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Based upon observations, records review, and interviews, the facility failed to follow its own policy for the use of medical restraints. Review of 4(#1, #2, #3, #4) of 14 (#1 - #14)revealed the facility failed to:

- ensure physician's orders for restraints were written per facility policy.

- provide documentation of nursing assessment for patients reviewed who had restraints applied.

- provide the least restrictive interventions when restraint was used.

- provide assessment to determine the patient was released from restraint at the earliest possible time.

Refer to Tag A-154

This deficient practice caused harm to 4 of 14 (#1, #2, #3, #4) resulting in the death of patient #1 and had the likelihood to cause harm to all patient receiving care on the medical unit.

Based upon observations, records review, and interviews, the facility failed to follow its own policy for the use of medical restraints. Review of 4(#1, #2, #3, #4) of 14 (#1 - #14)revealed the facility failed to:

- ensure physician's orders for restraints were written per facility policy.

- provide documentation of nursing assessment for patients reviewed who had restraints applied.

- provide the least restrictive interventions when restraint was used.

- provide assessment to determine the patient was released from restraint at the earliest possible time.

This deficient practice caused harm to 4 of 14 (#1, #2, #3, #4) resulting in the death of patient #1 and had the potential to cause harm to all patient receiving care on the medical unit.

During an interview on 4/24/13 at 10:30 AM, staff #5 reported that the facility had a medical floor referred to as M2 or Med 2. Staff #5 reported that the patients requiring a medical intervention or closer observation would be sent to this unit. Staff #5 stated, "Now keep in mind. This is not a place where intense medical care is given. I would say it's not even the equivalent of nursing home care." Staff #5 reported that the physicians round on the patients more often and the nursing staff can be more attentive.

Review of the facility's policy titled "RESTRAINT/SECLUSION PROCEDURES INCLUDING MEDICAL RESTRAINT" which was last revised 10/11 and last reviewed 7/12, revealed the following:

"Definitions:

Protective/Supportive Device: Device used voluntarily to prevent injury or to permit wounds to heal.

Supportive Device: A device voluntarily used by an individual to posturally support the individual or to assist the individual who cannot obtain or maintain normal bodily functioning.

Medical Restraint: The application of a physical hold or a mechanical device used to limit mobility or temporarily immobilize a patient related to a medical/physical condition and/or post-surgical care or post-dental procedure in a non-emergency situation.

Prohibited Practices:

1. No intervention, voluntary or involuntary, shall be used as a means of discipline, retaliation, punishment, or coercion; for the purpose of convenience of staff members or other individuals; or as a substitute for effective treatment or habilitation.

3. Supportive or protective devices shall not be used in a behavioral emergency or without the individual's consent.

II. Medical Restraint

A. Initiation of Medical Restraint

1. Only a physician member of medical staff may order a medical restraint.

2. If restraint is not part of the usual and customary procedure, it shall be used only if it is medically necessary and needed to ensure the patient's safety. It shall be used only after less restrictive interventions have been considered and determined to be ineffective or are judged unlikely to protect the patient or others from harm.

3. Any use of the behavioral restraint chair for medical restraint use requires the PRIOR approval of the clinical director or his designee.

4. If a physician is not present, a clinically competent RN will perform a face to face assessment of the patient, and notify the physician of circumstances necessitating the intervention. An assessment must be done to determine that the risks associated with the use of the restraint are outweighed by the risks of not using it.

5. The RN will obtain a physician's order prior to implementation. The ordering physician will examine the patient and order or validate a telephone order within 24 hours.

B. Implementation of Medical Restraint

1. Physician Responsibility

a. When a physician is present at the time of the medical restraint, the physician will assume oversight of the medical restraint and will perform a face-to-face evaluation to determine necessity for the medical restraint. The order will include:

1.) Consideration of relative contraindications

2.) Consideration of alternatives to the intervention

3.) Specify type of intervention ordered

4.) Any special consideration for the use of restraint

5.) Specific reason/rationale for the intervention

6.) Maximum length of time for the intervention

7.) Who is responsible for implementing the restraint

8.) Intervals for release for exercise

9.) Specific assessment monitoring frequency and rationale (at a minimum, a patient is monitored every two hours).

2. RN Responsibility

a. The clinically competent RN will ensure that the following is explained to the patient and documented in the patient record:

1.) Specific intervention ordered

2.) Specific reason/rationale for the intervention

3.) Process for monitoring during the intervention

4.) Medication education if relevant

5.) Patient's response to the explanation

b. The clinically competent RN will supervise the application of the medical restraint to ensure adequate circulatory functioning and that no adverse effects of the restraint are present.


c. If the physician ordering the intervention is not the attending physician, the attending physician must be notified no later than the next business day unless it is clinically indicated to notify sooner. Upon notification, the attending physician must document a review of the intervention.

d. The clinically competent RN will ensure that the LAR (Legally Authorized Representative) and/or family (with appropriate patient consent) are notified as agreed upon following the intervention. The notification will be documented in the patient record.

C. Documentation Requirements (Medical Restraints)

1. A Restraint/Seclusion/Medical Restraint Checklist (MHRS 7-4 or other facility-approved form) will be initiated and reflect the following as identified in the physician's order:

a. Reason for and type of medical restraint

b. Date and time applied

c. Specific criteria for release

2. The clinically competent RN is responsible for patient assessment during a medical restraint. The clinically competent RN also ensures documentation by authorized staff of the following at the time of the intervention and at intervals specified in the physician's order (at least every 2 hours):

a. Patient's mental status (level of consciousness, sensorium)

b. Signs of injury associated with the application of restraint

c. Nutrition/hydration

d. Circulation and range of motion in the extremities

e. Vital Signs (respiratory and cardiac status)

f. Hygiene and elimination

g. Physical and psychological status and comfort, and

h. Readiness for discontinuation of the restraint

3. Information regarding the intervention will be reviewed by both shifts at shift change. This will be documented by the oncoming shift and includes:

a. The time of the intervention

b. Current physical, mental, and medical status

c. Time medications were given and care that was needed

4. Off going authorized staff assigned to the patient will introduce authorized oncoming staff being assigned to the patient."

Review of the medical record for patient #1 revealed that patient was a 62 year old female sent from another hospital on 2/15/12 with a history of Bipolar Disorder.

Review of the admission assessment revealed Patient #1 seemed to be sedated but quite agitated on admission. Patient was constantly trying to get up and was unsteady on her feet. She was talking nonsensically. Patient had bruises on her arms and scratches and bruises on her forehead. Patient was admitted with a diagnosis of Bipolar Disorder, Manic with psychotic features but could not rule out delirium. Patient was admitted to an adult unit on 2/15/12 at approximately 7:30 pm. with 1:1 monitoring within arm's reach while awake and 1:1 monitoring in eye sight while asleep.

Further review of the medical record revealed patient was uncooperative with interview and nursing assessment. Patient was purposefully sliding out of chair and laying on the floor and scooted under the chair picking at the underside. Concentration was poor and client was noted picking at the air. Documentation also revealed patient was noted touching breasts and exposing herself inappropriately requiring frequent redirection. At 11:41 pm on 2/15/12, patient continued to roll in the floor and grabbing at others shoes and shoestrings. At 12:52 am, patient was turned over to the night shift and patient was in the lobby at that time.

On 2/16/12 at 1:10 am, nursing notes revealed patient #1 had been awake in the lobby since the beginning of the shift. At 6:50 am, change of shift and staff "hand off" occurred. There was no documentation on the nursing note or the "Specialized Observation Checksheet" of patient sleeping that night.

Further review of nursing documentation revealed on 2/16/12 at 7:58 am, patient was not responding verbally and seemed to not hear staff attempting to speak to her. Patient was rubbing her hands and body on the walls and refused to cooperate with vital signs. At 11:04 am, physician (Staff # 35) evaluated patient as patient was too psychotic to transport to clinic for physical as evidenced by rolling in the floor and moving her arms in a swimming motion. Vital signs were obtained - Temperature - 97.4, Pulse - 82, Respirations - 22, Blood Pressure - 160/90. Stat labs were ordered and drawn at 11:49 am for Chemistry Panel and Complete Blood Count. Results were received at 12:45 am. White Blood Count was elevated at 23,000 (Reference Range - 4800 - 10,000).

Review of physician's (Staff #35) orders written on 2/16/2012 at 2:16 pm revealed the following: "Medical Restraint-Patient refuses physical: Take patient for physical exam. Provide physical support while doing physical exam. 1 restraint chair. RN is responsible for implementing and overseeing the restraint. Monitoring frequency: At a minimum a patient is monitored every 2 hours and MHRS7-4 (restraint monitoring form) required. Rationale: Procedure completed in less than 30 minutes. Maximum length of time for Intervention: 10 minutes; Alternative Interventions attempted: Verbal Intervention; Contraindications: No. Reason: Specify reason/rationale for the intervention: Refusing Physical Exam; Criteria for release: Physical Exam Completed in less than 30 minutes (In addition, the patient is so psychotic, she is attempting to "swim" off of a regular wheel chair. The restraint chair is needed for her safety during the transport.)"

Further review of physician's (Staff #20) order dated 2/16/2013 at 2:30 pm revealed:

"1.) Transfer to Med 2 (Medical Unit 2): Continue all previous orders.

2.) Insert NGT (Nasogastric Tube) and start Ensure 1 can q 4 hrly (every 4 hours) via NGT from 6 am to 10 pm - no 2 am dose.

3.) Water 200ml q 2 hrly via NGT between NGT feedings.

4.) Bilateral wrist and vest restraints to prevent removal of NGT and for safety. (Stop Date/Time: 2/17/12 @2:29 pm.)

5.) Continue 1:1 observation.

6.) Repeat CBC and BMP state to local lab in am.

7.) Inderal 10 mg po TID.

8.) Colace 100 mg (liquid or capsule po/via NGT BID (2 times day).

9.) Keep head end elevated to 45 degrees or more at all times.

10.) Change position q 2 hrly to prevent decubitis formation.

11.) Insert foley catheter and monitor input/output."

Further review of the electronic physician's order #1098801 ordered by Staff #20 on 2/16/12 at 2:30 pm revealed the following:
Order Type: RESTRICTIONS; Order Description: Bilateral Wrist and Vest Restraints to prevent removal of NGT and for safety. Start Date/Time: 2/16/12 @2:30 pm. Stop Date/Time: 2/17/12 at 2:29 pm. This order was written as an order for Restrictions and not a Medical Restraint.

Review of nurses' notes dated 2/16/2012 at 4:16 pm. revealed that patient #1 was transported to Med-2 via restraint chair for observation due to not eating, poor fluid intake and dehydration. There was no documentation that patient was removed from the restraint chair upon arrival to the unit. Review of the "Restraint/Seclusion Flowsheets" revealed no flowsheet or nurses' note that documented when patient was restrained in the restraint chair, no monitoring while patient in the restraint chair to go to admissions clinic or while in admissions clinic. There also was no documentation when patient was released from the restraint chair after being transported to Med-2 via restraint chair. Review of the "Specialized Observation Checksheet" revealed patient #1 was on 1:1 monitoring and was in admissions unit from 2:30 pm-3:00 pm.

Further review of nurses' notes dated 2/16/12 at 5:43 pm. revealed patient had a foley catheter inserted, NGT inserted, and received first tube feeding. Documentation further revealed the patient was thrashing about in the bed, kicking her feet in the air, pulling on her covers and trying to pull her foley catheter and NGT out. Bilateral wrist restraints were applied to prevent patient from pulling her NGT and foley catheter out. There was no documentation of the vest restraint being applied. At 6:31 pm, documentation revealed that the physician was called due to patient being restless and thrashing in bed, and being agitated. Telephone order was received for Thorazine(antipsychotic medication) 50 mg. IM (intramuscular) STAT (now). Nurses notes revealed medication was administered at 6:00 pm but patient remained restless and thrashing about in bed at 7:00 pm and 8:00 pm. There was no documentation that the physician was notified that medication was ineffective. The next nurses' note (4 hours later) at 12:18 am on 2/17/12 revealed patient continued to be awake and restless, moving both legs as if she was peddling a bicycle. Also noted, the patient was not talking when addressed and did not appear to be in pain. There was no nursing documentation that patient received an RN assessment related to the restraints or determination for continued need for use of restraints.

The next nurses' note was at 5:33am on 2/17/12 (5 hours later) revealed that patient#1 had not slept through shift and patient remained restless and constantly moving her legs. Documentation at 6:34 am revealed that patient was now talking and verbally abusive to staff, physically assaultive when receiving personal care, and now sitting up in a geri-chair and continued to curse staff.

Further review of nurse's notes revealed progress note written at 11:57 am (5 1/2 hours later): "Received client at change of shift on 1:1 observation for safety. Client has bilateral soft wrist restraints in place as well as Houdini to prevent her extracting her NGT or foley catheter. She has NGT in place for nutritional supplements and foley catheter that is draining clear yellow urine. Client will not engage in conversation. She is seated in a geri-chair and will attempt to grab staff with her legs and squeeze when they approach. Her vital signs this morning were 130/95, 97, 63, 20 and 100% on room air. She is in no acute distress. Will continue to observe and monitor throughout the shift." There was no nursing documentation that patient received an RN assessment related to the restraints or determination for continued need for use of restraints.

Nursing progress note dated 2/17/12 at 10:21 pm (10 hours later) revealed the following:

"Received the patient at shift change still on 1:1 observation arm's length for safety. She is alert, awake, responds coherently to questions. She is much improved compared to how she was yesterday. She has been sitting in the TV room with some of her peers watching TV. She vomited undigested food particles x1 at 1600 (4:00 pm). When I assessed her, she denied pain, denied stomach upset. She stated "I feel fine". I told her she looked better today than yesterday and she responded "I feel better today". She still has her NGT for feeding. She ate 10% of her evening meal at 1700 (5:00 pm), keep it down, no further vomiting noted. She was also tube fed per order and she tolerated her feeding well without any nausea or vomiting noted. Her foley catheter remains intact and in place for monitoring her urine output. Will continue to monitor the patient." There was no nursing documentation that patient was still in restraints, received an RN assessment related to the restraints, or determination for continued need for use of restraints since patient is coherent and condition improving.

Review of physician's orders revealed patient #1's initial restraint orders dated 2/16/12 at 2:30 pm, expired at 2/17/12 at 2:29 pm. A new order was NOT written to continue restraints on 2/17/12. Review of physician's progress note for 2/17/12 at 4:14 pm. revealed no documentation of continued need for restraint with only one statement related to restraints: "Patient is in a geri-chair with wrist restraints-her eyes are open, her heart rate regular and rhythmic."

Review of the "Specialized Observation Checksheet" for 2/16/12 - 2/17/13 revealed the following:

2/16/112

3:30 pm - 01:00 am revealed patient was resting in bed. (9.5 hours)

2/17/12

1:15 am - 6:15 am-revealed patient ' s location was in lobby and resting in bed at the same time. (5 hours)

6:30 am - 4:15 pm-revealed patient ' s location was in the lobby or hallway. (9 hours)

4:30 pm - 5:30 pm-patient was documented on checksheet as resting in bed. (1 hour)

5:45 pm - 10:15 pm- patient ' s location was in lobby.( 4.5 hours)

No documentation was found on "Specialized Observation Checksheet" or nurse's notes that patient was toileted, food or fluids offered, bath needs assessed, or comfort measures provided during this time frame.

Review of the "Restraint/Seclusion Flowsheet" revealed a form that contained a checklist that included the following:

- Restraint Type
- Seclusion
- Medical
- Protective/Supportive device
- Exact Date/Time of Application
- Reason for use
- Specific Criteria for Release
- Exact Date/Time of Release

The flowsheet also contained columns for the monitoring intervals that had sections for Location, Behavior, and Intervention, that contained a checklist under each section to document the status of the patient at the monitored time. The form also contained a signature line for the person monitoring and the supervising RN.

Review of the "Restraint/Seclusion Flowsheet" for Patient #1 revealed there was no restraint documentation from the time the restraint order was written on 2/16/12 at 2:30 pm until 2/16/12 at 12:00 midnight. Review of the "Restraint/Seclusion Flowsheet" dated 2/17/12 from 12:00 am - 6:00 am revealed that patient # 1 had a posey vest and soft wrist restraints to prevent pulling out tubes. There was no "Specific Criteria for Release" documented. Patient's location was the bedroom, behavior was quiet and calm, and patient had constant observation by a male staff person. There was no documentation on the flow sheet of restraint release interventions, no offer of food or fluids, no bath/shower offered, no toileting provided, no comfort measures, and no vital signs assessed.
At 8:00 am on 2/17/12, the "Restrain/Seclusion Flowsheet" revealed the restraint type for patient #1 was "soft wrist/Houdini". (A vest restraint was ordered. There was no order for "Houdini" restraint.) The patient location was in the lobby. The Reason for Use was documented "safety". There was no documentation of "Specific Criteria for Release".

Further review revealed that patient was in the lobby, no behavior was documented. There was no interventions documented for constant observation by same gender, vital signs, fluids offered, toileting needs, comfort measures. At 10:00 am, the "Restraint/Seclusion Flowsheet" indicated that patient was located in the hallway and her behavior was quiet and calm. There were no interventions documented for constant observation by same gender, no nourishment needs assessed for food or fluids, no bath or toileting needs assessed, no vital signs assessed and no comfort measures provided. At 12:00 pm, the only thing documented in the monitoring column was the signature of the monitoring staff and the RN. At 2:00 pm, the flowsheet indicated patient was in the hallway. No behavior was documented. There were no interventions documented for constant observation by same gender, no vital signs, no nourishment needs assessed for food and fluids, no bath or toileting needs assessed and no comfort measures provided. At 4:00 pm, the flow sheet indicated patient was in the hallway. Behavior was quiet and calm. There were no documentation for protection from others, bath needs assessed, or comfort measures provided. The monitoring columns for 2/17/12 at 6:00 pm, 8:00 pm, and 10:00 pm revealed lines drawn through the column with no documentation of the patient's location, behavior or interventions.

On 4/30/2013 during a tour of M2 at 2:00 PM in the nurse's station, nursing staff were requested to explain "Houdini" restraint. Staff #12 did not demonstrate the "Houdini" restraint but reported the "Houdini" was placed over the head of a patient (like a tee shirt with the sleeves and side seams cut out). She continued indicating the restraint was longer in the back and was pulled between the patients legs like the "saddle" with opposing straps that were secured across opposite thighs and secured behind the patient out of reach. The staff nurse explained the purpose of the Houdini was greater restraint of the patient's ability to slide from a chair or lean forward and fall out.

Review of nurses' notes dated 2/18/12 at 12:25 am revealed that patient vomited at approximately 11:30 pm. and continued to feel nauseated. On-call physician notified and order was given for Phenergan 25 mg. intramuscular now X1. Injection was given and patient was cooperative. Patient continued to be monitored per 1:1 protocol. Nurses' note timed at 1:01 am revealed medication given appeared to be effective. Patient verbalized feeling better. No further incidents of vomiting. Next note written at 6:30am (5 ? hours later) revealed that patient had approximately 1280 ml of fluid via NGT this shift. She had foley catheter output of 650 ml. Patient more talkative this am and smiles at staff. No undesired behaviors reported. Will continue to monitor per 1:1 protocol. Further review of nurses notes revealed the next nursing documentation was timed 12:02 pm (5 ? hours later) and revealed client remains on 1:1 observation as ordered for safety. VS 95/63, 95, 20, 96.3, O2 sat 94%, NGT and foley catheter in place. Patient has been sitting up in the geri-chair. Patient had no complaints of pain, nausea, or vomiting. Six hours later at 6:12pm, nursing documentation revealed patient remains on 1:1 observation as ordered for safety. V/S 111/77, 77, 20, 96.8, O2 Sat 94%. NGT and foley catheter in place, and patient sitting up in geri-chair. Patient voiced no complaints. During this 18 hour period, there was no documentation by the RN that patient was in restraints, that patient received an RN assessment related to the restraints, or determination for the release of the restraints.



Review of "Specialized Observation Checksheet" dated 2/18/12 from 11:30 pm (2/17/12) - 6:30 am, documentation revealed that patient was in the bed resting or asleep. At 6:45 am, patient was noted to be in the lobby and a staff assignment change occurred. From 7:00 am - 4:00 pm, patient was documented being in the lobby. There was no documentation that patient had been moved, ambulated, toileted, or bathed for 9 hours. From 4:15 pm - 11pm, checksheet revealed patient was in the lobby and a staff assignment change occurred. There was no documentation that patient had been moved, ambulated, toileted, or bathed for 7 hours. This was the last of the documentation on the "Specialized Observation Checksheet " for Patient #1.

Review of the "Restraint/Seclusion Flowsheet" dated 2/18/12 from 8:00 am - 2:00 pm revealed that patient had a posey vest and soft wrist restraints with safety documented as the reason for the restraint. There was no "Specific Criteria for Release" documented. Patient's location was the hallway, behavior was quiet and calm, and patient had constant observation by staff person of the same gender. There was no documentation on the flow sheet of restraint release interventions, no offer of food or fluids, no bath/shower offered, no toileting provided, no comfort measures, and no vital signs assessed.

Review of the "Restraint/Seclusion Flowsheet" dated 2/18/12 from 4:00 pm - 8:00 pm revealed that patient had a vest and wrist restraints with safety documented as the reason for the restraint. There was no "Specific Criteria for Release" documented. Patient's location was the lobby, behavior was quiet and calm, and patient had constant observation by staff person of the same gender. There was no documentation on the flowsheet of restraint release interventions, no offer of food or fluids, no bath/shower offered, no toileting provided, no comfort measures, and no vital signs assessed. This was the last of the documentation on the "Restraint/Seclusion Flowsheet" for Patient #1.

Review of Staff #40's physician order #1099548 dated 2/18/12 at 9:56 pm. revealed the following: Order Type: MEDICAL RESTRAINT; Order Description: MEDICAL RESTRAINT-HOUDINI; Monitoring Frequency-2 HOURS; Reason-SAFETY. The last order for restraints written on 2/16/12 at 2:30 pm. expired at 2/17/12 at 2:29 pm. Patient #1 was restrained without a physician's order for 31.5 hours.

Review of Staff #37 nurses' notes dated 2/18/2012 at 11:15 pm (4 hours since last RN documentation) revealed the following: "The client remains on 1:1 observation. Staff came to this nurse and reported that the client "looked funny". This nurse went to assess the client. The client looked cyanotic around her mouth, she was not breathing, no pulse felt, her restraint was removed from the bed and was noted to be non-restricting to the client and she was moved to the floor. CPR (CardioPulmonary Resuscitation) was started, 2222 (CODE) called, AED (Automated External Defibrillator) retrieved and placed on, CPR continued until the paramedics arrived. Client moved out to (sic) local hospital with staff via ambulance."

Review of note written by the Psychiatric Nursing Assistant, Staff #38, written as a late entry on 2/20/12 revealed the following: "Client was put in bed at 9:30 pm and client had on soft wrist restraints and Houdini. I was sitting arm's length with the client. She was kicking her legs under the covers for 25 minutes. I was looking at client when staff ... walked in the room. I looked at staff and then back at the patient and she seemed to be having a seizure. I went to get the RN (staff #37), when we returned to the room the patient's lips were blue and she was not breathing. We untied the wrist restraints and the Houdini and put the patient on the floor and put the AED on the patient's chest and waited for the machine to shock the patient or begin CPR. The machine said to begin CPR. RN began CPR and I gave breaths after 30 compressions. We continued CPR until 22:20 when EMTs arrived. She was transported to the emergency room and CPR was continued there and she was pronounced dead at 11:13 by the ER physician."

Review of the "Autopsy Report" for Patient #1 dated 5/29/12 revealed the following findings:
1. Pulmonary thromboembolism:

a. Deep vein thrombosis.

b. Relative immobility associated with hospitalization for psychosis.

c. Dehydration associated with psychosis

d. History that the decedent was restrained in bed, showed facial congestion, stopped breathing and became cyanotic.

2. History of bipolar disorder, hypertension, and hypercholesterolemia.


During a tour of the facility on 4/24/13 at 10:00 AM, patients #3, #2, and #4 were observed on the medical unit to have a Nasal Gastric Tubes (NGT) inserted.

Patients #3 and #2 had multiple mechanical restraints and I: I observation (one staff member to one patient).

Patient #3 was in a Broda chair with a Psychiatric Nurses Aid (PNA) monitoring, a saddle restraint, and bilateral soft wrist restraints (BSWR). A Broda chair is on four caster type wheels and the chair's seat can be tilted sufficiently to prevent the patient from rising, sliding or falling forward off the chair.

Patient #3 and #2's hands were restrained very close to the seat of the chair. Patient #2 was in a Broda chair with a Houdini suit and BSWR secured tightly.

During a tour of the facility on 4/24/13 at 10:00AM, staff #8 was interviewed concerning restraints and NGT. Staff #8 was questioned on the different ways a person can be hydrated on the medical unit if nothing is being taken by mouth. Staff #8 reported those patients are encouraged to drink fluids but if they are not eating or drinking, then the physician will order a NGT for fluids and nutrition. Staff #8 reported that if the patient misses 3 meals, or consumes less than 50%, the physician will order a NGT. When asked if Intravenous fluids (IV) are ever given or considered, staff #8 stated, "Yes. We have given IV's before but usually the doctor will just order the feeding tube." Staff #8 was asked if the patient refused the feeding tube, what would be the next step. Staff #8 stated, "If the doctor writes the order we put it in and if the patient fights us we have to get restraint orders." Staff #8 was asked to show the surveyors what a Houdini suit looks like and how it is applied. Staff #8 pulled out the restraint and demonstrated how the nylon vest is pulled over the patient's head. The arms are cut out resembling a vest. Attached to the back and bottom of the vest is the saddle bottom. The saddle is pulled between the legs similar to a diaper. There are ties attached to both sides. The ties come up around the waist and are secured in the back of a chair. Staff #8 and staff #3 confirmed that this restraint was referred to as the Houdini suit. Staff #8 and staff #3 confirmed that patient #2 was wearing a Houdini suit.

On 4/25/13 at 11:20AM lunch service was observed on the medical unit (M2). Patient #3 was in a Broda chair with a soft saddle restraint, BSWR, and NGT Patient #3 had an order for mechanical soft diet but was given a regular diet. Patient #3 was served a tray in the dining/ TV area. Her hands remained tied down and the assigned 1:1 PNA hand fed her. Patient #3 consumed a serving of peaches, a serving of Jell-O, and a serving of applesauce. Patient #3 was offered chocolate pudding and chicken spaghetti but she turned her head away. Patient #3 was not offered any fluids during the meal or any food substitutions. Patient #3's tray was taken away within 14 minutes and only one attempt to feed her. Patient #3 was never released from the wrist restraints to eat independently nor was a trial release attempted. Patient #3 was offered fluids after the meal tray was taken away.

On 4/25/13 at 12:00PM, Patient #2 was leaning forward, drooling, and tongue protruding. His tray was sat in front of him for 7 minutes before the PNA attempted to feed him. Patient #2 was difficult to arouse and wrist restraints were never released to allow patient to feed himself. The PNA offered the patient fluids by putting it to his lips. Patient #2 did sip from the cup but he was never offered a straw. The PNA made several attempts to offer food to the patient. However, the PNA held the fork away from patient #2's mouth and gave verbal commands to open his mouth. PNA never brought the food to the patient's mouth. A different PNA sat down 18 minutes later and helped Patient #2 consume a few bites of applesauce before the lunch was completed.

On 4/25/13 at 12:10PM, Patient # 4 was observed being escorted into the dining/TV area with assistance by a PNA. Patient #4 had a feeding tube on 4/24/13. Patient #4 did not have a feeding tube at this time. Patient #4 was slumped over in the chair and was difficult to wake. She was unable to stay awake to eat her meal after multiple attempts from the staff. During observations, Staff #9 reported that patient #4 had complained about the food. She was use to eating Mexican food. Staff #9 reported that she had called the dietician and ordered patient #4 a meal that would be more "ethnic" to the patients likes two days ago. The meal served for lunch was green peas and chicken spaghetti. Patient #4 was not able to wake long enough to complete the current meal. The meal was removed and patient was recorded to eat 0% of meal. No other substitutes were offered.

During an interview 4/25/13 at 12:20PM, staff #9 was asked if the patients were ever released from the wrist restraints to eat on their own. She reported that they were when possible. Staff #9 reported that Pat

Based upon observations, records review, and interviews, the facility failed to follow its own policy for the use of medical restraints. Review of 4(#1, #2, #3, #4) of 14 (#1 - #14)revealed the facility failed to:

- provide documentation of nursing assessment and interventions for patients reviewed who had restraints applied.

- provide nursing assessment and interventions to ensure the least restrictive interventions were used when restraint was used.

- provide nursing assessment and inteventions to ensure patients were released from restraint at the earliest possible time.

Refer to Tag A-395

This deficient practice caused harm to 4 of 14 (#1, #2, #3, #4) resulting in the death of patient #1 and had the likelihood to cause harm to all patient receiving care on the medical unit.

Based upon observations, records review, and interviews, the facility failed to follow its own policy for the use of medical restraints. Review of 4(#1, #2, #3, #4) of 14 (#1 - #14)revealed the facility failed to:

- provide documentation of nursing assessment for patients reviewed who had restraints applied.

- provide the least restrictive interventions when restraint was used.

- provide assessment to determine the patient was released from restraint at the earliest possible time.

This deficient practice caused harm to 4 of 14 (#1, #2, #3, #4) resulting in the death of patient #1 and had the likelihood to cause harm to all patient receiving care on the medical unit.

During an interview on 4/24/13 at 10:30 am., staff #5 reported that the facility had a medical floor referred to as M2 or Med 2. Staff #5 reported that the patients requiring a medical intervention or closer observation would be sent to this unit. Staff #5 stated, "Now keep in mind. This is not a place where intense medical care is given. I would say it's not even the equivalent of nursing home care." Staff #5 reported that the physicians round on the patients more often and the nursing staff can be more attentive.

Review of the facility's policy titled "RESTRAINT/SECLUSION PROCEDURES INCLUDING MEDICAL RESTRAINT" which was last revised 10/11 and last reviewed 7/12, revealed the following:

"Definitions:

Protective/Supportive Device: Device used voluntarily to prevent injury or to permit wounds to heal.

Supportive Device: A device voluntarily used by an individual to posturally support the individual or to assist the individual who cannot obtain or maintain normal bodily functioning.

Medical Restraint: The application of a physical hold or a mechanical device used to limit mobility or temporarily immobilize a patient related to a medical/physical condition and/or post-surgical care or post-dental procedure in a non-emergency situation.

Prohibited Practices:

1. No intervention, voluntary or involuntary, shall be used as a means of discipline, retaliation, punishment, or coercion; for the purpose of convenience of staff members or other individuals; or as a substitute for effective treatment or habilitation.

3. Supportive or protective devices shall not be used in a behavioral emergency or without the individual ' s consent.

II. Medical Restraint

A. Initiation of Medical Restraint

1. Only a physician member of medical staff may order a medical restraint.

2. If restraint is not part of the usual and customary procedure, it shall be used only if it is medically necessary and needed to ensure the patient's safety. It shall be used only after less restrictive interventions have been considered and determined to be ineffective or are judged unlikely to protect the patient or others from harm.

3. Any use of the behavioral restraint chair for medical restraint use requires the PRIOR approval of the clinical director or his designee.

4. If a physician is not present, a clinically competent RN will perform a face to face assessment of the patient, and notify the physician of circumstances necessitating the intervention. An assessment must be done to determine that the risks associated with the use of the restraint are outweighed by the risks of not using it.

5. The RN will obtain a physician's order prior to implementation. The ordering physician will examine the patient and order or validate a telephone order within 24 hours.

B. Implementation of Medical Restraint

1. Physician Responsibility

a. When a physician is present at the time of the medical restraint, the physician will assume oversight of the medical restraint and will perform a face-to-face evaluation to determine necessity for the medical restraint. The order will include:


1.) Consideration of relative contraindications

2.) Consideration of alternatives to the intervention

3.) Specify type of intervention ordered

4.) Any special consideration for the use of restraint

5.) Specific reason/rationale for the intervention

6.) Maximum length of time for the intervention

7.) Who is responsible for implementing the restraint

8.) Intervals for release for exercise

9.) Specific assessment monitoring frequency and rationale (at a minimum, a patient is monitored every two hours).

2. RN Responsibility

a. The clinically competent RN will ensure that the following is explained to the patient and documented in the patient record:

1.) Specific intervention ordered

2.) Specific reason/rationale for the intervention

3.) Process for monitoring during the intervention

4.) Medication education if relevant

5.) Patient's response to the explanation

b. The clinically competent RN will supervise the application of the medical restraint to ensure adequate circulatory functioning and that no adverse effects of the restraint are present.

c. If the physician ordering the intervention is not the attending physician, the attending physician must be notified no later than the next business day unless it is clinically indicated to notify sooner. Upon notification, the attending physician must document a review of the intervention.

d. The clinically competent RN will ensure that the LAR (Legally Authorized Representative) and/or family (with appropriate patient consent) are notified as agreed upon following the intervention. The notification will be documented in the patient record.

C. Documentation Requirements (Medical Restraints)

1. A Restraint/Seclusion/Medical Restraint Checklist (MHRS 7-4 or other facility-approved form) will be initiated and reflect the following as identified in the physician's order:

a. Reason for and type of medical restraint

b. Date and time applied

c. Specific criteria for release

2. The clinically competent RN is responsible for patient assessment during a medical restraint. The clinically competent RN also ensures documentation by authorized staff of the following at the time of the intervention and at intervals specified in the physician's order (at least every 2 hours):

a. Patient's mental status (level of consciousness, sensorium)

b. Signs of injury associated with the application of restraint

c. Nutrition/hydration

d. Circulation and range of motion in the extremities

e. Vital Signs (respiratory and cardiac status)

f. Hygiene and elimination

g. Physical and psychological status and comfort, and

h. Readiness for discontinuation of the restraint

3. Information regarding the intervention will be reviewed by both shifts at shift change. This will be documented by the oncoming shift and includes:

a. The time of the intervention

b. Current physical, mental, and medical status

c. Time medications were given and care that was needed

4. Off going authorized staff assigned to the patient will introduce authorized oncoming staff being assigned to the patient."

Review of the medical record for patient #1 revealed that patient was a 62 year old female transferred from another hospital on 2/15/12 with a history of Bipolar Disorder.

Review of the admission assessment revealed that Patient #1 seemed to be sedated but quite agitated on admission. Patient was constantly trying to get up and was unsteady on her feet. She was talking nonsensically. Patient had bruises on her arms and scratches and bruises on her forehead. Patient was admitted with a diagnosis of Bipolar Disorder, Manic with psychotic features but could not rule out delirium. Patient was admitted to an adult unit on 2/15/12 at approximately 7:30 pm. with 1:1 monitoring within arm's reach while awake and 1:1 monitoring in eye sight while asleep.

Further review of the medical record revealed that patient was uncooperative with interview and nursing assessment. Patient was purposefully sliding out of chair and laying on the floor and scooted under the chair picking at the underside. Concentration was poor and client was noted picking at the air. Documentation also revealed patient was noted touching breasts and exposing herself inappropriately requiring frequent redirection. At 11:41 pm on 2/15/12, patient continued to roll in the floor and grabbing at others shoes and shoestrings. At 12:52 am, patient was turned over to the night shift and patient was in the lobby at that time.

On 2/16/12 at 1:10 am, nursing notes revealed that patient #1 had been awake in the lobby since the beginning of the shift. At 6:50 am, change of shift and staff "hand off" occurred. There was no documentation on the nursing note or the "Specialized Observation Checksheet" of patient sleeping that night.

Further review of nursing documentation on 2/16/12 at 7:58 am revealed that patient was not responding verbally and seemed to not hear staff attempting to speak to her. Patient was rubbing her hands and body on the walls and refused to cooperate with vital signs. At 11:04 am, Staff # 35 evaluated patient as patient was too psychotic to transport to clinic for physical as evidenced by rolling in the floor and moving her arms in a swimming motion. Vital signs were obtained: Temperature - 97.4, Pulse - 82, Respirations - 22, Blood Pressure - 160/90. Stat labs were ordered and drawn at 11:49 am for Chemistry Panel and Complete Blood Count. Results were received at 12:45 am. White Blood Count was elevated at 23,000 (Reference Range - 4800 - 10,000).

Review of Staff #35 orders written on 2/16/2012 at 2:16 pm revealed the following: "Medical Restraint-Patient refuses physical: Take patient for physical exam. Provide physical support while doing physical exam. 1 restraint chair. RN is responsible for implementing and overseeing the restraint. Monitoring frequency: At a minimum a patient is monitored every 2 hours and MHRS7-4 (restraint monitoring form) required. Rationale: Procedure completed in less than 30 minutes. Maximum length of time for Intervention: 10 minutes; Alternative Interventions attempted: Verbal Intervention; Contraindications: No. Reason: Specify reason/rationale for the intervention: Refusing Physical Exam; Criteria for release: Physical Exam Completed in less than 30 minutes (In addition, the patient is so psychotic, she is attempting to "swim" off of a regular wheel chair. The restraint chair is needed for her safety during the transport.)"

Review of Staff #20 order dated 2/16/2013 at 2:30 pm revealed:

"1.) Transfer to Med 2 (Medical Unit 2): Continue all previous orders.

2.) Insert NGT (Nasogastric Tube) and start Ensure 1 can q 4 hrly (every 4 hours) via NGT from 6 am to 10 pm - no 2 am dose.

3.) Water 200ml q 2 hrly via NGT between NGT feedings.

4.) Bilateral wrist and vest restraints to prevent removal of NGT and for safety. (Stop Date/Time: 2/17/12 @2:29 pm.

5.) Continue 1:1 observation.

6.) Repeat CBC and BMP state to local lab in am.

7.) Inderal 10 mg po TID.

8.) Colace 100 mg (liquid or capsule po/via NGT BID (2 times day).

9.) Keep head end elevated to 45degrees or more at all times.

10.) Change position q 2 hrly to prevent decubitis formation.

11.) Insert foley catheter and monitor input/output."

Further review of the electronic physician's order #1098801 ordered by Staff #20 on 2/16/12 at 2:30 pm revealed the following: Order Type: RESTRICTIONS; Order Description: Bilateral Wrist and Vest Restraints to prevent removal of NGT and for safety. Start Date/Time: 2/16/12 @2:30 pm. Stop Date/Time: 2/17/12 at 2:29 pm. This order was written as an order for Restrictions and not a Medical Restraint.

Review of nurses' notes dated 2/16/2012 at 4:16 pm. revealed that patient #1 was transported to Med-2 via restraint chair for observation due to not eating, poor fluid intake and dehydration. There was no documentation that patient was removed from the restraint chair upon arrival to the unit. Review of the "Restraint/Seclusion Flowsheets" revealed no flowsheet or nurses' note that documented when patient was restrained in the restraint chair, no monitoring while patient in the restraint chair to go to admissions clinic or while in admissions clinic. There also was no documentation when patient was released from the restraint chair after being transported to Med-2 via restraint chair. Review of the "Specialized Observation Checksheet" revealed patient #1 was on 1:1 monitoring and was in admissions unit from 2:30 pm-3:00 pm.

Further review of nurses' notes dated 2/16/12 at 5:43 pm. revealed patient had a foley catheter inserted, NGT inserted, and received first tube feeding. Documentation further revealed the patient was thrashing about in the bed, kicking her feet in the air, pulling on her covers and trying to pull her foley catheter and NGT out. Bilateral wrist restraints were applied to prevent patient from pulling her NGT and foley catheter out. There was no documentation of the vest restraint being applied. At 6:31 pm, documentation revealed physician was called due to patient being restless and thrashing in bed, and being agitated. Telephone order was received for Thorazine(antipsychotic medication) 50 mg. IM (intramuscular) STAT (now). Nurses notes revealed medication was administered at 6:00 pm but patient remained restless and thrashing about in bed at 7:00 pm and 8:00 pm. There was no documentation that the physician was notified that medication was ineffective. The next nurses' note (4 hours later) at 12:18 am on 2/17/12 revealed patient continued to be awake and restless, moving both legs as if she was peddling a bicycle. Also noted, the patient was not talking when addressed and did not appear to be in pain. There was no nursing documentation that patient received an RN assessment related to the restraints or determination for continued need for use of restraints.

The next nurses' note was at 5:33am on 2/17/12 (5 hours later) revealed patient#1 had not slept through shift and patient remained restless and constantly moving her legs. Documentation at 6:34 am revealed patient was now talking and verbally abusive to staff, physically assaultive when receiving personal care, and now sitting up in a geri-chair and continued to curse staff.

Further review of nurse's notes revealed progress note written at 11:57 am (5 1/2 hours later): "Received client at change of shift on 1:1 observation for safety. Client has bilateral soft wrist restraints in place as well as Houdini to prevent her extracting her NGT or foley catheter. She has NGT in place for nutritional supplements and foley catheter that is draining clear yellow urine. Client will not engage in conversation. She is seated in a geri-chair and will attempt to grab staff with her legs and squeeze when they approach. Her vital signs this morning were 130/95, 97, 63, 20 and 100% on room air. She is in no acute distress. Will continue to observe and monitor throughout the shift." There was no nursing documentation that patient received an RN assessment related to the restraints or determination for continued need for use of restraints.

Nursing progress note dated 2/17/12 at 10:21 pm (10 hours later) revealed the following: "Received the patient at shift change still on 1:1 observation arm's length for safety. She is alert, awake, responds coherently to questions. She is much improved compared to how she was yesterday. She has been sitting in the TV room with some of her peers watching TV. She vomited undigested food particles x1 at 1600(4:00pm). When I assessed her, she denied pain, denied stomach upset. She stated "I feel fine". I told her she looked better today than yesterday and she responded "I feel better today". She still has her NGT for feeding. She ate 10% of her evening meal at 1700(5:00pm), keep it down, no further vomiting noted. She was also tube fed per order and she tolerated her feeding well without any nausea or vomiting noted. Her foley catheter remains intact and in place for monitoring her urine output. Will continue to monitor the patient." There was no nursing documentation that patient was still in restraints, received an RN assessment related to the restraints, or determination for continued need for use of restraints since patient is coherent and condition improving.

Review of physician's orders revealed patient #1's initial restraint orders dated 2/16/12 at 2:30 pm, expired at 2/17/12 at 2:29 pm. A new order was NOT written to continue restraints on 2/17/12. Review of physician's progress note for 2/17/12 at 4:14 pm. revealed no documentation of continued need for restraint with only one statement related to restraints: "Patient is in a geri-chair with wrist restraints-her eyes are open, her heart rate regular and rhythmic."

Review of the "Specialized Observation Checksheet" for 2/16/12 - 2/17/13 revealed the following:

2/16/112
3:30 pm - 01:00 am revealed patient was resting in bed. (9.5 hours)

2/17/12
1:15 am - 6:15 am-revealed patient ' s location was in lobby and resting in bed at the same time. (5 hours)

6:30 am - 4:15 pm-revealed patient ' s location was in the lobby or hallway. (9 hours)

4:30 pm - 5:30 pm-patient was documented on checksheet as resting in bed. (1 hour)

5:45 pm - 10:15 pm- patient ' s location was in lobby.( 4.5 hours)

No documentation was found on "Specialized Observation Checksheet" or nurse's notes that patient was toileted, food or fluids offered, bath needs assessed, or comfort measures provided during this time frame.

Review of the "Restraint/Seclusion Flowsheet" revealed a form that contained a checklist that included the following:
- Restraint Type
- Seclusion
- Medical
- Protective/Supportive device
- Exact Date/Time of Application
- Reason for use
- Specific Criteria for Release
- Exact Date/Time of Release

The flowsheet also contained columns for the monitoring intervals that had sections for Location, Behavior, and Intervention, that contained a checklist under each section to document the status of the patient at the monitored time. The form also contained a signature line for the person monitoring and the supervising RN.

Review of the "Restraint/Seclusion Flowsheet" for Patient #1 revealed there was no restraint documentation from the time the restraint order was written on 2/16/12 at 2:30 pm until 2/16/12 at 12:00 midnght. Review of the "Restraint/Seclusion Flowsheet" dated 2/17/12 from 12:00 am - 6:00 am revealed that patient # 1 had a posey vest and soft wrist restraints to prevent pulling out tubes. There was no "Specific Criteria for Release" documented. Patient's location was the bedroom, behavior was quiet and calm, and patient had constant observation by a male staff person. There was no documentation on the flow sheet of restraint release interventions, no offer of food or fluids, no bath/shower offered, no toileting provided, no comfort measures, and no vital signs assessed.
At 8:00 am on 2/17/12, the "Restrain/Seclusion Flowsheet" revealed the restraint type for patient #1 was "soft wrist/Houdini". (A vest restraint was ordered. There was no order for "Houdini" restraint.) The patient location was in the lobby. The Reason for Use was documented "safety". There was no documentation of "Specific Criteria for Release".

Further review revealed that patient was in the lobby, no behavior was documented. There was no interventions documented for constant observation by same gender, vital signs, fluids offered, toileting needs, comfort measures. At 10:00 am, the "Restraint/Seclusion Flowsheet" indicated patient was located in hallway and her behavior was quiet and calm. There were no interventions documented for constant observation by same gender, no nourishment needs assessed for food or fluids, no bath or toileting needs assessed, no vital signs assessed and no comfort measures provided. At 12:00 pm, the only thing documented in the monitoring column was the signature of the monitoring staff and the RN. At 2:00 pm, the flowsheet indicated patient was in the hallway. No behavior was documented. There were no interventions documented for constant observation by same gender, no vital signs, no nourishment needs assessed for food and fluids, no bath or toileting needs assessed and no comfort measures provided. At 4:00 pm, the flow sheet indicated patient was in the hallway. Behavior was quiet and calm. There were no documentation for protection from others, bath needs assessed, or comfort measures provided. The monitoring columns for 2/17/12 at 6:00 pm, 8:00 pm, and 10:00 pm revealed lines drawn through the column with no documentation of the patient's location, behavior or interventions.

On 4/30/2013 during a tour of M2 at 2:00 PM in the nurse's station, nursing staff were requested to explain "Houdini" restraint. Staff #12 did not demonstrate the "Houdini" restraint but reported the "Houdini" was placed over the head of a patient (like a tee shirt with the sleeves and side seams cut out). She continued indicating the restraint was longer in the back and was pulled between the patients legs like the "saddle" with opposing straps that were secured across opposite thighs and secured behind the patient out of reach. The staff nurse explained the purpose of the Houdini was greater restraint of the patient's ability to slide from a chair or lean forward and fall out.

Review of nurses' notes dated 2/18/12 at 12:25 am revealed patient vomited at approximately 11:30 pm. and continued to feel nauseated. On-call physician notified and order was given for Phenergan 25 mg. intramuscular now X1. Injection was given and patient was cooperative. Patient continued to be monitored per 1:1 protocol. Nurses' note timed at 1:01 am revealed medication given appeared to be effective. Patient verbalized feeling better. No further incidents of vomiting. Next note written at 6:30am (5 ? hours later) revealed patient had approximately 1280 ml of fluid via NGT this shift. She had foley catheter output of 650 ml. Patient more talkative this am and smiles at staff. No undesired behaviors reported. Will continue to monitor per 1:1 protocol.


Further review of nurses notes revealed that the next nursing documentation was timed 12:02 pm (5 ? hours later) and revealed client remains on 1:1 observation as ordered for safety. VS 95/63, 95, 20, 96.3, O2 sat 94%, NGT and foley catheter in place. Patient has been sitting up in the geri-chair. Patient had no complaints of pain, nausea, or vomiting. Six hours later at 6:12pm, nursing documentation revealed patient remains on 1:1 observation as ordered for safety. V/S 111/77, 77, 20, 96.8, O2 Sat 94%. NGT and foley catheter in place, and patient sitting up in geri-chair. Patient voiced no complaints. During this 18 hour period, there was no documentation by the RN that patient was in restraints, that patient received an RN assessment related to the restraints, or determination for the release of the restraints.


Review of "Specialized Observation Checksheet" dated 2/18/12 from 11:30pm (2/17/12) - 6:30am, documentation revealed patient was in the bed resting or asleep. At 6:45 am, patient was noted to be in the lobby and a staff assignment change occurred. From 7:00 am - 4:00 pm, patient was documented being in the lobby. There was no documentation that patient had been moved, ambulated, toileted, or bathed for 9 hours. From 4:15 pm - 11pm, checksheet revealed patient was in the lobby and a staff assignment change occurred. There was no documentation that patient had been moved, ambulated, toileted, or bathed for 7 hours. This was the last of the documentation on the "Specialized Observation Checksheet " for Patient #1.

Review of the "Restraint/Seclusion Flowsheet" dated 2/18/12 from 8:00 am - 2:00 pm revealed that patient had a posey vest and soft wrist restraints with safety documented as the reason for the restraint. There was no "Specific Criteria for Release" documented. Patient's location was the hallway, behavior was quiet and calm, and patient had constant observation by staff person of the same gender. There was no documentation on the flow sheet of restraint release interventions, no offer of food or fluids, no bath/shower offered, no toileting provided, no comfort measures, and no vital signs assessed.

Review of the "Restraint/Seclusion Flowsheet" dated 2/18/12 from 4:00 pm - 8:00 pm revealed that patient had a vest and wrist restraints with safety documented as the reason for the restraint. There was no "Specific Criteria for Release" documented. Patient's location was the lobby, behavior was quiet and calm, and patient had constant observation by staff person of the same gender. There was no documentation on the flowsheet of restraint release interventions, no offer of food or fluids, no bath/shower offered, no toileting provided, no comfort measures, and no vital signs assessed. This was the last of the documentation on the "Restraint/Seclusion Flowsheet" for Patient #1.

Review of Staff #40's physician order #1099548 dated 2/18/12 at 9:56 pm. revealed the following: Order Type: MEDICAL RESTRAINT; Order Description: MEDICAL RESTRAINT-HOUDINI; Monitoring Frequency-2 HOURS; Reason-SAFETY. The last order for restraints written on 2/16/12 at 2:30 pm. expired at 2/17/12 at 2:29 pm. Patient #1 was restrained without a physician's order for 31.5 hours.

Review of Staff #37 nurses' notes dated 2/18/2012 at 11:15 pm (4 hours since last RN documentation) revealed the following: "The client remains on 1:1 observation. Staff came to this nurse and reported that the client "looked funny". This nurse went to assess the client. The client looked cyanotic around her mouth, she was not breathing, no pulse felt, her restraint was removed from the bed and was noted to be non-restricting to the client and she was moved to the floor. CPR (CardioPulmonary Resuscitation) was started, 2222 (CODE) called, AED (Automated External Defibrillator) retrieved and placed on, CPR continued until the paramedics arrived. Client moved out to (sic) local hospital with staff via ambulance."

Review of note written by the Psychiatric Nursing Assistant, Staff #38, written as a late entry on 2/20/12 revealed the following: "Client was put in bed at 9:30 pm and client had on soft wrist restraints and Houdini. I was sitting arm's length with the client. She was kicking her legs under the covers for 25 minutes. I was looking at client when staff ... walked in the room. I looked at staff and then back at the patient and she seemed to be having a seizure. I went to get the RN (staff #37), when we returned to the room the patient's lips were blue and she was not breathing. We untied the wrist restraints and the Houdini and put the patient on the floor and put the AED on the patient's chest and waited for the machine to shock the patient or begin CPR. The machine said to begin CPR. RN began CPR and I gave breaths after 30 compressions. We continued CPR until 22:20 when EMTs arrived. She was transported to the emergency room and CPR was continued there and she was pronounced dead at 11:13 by the ER physician."

Review of the "Autopsy Report" for Patient #1 dated 5/29/12 revealed the following findings:

1. Pulmonary thromboembolism:

a. Deep vein thrombosis.

b. Relative immobility associated with hospitalization for psychosis.

c. Dehydration associated with psychosis

d. History that the decedent was restrained in bed, showed facial congestion, stopped breathing and became cyanotic.

2. History of bipolar disorder, hypertension, and hypercholesterolemia.


During a tour of the facility on 4/24/13 at 10:00AM, patients #3, #2, and #4 were observed on the medical unit to have a Nasal Gastric Tubes (NGT) inserted. Patients #3 and #2 had multiple mechanical restraints and 1:1 observation (one staff member to one patient). Patient #3 was in a Broda chair with a Psychiatric Nurses Aid (PNA) monitoring, a saddle restraint, and bilateral soft wrist restraints (BSWR). A Broda chair is on four caster type wheels and the chair's seat can be tilted sufficiently to prevent the patient from rising, sliding or falling forward off the chair. Patient #3 and #2's hands were restrained very close to the seat of the chair. Patient #2 was in a Broda chair with a Houdini suit and BSWR secured tightly.

During a tour of the facility on 4/24/13 at 10:00AM, staff #8 was interviewed concerning restraints and NGT. Staff #8 was questioned on the different ways a person can be hydrated on the medical unit if nothing is being taken by mouth. Staff #8 reported those patients are encouraged to drink fluids but if they are not eating or drinking, then the physician will order a NGT for fluids and nutrition. Staff #8 reported that if the patient misses 3 meals, or consumes less than 50%, the physician will order a NGT. When asked if Intravenous fluids (IV) are ever given or considered, staff #8 stated, "Yes. We have given IV's before but usually the doctor will just order the feeding tube." Staff #8 was asked if the patient refused the feeding tube, what would be the next step. Staff #8 stated, "If the doctor writes the order we put it in and if the patient fights us we have to get restraint orders."

Staff #8 was asked to show the surveyors what a Houdini suit looks like and how it is applied. Staff #8 pulled out the restraint and demonstrated how the nylon vest is pulled over the patient's head. The arms are cut out resembling a vest. Attached to the back and bottom of the vest is the saddle bottom. The saddle is pulled between the legs similar to a diaper. There are ties attached to both sides. The ties come up around the waist and are secured in the back of a chair. Staff #8 and staff #3 confirmed that this restraint was referred to as the Houdini suit. Staff #8 and staff #3 confirmed that patient #2 was wearing a Houdini suit.

On 4/25/13 at 11:20AM lunch service was observed on the medical unit (M2). Patient #3 was in a Broda chair with a soft saddle restraint, BSWR, and NGT Patient #3 had an order for mechanical soft diet but was given a regular diet. Patient #3 was served a tray in the dining/ TV area. Her hands remained tied down and the assigned 1:1 PNA hand fed her. Patient #3 consumed a serving of peaches, a serving of Jell-O, and a serving of applesauce. Patient #3 was offered chocolate pudding and chicken spaghetti but she turned her head away. Patient #3 was not offered any fluids during the meal or any food substitutions. Patient #3's tray was taken away within 14 minutes and only one attempt to feed her. Patient #3 was never released from the wrist restraints to eat independently nor was a trial release attempted. Patient #3 was offered fluids after the meal tray was taken away.

On 4/25/13 at 12:00PM, Patient #2 was leaning forward, drooling, and tongue protruding. His tray was sat in front of him for 7 minutes before the PNA attempted to feed him. Patient #2 was difficult to arouse and wrist restraints were never released to allow patient to feed himself. The PNA offered the patient fluids by putting it to his lips. Patient #2 did sip from the cup but he was never offered a straw. The PNA made several attempts to offer food to the patient. However, the PNA held the fork away from patient #2's mouth and gave verbal commands to open his mouth. PNA never brought the food to the patient's mouth. A different PNA sat down 18 minutes later and helped Patient #2 consume a few bites of applesauce before the lunch was completed.

On 4/25/13 at 12:10PM Patient # 4 was observed being escorted into the dining/TV area with assistance by a PNA. Patient #4 had a feeding tube on 4/24/13. Patient #4 did not have a feeding tube at this time. Patient #4 was slumped over in the chair and was difficult to wake. She was unable to stay awake to eat her meal after multiple attempts from the staff. During observations, Staff #9 reported that patient #4 had complained about the food. She was use to eating Mexican food. Staff #9 reported that she had called the dietician and ordered patient #4 a meal that would be more "ethnic" to the patients likes two days ago. The meal served for lunch was green peas and chicken spaghetti. Patient #4 was not able to wake long enough to complete the current meal. The meal was removed and patient was recorded to eat 0% of meal. No other substitutes were offered.

During an interview 4/25/13 at 12:20PM, staff #9 was asked if the patients were ever released from the wrist restraints to eat on their own. She reported that they were when possible. Staff #9 reported that Patient #3 was not released because she pulls out her NGT each time and so does patient #2. Staff #9 was asked if the restraints were a convenience for the st