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Based on document review and interview, it was determined that for 1 of 10 clinical records (Pt #1) reviewed for nonviolent restraints, the Hospital failed to ensure a less restrictive intervention was attempted prior to placing Pt #1 in an enclosure bed (nonviolent restraint).

Findings include:

1. On 1/5/2022, the Hospital's policy titled, "Restraint Use-Violent/Self Destructive Behavior and Nonviolent/Non-Self-Destructive Behavior" (July 2021) was reviewed and required, "Restraints are used only when clinically justified or warranted by patient behavior that threatens the immediate physical safety of patient/staff/others, and nonphysical or less restrictive interventions are ineffective or not viable...The use of restraint will be implemented in the least restrictive, safe and appropriate manner possible..."

2. On 1/5/2022, Pt #1's clinical record (dated 12/6/2021 to 12/26/2021) was reviewed and indicated:
-Pt #1 was admitted to the Hospital on 12/6/2021 with the diagnosis of dementia and dehydration.
-Pt #1 was placed on a nonviolent restraint (enclosure bed) on 12/7/2021 without any attempts at a less restrictive intervention.

3. On 1/5/2022 at 10:00 AM, an interview was conducted with the Director of Quality ( E#3). E #3 stated that there was no less restrictive intervention applied to Pt #1.

Based on document review and interview, it was determined that for 1 of 10 clinical records (Pt #1) reviewed for nonviolent restraints, the Hospital failed to ensure a less restrictive intervention was utilized to protect Pt #1 or others from harm.

Findings include:

1. On 1/5/2022, the Hospital's policy titled, "Restraint Use-Violent/Self Destructive Behavior and Nonviolent/Non-Self-Destructive Behavior" (July 2021) was reviewed and required, "Restraints are used only when clinically justified or warranted by patient behavior that threatens the immediate physical safety of patient/staff/others, and nonphysical or less restrictive interventions are ineffective or not viable...The use of restraint will be implemented in the least restrictive, safe and appropriate manner possible..."

2. On 1/5/2022, Pt #1's clinical record (dated 12/6/2021 to 12/26/2021) was reviewed and indicated:
-Pt #1 was admitted to the Hospital on 12/6/2021 with the diagnosis of dementia and dehydration.
-Pt #1 was placed on a nonviolent restraint (enclosure bed) on 12/7/2021 without any attempts at a less restrictive intervention.

3. On 1/5/2022 at 10:00 AM, an interview was conducted with the Director of Quality ( E#3). E #3 stated that there was no less restrictive intervention applied to Pt #1.

Based on document review and interview, it was determined that for 2 of 10 clinical records (Pts. #1 & #2) reviewed for nonviolent/non self destructive restraints, the Hospital failed to ensure that physician orders were obtained every 24 hours, as required.

Findings include:

1. On 1/3/2022, the Hospital's policy titled, "Restraint Use -Violent/Self-Destructive Behavior and Nonviolent Non-Self Destructive Behavior" (revised July 2021) was reviewed and required, "Nonviolent/Non-Self-Destructive Restraint Orders...Orders are good for 24 hours..."

2. On 1/3/2022, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 12/6/2021 with a diagnosis of urinary tract infection and dementia. On 1/3/2022, Pt #1's physician orders dated 12/6/2021 thru 12/26/2021 were reviewed and indicated:

-Restraint orders for "Restraint nonviolent bed enclosure" dated 12/7/2021 thru 12/15/2021

-Restraint order for "Restraint nonviolent bed enclosure" dated 12/19/2021 thru 12/24/2021 and then on 12/26/2021.

There was no order for the restraint nonviolent bed enclosure on 12/16/2021, 12/17/2021, 12/18/2021 and 12/25/2021, even though Pt. #1 was in restraints on those days.

3. On 1/3/2022, Pt. #2's clinical record was reviewed. Pt. #2 was admitted on 12/7/2021 with a diagnoses of encephalopathy (brain disease) and delirium (confused thinking). Pt. #2 had a restraint order dated 12/31/2021 at 10:00 AM, for "non violent restraints for 1 day". A subsequent restraint order was dated 1/1/2022 at 11:06 PM, 1 day and 13 hours later, for "non violent restraints for 1 day". Pt. #2's restraint flow sheet indicated that Pt. #2 was in restraints for 13 hours without an order.

4. On 1/3/2022 at 11:45 AM, an interview regarding Pt. #1 was conducted with the Team Leader for 45 South (E #1). E #1 stated that an order for an enclosure bed should be obtained from a physician every day.

5. On 1/4/2022 at 9:25 AM, an interview regarding Pt. #2 was conducted with the Quality Manager (E #3). E #3 stated she did not know why the Physician's restraint order was not renewed on a timely basis.

Based on document review and interview, it was determined that for 5 of 10 clinical records (Pts. #1, #2, #5, #9, ) reviewed for restraints, the Hospital failed to ensure that staff monitored patients in non-violent restraints every two hours, as required.

Findings include:

1. On 1/3/2022, the Hospital's policy titled, "Restraint Use -Violent/Self Destructive Behavior and Nonviolent/Non Self-Destructive Behavior" (revised July 2021) was reviewed and required, "Nonviolent/Non-self-destructive patient monitoring - Monitoring of the patient's behavior and physical needs/status is conducted and documented at least every 2 hours... The reassessment shall include - physical/psychosocial well being, respiratory and circulatory status, skin integrity, range of motion... Restraint type - Enclosure bed (net bed that prevents the patient from freely exiting the bed is considered a restraint) - observations skin, behavior, vital signs, interventions every 2 hours and bed safety check..."

2. On 1/3/2022, Pt #1's clinical record dated 12/6/2021 thru 12/26/2021 was reviewed and indicated:

- Pt #1 was admitted to the hospital on 12/6/2021, with the diagnosis of dementia.

- Pt #1's flowsheets dated 12/7/2021 thru 12/26/2021 noted that Pt #1 was in an enclosure bed from 12/7/2021 thru 12/26/2021.

- Pt #1's "Restraint Monitoring Flowsheets" dated 12/6/2021 thru 12/26/2021 noted lack of every 2 hour monitoring on the following dates and times:

- 12/7/2021 from 3:00 PM to 8:00 PM (5 hours) not the required every 2 hours.

- 12/12/2021 from 1:00 AM to 4:00 AM (3 hours) not the required every 2 hours.

- 12/16/2021 from 3:00 PM to 11:00 PM (8 hours) not the required every 2 hours.

- 12/16/2021 from 11:00 PM to 6:58 AM on 12/17/2021 (7 hours and 58 minutes - not the required every 2 hours).

- 12/17/2021 from 3:00 PM to 6:14 PM (3 hours and 14 minutes - not the required every 2 hours).

- 12/17/2021 from 6:14 PM to 11:00 PM (4 hours and 46 minutes - not the required every 2 hours).

- 12/19/2021 from 2:00 PM to 6:00 PM (4 hours) not the required every 2 hours.

- 12/20/2021 from 3:00 PM to 9:15 PM (6 hours and 15 minutes - not the required every 2 hours).

3. On 1/3/2022, Pt. #2's clinical record was reviewed. Pt. #2 was admitted on 12/7/2021 with a diagnoses of encephalopathy (brain disease) and delirium (confused thinking).

- Pt. #2 had a restraint order dated 12/31/2021 at 10:00 AM, for "non violent restraints for 1 day", which included soft restraints to bilateral wrists, right ankle, mittens, and bed siderails up x 4.

- Pt. #2's restraint monitoring flowsheets lacked documentation of care and assessment every 2 hours on 12/31/2021 between 2:00 PM and 7:00 PM, for 5 hours.

4. On 1/3/2022, Pt. #5's clinical record was reviewed. Pt. #5 was admitted on 12/14/2021 with a diagnosis of acute cholecystitis (inflammation of gallbladder).

- Pt. #5 had a restraint order dated 12/19/2021 at 7:57 PM, for "non violent bed enclosure".

- Pt. #5's restraint monitoring flowsheets lacked documentation of care and assessment every 2 hours on 12/19/2021 between 8:00 PM and 12/20/2021, 8:00 AM, for 12 hours.

5. On 1/3/2022, Pt. #9's clinical record was reviewed. Pt. #9 was admitted on 12/27/2021 with a diagnosis of cervical spine fracture.

- Pt. #9 had a restraint orders dated 12/27/2021 at 7:51 PM and 12/28/2021 at 7:59 PM, for "non violent bed enclosure".

- Pt. #9's restraint monitoring flowsheets lacked documentation of care and assessment every 2 hours on 12/28/2021 between 12:00 AM and 9:00 AM, for 9 hours.

6. On 1/3/2022, Pt. #10's clinical record was reviewed. Pt. #10 was admitted on 12/27/2021 with a diagnosis of altered mental status.

- Pt. #10 had a restraint orders dated 12/29/2021 at 1:11 PM and on 12/30/2021 at 3:46 PM, for "non violent bed enclosure".

- Pt. #10's restraint monitoring flowsheets lacked documentation of care and assessment every 2 hours on 12/30/2021 between 11:00 AM and 3:46 PM, for over 4 hours and from 3:46 PM to 12/31/2021 at 3:20 AM.

7. On 1/3/2022 at 11:50 AM, an interview was conducted with the Team Leader of 45 South, Medical Surgical Unit(E #1). E #1 stated that a patient in nonviolent restraints should be monitored every 2 hours.

8. On 1/4/2022 at 9:25 AM, an interview was conducted with the Quality Manager (E #3). E #3 stated the nurses are making hourly rounding and checking restraints, but with the heavy workload, it is hard to document every 2 hours.