019, revealed less restrictive means is a "method that restricts the patient's movement the least (e.g. A mitt is less restrictive than a two-point wrist restraint)."


The policy further stated "At all times, the least restrictive intervention for the safety of the patient is used. The following is a list of restraint types used at PAMC (Providence Alaska Medical Center) from less restrictive to most restrictive . . . Four side rails, Mitts, Secure Sleeve Protector, Posey bed, Posey vest, Omni belt . . . Soft limb, Spit hood, Posey twice as tough cuff."


Document review on 9/17/20 of facility's Restraint Management training, revealed in both non-violent and violent restraints, "Alternatives must be attempted first . . . and deemed ineffective before a restraint is initiated.


According to American Nurse Official Journal ANA. "When and how to use restraints". 2015. Accessed at https://www.myamericannurse.com/use-restraints/, revealed "use restraints only as a last resort, after attempting or exploring alternatives. Alternatives include having staff . . . sit with the patient, using distraction or de-escalation strategies, offering reassurance, using bed or chair alarms, and administering certain medications." It further revealed that "If appropriate alternatives have been attempted or considered but have proven insufficient or ineffective or are deemed potentially unsuccessful, restraint may be appropriate. A provider order must be obtained for patient restraint."


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Based on record review, interview, and document review the facility failed to ensure that less restrictive interventions were used before restraint implementation for 1 patient (#1) out of 11 sampled patients. This failed practice placed the Patient at risks of harm, inappropriate care and psychological effects. Findings:

Record review from 9/3-18/20 of the medical record dated 8/5/20, revealed Patient #1 was brought to Emergency Department (ED) from home due to pain after fall. Patient has history of "recurrent falls, recent left hip fracture with intramedullary nailing, dementia . . . depression and chronic pain."

Further review of the medical record revealed, Patient #1 "had an in-house hospital fall. . . which resulted in a distal femoral shaft fracture." Patient #1 had "cognitive deficits," "Hard of Hearing" and had a Dx [diagnosis] [of] "Dementia."

Review of medical record on 9/13-18/20, the Nurse's "Plan of Care" dated 8/16/20 at 6:30 am signed by LN #3, revealed Patient #1 level of consciousness (LOC) was alert, orientation UTA [unable to assess] due to language barrier, confused, pulling out tubes and lines. Pt [patient] was calm and cooperative when . . . daughter was around at early shift. Slept for a while and wake up very restless, pt [patient] pulled out . . . purewick, and tried to remove . . . drain and dressings. Called daughter to asked [ask]. . . to translate what . . . [Patient #1] wants." Patient #1's daughter stated, "she is confused right now".

Record review of medical record on 9/13-18/20, revealed the Nurse's "Plan of Care" dated 8/16/20 signed by LN (#3), stated at "0630: pt [patient] was combative, kicking, biting, staff while changing her brief, needed 3 staff to attend . . . in changing."

Record review on 9/11/20 at 3:40 pm of Providence Quality/Risk Event Reviewer Form dated 8/18/20, revealed CNA #1 emailed his/her supervisor on 8/16/20 which stated the incident happened on 8/15/20 at 06:30 am. "[LN #3] entered patient's room and attempted to change . . . [Patient #1's] brief. Pt. [Patient #1] is non-English speaking . . . and staff were not using interpreter. Pt [Patient #1] was confused and started to combat due to not understanding what was happening. [LN #3] called the second RN [registered nurse], unknown and the PCT [primary care technician] to help hold the patient down. Pt. [Patient #1] tried to fight [LN #3]. [LN #3] pushed the pt.'s [Patient #1] own wrists into . . . [his/her] mouth and told . . . [his/her] to bite it instead. The pt. was still fighting and [LN #3] continued to push the pt's [Patient #1] wrist into . . . [his/her] mouth. The second RN (unknown name) used her knee to hold the pt's [Patient #1] right leg down. The RN (unknown name) continued pinning pt [Patient #1] Down to change. . . [his/her] and climbed on the bed to pin the pt's [Patient #1] arm down to . . . [his/her] chest. The whole time, they started speaking Tagolog and laughing as pt. struggled to be free. [Patient #1] started to yell 'don't do that' in English. The staff refused to acknowledge her and continued to force her down and reapply dressing onto her hemo-vac site. No one seemed to call the interpreter to explain what was happening to pt. [Patient #1]. The RN (LN #3] noted that the interpreter was not called all shift. After they finished changing . . . [his/her], they left the room. At 7:03 am, pt. [Patient #1] Started to yell . . . They made fun of . . . [him/her] and mock . . . [him/her] outside . . . [him/her] room. They continued to laugh . . . The pt. is hard of hearing and confused."

Record review on 9/16-17/20 of the Nurse Manager's (NM) investigation with CNA #1 dated 8/21/20, revealed CNA #1 stated "The Patient needed brief changed and had a hemo-vac . . ." LN #3 called her [for] help due to patient's agitation. The patient became very agitated and tried to hit LN #3, he/she then took the patient's wrist and put the wrist in the patient's mouth . . . then . . . LN #1 had her knee on the patient's leg, then . . . grabbed patient's arms on . . . [his/her] chest . . ."

During an interview with CNA #1 on 9/14/20 at 10:50 am, about the incident that happened on 8/16/20, CNA #1 stated on 8/16/20 at 6:30 am he/she was watching the monitor for Patient #1 for fall prevention. He/she had watched patient (Patient #1) couple of times. Patient #1 "had moments being confused". The incident happened after surgery. Staff tried to "change the patient". Patient #1 had been upset.

CNA #1 further stated LN #3 "put hand over patient mouth and stayed there." LN #3 told the patient to bite his/her hand. LN #1 "put her knee" to "put patient down" and continue to "pin" him/her down. LN #1 was holding patient's wrist, while holding down patient's knee. LNs #1 and #3 were speaking Tagalog and laughing. Patient #1 was screaming while changing his/her brief and dressing. The LNs (#1 and #3) were yelling and so was Patient #1. CNA # 3 came in right at the end of it. CNA #1 also stated that Patient #1 had difficulty hearing.

When asked if changing brief was an urgent care need, she responded "No", if patient was aggressive, they could "wing it" then "go back" after 30 minutes to 1 hour.

During an interview with CNA #2 on 9/14/20 at 11:22 am, about the incident that happened on 8/16/20, CNA #2 stated he/she was working with CNA #1 at the monitor studio [Telemetry]. He/she was watching a patient next to Patient #1's room. CNA #2 stated that he/she could hear Patient #1 "screaming all throughout the night", "confused", and "in pain not getting medicine."

CNA #2 further stated, CNA #1 pointed out to her and said, "look at this". They were changing him/her in the "middle of screaming." CNA #2 described that nurses were "frustrated." There were two nurses [LN #1 and #3] helping out and tech [CNA #3] went to room. They were trying to change him/her "holding down." Both nurses were "aggressive". The Primary nurse [LN #3] was "frustrated trying to get her job done."

During an interview with LN #3 on 9/14/20 at 1:59 pm, when asked about the event involving Patient #1, LN #3 further explained "it was a busy night," Patient #1 was yelling, pulling IV, drain and dressing so they were preventing the Patient #1 from doing it. LN #3 also stated he/she needed to change the dressing but had run out of medipore tape. LN #3 asked the other nurse [LN #1] to help so he/she could go get the tape. LN # 1 was holding Patient #1 while LN #3 was "out not even a minute." When LN #3 was changing the brief and dressing, LN #1 was on the right side.

When asked if changing patient's brief was an urgent care need, LN #3 stated it was urgent because it was end of shift. LN #3 explained that a good team was to finish the task and not to pass it on to the next shift. Patient # 1 was soaked so LN #3 was preventing the development of pressure sore, dressing to get soaked, and infection so they made sure the patient was cleaned. LN #3 considered changing the brief as an emergency care need.

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about the incident with Patient #1 on 8/16/20, LN #1 stated Patient #1 was not his/her patient at that time. LN #1 described that Patient #1 "was combative, confused and hard of hearing." LN #1 stated LN #3 asked for her help because Patient #1 urinated and they were changing her brief. CNA #3 was not there; CNA #3 was with another patient. LNs (#1 and #3) waited for CNA #3 for few minutes but CNA #3 was still with other patient. Patient #1's brief was already removed so they changed the brief. Patient #1 "was combative," so LN #1 told LN #3 they would "hold" Patient #1's hand while LN #3 cleaned Patient #1. LN #1 also stated that Patient #1 was "soaked with [urine] up the back." LN #3 also changed the dressing. LN #1 stated if the dressing was not changed, the patient would be prone to infection and they don't want that to happen.

LN #1 stated he/she was "holding" Patient #1's two arms "with her left hand but not really tight" because Patient #1 was "old and bones are fragile."

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about definition of restraint, LN #1 stated . . . physical was for violent and non-violent. Violent restraint is used when patient was pulling IV (intravenous), NGT (nasogastric tube), and catheter . . . LN #1 also stated they "use wrist restraint" so patient could "not harm himself" and "other" or "pull catheter and IV." They use device . . . for wrist and ankle so patient will not get hurt. For non-violent restraint, LN #1 stated they "use mitten so patients could not scratch themselves."

When asked about holding Patient #1, LN #1 stated they were "just doing the right acceptable pressure, . . . it was done very quickly because they need to log roll" Patient (#1). LN #1 taught it was the "best thing to do" that time. He/she "did not consider it as a restraint" because "they did it to keep the patient from hurting them."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA # 2 dated on 8/20/20, revealed CNA #2 stated "The patient arms were on . . . [his/her] chest they had use physical force, yeah it was a little aggressive, it was rough, the patient was unable to move, the patient was so agitated, they were trying to change . . . [Patient #1] and get the job done."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA #3 dated on 8/20/20, revealed CNA #3 stated "Yes, we changed her . . . We wanted to change the patient's brief, but she's kicking and biting . . . very combative . . . LN #3 was on one side of bed, LN #1 on the other side. . . We had to hold her down, we hold her like this, LN #1 put her leg on the bed so that the patient
wouldn't kick us . . ., but didn't put her leg on the patient. . . LN #3 and LN #1 were holding . . . [Patient #1] arms and legs while we were changing . . ."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #1 dated on 8/21/20, revealed LN #1 stated LN #3 asked her help to change Patient's brief because he/she was soaked. Patient #1 was combative and hitting them both. LN #1 stated he/she "could not hold both patient's arm with one hand". LN #3 was "holding one hand" and LN #1 was "holding the right leg". LN #1 put her "knee on the bed for self-defense" so they "could change . . . [Patient]".

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #3 dated on 8/21/20, revealed LN #3 stated he/she and CNA #3 were "changing . . . [Patient's brief]" and asked LN #1 to help. He/she was holding the . . . [Patient's] hands. Patient was kicking CNA #3 while he/she was "trying to take Patient's brief." LN #1 was "holding the Patient's leg." When asked by Nurse Manager if LN #3 used excessive physical force to restrain the patient while providing care, LN #3 replied "Just enough for patient not to hurt me or bite my hand."

Record review of the medical record from 9/3-18/20, there was no documentation showing a least restrictive intervention was used to manage Patient #1's pain and aggression.

Review of Providence Hospital's "Restraint Management" policy on 9/4/20 at 9:45 am, revealed restraint is defined as "any a manual method, physical or mechanical device . . . that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely."

The policy also defined "Non-violent, Non self-destructive Restraint: Restraint used when the patient is demonstrating behavior that is interfering with treatment (pulling on or reaching for lines, tubes, drains, dressings . . .)" and "Violent or Self-Destructive Restraint: Restraint used to restrict patient movement due to severely aggressive, destructive, violent . . . that places the patient or others in imminent danger when non-physical interventions are not effective. The goal of the restraint is to keep the patient and others physically safe in an emergent situation."

Review of Providence Hospital Restraint Management policy dated 12/2019, revealed less restrictive means is a "method that restricts the patient's movement the least (e.g. A mitt is less restrictive than a two-point wrist restraint)."

The policy further stated "At all times, the least restrictive intervention for the safety of the patient is used. The following is a list of restraint types used at PAMC (Providence Alaska Medical Center) from less restrictive to most restrictive . . . Four side rails, Mitts, Secure Sleeve Protector, Posey bed, Posey vest, Omni belt . . . Soft limb, Spit hood, Posey twice as tough cuff."

Document review on 9/17/20 of the facility's Restraint Management training, to avoid the use of violent restraint, "Understand the signs of impending aggression and escalation", "medicate early offer meds [medication] to reduce anxiety/agitation before the person escalates."

Document review on 9/17/20 of facility's Restraint Management training revealed, "Alternatives must be attempted first . . ."


According to American Nurse Official Journal ANA. "When and how to use restraints". 2015. Accessed at https://www.myamericannurse.com/use-restraints/, revealed "use restraints only as a last resort, after attempting or exploring alternatives. Alternatives include having staff . . . sit with the patient, using distraction or de-escalation strategies, offering reassurance, using bed or chair alarms, and administering certain medications." It further revealed that "If appropriate alternatives have been attempted or considered but have proven insufficient or ineffective or are deemed potentially unsuccessful, restraint may be appropriate. A provider order must be obtained for patient restraint. . . update and revise the care plan for a restrained patient to help find ways to reduce the restraint period and prevent further restraint episodes."

According to American Medical Association (AMA) "Use of Restraints". Accessed on 9/18/10 at https://www.ama-assn.org/delivering-care/ethics/use-restraints revealed "All individuals have a fundamental right to be free from unreasonable bodily restraint. . . when a patient poses a significant danger to self or others, it may be appropriate to restrain the patient involuntarily. In such situations, the least restrictive restraint reasonable should be implemented. . ."


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Based on record review, interview, and document review, the facility failed to ensure the use of restraint for 1 patient (#1) out of 11 sampled patients was in accordance with a written modification to the patient's plan of care. This failed practice placed the Patient at risks of harm, inappropriate care and evaluation. Findings:

Record review from 9/3-18/20 of the medical record dated 8/5/20, revealed Patient #1 was brought to Emergency Department (ED) from home due to pain after fall. Patient has history of "recurrent falls, recent left hip fracture with intramedullary nailing, dementia . . . depression and chronic pain."

The medical record also revealed Patient #1 was "fighting all cares, moaning and gesturing to left hip", prior to receiving 50 mcg Fentanyl. Patient #1 "speaks Korean only but due to [his/her] dementia [,] [he/she was] not able to communicate by speech."

Further review of the medical record revealed, Patient #1 "had an in-house hospital fall. . . which resulted in a distal femoral shaft fracture." Patient #1 had "cognitive deficits," "Hard of Hearing" and had a Dx [diagnosis] [of] "Dementia."

Review of Physician's "Operative Report" dated 8/14/20 revealed Patient #1 had open reduction and internal fixation (a surgical implementation of implants for the purpose of repairing a bone) on 8/14/20 and Hemovac drain (used to remove fluids that build up in an area of the body after surgery) was in place.

Review of Physician's "Progress Note" dated 8/15/20, revealed "It is difficult to assess [Patient's] true mental status . . . suspect [s] . . . some degree of AMS [altered mental status] or delirium postoperatively. . . daughter . . . concern for some altered behavior however agrees that it may be postoperative . . . state[s] that the patient has never had similar postoperative symptoms."

Review of "Progress Note" further revealed physician's "assessment and plan . . . E-sitter and judicious pain meds [medication] . . . altered mental status . . . likely from anesthesia and pain meds in the last day . . .supportive care . . . limit mind affecting pain meds as possible"

Record review of medical record on 9/13-18/20, revealed Nurse's "Plan of Care" dated 8/15/20 signed by Licensed Nurse (LN #1), stated Patient #1 "complaint of pain to LLE[left lower extremity], PRN[as needed] Norco (HYDROcodone-acetamenophen) 1 tab 5/325 mg given with relief and schedule Tylenol"

Record Review on 9/17/20 of Medication Administration Record (MAR) dated from 8/13-16/20, revealed HYDROcodone-acetamenophen (NORCO) 5-325 mg per tablet 1-2 tablet, frequency every 8 hours PRN for pain was given at 8/14/20 at "2200 (1 tablet)." There was no entry of NORCO being administered in the MAR thereafter.

Further review of medical record on 9/13-18/20, revealed Nurse's "Plan of Care" dated 8/15/20 signed by LN #2 at 1846, revealed "Pain managed with scheduled Tylenol and Lidocaine patch."

Record Review on 9/17/20 of Medication Administration Record (MAR) dated from 8/13-16/20, revealed Acetaminophen (TYLENOL) tablet 1,000 mg every 8 hours was given on 8/15/20 at "2106 (1,000 mg)." It further revealed Tylenol was not given on 8/16/20.

Further review of the MAR on 9/17/20, revealed Lidocaine (LIDODERM) 5% patch 1 patch daily. The instruction was to apply "for 12 hours, then remove for 12 hours." The patch was due at "2106 (1 patch)."

Review of medical record on 9/13-18/20, the "Esafety Aide Shift Note" dated 8/16/20 signed by Certified Nursing Assistant (CNA #1) at 0632, revealed "Throughout the shift: The patient was verbally redirected 16 times. The primary caregiver was called 6 times. The STAT alarm was activated 0 times."

Review of medical record on 9/13-18/20, the Nurse's "Plan of Care" dated 8/16/20 at 6:30 am signed by LN #3, revealed Patient #1 level of consciousness (LOC) was alert, orientation UTA [unable to assess] due to language barrier, confused, pulling out tubes and lines. Pt [patient] was calm and cooperative when . . . daughter was around at early shift. Slept for a while and wake up very restless, pt [patient] pulled out . . . purewick, and tried to remove . . . drain and dressings. Called daughter to asked [ask]. . . to translate what . . . [Patient #1] wants." Patient #1's daughter stated, "she is confused right now".

Review of plan of care further revealed "non-verbal cues for pain noted, scheduled Tylenol was given at HS"

Record Review on 9/17/20 of Medication Administration Record (MAR) dated from 8/13-16/20, revealed "acetaminophen (Tylenol) tablet 1,000 mg EVERY 8 HOURS Route PO ..." was given on 8/15/20 at 2106.

Record review of medical record on 9/13-18/20, revealed the Nurse's "Plan of Care" dated 8/16/20 signed by LN (#3), stated at "0630: pt [patient] was combative, kicking, biting, staff while changing her brief, needed 3 staff to attend . . . in changing."

Record review on 9/11/20 at 3:40 pm of Providence Quality/Risk Event Reviewer Form dated 8/18/20, revealed CNA #1 emailed his/her supervisor on 8/16/20 which stated the incident happened on 8/15/20 at 06:30 am. "[LN #3] entered patient's room and attempted to change . . . [Patient #1's] brief. Pt. [Patient #1] is non-English speaking . . . and staff were not using interpreter. Pt [Patient #1] was confused and started to combat due to not understanding what was happening. [LN #3] called the second RN [registered nurse], unknown and the PCT [primary care technician] to help hold the patient down. Pt. [Patient #1] tried to fight [LN #3]. [LN #3] pushed the pt.'s [Patient #1] own wrists into . . . [his/her] mouth and told . . . [his/her] to bite it instead. The pt. was still fighting and [LN #3] continued to push the pt's [Patient #1] wrist into . . . [his/her] mouth. The second RN (unknown name) used her knee to hold the pt's [Patient #1] right leg down. The RN (unknown name) continued pinning pt [Patient #1] Down to change. . . [his/her] and climbed on the bed to pin the pt's [Patient #1] arm down to . . . [his/her] chest. The whole time, they started speaking Tagolog and laughing as pt. struggled to be free. [Patient #1] started to yell 'don't do that' in English. The staff refused to acknowledge her and continued to force her down and reapply dressing onto her hemo-vac site. No one seemed to call the interpreter to explain what was happening to pt. [Patient #1]. The RN (LN #3] noted that the interpreter was not called all shift. After they finished changing . . . [his/her], they left the room. At 7:03 am, pt. [Patient #1] Started to yell . . . They made fun of . . . [him/her] and mock . . . [him/her] outside . . . [him/her] room. They continued to laugh . . . The pt. is hard of hearing and confused."

Record review on 9/16-17/20 of the Nurse Manager's (NM) investigation with CNA #1 dated 8/21/20, revealed CNA #1 stated "The Patient needed brief changed and had a hemo-vac . . ." LN #3 called her [for] help due to patient's agitation. The patient became very agitated and tried to hit LN #3, he/she then took the patient's wrist and put the wrist in the patient's mouth . . . then . . . LN #1 had her knee on the patient's leg, then . . . grabbed patient's arms on . . . [his/her] chest . . ."

During an interview with the facility's Program Manager Regulatory Compliance (PMRC) on 9/11/20, she stated that the incident happened on 8/16/20, the telesitter must have wrote the wrong date in the report.

During an interview with CNA #1 on 9/14/20 at 10:50 am, about the incident that happened on 8/16/20, CNA #1 stated on 8/16/20 at 6:30 am he/she was watching the monitor for Patient #1 for fall prevention. He/she had watched patient (Patient #1) couple of times. Patient #1 "had moments being confused". The incident happened after surgery. Staff tried to "change the patient". Patient #1 had been upset.

CNA #1 further stated LN #3 "put hand over patient mouth and stayed there." LN #3 told the patient to bite his/her hand. LN #1 "put her knee" to "put patient down" and continue to "pin" him/her down. LN #1 was holding patient's wrist, while holding down patient's knee. LNs #1 and #3 were speaking Tagalog and laughing. Patient #1 was screaming while changing his/her brief and dressing. The LNs (#1 and #3) were yelling and so was Patient #1. CNA #3 came in right at the end of it. CNA #1 also stated that Patient #1 had difficulty hearing.

When asked if changing brief was an urgent care need, she responded "No", if patient was aggressive, they could "wing it" then "go back" after 30 minutes to 1 hour.

During an interview with CNA #2 on 9/14/20 at 11:22 am, about the incident that happened on 8/16/20, CNA #2 stated he/she was working with CNA #1 at the monitor studio [Telemetry]. He/she was watching a patient next to Patient #1's room. CNA #2 stated that he/she could hear Patient #1 "screaming all throughout the night", "confused", and "in pain not getting medicine."

CNA #2 further stated, CNA #1 pointed out to her and said, "look at this". They were changing him/her in the "middle of screaming." CNA #2 described that nurses were "frustrated." There were two nurses [LN #1 and #3] helping out and tech [CNA #3] went to room. They were trying to change him/her "holding down." Both nurses were "aggressive". The Primary nurse [LN #3] was "frustrated trying to get her job done."

During an interview with LN #3 on 9/14/20 at 1:59 pm, when asked what to do if patient refused care, LN #3 stated "we don't argue." "We go out and return after few minutes." He/she added if the patient was confused and care was necessary, "we do it for them." He/she further explained they need to do it so pressure ulcer would not develop especially when patient is soiled of stool or urine.

LN #3 gave a scenario when patient refused care by the technician and the patient tried to hit the technician, LN #3 told technician to leave patient alone. Then, LN #3 tried to approach the patient with a low tone, the patient allowed her to change [the brief]. He/she further explained that with the proper tone of voice the patient will participate. Patient would not participate if the tone is high pitched or loud.

When asked about the incident on 8/16/20, LN #3 stated the patient [Patient #1] was Korean and not speaking English. That night Patient #1 was yelling. LN #3 stated he/she did not use narcotic because it makes Patient #1 lethargic. LN #3 further explained that prior to that incident, a nurse [not identified] from surgery gave Patient #1 narcotic which made the patient lethargic.

LN #3 added that on his/her shift, Patient # 1 was alert, confused and yelling. The incident happened at 6:30 am. As per hospital policy, if the patient was confused, they need "to change" [the brief of] the patient because he/she was "soaked with urine." According to LN #3, Patient #1 tried to bite LN #3 and was kicking the technician. So, LN #3 asked the technician to call for help. There were three of them who tried to help Patient #1 to not break Patient #1's bone.

LN #3 further explained "it was a busy night," Patient #1 was yelling, pulling IV, drain and dressing so they were preventing the Patient #1 from doing it. LN #3 also stated he/she needed to change the dressing but had run out of medipore tape. LN #3 asked the other nurse [LN #1] to help so he/she could go get the tape. LN # 1 was holding Patient #1 while LN #3 was "out not even a minute." When LN #3 was changing the brief and dressing, LN #1 was on the right side.

When asked if changing patient's brief was an urgent care need, LN #3 stated it was urgent because it was end of shift. LN #3 explained that a good team was to finish the task and not to pass it on to the next shift. Patient # 1 was soaked so LN #3 was preventing the development of pressure sore, dressing to get soaked, and infection so they made sure the patient was cleaned. LN #3 considered changing the brief as an emergency care need.

LN #3 further explained that if the care was not done, patient would not be happy, they could report them, and other people would think they are abusing the patient.

During the interview with LN #3 on 9/14/20 at 1:59 pm, when asked about pain medication, LN #3 stated he/she followed doctor's order of "no narcotic." There was an order of Tylenol, but Patient #1 tried not to take medication. Patient #1 could recognize Tylenol and took it out of the medicine cap. LN #3 stated he/she did not give medication because narcotic can escalate consciousness. When asked if Patient #1 might be in pain the whole night, LN #3 replied "yes."

On 9/14/20 at 1:59 pm, when asked about definition of restraint, LN #3 stated holding the patient to prevent him/her from doing what he/she wants to do. LN #3 stated that they did not meant any harm to the patient. He/she explained that Patient #1 was hard of hearing and didn't understand so use of low tone would not work. If the Patient #1 was able to understand, they would not have had any issue.

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked if they had ever had a patient who refused care and what they would do if a patient refused care, LN #1 stated "yes", if patient refused care, she would "explain type of care" to the patient and "reorient the patient . . ." LN #1 further explained that if the patient was still refusing care, "it is not a big deal" if it will not compromise the condition of the patient, LN #1 would "wait for few hours, then asked the patient again."

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about the incident with Patient #1 on 8/16/20, LN #1 stated Patient #1 was not his/her patient at that time. LN #1 described that Patient #1 "was combative, confused and hard of hearing." LN #1 stated LN #3 asked for her help because Patient #1 urinated and they were changing her brief. CNA #3 was not there; CNA #3 was with another patient. LNs (#1 and #3) waited for CNA #3 for few minutes but CNA #3 was still with other patient. Patient #1's brief was already removed so they changed the brief. Patient #1 "was combative," so LN #1 told LN #3 they would "hold" Patient #1's hand while LN #3 cleaned Patient #1. LN #1 also stated that Patient #1 was "soaked with [urine] up the back." LN #3 also changed the dressing. LN #1 stated if the dressing was not changed, the patient would be prone to infection and they don't want that to happen.

LN #1 stated they always log roll the patient with broken leg or hip using bedsheet or pad. LN #3 was on Patient #'s left side. They turned the patient towards LN #1 first but not all the way about "35 degrees" angle to "insert [brief]," then they turned Patient #1 towards LN #3 but not all the way about '"20 degrees" angle to "pull [brief]." They don't want to break Patient #1's bone and go to surgery because of wrong turn.

LN #1 stated he/she was "holding" Patient #1's two arms "with her left hand but not really tight" because Patient #1 was "old and bones are fragile."

When asked if he/she was in the room the whole time, LN #1 stated "Yes." He/she came in at the middle of the process and was in the room the whole time, LN #3 left the room for "not even a minute" to get supplies. CNA #3 came back when they were done.

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about definition of restraint, LN #1 stated . . . physical was for violent and non-violent. Violent restraint is used when patient was pulling IV (intravenous), NGT (nasogastric tube), and catheter . . . LN #1 also stated they "use wrist restraint" so patient could "not harm himself" and "other" or "pull catheter and IV." They use device . . . for wrist and ankle so patient will not get hurt. For non-violent restraint, LN #1 stated they "use mitten so patients could not scratch themselves."

Surveyor asked LN #1 if holding needs to be done when patient wants to get out of bed, hit a nurse or hurt others, LN #1 stated he/she would "redirect" the patient. If the patient was confused or combative, he/she would ask for help, stay with the patient but not to put down the patient.

When asked about holding Patient #1, LN #1 stated they were "just doing the right acceptable pressure, . . . it was done very quickly because they need to log roll" Patient (#1). LN #1 taught it was the "best thing to do" that time. He/she "did not consider it as a restraint" because "they did it to keep the patient from hurting them."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA # 2 dated on 8/20/20, revealed CNA #2 stated "The patient arms were on . . . [his/her] chest they had use physical force, yeah it was a little aggressive, it was rough, the patient was unable to move, the patient was so agitated, they were trying to change . . . [Patient #1] and get the job done."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA #3 dated on 8/20/20, revealed CNA #3 stated "Yes, we changed her . . . We wanted to change the patient's brief, but she's kicking and biting . . . very combative . . . LN #3 was on one side of bed, LN #1 on the other side. . . We had to hold her down, we hold her like this, LN #1 put her leg on the bed so that the patient
wouldn't kick us . . ., but didn't put her leg on the patient. . . LN #3 and LN #1 were holding . . . [Patient #1] arms and legs while we were changing . . ."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #1 dated on 8/21/20, revealed LN #1 stated LN #3 asked her help to change Patient's brief because he/she was soaked. Patient #1 was combative and hitting them both. LN #1 stated he/she "could not hold both patient's arm with one hand". LN #3 was "holding one hand" and LN #1 was "holding the right leg". LN #1 put her "knee on the bed for self-defense" so they "could change . . . [Patient]".

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #3 dated on 8/21/20, revealed LN #3 stated he/she and CNA #3 were "changing . . . [Patient's brief]" and asked LN #1 to help. He/she was holding the . . . [Patient's] hands. Patient was kicking CNA #3 while he/she was "trying to take Patient's brief." LN #1 was "holding the Patient's leg." When asked by Nurse Manager if LN #3 used excessive physical force to restrain the patient while providing care, LN #3 replied "Just enough for patient not to hurt me or bite my hand."

During an interview with the Nurse Manager (NM) on 9/10/20 at 2:45 pm, when asked about managing dementia patients, he stated they were concerned about safety and risk for fall. If the patient became violent, caregiver leaves the room. Caregivers also should ensure their own safety, protect themselves and recognize their vulnerability then return to the patient when he/she is no longer violent.

During an interview on 9/15/20 from 4:15- 5:00 pm, with NM, stated he investigated the incident with Patient #1. During the investigation the NM stated the Patient was hard of hearing, spoke Korean as the primary language, and was confused. The NM further stated any patient has the right to refuse care. The NM stated during the investigation he found no translator was used by staff when working with the patient that shift. The NM, when asked if a wet undergarment was an emergency that would require a manual hold, he stated it was not an emergency. He further stated holding the patient as LN #1 and 3 did would be a restraint no matter the length of time of the hold without the consent of the patient.

The NM stated the expectations would be the staff step back, ask for help, have other staff approach the patient, see what needs the patient might have that aren't being met to cause the behaviors.

Record review of the medical record from 9/3-18/20, revealed there was no documentation showing a least restrictive intervention had been tried and was not effective.

Record review on 9/3-18/20 of Pt's #1 medical record, revealed there was no pain medication administered after the last dose of Tylenol on 8/15/20 at 2106.

Record review on 9/3-18/20 of Pt's #1 medical record, revealed there was no modification of care or other interventions done to manage Patient #1's aggression and pain.

Record review on 9/3-18/20 of Pt's #1 medical record, revealed there was no documentation of pain assessment using behavioral scale or other pain scale.

Document review on 9/4/20 at 9:45 am of the facility's "Restraint Management" policy dated 12/2019, revealed " . . . Non violent, Non self-destructive Restraint: Restraint used when the patient is demonstrating behavior that is interfering with treatment (pulling on or reaching for lines, tubes, drains, dressings . . .)" and "Violent or Self-Destructive Restraint: Restraint used to restrict patient movement due to severely aggressive, destructive, violent . . . that places the patient or others in imminent danger when non-physical interventions are not effective. The goal of the restraint is to keep the patient and others physically safe in an emergent situation."

Document review on 9/17/20 of the facility's Restraint Management training, revealed one of the roles of the RN is to "create a Care Plan within the medical record" related to both non-violent and violent restraints.

According to "The Journal of Pain". 2016. "Guidelines on the Management of Postoperative Pain". Accessed on 9/16/20 at this link https://rsds.org/wp-content/uploads/2014/12/mgt-post-oppain.pdf, revealed that in pain assessment of patients who cannot adequately report
their pain because of cognitive deficits, sedation, developmental stage, or other factors, clinicians might
need to use behavioral assessment tools and solicit input from caregivers to assess pain.

According to PubMed.gov "Postoperative analgesia in elderly patients". 2013. Accessed on 9/16/20 at https://pubmed.ncbi.nlm.nih.gov/23288604/, revealed cognitively intact older patients can use most commonly used unidimensional pain scales such as the visual analogue scale (VAS), verbal rating scale (VRS), numeric rating scale (NRS) and facial pain scale (FPS).

According to The Joint Commission "Physical Hold vs Restraint or Seclusion". Accessed on 9/16/20 at https://www.jointcommission.org/standards/standard-faqs/behavioral-health/care-treatment-and-services-cts/000002269/, revealed for "adults, physical holding is a restraint, thus there are no separate standards related to physical holding for adults."
It further revealed the definition of restraint as any method of restricting an individual's freedom of movement, . . ."

According to Alzheimer's Association "Aggression and anger" Accessed on 9/18/20 at https://www.alz.org/help-support/caregiving/stages-behaviors/agression-anger, revealed to respond to aggression, "identify the immediate cause. . . what happened right before the reaction that may have triggered the behavior." It also stated to rule out pain as the cause of the behavior. "Pain can trigger aggressive behavior for a person with dementia."

According to American Nurse Official Journal ANA. "When and how to use restraints". 2015. Accessed at https://www.myamericannurse.com/use-restraints/, revealed "use restraints only as a last resort, after attempting or exploring alternatives. Alternatives include having staff . . . sit with the patient, using distraction or de-escalation strategies, offering reassurance, using bed or chair alarms, and administering certain medications." It further revealed that "If appropriate alternatives have been attempted or considered but have proven insufficient or ineffective or are deemed potentially unsuccessful, restraint may be appropriate. A provider order must be obtained for patient restraint. Be sure to update and revise the care plan for a restrained patient to help find ways to reduce the restraint period and prevent further restraint episodes."



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Based on record review, interview, and document review, the facility failed to ensure the use of restraint for 1 patient (#1) out of 11 sampled patients was conducted in accordance to hospital policy. This failed practice placed the Patient at risks of harm. Findings:

Record review from 9/3-18/20 of the medical record dated 8/5/20, revealed Patient #1 was brought to Emergency Department (ED) from home due to pain after fall. Patient has history of "recurrent falls, recent left hip fracture with intramedullary nailing, dementia . . . depression and chronic pain."

The medical record also revealed Patient #1 was "fighting all cares, moaning and gesturing to left hip", prior to receiving 50 mcg Fentanyl. Patient #1 "speaks Korean only but due to [his/her] dementia [,] [he/she was] not able to communicate by speech."

Further review of the medical record revealed, Patient #1 "had an in-house hospital fall. . . which resulted in a distal femoral shaft fracture." Patient #1 had "cognitive deficits," "Hard of Hearing" and had a Dx [diagnosis] [of] "Dementia."

Review of Physician's "Operative Report" dated 8/14/20 revealed Patient #1 had open reduction and internal fixation (a surgical implementation of implants for the purpose of repairing a bone) on 8/14/20 and Hemovac drain (used to remove fluids that build up in an area of the body after surgery) was in place.

Review of Physician's "Progress Note" dated 8/15/20, revealed "It is difficult to assess [Patient's] true mental status . . . suspect [s] . . . some degree of AMS [altered mental status] or delirium postoperatively. . . daughter . . . concern for some altered behavior however agrees that it may be postoperative . . . state[s] that the patient has never had similar postoperative symptoms."

Review of "Progress Note" further revealed physician's "assessment and plan . . . E-sitter and judicious pain meds [medication] . . . altered mental status . . . likely from anesthesia and pain meds in the last day . . .supportive care . . . limit mind affecting pain meds as possible"

Record review of medical record on 9/13-18/20, revealed Nurse's "Plan of Care" dated 8/15/20 signed by Licensed Nurse (LN #1), stated Patient #1 "complaint of pain to LLE[left lower extremity], PRN[as needed] Norco (HYDROcodone-acetamenophen) 1 tab 5/325 mg given with relief and schedule Tylenol"

Record Review on 9/17/20 of Medication Administration Record (MAR) dated from 8/13-16/20, revealed HYDROcodone-acetamenophen (NORCO) 5-325 mg per tablet 1-2 tablet, frequency every 8 hours PRN for pain was given at 8/14/20 at "2200 (1 tablet)." There was no entry of NORCO being administered in the MAR thereafter.

Further review of medical record on 9/13-18/20, revealed Nurse's "Plan of Care" dated 8/15/20 signed by LN #2 at 1846, revealed "Pain managed with scheduled Tylenol and Lidocaine patch."

Record Review on 9/17/20 of Medication Administration Record (MAR) dated from 8/13-16/20, revealed Acetaminophen (TYLENOL) tablet 1,000 mg every 8 hours was given on 8/15/20 at "2106 (1,000 mg)." It further revealed Tylenol was not given on 8/16/20.

Further review of the MAR on 9/17/20, revealed Lidocaine (LIDODERM) 5% patch 1 patch daily. The instruction was to apply "for 12 hours, then remove for 12 hours." The patch was due at "2106 (1 patch)."

Review of medical record on 9/13-18/20, the "Esafety Aide Shift Note" dated 8/16/20 signed by Certified Nursing Assistant (CNA #1) at 0632, revealed "Throughout the shift: The patient was verbally redirected 16 times. The primary caregiver was called 6 times. The STAT alarm was activated 0 times."

Review of medical record on 9/13-18/20, the Nurse's "Plan of Care" dated 8/16/20 at 6:30 am signed by LN #3, revealed Patient #1 level of consciousness (LOC) was alert, orientation UTA [unable to assess] due to language barrier, confused, pulling out tubes and lines. Pt [patient] was calm and cooperative when . . . daughter was around at early shift. Slept for a while and wake up very restless, pt [patient] pulled out . . . purewick, and tried to remove . . . drain and dressings. Called daughter to asked [ask]. . . to translate what . . . [Patient #1] wants." Patient #1's daughter stated, "she is confused right now".

Review of plan of care further revealed "non-verbal cues for pain noted, scheduled Tylenol was given at HS"

Record Review on 9/17/20 of Medication Administration Record (MAR) dated from 8/13-16/20, revealed "acetaminophen (Tylenol) tablet 1,000 mg EVERY 8 HOURS Route PO ..." was given on 8/15/20 at 2106.

Record review of medical record on 9/13-18/20, revealed the Nurse's "Plan of Care" dated 8/16/20 signed by LN (#3), stated at "0630: pt [patient] was combative, kicking, biting, staff while changing her brief, needed 3 staff to attend . . . in changing."

Record review on 9/11/20 at 3:40 pm of Providence Quality/Risk Event Reviewer Form dated 8/18/20, revealed CNA #1 emailed his/her supervisor on 8/16/20 which stated the incident happened on 8/15/20 at 06:30 am. "[LN #3] entered patient's room and attempted to change . . . [Patient #1's] brief. Pt. [Patient #1] is non-English speaking . . . and staff were not using interpreter. Pt [Patient #1] was confused and started to combat due to not understanding what was happening. [LN #3] called the second RN [registered nurse], unknown and the PCT [primary care technician] to help hold the patient down. Pt. [Patient #1] tried to fight [LN #3]. [LN #3] pushed the pt.'s [Patient #1] own wrists into . . . [his/her] mouth and told . . . [his/her] to bite it instead. The pt. was still fighting and [LN #3] continued to push the pt's [Patient #1] wrist into . . . [his/her] mouth. The second RN (unknown name) used her knee to hold the pt's [Patient #1] right leg down. The RN (unknown name) continued pinning pt [Patient #1] Down to change. . . [his/her] and climbed on the bed to pin the pt's [Patient #1] arm down to . . . [his/her] chest. The whole time, they started speaking Tagolog and laughing as pt. struggled to be free. [Patient #1] started to yell 'don't do that' in English. The staff refused to acknowledge her and continued to force her down and reapply dressing onto her hemo-vac site. No one seemed to call the interpreter to explain what was happening to pt. [Patient #1]. The RN (LN #3] noted that the interpreter was not called all shift. After they finished changing . . . [his/her], they left the room. At 7:03 am, pt. [Patient #1] Started to yell . . . They made fun of . . . [him/her] and mock . . . [him/her] outside . . . [him/her] room. They continued to laugh . . . The pt. is hard of hearing and confused."

Record review on 9/16-17/20 of the Nurse Manager's (NM) investigation with CNA #1 dated 8/21/20, revealed CNA #1 stated "The Patient needed brief changed and had a hemo-vac. . ." LN #3 called her [for] help due to patient's agitation. The patient became very agitated and tried to hit LN #3, he/she then took the patient's wrist and put the wrist in the patient's mouth . . . then . . . LN #1 had her knee on the patient's leg, then . . . grabbed patient's arms on . . . [his/her] chest . . ."

During an interview with the facility's Program Manager Regulatory Compliance (PMRC) on 9/11/20, she stated that the incident happened on 8/16/20, the telesitter must have wrote the wrong date in the report.

During an interview with CNA #1 on 9/14/20 at 10:50 am, about the incident that happened on 8/16/20, CNA #1 stated on 8/16/20 at 6:30 am he/she was watching the monitor for Patient #1 for fall prevention. He/she had watched patient (Patient #1) couple of times. Patient #1 "had moments being confused". The incident happened after surgery. Staff tried to "change the patient". Patient #1 had been upset.

CNA #1 further stated LN #3 "put hand over patient mouth and stayed there." LN #3 told the patient to bite his/her hand. LN #1 "put her knee" to "put patient down" and continue to "pin" him/her down. LN #1 was holding patient's wrist, while holding down patient's knee. LNs #1 and #3 were speaking Tagalog and laughing. Patient #1 was screaming while changing his/her brief and dressing. The LNs (#1 and #3) were yelling and so was Patient #1. CNA # 3 came in right at the end of it. CNA #1 also stated that Patient #1 had difficulty hearing.

When asked if changing brief was an urgent care need, she responded "No", if patient was aggressive, they could "wing it" then "go back" after 30 minutes to 1 hour.

During an interview with CNA #2 on 9/14/20 at 11:22 am, about the incident that happened on 8/16/20, CNA #2 stated he/she was working with CNA #1 at the monitor studio [Telemetry]. He/she was watching a patient next to Patient #1's room. CNA #2 stated that he/she could hear Patient #1 "screaming all throughout the night", "confused", and "in pain not getting medicine."

CNA #2 further stated, CNA #1 pointed out to her and said "look at this". They were changing him/her in the "middle of screaming." CNA #2 described that nurses were "frustrated." There were two nurses [LN #1 and #3] helping out and tech [CNA #3] went to room. They were trying to change him/her "holding down." Both nurses were "aggressive". The Primary nurse [LN #3] was "frustrated trying to get her job done."

During an interview with LN #3 on 9/14/20 at 1:59 pm, when asked what to do if patient refused care, LN #3 stated "we don't argue." "We go out and return after few minutes." He/she added if the patient was confused and care was necessary, "we do it for them." He/she further explained they need to do it so pressure ulcer would not develop especially when patient is soiled of stool or urine.

LN #3 gave a scenario when patient refused care by the technician and the patient tried to hit the technician, LN #3 told technician to leave patient alone. Then, LN #3 tried to approach the patient with a low tone, the patient allowed her to change [the brief]. He/she further explained that with the proper tone of voice the patient will participate. Patient would not participate if the tone is high pitched or loud.

When asked about the incident on 8/16/20, LN #3 stated the patient [Patient #1] was Korean and not speaking English. That night Patient #1 was yelling. LN #3 stated he/she did not use narcotic because it makes Patient #1 lethargic. LN #3 further explained that prior to that incident, a nurse [not identified] from surgery gave Patient #1 narcotic which made the patient lethargic.

LN #3 added that on his/her shift, Patient # 1 was alert, confused and yelling. The incident happened at 6:30 am. As per hospital policy, if the patient was confused, they need "to change" [the brief of] the patient because he/she was "soaked with urine." According to LN #3, Patient #1 tried to bite LN #3 and was kicking the technician. So, LN #3 asked the technician to call for help. There were three of them who tried to help Patient #1 to not break Patient #1's bone.

LN #3 further explained "it was a busy night," Patient #1 was yelling, pulling IV, drain and dressing so they were preventing the Patient #1 from doing it. LN #3 also stated he/she needed to change the dressing but had run out of medipore tape. LN #3 asked the other nurse [LN #1] to help so he/she could go get the tape. LN # 1 was holding Patient #1 while LN #3 was "out not even a minute." When LN #3 was changing the brief and dressing, LN #1 was on the right side.

When asked if changing patient's brief was an urgent care need, LN #3 stated it was urgent because it was end of shift. LN #3 explained that a good team was to finish the task and not to pass it on to the next shift. Patient # 1 was soaked so LN #3 was preventing the development of pressure sore, dressing to get soaked, and infection so they made sure the patient was cleaned. LN #3 considered changing the brief as an emergency care need.

LN #3 further explained that if the care was not done, patient would not be happy, they could report them, and other people would think they are abusing the patient.

During the interview with LN #3 on 9/14/20 at 1:59 pm, when asked about pain medication, LN #3 stated he/she followed doctor's order of "no narcotic." There was an order of Tylenol, but Patient #1 tried not to take medication. Patient #1 could recognize Tylenol and took it out of the medicine cap. LN #3 stated he/she did not give medication because narcotic can escalate consciousness. When asked if Patient #1 might be in pain the whole night, LN #3 replied "yes."

On 9/14/20 at 1:59 pm, when asked about definition of restraint, LN #3 stated holding the patient to prevent him/her from doing what he/she wants to do. LN #3 stated that they did not meant any harm to the patient. He/she explained that Patient #1 was hard of hearing and didn't understand so use of low tone would not work. If the Patient #1 was able to understand, they would not have had any issue.

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked if they had ever had a patient who refused care and what they would do if a patient refused care, LN #1 stated "yes", if patient refused care, she would "explain type of care" to the patient and "reorient the patient . . ." LN #1 further explained that if the patient was still refusing care, "it is not a big deal" if it will not compromise the condition of the patient, LN #1 would "wait for few hours, then asked the patient again."

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about the incident with Patient #1 on 8/16/20, LN #1 stated Patient #1 was not his/her patient at that time. LN #1 described that Patient #1 "was combative, confused and hard of hearing." LN #1 stated LN #3 asked for her help because Patient #1 urinated and they were changing her brief. CNA #3 was not there; CNA #3 was with another patient. LNs (#1 and #3) waited for CNA #3 for few minutes but CNA #3 was still with other patient. Patient #1's brief was already removed so they changed the brief. Patient #1 "was combative," so LN #1 told LN #3 they would "hold" Patient #1's hand while LN #3 cleaned Patient #1. LN #1 also stated that Patient #1 was "soaked with [urine] up the back." LN #3 also changed the dressing. LN #1 stated if the dressing was not changed, the patient would be prone to infection and they don't want that to happen.

LN #1 stated they always log roll the patient with broken leg or hip using bedsheet or pad. LN #3 was on Patient #'s left side. They turned the patient towards LN #1 first but not all the way about "35 degrees" angle to "insert [brief]," then they turned Patient #1 towards LN #3 but not all the way about '"20 degrees" angle to "pull [brief]." They don't want to break Patient #1's bone and go to surgery because of wrong turn.

LN #1 stated he/she was "holding" Patient #1's two arms "with her left hand but not really tight" because Patient #1 was "old and bones are fragile."

When asked if he/she was in the room the whole time, LN #1 stated "Yes." He/she came in at the middle of the process and was in the room the whole time, LN #3 left the room for "not even a minute" to get supplies. CNA #3 came back when they were done.

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about definition of restraint, LN #1 stated . . . physical was for violent and non-violent. Violent restraint is used when patient was pulling IV (intravenous), NGT (nasogastric tube), and catheter . . . LN #1 also stated they "use wrist restraint" so patient could "not harm himself" and "other" or "pull catheter and IV." They use device . . . for wrist and ankle so patient will not get hurt. For non-violent restraint, LN #1 stated they "use mitten so patients could not scratch themselves."


Surveyor asked LN #1 if holding needs to be done when patient wants to get out of bed, hit a nurse or hurt others, LN #1 stated he/she would "redirect" the patient. If the patient was confused or combative, he/she would asked for help, stay with the patient but not to put down the patient.

When asked about holding Patient #1, LN #1 stated they were "just doing the right acceptable pressure, . . . it was done very quickly because they need to log roll" Patient (#1). LN #1 taught it was the "best thing to do" that time. He/she "did not consider it as a restraint" because "they did it to keep the patient from hurting them."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA # 2 dated on 8/20/20, revealed CNA #2 stated "The patient arms were on . . . [his/her] chest they had use physical force, yeah it was a little aggressive, it was rough, the patient was unable to move, the patient was so agitated, they were trying to change . . . [Patient #1] and get the job done."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA #3 dated on 8/20/20, revealed CNA #3 stated "Yes, we changed her . . . We wanted to change the patient's brief, but she's kicking and biting . . . very combative . . . LN #3 was on one side of bed, LN #1 on the other side. . . We had to hold her down, we hold her like this, LN #1 put her leg on the bed so that the patient
wouldn't kick us . . ., but didn't put her leg on the patient. . . LN #3 and LN #1 were holding . . . [Patient #1] arms and legs while we were changing . . ."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #1 dated on 8/21/20, revealed LN #1 stated LN #3 asked her help to change Patient's brief because he/she was soaked. Patient #1 was combative and hitting them both. LN #1 stated he/she "could not hold both patient's arm with one hand". LN #3 was "holding one hand" and LN #1 was "holding the right leg". LN #1 put her "knee on the bed for self-defense" so they "could change . . . [Patient]".

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #3 dated on 8/21/20, revealed LN #3 stated he/she and CNA #3 were "changing . . . [Patient's brief]" and asked LN #1 to help. He/she was holding the . . . [Patient's] hands. Patient was kicking CNA #3 while he/she was "trying to take Patient's brief." LN #1 was "holding the Patient's leg." When asked by Nurse Manager if LN #3 used excessive physical force to restrain the patient while providing care, LN #3 replied "Just enough for patient not to hurt me or bite my hand."

During an interview with the Nurse Manager (NM) on 9/10/20 at 2:45 pm, when asked about managing dementia patients, he stated they were concerned about safety and risk for fall. If the patient became violent, caregiver leaves the room. Caregivers also should ensure their own safety, protect themselves and recognize their vulnerability then return to the patient when he/she is no longer violent.

During an interview on 9/15/20 from 4:15- 5:00 pm, with NM, stated he investigated the incident with Patient #1. During the investigation the NM stated the Patient was hard of hearing, spoke Korean as the primary language, and was confused. The NM further stated any patient has the right to refuse care. The NM stated during the investigation he found no translator was used by staff when working with the patient that shift. The NM, when asked if a wet undergarment was an emergency that would require a manual hold, he stated it was not an emergency. He further stated holding the patient as LN #1 and 3 did would be a restraint no matter the length of time of the hold without the consent of the patient.

The NM stated the expectations would be the staff step back, ask for help, have other staff approach the patient, see what needs the patient might have that aren't being met to cause the behaviors.

During an interview with Facility's Program Manager Regulatory Compliance on 9/11/20 at 3:50 pm, she stated holding patient down is a restraint without order.

Record review on 9/3-18/20 of Pt's #1 medical record, there was no restraint order.

Record review of the medical record from 9/3-18/20, there was no documentation showing a least restrictive intervention was done and not effective.

Record review on 9/16-17 of the NM's conversation with Patient #1's daughter, revealed when the daughter visited her mother on 8/17/20, "her mother showed her wrist that had bruises on them. . . the right wrist bruise was very noticeable, and the left bruise was smaller."

On the same conversation with the daughter NM stated he "examined patient's wrist on (8/21) . . . did not see any form of bruising directly on the patient's bilateral wrists."

Record review of the medical record from 9/3-18/20, there is no documentation showing that face to face evaluation of LIP or physician was conducted.

Document review 9/4/20 at 9:45 am of facility's "Restraint Management" policy dated 12/2019, revealed restraint is defined as "any a manual method, physical or mechanical device . . . that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely."

The policy also defined "Non-violent, Non self-destructive Restraint: Restraint used when the patient is demonstrating behavior that is interfering with treatment (pulling on or reaching for lines, tubes, drains, dressings . . .)" and "Violent or Self-Destructive Restraint: Restraint used to restrict patient movement due to severely aggressive, destructive, violent . . . that places the patient or others in imminent danger when non-physical interventions are not effective. The goal of the restraint is to keep the patient and others physically safe in an emergent situation."

The policy further revealed:

" . . . RN must obtain order from LIP (Licensed Independent Practitioner) upon application of the restraint or immediately thereafter. . . "

". . .RN may enter the order in the electronic record. . ."

". . . a physician or other LIP must see and assess or re-assess the patient . . . after restraints are applied, an assessment will be made immediately to evaluate that the restraints were applied properly and safely. . ."

". . . RN documents . . . a description of the patient's behavior and intervention used."

". . . RN documents . . . Alternatives or other less restrictive interventions attempted."

According to American Nurse Official Journal ANA. "When and how to use restraints". 2015. Accessed at https://www.myamericannurse.com/use-restraints/, revealed "use restraints only as a last resort, after attempting or exploring alternatives. Alternatives include having staff . . . sit with the patient, using distraction or de-escalation strategies, offering reassurance, using bed or chair alarms, and administering certain medications." It further revealed that "If appropriate alternatives have been attempted or considered but have proven insufficient or ineffective or are deemed potentially unsuccessful, restraint may be appropriate. A provider order must be obtained for patient restraint.


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Based record review, interview, and document review the facility failed to ensure the use of restraint for 1 patient (#1) out of 11 sampled patients was conducted in a manner that was approved by the LIP or physician. This failed practice placed the Patient at risks of harm and inappropriate care. Findings:

Record review from 9/3-18/20 of the medical record dated 8/5/20, revealed Patient #1 was brought to Emergency Department (ED) from home due to pain after fall. Patient has history of "recurrent falls, recent left hip fracture with intramedullary nailing, dementia . . . depression and chronic pain."

Further review of the medical record revealed, Patient #1 "had an in-house hospital fall . . . which resulted in a distal femoral shaft fracture." Patient #1 had "cognitive deficits," "Hard of Hearing" and had a Dx [diagnosis] [of] "Dementia."

Review of medical record on 9/13-18/20, the Nurse's "Plan of Care" dated 8/16/20 at 6:30 am signed by LN #3, revealed Patient #1 level of consciousness (LOC) was alert, orientation UTA [unable to assess] due to language barrier, confused, pulling out tubes and lines. Pt [patient] was calm and cooperative when . . . daughter was around at early shift. Slept for a while and wake up very restless, pt [patient] pulled out . . . purewick, and tried to remove . . . drain and dressings. Called daughter to asked [ask]. . . to translate what . . . [Patient #1] wants." Patient #1's daughter stated, "she is confused right now".

Record review of medical record on 9/13-18/20, revealed the Nurse's "Plan of Care" dated 8/16/20 signed by LN (#3), stated at "0630: pt [patient] was combative, kicking, biting, staff while changing her brief, needed 3 staff to attend . . . in changing."

Record review on 9/11/20 at 3:40 pm of Providence Quality/Risk Event Reviewer Form dated 8/18/20, revealed CNA #1 emailed his/her supervisor on 8/16/20 which stated the incident happened on 8/15/20 at 06:30 am. "[LN #3] entered patient's room and attempted to change . . . [Patient #1's] brief. Pt. [Patient #1] is non-English speaking . . . and staff were not using interpreter. Pt [Patient #1] was confused and started to combat due to not understanding what was happening. [LN #3] called the second RN [registered nurse], unknown and the PCT [primary care technician] to help hold the patient down. Pt. [Patient #1] tried to fight [LN #3]. [LN #3] pushed the pt.'s [Patient #1] own wrists into . . . [his/her] mouth and told . . . [his/her] to bite it instead. The pt. was still fighting and [LN #3] continued to push the pt's [Patient #1] wrist into . . . [his/her] mouth. The second RN (unknown name) used her knee to hold the pt's [Patient #1] right leg down. The RN (unknown name) continued pinning pt [Patient #1] Down to change. . . [his/her] and climbed on the bed to pin the pt's [Patient #1] arm down to . . . [his/her] chest. The whole time, they started speaking Tagolog and laughing as pt. struggled to be free. [Patient #1] started to yell 'don't do that' in English. The staff refused to acknowledge her and continued to force her down and reapply dressing onto her hemo-vac site. No one seemed to call the interpreter to explain what was happening to pt. [Patient #1]. The RN (LN #3] noted that the interpreter was not called all shift. After they finished changing . . . [his/her], they left the room. At 7:03 am, pt. [Patient #1] Started to yell . . . They made fun of . . . [him/her] and mock . . . [him/her] outside . . . [him/her] room. They continued to laugh . . . The pt. is hard of hearing and confused."

Record review on 9/16-17/20 of the Nurse Manager's (NM) investigation with CNA #1 dated 8/21/20, revealed CNA #1 stated "The Patient needed brief changed and had a hemo-vac. . ." LN #3 called her [for] help due to patient's agitation. The patient became very agitated and tried to hit LN #3, he/she then took the patient's wrist and put the wrist in the patient's mouth . . . then . . . LN #1 had her knee on the patient's leg, then . . . grabbed patient's arms on . . . [his/her] chest . . ."

During an interview with CNA #1 on 9/14/20 at 10:50 am, about the incident that happened on 8/16/20, CNA #1 stated on 8/16/20 at 6:30 am he/she was watching the monitor for Patient #1 for fall prevention. He/she had watched patient (Patient #1) couple of times. Patient #1 "had moments being confused". The incident happened after surgery. Staff tried to "change the patient". Patient #1 had been upset.

CNA #1 further stated LN #3 "put hand over patient mouth and stayed there." LN #3 told the patient to bite his/her hand. LN #1 "put her knee" to "put patient down" and continue to "pin" him/her down. LN #1 was holding patient's wrist, while holding down patient's knee. LNs #1 and #3 were speaking Tagalog and laughing. Patient #1 was screaming while changing his/her brief and dressing. The LNs (#1 and #3) were yelling and so was Patient #1. CNA # 3 came in right at the end of it. CNA #1 also stated that Patient #1 had difficulty hearing.

When asked if changing brief was an urgent care need, she responded "No", if patient was aggressive they could "wing it" then "go back" after 30 minutes to 1 hour.

During an interview with CNA #2 on 9/14/20 at 11:22 am, about the incident that happened on 8/16/20, CNA #2 stated he/she was working with CNA #1 at the monitor studio [Telemetry]. He/she was watching a patient next to Patient #1's room. CNA #2 stated that he/she could hear Patient #1 "screaming all throughout the night", "confused", and "in pain not getting medicine."

CNA #2 further stated, CNA #1 pointed out to her and said "look at this". They were changing him/her in the "middle of screaming." CNA #2 described that nurses were "frustrated." There were two nurses [LN #1 and #3] helping out and tech [CNA #3] went to room. They were trying to change him/her "holding down." Both nurses were "aggressive". The Primary nurse [LN #3] was "frustrated trying to get her job done."

During an interview with LN #3 on 9/14/20 at 1:59 pm, when asked about the event involving Patient #1, LN #3 further explained "it was a busy night," Patient #1 was yelling, pulling IV, drain and dressing so they were preventing the Patient #1 to do it. LN #3 also stated he/she needed to change the dressing but he/she run out of medipore tape. He/she asked the other nurse [LN #1] to help so she can get the tape. LN # 1 was holding the Patient #1 while LN #3 was "out not even a minute." When LN #3 was changing the brief and dressing, LN #1 was on the right side.

When asked if changing patient's brief was an urgent care need, LN #3 stated it was urgent because it was end of shift. LN #3 explained that a good team was to finish the task and not to pass it on to the next shift. Patient # 1 was soaked so LN #3 was preventing the development of pressure sore, dressing to get soaked, and infection so they made sure the patient was cleaned. LN #3 considered changing the brief as an emergency care need.

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about the incident with Patient #1 on 8/16/20, LN #1 stated Patient #1 was not his/her patient at that time. LN #1 described that Patient #1 "was combative, confused and hard of hearing." LN #1 stated LN #3 asked for her help because Patient #1 urinated and they were changing her brief. CNA #3 was not there; CNA #3 was with another patient. LNs (#1 and #3) waited for CNA #3 for few minutes but CNA #3 was still with other patient. Patient #1's brief was already removed so they changed the brief. Patient #1 "was combative," so LN #1 told LN #3 they would "hold" Patient #1's hand while LN #3 cleaned Patient #1. LN #1 also stated that Patient #1 was "soaked with [urine] up the back." LN #3 also changed the dressing. LN #1 stated if the dressing was not changed, the patient would be prone to infection and they don't want that to happen.

LN #1 stated he/she was "holding" Patient #1's two arms "with her left hand but not really tight" because Patient #1 was "old and bones are fragile."

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about definition of restraint, LN #1 stated . . . physical was for violent and non-violent. Violent restraint is used when patient was pulling IV (intravenous), NGT (nasogastric tube), and catheter . . . LN #1 also stated they "use wrist restraint" so patient could "not harm himself" and "other" or "pull catheter and IV." They use device . . . for wrist and ankle so patient will not get hurt. For non-violent restraint, LN #1 stated they "use mitten so patients could not scratch themselves."

When asked about holding Patient #1, LN #1 stated they were "just doing the right acceptable pressure, . . . it was done very quickly because they need to log roll" Patient (#1). LN #1 taught it was the "best thing to do" that time. He/she "did not consider it as a restraint" because "they did it to keep the patient from hurting them."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA # 2 dated on 8/20/20, revealed CNA #2 stated "The patient arms were on . . . [his/her] chest they had use physical force, yeah it was a little aggressive, it was rough, the patient was unable to move, the patient was so agitated, they were trying to change . . . [Patient #1] and get the job done."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA #3 dated on 8/20/20, revealed CNA #3 stated "Yes, we changed her . . . We wanted to change the patient's brief, but she's kicking and biting . . . very combative . . . LN #3 was on one side of bed, LN #1 on the other side. . . We had to hold her down, we hold her like this, LN #1 put her leg on the bed so that the patient
wouldn't kick us . . . , but didn't put her leg on the patient. . . LN #3 and LN #1 were holding . . . [Patient #1] arms and legs while we were changing . . ."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #1 dated on 8/21/20, revealed LN #1 stated LN #3 asked her help to change Patient's brief because he/she was soaked. Patient #1 was combative and hitting them both. LN #1 stated he/she "could not hold both patient's arm with one hand". LN #3 was "holding one hand" and LN #1 was "holding the right leg". LN #1 put her "knee on the bed for self-defense" so they "could change . . . [Patient]".

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #3 dated on 8/21/20, revealed LN #3 stated he/she and CNA #3 were "changing . . . [Patient's brief]" and asked LN #1 to help. He/she was holding the . . . [Patient's] hands. Patient was kicking CNA #3 while he/she was "trying to take Patient's brief." LN #1 was "holding the Patient's leg." When asked by Nurse Manager if LN #3 used excessive physical force to restrain the patient while providing care, LN #3 replied "Just enough for patient not to hurt me or bite my hand."

During an interview with facility's Program Manager Regulatory Compliance on 9/11/20 at 3:50 pm, she stated holding a patient down is a restraint without order.

Record review on 9/3-18/20 of Patient #1's medical record revealed there was no restraint order.

Review of Providence Hospital's "Restraint Management" policy on 9/4/20 at 9:45 am, revealed restraint is defined as "any a manual method, physical or mechanical device . . . that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely."

The policy also defined "Non-violent, Non self-destructive Restraint: Restraint used when the patient is demonstrating behavior that is interfering with treatment (pulling on or reaching for lines, tubes, drains, dressings . . .)" and "Violent or Self-Destructive Restraint: Restraint used to restrict patient movement due to severely aggressive, destructive, violent . . . that places the patient or others in imminent danger when non-physical interventions are not effective. The goal of the restraint is to keep the patient and others physically safe in an emergent situation."

The policy further stated that in initiation of non-violent, non-self-destructive and violent or self-destructive restraints, the "RN must obtain order from LIP (Licensed Independent Practitioner) upon application of the restraint or immediately thereafter." "Telephone orders for restrains may be accepted." "RN may enter the order in the electronic record."

Document review on 9/17/20 of the facility's Restraint Management training, revealed on application of restraints, ". . . an RN must obtain an order upon application of the restraint or immediately thereafter." It further revealed that "Any licensed provider (LIP) can provide and order restraints."

According to American Nurse Official Journal ANA. "When and how to use restraints". 2015. Accessed at https://www.myamericannurse.com/use-restraints/, revealed "use restraints only as a last resort, after attempting or exploring alternatives. Alternatives include having staff . . . sit with the patient, using distraction or de-escalation strategies, offering reassurance, using bed or chair alarms, and administering certain medications." It further revealed that "If appropriate alternatives have been attempted or considered but have proven insufficient or ineffective or are deemed potentially unsuccessful, restraint may be appropriate. A provider order must be obtained for patient restraint."

According to American Medical Association (AMA) "Use of Restraints". Accessed on 9/18/10 at https://www.ama-assn.org/delivering-care/ethics/use-restraints revealed "All individuals have a fundamental right to be free from unreasonable bodily restraint. At times, however, health conditions may result in behavior that puts patients at risk of harming themselves. In such situations, it may be ethically justifiable for physicians to order the use of chemical or physical restraint to protect the patient."

"Except in emergencies, patients should be restrained only on a physician's explicit order. Patients should never be restrained punitively, for convenience, or as an alternate to reasonable staffing."


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Based on record review, interview, and document review, the facility failed to ensure that the attending physician was consulted as soon as possible of the use of manual restraint for 1 patient (#1) out of 11 sampled patients. This failed practice placed the Patient at risks of harm and inappropriate care. Findings:

Record review from 9/3-18/20 of the medical record dated 8/5/20, revealed Patient #1 was brought to Emergency Department (ED) from home due to pain after fall. Patient has history of "recurrent falls, recent left hip fracture with intramedullary nailing, dementia . . . depression and chronic pain."

Further review of the medical record revealed, Patient #1 "had an in-house hospital fall . . . which resulted in a distal femoral shaft fracture." Patient #1 had "cognitive deficits," "Hard of Hearing" and had a Dx [diagnosis] [of] "Dementia."

Review of medical record on 9/13-18/20, the Nurse's "Plan of Care" dated 8/16/20 at 6:30 am signed by LN #3, revealed Patient #1 level of consciousness (LOC) was alert, orientation UTA [unable to assess] due to language barrier, confused, pulling out tubes and lines. Pt [patient] was calm and cooperative when . . . daughter was around at early shift. Slept for a while and wake up very restless, pt [patient] pulled out . . . purewick, and tried to remove . . . drain and dressings. Called daughter to asked [ask]. . . to translate what . . . [Patient #1] wants." Patient #1's daughter stated, "she is confused right now".

Record review of medical record on 9/13-18/20, revealed the Nurse's "Plan of Care" dated 8/16/20 signed by LN (#3), stated at "0630: pt [patient] was combative, kicking, biting, staff while changing her brief, needed 3 staff to attend . . . in changing."

Record review on 9/11/20 at 3:40 pm of Providence Quality/Risk Event Reviewer Form dated 8/18/20, revealed CNA #1 emailed his/her supervisor on 8/16/20 which stated the incident happened on 8/15/20 at 06:30 am. "[LN #3] entered patient's room and attempted to change . . . [Patient #1's] brief. Pt. [Patient #1] is non-English speaking . . . and staff were not using interpreter. Pt [Patient #1] was confused and started to combat due to not understanding what was happening. [LN #3] called the second RN [registered nurse], unknown and the PCT [primary care technician] to help hold the patient down. Pt. [Patient #1] tried to fight [LN #3]. [LN #3] pushed the pt.'s [Patient #1] own wrists into . . . [his/her] mouth and told . . . [his/her] to bite it instead. The pt. was still fighting and [LN #3] continued to push the pt's [Patient #1] wrist into . . . [his/her] mouth. The second RN (unknown name) used her knee to hold the pt's [Patient #1] right leg down. The RN (unknown name) continued pinning pt [Patient #1] Down to change. . . [his/her] and climbed on the bed to pin the pt's [Patient #1] arm down to . . . [his/her] chest. The whole time, they started speaking Tagolog and laughing as pt. struggled to be free. [Patient #1] started to yell 'don't do that' in English. The staff refused to acknowledge her and continued to force her down and reapply dressing onto her hemo-vac site. No one seemed to call the interpreter to explain what was happening to pt. [Patient #1]. The RN (LN #3] noted that the interpreter was not called all shift. After they finished changing . . . [his/her], they left the room. At 7:03 am, pt. [Patient #1] Started to yell . . . They made fun of . . . [him/her] and mock . . . [him/her] outside . . . [him/her] room. They continued to laugh . . . The pt. is hard of hearing and confused."

Record review on 9/16-17/20 of the Nurse Manager's (NM) investigation with CNA #1 dated 8/21/20, revealed CNA #1 stated "The Patient needed brief changed and had a hemo-vac . . ." LN #3 called her [for] help due to patient's agitation. The patient became very agitated and tried to hit LN #3, he/she then took the patient's wrist and put the wrist in the patient's mouth . . . then . . . LN #1 had her knee on the patient's leg, then . . . grabbed patient's arms on . . . [his/her] chest . . ."

During an interview with CNA #1 on 9/14/20 at 10:50 am, about the incident that happened on 8/16/20, CNA #1 stated on 8/16/20 at 6:30 am he/she was watching the monitor for Patient #1 for fall prevention. He/she had watched patient (Patient #1) couple of times. Patient #1 "had moments being confused". The incident happened after surgery. Staff tried to "change the patient". Patient #1 had been upset.

CNA #1 further stated LN #3 "put hand over patient mouth and stayed there." LN #3 told the patient to bite his/her hand. LN #1 "put her knee" to "put patient down" and continue to "pin" him/her down. LN #1 was holding patient's wrist, while holding down patient's knee. LNs #1 and #3 were speaking Tagalog and laughing. Patient #1 was screaming while changing his/her brief and dressing. The LNs (#1 and #3) were yelling and so was Patient #1. CNA # 3 came in right at the end of it. CNA #1 also stated that Patient #1 had difficulty hearing.

When asked if changing brief was an urgent care need, she responded "No", if patient was aggressive, they could "wing it" then "go back" after 30 minutes to 1 hour.

During an interview with CNA #2 on 9/14/20 at 11:22 am, about the incident that happened on 8/16/20, CNA #2 stated he/she was working with CNA #1 at the monitor studio [Telemetry]. He/she was watching a patient next to Patient #1's room. CNA #2 stated that he/she could hear Patient #1 "screaming all throughout the night", "confused", and "in pain not getting medicine."

CNA #2 further stated, CNA #1 pointed out to her and said, "look at this". They were changing him/her in the "middle of screaming." CNA #2 described that nurses were "frustrated." There were two nurses [LN #1 and #3] helping out and tech [CNA #3] went to room. They were trying to change him/her "holding down." Both nurses were "aggressive". The Primary nurse [LN #3] was "frustrated trying to get her job done."

During an interview with LN #3 on 9/14/20 at 1:59 pm, when asked about the event involving Patient #1, LN #3 further explained "it was a busy night," Patient #1 was yelling, pulling IV, drain and dressing so they were preventing the Patient #1 from doing it. LN #3 also stated he/she needed to change the dressing but had run out of medipore tape. LN #3 asked the other nurse [LN #1] to help so he/she could go get the tape. LN # 1 was holding Patient #1 while LN #3 was "out not even a minute." When LN #3 was changing the brief and dressing, LN #1 was on the right side.

When asked if changing patient's brief was an urgent care need, LN #3 stated it was urgent because it was end of shift. LN #3 explained that a good team was to finish the task and not to pass it on to the next shift. Patient # 1 was soaked so LN #3 was preventing the development of pressure sore, dressing to get soaked, and infection so they made sure the patient was cleaned. LN #3 considered changing the brief as an emergency care need.

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about the incident with Patient #1 on 8/16/20, LN #1 stated Patient #1 was not his/her patient at that time. LN #1 described that Patient #1 "was combative, confused and hard of hearing." LN #1 stated LN #3 asked for her help because Patient #1 urinated and they were changing her brief. CNA #3 was not there, CNA #3 was with another patient. LNs (#1 and #3) waited for CNA #3 for few minutes but CNA #3 was still with other patient. Patient #1's brief was already removed so they changed the brief. Patient #1 "was combative," so LN #1 told LN #3 they would "hold" Patient #1's hand while LN #3 cleaned Patient #1. LN #1 also stated that Patient #1 was "soaked with [urine] up the back." LN #3 also changed the dressing. LN #1 stated if the dressing was not changed, the patient would be prone to infection and they don't want that to happen.

LN #1 stated he/she was "holding" Patient #1's two arms "with her left hand but not really tight" because Patient #1 was "old and bones are fragile."

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about definition of restraint, LN #1 stated . . . physical was for violent and non-violent. Violent restraint is used when patient was pulling IV (intravenous), NGT (nasogastric tube), and catheter . . . LN #1 also stated they "use wrist restraint" so patient could "not harm himself" and "other" or "pull catheter and IV." They use device . . . for wrist and ankle so patient will not get hurt. For non-violent restraint, LN #1 stated they "use mitten so patients could not scratch themselves."

When asked about holding Patient #1, LN #1 stated they were "just doing the right acceptable pressure, . . . it was done very quickly because they need to log roll" Patient (#1). LN #1 taught it was the "best thing to do" that time. He/she "did not consider it as a restraint" because "they did it to keep the patient from hurting them."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA # 2 dated on 8/20/20, revealed CNA #2 stated "The patient arms were on . . . [his/her] chest they had use physical force, yeah it was a little aggressive, it was rough, the patient was unable to move, the patient was so agitated, they were trying to change . . . [Patient #1] and get the job done."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA #3 dated on 8/20/20, revealed CNA #3 stated "Yes, we changed her . . . We wanted to change the patient's brief, but she's kicking and biting . . . very combative . . . LN #3 was on one side of bed, LN #1 on the other side. . . We had to hold her down, we hold her like this, LN #1 put her leg on the bed so that the patient
wouldn't kick us . . ., but didn't put her leg on the patient. . . LN #3 and LN #1 were holding . . . [Patient #1] arms and legs while we were changing . . ."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #1 dated on 8/21/20, revealed LN #1 stated LN #3 asked her help to change Patient's brief because he/she was soaked. Patient #1 was combative and hitting them both. LN #1 stated he/she "could not hold both patient's arm with one hand". LN #3 was "holding one hand" and LN #1 was "holding the right leg". LN #1 put her "knee on the bed for self-defense" so they "could change . . . [Patient]".

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #3 dated on 8/21/20, revealed LN #3 stated he/she and CNA #3 were "changing . . . [Patient's brief]" and asked LN #1 to help. He/she was holding the . . . [Patient's] hands. Patient was kicking CNA #3 while he/she was "trying to take Patient's brief." LN #1 was "holding the Patient's leg." When asked by Nurse Manager if LN #3 used excessive physical force to restrain the patient while providing care, LN #3 replied "Just enough for patient not to hurt me or bite my hand."

Record review on 9/16-17 of the NM's conversation with Patient #1's daughter, revealed when the daughter visited her mother on 8/17/20, "her mother showed her wrist that had bruises on them. . . the right wrist bruise was very noticeable and the left bruise was smaller."

On the same conversation with the daughter NM stated he "examined patient's wrist on (8/21) . . . did not see any form of bruising directly on the patients bilateral wrists."

Review of medical record from 9/3-18/20, there is no documentation that the attending physician was consulted as soon as possible after manual restraint was applied.

Based on interview with facility's Program Manager Regulatory Compliance on 9/11/20 at 3:50 pm, she stated holding patient down is a restraint without order.

Record review on 9/3-18/20 of Patient #1's medical record revealed there was no restraint order.

Review of Providence Hospital's "Restraint Management" policy on 9/4/20 at 9:45 am, revealed restraint is defined as "any a manual method, physical or mechanical device . . . that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely."

The policy also defined "Non-violent, Non self-destructive Restraint: Restraint used when the patient is demonstrating behavior that is interfering with treatment (pulling on or reaching for lines, tubes, drains, dressings . . .)" and "Violent or Self-Destructive Restraint: Restraint used to restrict patient movement due to severely aggressive, destructive, violent . . . that places the patient or others in imminent danger when non-physical interventions are not effective. The goal of the restraint is to keep the patient and others physically safe in an emergent situation."

The policy also stated that in initiation of non-violent, non-self-destructive and violent or self-destructive restraints, the "RN must obtain order from LIP (Licensed Independent Practitioner) upon application of the restraint or immediately thereafter." "Telephone orders for restrains may be accepted." "RN may enter the order in the electronic record."

The policy further stated that ". . . a physician or other LIP must see and assess or re-assess the patient . . . after restraints are applied, an assessment will be made immediately to evaluate that the restraints were applied properly and safely."


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Based on record review, interview, and document review, the facility failed to ensure that a face-to- face evaluation was conducted after the use of manual restraint for 1 patient (#1) out of 11 sampled patients. This failed practice placed the Patient at risks of harm and inappropriate care. Findings:

Record review from 9/3-18/20 of the medical record dated 8/5/20, revealed Patient #1 was brought to Emergency Department (ED) from home due to pain after fall. Patient has history of "recurrent falls, recent left hip fracture with intramedullary nailing, dementia . . . depression and chronic pain."

Further review of the medical record revealed, Patient #1 "had an in-house hospital fall. . . which resulted in a distal femoral shaft fracture." Patient #1 had "cognitive deficits," "Hard of Hearing" and had a Dx [diagnosis] [of] "Dementia."

Review of medical record on 9/13-18/20, the Nurse's "Plan of Care" dated 8/16/20 at 6:30 am signed by LN #3, revealed Patient #1 level of consciousness (LOC) was alert, orientation UTA [unable to assess] due to language barrier, confused, pulling out tubes and lines. Pt [patient] was calm and cooperative when . . . daughter was around at early shift. Slept for a while and wake up very restless, pt [patient] pulled out . . . purewick, and tried to remove . . . drain and dressings. Called daughter to asked [ask]. . . to translate what . . . [Patient #1] wants." Patient #1's daughter stated, "she is confused right now".

Record review of medical record on 9/13-18/20, revealed the Nurse's "Plan of Care" dated 8/16/20 signed by LN (#3), stated at "0630: pt [patient] was combative, kicking, biting, staff while changing her brief, needed 3 staff to attend . . . in changing."

Record review on 9/11/20 at 3:40 pm of Providence Quality/Risk Event Reviewer Form dated 8/18/20, revealed CNA #1 emailed his/her supervisor on 8/16/20 which stated the incident happened on 8/15/20 at 06:30 am. "[LN #3] entered patient's room and attempted to change . . . [Patient #1's] brief. Pt. [Patient #1] is non-English speaking . . . and staff were not using interpreter. Pt [Patient #1] was confused and started to combat due to not understanding what was happening. [LN #3] called the second RN [registered nurse], unknown and the PCT [primary care technician] to help hold the patient down. Pt. [Patient #1] tried to fight [LN #3]. [LN #3] pushed the pt.'s [Patient #1] own wrists into . . . [his/her] mouth and told . . . [his/her] to bite it instead. The pt. was still fighting and [LN #3] continued to push the pt's [Patient #1] wrist into . . . [his/her] mouth. The second RN (unknown name) used her knee to hold the pt's [Patient #1] right leg down. The RN (unknown name) continued pinning pt [Patient #1] Down to change. . . [his/her] and climbed on the bed to pin the pt's [Patient #1] arm down to . . . [his/her] chest. The whole time, they started speaking Tagolog and laughing as pt. struggled to be free. [Patient #1] started to yell 'don't do that' in English. The staff refused to acknowledge her and continued to force her down and reapply dressing onto her hemo-vac site. No one seemed to call the interpreter to explain what was happening to pt. [Patient #1]. The RN (LN #3] noted that the interpreter was not called all shift. After they finished changing . . . [his/her], they left the room. At 7:03 am, pt. [Patient #1] Started to yell . . . They made fun of . . . [him/her] and mock . . . [him/her] outside . . . [him/her] room. They continued to laugh . . . The pt. is hard of hearing and confused."

Record review on 9/16-17/20 of the Nurse Manager's (NM) investigation with CNA #1 dated 8/21/20, revealed CNA #1 stated "The Patient needed brief changed and had a hemo-vac. . ." LN #3 called her [for] help due to patient's agitation. The patient became very agitated and tried to hit LN #3, he/she then took the patient's wrist and put the wrist in the patient's mouth . . . then . . . LN #1 had her knee on the patient's leg, then . . . grabbed patient's arms on . . . [his/her] chest . . ."

During an interview with CNA #1 on 9/14/20 at 10:50 am, about the incident that happened on 8/16/20, CNA #1 stated on 8/16/20 at 6:30 am he/she was watching the monitor for Patient #1 for fall prevention. He/she had watched patient (Patient #1) couple of times. Patient #1 "had moments being confused". The incident happened after surgery. Staff tried to "change the patient". Patient #1 had been upset.

CNA #1 further stated LN #3 "put hand over patient mouth and stayed there." LN #3 told the patient to bite his/her hand. LN #1 "put her knee" to "put patient down" and continue to "pin" him/her down. LN #1 was holding patient's wrist, while holding down patient's knee. LNs #1 and #3 were speaking Tagalog and laughing. Patient #1 was screaming while changing his/her brief and dressing. The LNs (#1 and #3) were yelling and so was Patient #1. CNA # 3 came in right at the end of it. CNA #1 also stated that Patient #1 had difficulty hearing.

When asked if changing brief was an urgent care need, she responded "No", if patient was aggressive, they could "wing it" then "go back" after 30 minutes to 1 hour.

During an interview with CNA #2 on 9/14/20 at 11:22 am, about the incident that happened on 8/16/20, CNA #2 stated he/she was working with CNA #1 at the monitor studio [Telemetry]. He/she was watching a patient next to Patient #1's room. CNA #2 stated that he/she could hear Patient #1 "screaming all throughout the night", "confused", and "in pain not getting medicine."

CNA #2 further stated, CNA #1 pointed out to her and said, "look at this". They were changing him/her in the "middle of screaming." CNA #2 described that nurses were "frustrated." There were two nurses [LN #1 and #3] helping out and tech [CNA #3] went to room. They were trying to change him/her "holding down." Both nurses were "aggressive". The Primary nurse [LN #3] was "frustrated trying to get her job done."

During an interview with LN #3 on 9/14/20 at 1:59 pm, when asked about the event involving Patient #1, LN #3 explained "it was a busy night," Patient #1 was yelling, pulling IV, drain and dressing so they were preventing the Patient #1 from doing it. LN #3 also stated he/she needed to change the dressing but had run out of medipore tape. LN #3 asked the other nurse [LN #1] to help so he/she could go get the tape. LN # 1 was holding Patient #1 while LN #3 was "out not even a minute." When LN #3 was changing the brief and dressing, LN #1 was on the right side.

When asked if changing patient's brief was an urgent care need, LN #3 stated it was urgent because it was end of shift. LN #3 explained that a good team was to finish the task and not to pass it on to the next shift. Patient # 1 was soaked so LN #3 was preventing the development of pressure sore, dressing to get soaked, and infection so they made sure the patient was cleaned. LN #3 considered changing the brief as an emergency care need.

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about the incident with Patient #1 on 8/16/20, LN #1 stated Patient #1 was not his/her patient at that time. LN #1 described that Patient #1 "was combative, confused and hard of hearing." LN #1 stated LN #3 asked for her help because Patient #1 urinated and they were changing her brief. CNA #3 was not there; CNA #3 was with another patient. LNs (#1 and #3) waited for CNA #3 for few minutes but CNA #3 was still with other patient. Patient #1's brief was already removed so they changed the brief. Patient #1 "was combative," so LN #1 told LN #3 they would "hold" Patient #1's hand while LN #3 cleaned Patient #1. LN #1 also stated that Patient #1 was "soaked with [urine] up the back." LN #3 also changed the dressing. LN #1 stated if the dressing was not changed, the patient would be prone to infection and they don't want that to happen.

LN #1 stated he/she was "holding" Patient #1's two arms "with her left hand but not really tight" because Patient #1 was "old and bones are fragile."

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about definition of restraint, LN #1 stated . . . physical was for violent and non-violent. Violent restraint is used when patient was pulling IV (intravenous), NGT (nasogastric tube), and catheter . . . LN #1 also stated they "use wrist restraint" so patient could "not harm himself" and "other" or "pull catheter and IV." They use device . . . for wrist and ankle so patient will not get hurt. For non-violent restraint, LN #1 stated they "use mitten so patients could not scratch themselves."

When asked about holding Patient #1, LN #1 stated they were "just doing the right acceptable pressure, . . . it was done very quickly because they need to log roll" Patient (#1). LN #1 taught it was the "best thing to do" that time. He/she "did not consider it as a restraint" because "they did it to keep the patient from hurting them."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA # 2 dated on 8/20/20, revealed CNA #2 stated "The patient arms were on . . . [his/her] chest they had use physical force, yeah it was a little aggressive, it was rough, the patient was unable to move, the patient was so agitated, they were trying to change . . . [Patient #1] and get the job done."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA #3 dated on 8/20/20, revealed CNA #3 stated "Yes, we changed her . . . We wanted to change the patient's brief, but she's kicking and biting . . . very combative . . . LN #3 was on one side of bed, LN #1 on the other side. . . We had to hold her down, we hold her like this, LN #1 put her leg on the bed so that the patient
wouldn't kick us . . ., but didn't put her leg on the patient. . . LN #3 and LN #1 were holding . . . [Patient #1] arms and legs while we were changing . . ."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #1 dated on 8/21/20, revealed LN #1 stated LN #3 asked her help to change Patient's brief because he/she was soaked. Patient #1 was combative and hitting them both. LN #1 stated he/she "could not hold both patient's arm with one hand". LN #3 was "holding one hand" and LN #1 was "holding the right leg". LN #1 put her "knee on the bed for self-defense" so they "could change . . . [Patient]".

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #3 dated on 8/21/20, revealed LN #3 stated he/she and CNA #3 were "changing . . . [Patient's brief]" and asked LN #1 to help. He/she was holding the . . . [Patient's] hands. Patient was kicking CNA #3 while he/she was "trying to take Patient's brief." LN #1 was "holding the Patient's leg." When asked by Nurse Manager if LN #3 used excessive physical force to restrain the patient while providing care, LN #3 replied "Just enough for patient not to hurt me or bite my hand."

Record review on 9/16-17 of the NM's conversation with Patient #1's daughter, revealed when the daughter visited her mother on 8/17/20, "her mother showed her wrist that had bruises on them. . . the right wrist bruise was very noticeable and the left bruise was smaller."

On the same conversation with the daughter NM stated he "examined patient's wrist on (8/21) . . . did not see any form of bruising directly on the patients bilateral wrists."

Record Review of medical record from 9/3-18/20, there was no documentation that the attending physician was consulted as soon as possible after manual restraint was applied.

Record Review of medical record from 9/3-18/20, there was no documentation that a face to face evaluation was conducted after restraint implementation on 8/16/20 to Patient #1.

Review of Providence Hospital's "Restraint Management" policy on 9/4/20 at 9:45 am, revealed restraint is defined as "any a manual method, physical or mechanical device . . . that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely."

The policy also defined "Nonviolent, Non self-destructive Restraint: Restraint used when the patient is demonstrating behavior that is interfering with treatment (pulling on or reaching for lines, tubes, drains, dressings . . .)" and "Violent or Self-Destructive Restraint: Restraint used to restrict patient movement due to severely aggressive, destructive, violent . . . that places the patient or others in imminent danger when non-physical interventions are not effective. The goal of the restraint is to keep the patient and others physically safe in an emergent situation."

The policy also stated that in initiation of non-violent, non-self-destructive and violent or self-destructive restraints, the "RN must obtain order from LIP (Licensed Independent Practitioner) upon application of the restraint or immediately thereafter." "Telephone orders for restrains may be accepted." "RN may enter the order in the electronic record."

The policy further stated that ". . . a physician or other LIP must see and assess or re-assess the patient . . . after restraints are applied, an assessment will be made immediately to evaluate that the restraints were applied properly and safely. . . The LIP must conduct an in person a face-to-face assessment within 1 hour after a violent or self-destructive restraint application . . . evaluation addresses . . . patient's immediate situation . . . reaction to the restraint and current situation . . . comprehensive physical and psychological assessment . . . LIP face-to-face assessment is still required even if restraints were discontinued before the one hour time frame."

According to Cornel Law School Legal Information Institute. "Orders for the use of restraint or seclusion". Accessed on 9/30/20 at https://www.law.cornell.edu/cfr/text/42/483.358, revealed ". . .Within 1 hour of the initiation of the emergency safety intervention a physician, or other licensed practitioner trained in the use of emergency safety interventions . . . to assess the physical and psychological wellbeing of residents, must conduct a face-to-face assessment of the physical and psychological wellbeing of the resident . . ."


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Based on record review, interview and document review, the facility failed to ensure that intervention used was documented in the medical record when restraint was used for 1 patient (#1) out of 11 sampled patients. This failed practice placed the Patient at risks harm, inappropriate care and evaluation. Findings:

Record review from 9/3-18/20 of the medical record dated 8/5/20, revealed Patient #1 was brought to Emergency Department (ED) from home due to pain after fall. Patient has history of "recurrent falls, recent left hip fracture with intramedullary nailing, dementia . . . depression and chronic pain."

Further review of the medical record revealed, Patient #1 "had an in-house hospital fall. . . which resulted in a distal femoral shaft fracture." Patient #1 had "cognitive deficits," "Hard of Hearing" and had a Dx [diagnosis] [of] "Dementia."

Review of medical record on 9/13-18/20, the Nurse's "Plan of Care" dated 8/16/20 at 6:30 am signed by LN #3, revealed Patient #1 level of consciousness (LOC) was alert, orientation UTA [unable to assess] due to language barrier, confused, pulling out tubes and lines. Pt [patient] was calm and cooperative when . . . daughter was around at early shift. Slept for a while and wake up very restless, pt [patient] pulled out . . . purewick, and tried to remove . . . drain and dressings. Called daughter to asked [ask]. . . to translate what . . . [Patient #1] wants." Patient #1's daughter stated, "she is confused right now".

Record review of medical record on 9/13-18/20, revealed the Nurse's "Plan of Care" dated 8/16/20 signed by LN (#3), stated at "0630: pt [patient] was combative, kicking, biting, staff while changing her brief, needed 3 staff to attend . . . in changing."

Record review on 9/11/20 at 3:40 pm of Providence Quality/Risk Event Reviewer Form dated 8/18/20, revealed CNA #1 emailed his/her supervisor on 8/16/20 which stated the incident happened on 8/15/20 at 06:30 am. "[LN #3] entered patient's room and attempted to change . . . [Patient #1's] brief. Pt. [Patient #1] is non-English speaking . . . and staff were not using interpreter. Pt [Patient #1] was confused and started to combat due to not understanding what was happening. [LN #3] called the second RN [registered nurse], unknown and the PCT [primary care technician] to help hold the patient down. Pt. [Patient #1] tried to fight [LN #3]. [LN #3] pushed the pt.'s [Patient #1] own wrists into . . . [his/her] mouth and told . . . [his/her] to bite it instead. The pt. was still fighting and [LN #3] continued to push the pt's [Patient #1] wrist into . . . [his/her] mouth. The second RN (unknown name) used her knee to hold the pt's [Patient #1] right leg down. The RN (unknown name) continued pinning pt [Patient #1] Down to change. . . [his/her] and climbed on the bed to pin the pt's [Patient #1] arm down to . . . [his/her] chest. The whole time, they started speaking Tagolog and laughing as pt. struggled to be free. [Patient #1] started to yell 'don't do that' in English. The staff refused to acknowledge her and continued to force her down and reapply dressing onto her hemo-vac site. No one seemed to call the interpreter to explain what was happening to pt. [Patient #1]. The RN (LN #3] noted that the interpreter was not called all shift. After they finished changing . . . [his/her], they left the room. At 7:03 am, pt. [Patient #1] Started to yell . . . They made fun of . . . [him/her] and mock . . . [him/her] outside . . . [him/her] room. They continued to laugh . . . The pt. is hard of hearing and confused."

Record review on 9/16-17/20 of the Nurse Manager's (NM) investigation with CNA #1 dated 8/21/20, revealed CNA #1 stated "The Patient needed brief changed and had a hemo-vac. . ." LN #3 called her [for] help due to patient's agitation. The patient became very agitated and tried to hit LN #3, he/she then took the patient's wrist and put the wrist in the patient's mouth . . . then . . . LN #1 had her knee on the patient's leg, then . . . grabbed patient's arms on . . . [his/her] chest . . ."

During an interview with CNA #1 on 9/14/20 at 10:50 am, about the incident that happened on 8/16/20, CNA #1 stated on 8/16/20 at 6:30 am he/she was watching the monitor for Patient #1 for fall prevention. He/she had watched patient (Patient #1) couple of times. Patient #1 "had moments being confused". The incident happened after surgery. Staff tried to "change the patient". Patient #1 had been upset.

CNA #1 further stated LN #3 "put hand over patient mouth and stayed there." LN #3 told the patient to bite his/her hand. LN #1 "put her knee" to "put patient down" and continue to "pin" him/her down. LN #1 was holding patient's wrist, while holding down patient's knee. LNs #1 and #3 were speaking Tagalog and laughing. Patient #1 was screaming while changing his/her brief and dressing. The LNs (#1 and #3) were yelling and so was Patient #1. CNA # 3 came in right at the end of it. CNA #1 also stated that Patient #1 had difficulty hearing.

When asked if changing brief was an urgent care need, she responded "No", if patient was aggressive, they could "wing it" then "go back" after 30 minutes to 1 hour.

During an interview with CNA #2 on 9/14/20 at 11:22 am, about the incident that happened on 8/16/20, CNA #2 stated he/she was working with CNA #1 at the monitor studio [Telemetry]. He/she was watching a patient next to Patient #1's room. CNA #2 stated that he/she could hear Patient #1 "screaming all throughout the night", "confused", and "in pain not getting medicine."

CNA #2 further stated, CNA #1 pointed out to her and said, "look at this". They were changing him/her in the "middle of screaming." CNA #2 described that nurses were "frustrated." There were two nurses [LN #1 and #3] helping out and tech [CNA #3] went to room. They were trying to change him/her "holding down." Both nurses were "aggressive". The Primary nurse [LN #3] was "frustrated trying to get her job done."

During an interview with LN #3 on 9/14/20 at 1:59 pm, when asked about the event involving Patient #1, LN #3 explained "it was a busy night," Patient #1 was yelling, pulling IV, drain and dressing so they were preventing the Patient #1 from doing it. LN #3 also stated he/she needed to change the dressing but had run out of medipore tape. LN #3 asked the other nurse [LN #1] to help so he/she could go get the tape. LN # 1 was holding Patient #1 while LN #3 was "out not even a minute." When LN #3 was changing the brief and dressing, LN #1 was on the right side.

When asked if changing patient's brief was an urgent care need, LN #3 stated it was urgent because it was end of shift. LN #3 explained that a good team was to finish the task and not to pass it on to the next shift. Patient # 1 was soaked so LN #3 was preventing the development of pressure sore, dressing to get soaked, and infection so they made sure the patient was cleaned. LN #3 considered changing the brief as an emergency care need.

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about the incident with Patient #1 on 8/16/20, LN #1 stated Patient #1 was not his/her patient at that time. LN #1 described that Patient #1 "was combative, confused and hard of hearing." LN #1 stated LN #3 asked for her help because Patient #1 urinated and they were changing her brief. CNA #3 was not there; CNA #3 was with another patient. LNs (#1 and #3) waited for CNA #3 for few minutes but CNA #3 was still with other patient. Patient #1's brief was already removed so they changed the brief. Patient #1 "was combative," so LN #1 told LN #3 they would "hold" Patient #1's hand while LN #3 cleaned Patient #1. LN #1 also stated that Patient #1 was "soaked with [urine] up the back." LN #3 also changed the dressing. LN #1 stated if the dressing was not changed, the patient would be prone to infection and they don't want that to happen.

LN #1 stated he/she was "holding" Patient #1's two arms "with her left hand but not really tight" because Patient #1 was "old and bones are fragile."

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about definition of restraint, LN #1 stated . . . physical was for violent and non-violent. Violent restraint is used when patient was pulling IV (intravenous), NGT (nasogastric tube), and catheter . . . LN #1 also stated they "use wrist restraint" so patient could "not harm himself" and "other" or "pull catheter and IV." They use device . . . for wrist and ankle so patient will not get hurt. For non-violent restraint, LN #1 stated they "use mitten so patients could not scratch themselves."

When asked about holding Patient #1, LN #1 stated they were "just doing the right acceptable pressure, . . . it was done very quickly because they need to log roll" Patient (#1). LN #1 taught it was the "best thing to do" that time. He/she "did not consider it as a restraint" because "they did it to keep the patient from hurting them."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA # 2 dated on 8/20/20, revealed CNA #2 stated "The patient arms were on . . . [his/her] chest they had use physical force, yeah it was a little aggressive, it was rough, the patient was unable to move, the patient was so agitated, they were trying to change . . . [Patient #1] and get the job done."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA #3 dated on 8/20/20, revealed CNA #3 stated "Yes, we changed her . . . We wanted to change the patient's brief, but she's kicking and biting . . . very combative . . . LN #3 was on one side of bed, LN #1 on the other side. . . We had to hold her down, we hold her like this, LN #1 put her leg on the bed so that the patient
wouldn't kick us . . ., but didn't put her leg on the patient. . . LN #3 and LN #1 were holding . . . [Patient #1] arms and legs while we were changing . . ."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #1 dated on 8/21/20, revealed LN #1 stated LN #3 asked her help to change Patient's brief because he/she was soaked. Patient #1 was combative and hitting them both. LN #1 stated he/she "could not hold both patient's arm with one hand". LN #3 was "holding one hand" and LN #1 was "holding the right leg". LN #1 put her "knee on the bed for self-defense" so they "could change . . . [Patient]".

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #3 dated on 8/21/20, revealed LN #3 stated he/she and CNA #3 were "changing . . . [Patient's brief]" and asked LN #1 to help. He/she was holding the . . . [Patient's] hands. Patient was kicking CNA #3 while he/she was "trying to take Patient's brief." LN #1 was "holding the Patient's leg." When asked by Nurse Manager if LN #3 used excessive physical force to restrain the patient while providing care, LN #3 replied "Just enough for patient not to hurt me or bite my hand."

Record review of medical record on 9/13-18/20, the Nurse's "Plan of Care" dated 8/16/20 at 6:30 am, LN #3 noted Patient's behavior when changing brief and dressing and needed 3 staff to help but did not described the intervention used to Patient #1.

Document review on 9/4/20 at 9:45 am of the facility's "Restraint Management" policy dated 12/2019, , revealed "The RN documents . . . a description of the patient's behavior and intervention used."

Document review on 9/17/20 of facility's "Restraint Management" training on alternatives to Non-violent restraints, ". . .Document alternatives attempted and the patient's response."

According to American Nurses ANA Official Journal. "Assessing and documenting patient restraint incidents". 2015. Accessed on 9/30/20 https://www.myamericannurse.com/assessment-documentation/, revealed "Accurate documentation of the restraint episode is vital to safe, effective patient care and provides information that can improve the quality of care. Document the reason for restraint and that you explained the reason to the patient and family. . . flowsheet should include the following: patient behavior . . . mental status . . .type of restraints used . . .condition of extremities, including circulation and sensation . . ."



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Based on record review, interview, and document review the facility failed to ensure there was documentation in the medical record that alternatives and less restrictive interventions were not effective before restraint was used for 1 patient (#1) out of 11 sampled patients. This failed practice placed the Patient at risks of harm, inappropriate care, and psychological effects. Findings:

Record review from 9/3-18/20 of the medical record dated 8/5/20, revealed Patient #1 was brought to Emergency Department (ED) from home due to pain after fall. Patient has history of "recurrent falls, recent left hip fracture with intramedullary nailing, dementia . . . depression and chronic pain."

Further review of the medical record revealed, Patient #1 "had an in-house hospital fall. . . which resulted in a distal femoral shaft fracture." Patient #1 had "cognitive deficits," "Hard of Hearing" and had a Dx [diagnosis] [of] "Dementia."

Review of medical record on 9/13-18/20, the Nurse's "Plan of Care" dated 8/16/20 at 6:30 am signed by LN #3, revealed Patient #1 level of consciousness (LOC) was alert, orientation UTA [unable to assess] due to language barrier, confused, pulling out tubes and lines. Pt [patient] was calm and cooperative when . . . daughter was around at early shift. Slept for a while and wake up very restless, pt [patient] pulled out . . . purewick, and tried to remove . . . drain and dressings. Called daughter to asked [ask]. . . to translate what . . . [Patient #1] wants." Patient #1's daughter stated, "she is confused right now".

Record review of medical record on 9/13-18/20, revealed the Nurse's "Plan of Care" dated 8/16/20 signed by LN (#3), stated at "0630: pt [patient] was combative, kicking, biting, staff while changing her brief, needed 3 staff to attend . . . in changing."

Record review on 9/11/20 at 3:40 pm of Providence Quality/Risk Event Reviewer Form dated 8/18/20, revealed CNA #1 emailed his/her supervisor on 8/16/20 which stated the incident happened on 8/15/20 at 06:30 am. "[LN #3] entered patient's room and attempted to change . . . [Patient #1's] brief. Pt. [Patient #1] is non-English speaking . . . and staff were not using interpreter. Pt [Patient #1] was confused and started to combat due to not understanding what was happening. [LN #3] called the second RN [registered nurse], unknown and the PCT [primary care technician] to help hold the patient down. Pt. [Patient #1] tried to fight [LN #3]. [LN #3] pushed the pt.'s [Patient #1] own wrists into . . . [his/her] mouth and told . . . [his/her] to bite it instead. The pt. was still fighting and [LN #3] continued to push the pt's [Patient #1] wrist into . . . [his/her] mouth. The second RN (unknown name) used her knee to hold the pt's [Patient #1] right leg down. The RN (unknown name) continued pinning pt [Patient #1] Down to change. . . [his/her] and climbed on the bed to pin the pt's [Patient #1] arm down to . . . [his/her] chest. The whole time, they started speaking Tagolog and laughing as pt. struggled to be free. [Patient #1] started to yell 'don't do that' in English. The staff refused to acknowledge her and continued to force her down and reapply dressing onto her hemo-vac site. No one seemed to call the interpreter to explain what was happening to pt. [Patient #1]. The RN (LN #3] noted that the interpreter was not called all shift. After they finished changing . . . [his/her], they left the room. At 7:03 am, pt. [Patient #1] Started to yell . . . They made fun of . . . [him/her] and mock . . . [him/her] outside . . . [him/her] room. They continued to laugh . . . The pt. is hard of hearing and confused."

Record review on 9/16-17/20 of the Nurse Manager's (NM) investigation with CNA #1 dated 8/21/20, revealed CNA #1 stated "The Patient needed brief changed and had a hemo-vac . . ." LN #3 called her [for] help due to patient's agitation. The patient became very agitated and tried to hit LN #3, he/she then took the patient's wrist and put the wrist in the patient's mouth . . . then . . . LN #1 had her knee on the patient's leg, then . . . grabbed patient's arms on . . . [his/her] chest . . ."

During an interview with CNA #1 on 9/14/20 at 10:50 am, about the incident that happened on 8/16/20, CNA #1 stated on 8/16/20 at 6:30 am he/she was watching the monitor for Patient #1 for fall prevention. He/she had watched patient (Patient #1) couple of times. Patient #1 "had moments being confused". The incident happened after surgery. Staff tried to "change the patient". Patient #1 had been upset.

CNA #1 further stated LN #3 "put hand over patient mouth and stayed there." LN #3 told the patient to bite his/her hand. LN #1 "put her knee" to "put patient down" and continue to "pin" him/her down. LN #1 was holding patient's wrist, while holding down patient's knee. LNs #1 and #3 were speaking Tagalog and laughing. Patient #1 was screaming while changing his/her brief and dressing. The LNs (#1 and #3) were yelling and so was Patient #1. CNA # 3 came in right at the end of it. CNA #1 also stated that Patient #1 had difficulty hearing.

When asked if changing brief was an urgent care need, she responded "No", if patient was aggressive, they could "wing it" then "go back" after 30 minutes to 1 hour.

During an interview with CNA #2 on 9/14/20 at 11:22 am, about the incident that happened on 8/16/20, CNA #2 stated he/she was working with CNA #1 at the monitor studio [Telemetry]. He/she was watching a patient next to Patient #1's room. CNA #2 stated that he/she could hear Patient #1 "screaming all throughout the night", "confused", and "in pain not getting medicine."

CNA #2 further stated, CNA #1 pointed out to her and said, "look at this". They were changing him/her in the "middle of screaming." CNA #2 described that nurses were "frustrated." There were two nurses [LN #1 and #3] helping out and tech [CNA #3] went to room. They were trying to change him/her "holding down." Both nurses were "aggressive". The Primary nurse [LN #3] was "frustrated trying to get her job done."

During an interview with LN #3 on 9/14/20 at 1:59 pm, when asked about the event involving Patient #1, LN #3 further explained "it was a busy night," Patient #1 was yelling, pulling IV, drain and dressing so they were preventing the Patient #1 from doing it. LN #3 also stated he/she needed to change the dressing but had run out of medipore tape. LN #3 asked the other nurse [LN #1] to help so he/she could go get the tape. LN # 1 was holding Patient #1 while LN #3 was "out not even a minute." When LN #3 was changing the brief and dressing, LN #1 was on the right side.

When asked if changing patient's brief was an urgent care need, LN #3 stated it was urgent because it was end of shift. LN #3 explained that a good team was to finish the task and not to pass it on to the next shift. Patient # 1 was soaked so LN #3 was preventing the development of pressure sore, dressing to get soaked, and infection so they made sure the patient was cleaned. LN #3 considered changing the brief as an emergency care need.

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about the incident with Patient #1 on 8/16/20, LN #1 stated Patient #1 was not his/her patient at that time. LN #1 described that Patient #1 "was combative, confused and hard of hearing." LN #1 stated LN #3 asked for her help because Patient #1 urinated and they were changing her brief. CNA #3 was not there; CNA #3 was with another patient. LNs (#1 and #3) waited for CNA #3 for few minutes but CNA #3 was still with other patient. Patient #1's brief was already removed so they changed the brief. Patient #1 "was combative," so LN #1 told LN #3 they would "hold" Patient #1's hand while LN #3 cleaned Patient #1. LN #1 also stated that Patient #1 was "soaked with [urine] up the back." LN #3 also changed the dressing. LN #1 stated if the dressing was not changed, the patient would be prone to infection and they don't want that to happen.

LN #1 stated he/she was "holding" Patient #1's two arms "with her left hand but not really tight" because Patient #1 was "old and bones are fragile."

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about definition of restraint, LN #1 stated . . . physical was for violent and non-violent. Violent restraint is used when patient was pulling IV (intravenous), NGT (nasogastric tube), and catheter . . . LN #1 also stated they "use wrist restraint" so patient could "not harm himself" and "other" or "pull catheter and IV." They use device . . . for wrist and ankle so patient will not get hurt. For non-violent restraint, LN #1 stated they "use mitten so patients could not scratch themselves."

When asked about holding Patient #1, LN #1 stated they were "just doing the right acceptable pressure, . . . it was done very quickly because they need to log roll" Patient (#1). LN #1 taught it was the "best thing to do" that time. He/she "did not consider it as a restraint" because "they did it to keep the patient from hurting them."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA # 2 dated on 8/20/20, revealed CNA #2 stated "The patient arms were on . . . [his/her] chest they had use physical force, yeah it was a little aggressive, it was rough, the patient was unable to move, the patient was so agitated, they were trying to change . . . [Patient #1] and get the job done."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA #3 dated on 8/20/20, revealed CNA #3 stated "Yes, we changed her . . . We wanted to change the patient's brief, but she's kicking and biting . . . very combative . . . LN #3 was on one side of bed, LN #1 on the other side. . . We had to hold her down, we hold her like this, LN #1 put her leg on the bed so that the patient
wouldn't kick us . . ., but didn't put her leg on the patient. . . LN #3 and LN #1 were holding . . . [Patient #1] arms and legs while we were changing . . ."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #1 dated on 8/21/20, revealed LN #1 stated LN #3 asked her help to change Patient's brief because he/she was soaked. Patient #1 was combative and hitting them both. LN #1 stated he/she "could not hold both patient's arm with one hand". LN #3 was "holding one hand" and LN #1 was "holding the right leg". LN #1 put her "knee on the bed for self-defense" so they "could change . . . [Patient]".

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #3 dated on 8/21/20, revealed LN #3 stated he/she and CNA #3 were "changing . . . [Patient's brief]" and asked LN #1 to help. He/she was holding the . . . [Patient's] hands. Patient was kicking CNA #3 while he/she was "trying to take Patient's brief." LN #1 was "holding the Patient's leg." When asked by Nurse Manager if LN #3 used excessive physical force to restrain the patient while providing care, LN #3 replied "Just enough for patient not to hurt me or bite my hand."

Record review of the medical record from 9/3-18/20, there was no documentation showing a least restrictive intervention was not effective.

Document review on 9/4/20 at 9:45 am of the facility's "Restraint Management" policy on 9/4/20 at 9:45 am, revealed restraint is defined as "any manual method, physical or mechanical device . . . that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely."

The policy also defined "Nonviolent, Non self-destructive Restraint: Restraint used when the patient is demonstrating behavior that is interfering with treatment (pulling on or reaching for lines, tubes, drains, dressings . . .)" and "Violent or Self-Destructive Restraint: Restraint used to restrict patient movement due to severely aggressive, destructive, violent . . . that places the patient or others in imminent danger when non-physical interventions are not effective. The goal of the restraint is to keep the patient and others physically safe in an emergent situation."

Document review on 9/4/20 at 9:45 am of the facility's "Restraint Management" policy dated 12/2019, revealed less restrictive means is a "method that restricts the patient's movement the least (e.g. A mitt is less restrictive than a two-point wrist restraint)."

The policy further stated "At all times, the least restrictive intervention for the safety of the patient is used. The following is a list of restraint types used at PAMC (Providence Alaska Medical Center) from less restrictive to most restrictive . . . Four side rails, Mitts, Secure Sleeve Protector, Posey bed, Posey vest, Omni belt . . . Soft limb, Spit hood, Posey twice as tough cuff."

Document review on 9/11/20 of facility's Restraint Management policy dated 12/2019, revealed "The RN documents . . . Alternatives or other less restrictive interventions attempted."

Document review on 9/17/20 at of facility's Restraint Management training, revealed on non-violent and violent restraints, "Alternatives must be attempted first . . . and deemed ineffective before a restraint is initiated. Document alternatives attempted and the patient's response." It further revealed, for application of restraint, "A staff RN trained in the use of restraints may initiate restraints when all alternatives have been attempted or considered and deemed insufficient."

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Based on record review, interview and document review, the facility failed to document in the medical record the response to restraint of 1 patient (#1) out of 11 sampled patients. This failed practice placed the Patient at risks of harm, inappropriate care and evaluation. Findings:

Record review from 9/3-18/20 of the medical record dated 8/5/20, revealed Patient #1 was brought to Emergency Department (ED) from home due to pain after fall. Patient has history of "recurrent falls, recent left hip fracture with intramedullary nailing, dementia . . . depression and chronic pain."

Further review of the medical record revealed, Patient #1 "had an in-house hospital fall. . . which resulted in a distal femoral shaft fracture." Patient #1 had "cognitive deficits," "Hard of Hearing" and had a Dx [diagnosis] [of] "Dementia."

Review of medical record on 9/13-18/20, the Nurse's "Plan of Care" dated 8/16/20 at 6:30 am signed by LN #3, revealed Patient #1 level of consciousness (LOC) was alert, orientation UTA [unable to assess] due to language barrier, confused, pulling out tubes and lines. Pt [patient] was calm and cooperative when . . . daughter was around at early shift. Slept for a while and wake up very restless, pt [patient] pulled out . . . purewick, and tried to remove . . . drain and dressings. Called daughter to asked [ask]. . . to translate what . . . [Patient #1] wants." Patient #1's daughter stated, "she is confused right now".

Record review of medical record on 9/13-18/20, revealed the Nurse's "Plan of Care" dated 8/16/20 signed by LN (#3), stated at "0630: pt [patient] was combative, kicking, biting, staff while changing her brief, needed 3 staff to attend . . . in changing."

Record review on 9/11/20 at 3:40 pm of Providence Quality/Risk Event Reviewer Form dated 8/18/20, revealed CNA #1 emailed his/her supervisor on 8/16/20 which stated the incident happened on 8/15/20 at 06:30 am. "[LN #3] entered patient's room and attempted to change . . . [Patient #1's] brief. Pt. [Patient #1] is non-English speaking . . . and staff were not using interpreter. Pt [Patient #1] was confused and started to combat due to not understanding what was happening. [LN #3] called the second RN [registered nurse], unknown and the PCT [primary care technician] to help hold the patient down. Pt. [Patient #1] tried to fight [LN #3]. [LN #3] pushed the pt.'s [Patient #1] own wrists into . . . [his/her] mouth and told . . . [his/her] to bite it instead. The pt. was still fighting and [LN #3] continued to push the pt's [Patient #1] wrist into . . . [his/her] mouth. The second RN (unknown name) used her knee to hold the pt's [Patient #1] right leg down. The RN (unknown name) continued pinning pt [Patient #1] Down to change. . . [his/her] and climbed on the bed to pin the pt's [Patient #1] arm down to . . . [his/her] chest. The whole time, they started speaking Tagolog and laughing as pt. struggled to be free. [Patient #1] started to yell 'don't do that' in English. The staff refused to acknowledge her and continued to force her down and reapply dressing onto her hemo-vac site. No one seemed to call the interpreter to explain what was happening to pt. [Patient #1]. The RN (LN #3] noted that the interpreter was not called all shift. After they finished changing . . . [his/her], they left the room. At 7:03 am, pt. [Patient #1] Started to yell . . . They made fun of . . . [him/her] and mock . . . [him/her] outside . . . [him/her] room. They continued to laugh . . . The pt. is hard of hearing and confused."

Record review on 9/16-17/20 of the Nurse Manager's (NM) investigation with CNA #1 dated 8/21/20, revealed CNA #1 stated "The Patient needed brief changed and had a hemo-vac . . ." LN #3 called her [for] help due to patient's agitation. The patient became very agitated and tried to hit LN #3, he/she then took the patient's wrist and put the wrist in the patient's mouth . . . then . . . LN #1 had her knee on the patient's leg, then . . . grabbed patient's arms on . . . [his/her] chest . . ."

During an interview with CNA #1 on 9/14/20 at 10:50 am, about the incident that happened on 8/16/20, CNA #1 stated on 8/16/20 at 6:30 am he/she was watching the monitor for Patient #1 for fall prevention. He/she had watched patient (Patient #1) couple of times. Patient #1 "had moments being confused". The incident happened after surgery. Staff tried to "change the patient". Patient #1 had been upset.

CNA #1 further stated LN #3 "put hand over patient mouth and stayed there." LN #3 told the patient to bite his/her hand. LN #1 "put her knee" to "put patient down" and continue to "pin" him/her down. LN #1 was holding patient's wrist, while holding down patient's knee. LNs #1 and #3 were speaking Tagalog and laughing. Patient #1 was screaming while changing his/her brief and dressing. The LNs (#1 and #3) were yelling and so was Patient #1. CNA # 3 came in right at the end of it. CNA #1 also stated that Patient #1 had difficulty hearing.

When asked if changing brief was an urgent care need, she responded "No", if patient was aggressive, they could "wing it" then "go back" after 30 minutes to 1 hour.

During an interview with CNA #2 on 9/14/20 at 11:22 am, about the incident that happened on 8/16/20, CNA #2 stated he/she was working with CNA #1 at the monitor studio [Telemetry]. He/she was watching a patient next to Patient #1's room. CNA #2 stated that he/she could hear Patient #1 "screaming all throughout the night", "confused", and "in pain not getting medicine."

CNA #2 further stated, CNA #1 pointed out to her and said, "look at this". They were changing him/her in the "middle of screaming." CNA #2 described that nurses were "frustrated." There were two nurses [LN #1 and #3] helping out and tech [CNA #3] went to room. They were trying to change him/her "holding down." Both nurses were "aggressive". The Primary nurse [LN #3] was "frustrated trying to get her job done."

During an interview with LN #3 on 9/14/20 at 1:59 pm, when asked about the event involving Patient #1, LN #3 explained "it was a busy night," Patient #1 was yelling, pulling IV, drain and dressing so they were preventing the Patient #1 from doing it. LN #3 also stated he/she needed to change the dressing but had run out of medipore tape. LN #3 asked the other nurse [LN #1] to help so he/she could go get the tape. LN # 1 was holding Patient #1 while LN #3 was "out not even a minute." When LN #3 was changing the brief and dressing, LN #1 was on the right side.

When asked if changing patient's brief was an urgent care need, LN #3 stated it was urgent because it was end of shift. LN #3 explained that a good team was to finish the task and not to pass it on to the next shift. Patient # 1 was soaked so LN #3 was preventing the development of pressure sore, dressing to get soaked, and infection so they made sure the patient was cleaned. LN #3 considered changing the brief as an emergency care need.

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about the incident with Patient #1 on 8/16/20, LN #1 stated Patient #1 was not his/her patient at that time. LN #1 described that Patient #1 "was combative, confused and hard of hearing." LN #1 stated LN #3 asked for her help because Patient #1 urinated and they were changing her brief. CNA #3 was not there; CNA #3 was with another patient. LNs (#1 and #3) waited for CNA #3 for few minutes but CNA #3 was still with other patient. Patient #1's brief was already removed so they changed the brief. Patient #1 "was combative," so LN #1 told LN #3 they would "hold" Patient #1's hand while LN #3 cleaned Patient #1. LN #1 also stated that Patient #1 was "soaked with [urine] up the back." LN #3 also changed the dressing. LN #1 stated if the dressing was not changed, the patient would be prone to infection and they don't want that to happen.

LN #1 stated he/she was "holding" Patient #1's two arms "with her left hand but not really tight" because Patient #1 was "old and bones are fragile."

During an interview with LN #1 on 9/15/20 at 9:05 am, when asked about definition of restraint, LN #1 stated . . . physical was for violent and non-violent. Violent restraint is used when patient was pulling IV (intravenous), NGT (nasogastric tube), and catheter . . . LN #1 also stated they "use wrist restraint" so patient could "not harm himself" and "other" or "pull catheter and IV." They use device . . . for wrist and ankle so patient will not get hurt. For non-violent restraint, LN #1 stated they "use mitten so patients could not scratch themselves."

When asked about holding Patient #1, LN #1 stated they were "just doing the right acceptable pressure, . . . it was done very quickly because they need to log roll" Patient (#1). LN #1 taught it was the "best thing to do" that time. He/she "did not consider it as a restraint" because "they did it to keep the patient from hurting them."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA # 2 dated on 8/20/20, revealed CNA #2 stated "The patient arms were on . . . [his/her] chest they had use physical force, yeah it was a little aggressive, it was rough, the patient was unable to move, the patient was so agitated, they were trying to change . . . [Patient #1] and get the job done."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with CNA #3 dated on 8/20/20, revealed CNA #3 stated "Yes, we changed her . . . We wanted to change the patient's brief, but she's kicking and biting . . . very combative . . . LN #3 was on one side of bed, LN #1 on the other side. . . We had to hold her down, we hold her like this, LN #1 put her leg on the bed so that the patient
wouldn't kick us . . ., but didn't put her leg on the patient. . . LN #3 and LN #1 were holding . . . [Patient #1] arms and legs while we were changing . . ."

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #1 dated on 8/21/20, revealed LN #1 stated LN #3 asked her help to change Patient's brief because he/she was soaked. Patient #1 was combative and hitting them both. LN #1 stated he/she "could not hold both patient's arm with one hand". LN #3 was "holding one hand" and LN #1 was "holding the right leg". LN #1 put her "knee on the bed for self-defense" so they "could change . . . [Patient]".

Record review on 9/16-17/20 of the Nurse Manager's investigation interview with LN #3 dated on 8/21/20, revealed LN #3 stated he/she and CNA #3 were "changing . . . [Patient's brief]" and asked LN #1 to help. He/she was holding the . . . [Patient's] hands. Patient was kicking CNA #3 while he/she was "trying to take Patient's brief." LN #1 was "holding the Patient's leg." When asked by Nurse Manager if LN #3 used excessive physical force to restrain the patient while providing care, LN #3 replied "Just enough for patient not to hurt me or bite my hand."

Document review on 9/11/20 of facility's Restraint Management policy dated 12/2019, revealed "The RN documents . . . The patient's response to the intervention used . . ."

Document review on 9/17/20 at ____of facility's Restraint Management training documentation of violent restraints for RNs, revealed ". . . Assessment at start, discontinuation . . .RN to assess and document minimum Q(every)2Hours."


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