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Based on document review and interview, the facility staff failed to ensure:

patients in restraints were provided nutrition and fluids, means for defecation or voiding without soiling themselves, and range of motion and circulation was checked every two (2) hours for two (2) of eight (8) patients (Patients #2 and #6);

documentation of a Physician's order for restraints for four (4) of ten (10) patients (Patients # 3, #6, #7, #8 and #9);

a physician, within 24 hours of placing a patient in restraints, documented why the restraints were necessary for four (4) of ten (10) patients (Patients #6, #7, #8 and #9);

restraints were removed from two (2) of eight (8) patients (Patient #8 and #9) at the earliest possible time;

documentation of ongoing assessment and monitoring of the patient's condition per the facility's policy for restraints for six (6) of ten (10) patients (Patients # 1, #3, #6, #7, and #9); and

less restrictive interventions were attempted and documented prior to placing a patient in restraints for three (3) of eight (8) patients (Patient #6, #7 and #8).

Under the Condition of Patient's Rights, please see the following standard tags for more specific information:
Tag 0168,
Tag 0172,
Tag 0174,
Tag 0175,
Tag 0186.

Based on document review and interview, it was determined that the facility failed to document a Physician's order for restraints for five (5) of ten (10) patients (Patients # 3, #6, #7, #8 and #9).

The findings include:

1. During clinical record review on February 3, 2021 between 9:30 a.m. and 12:00 p.m. the following was revealed:

Patient # 3 was admitted to the facility from the ED on January 29, 2021 at 8:07 a.m. with complaint of leg pain. Documentation revealed the admitting diagnosis was Acute DVT (deep venous thrombosis). Patient # 3 was deceased at the facility on February 1, 2021 at 6:04 a.m.

Documentation on January 31, 2021 reads in part:
3:00 a.m. "Intubated - critical condition lines. Type of Restraint: non-violent, Length of order: 24, non-violent, MD notified: yes, Order obtained: yes, face to face: yes, soft wrist restraint - right: continued, soft wrist restraint - left: start.
5:00 a.m. soft wrist restraint - right: continued, soft wrist restraint - left: continued.
8:00 a.m. soft wrist restraint - right: discontinued, soft wrist restraint - left: discontinued."

Patient # 3 had no MD order for the restraints contrary to documentation.

On February 2, 2021 at 10:00 a.m., a review of the facility policy provided by Staff Member # 2 titled "Restraint and/or Seclusion" reads in part "The use of restraint must be in accordance with the order of a physician who is responsible for the care of the patient (attending physician)."


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2. The medical records of Patients #6, #7, #8, and #9 were reviewed at various dates and times from 2/4/21 to 2/12/21. The medical records failed to consistently have documentation of a physicians order to place the patient in restraints and/or continue the restraints every twenty-four (24) hours. (The Non-Violent Restraint Documentation Error Logs were provided but contained information that did not match the medical records.)

Patient #6:
A physician's order for restraints was obtained on:
1/22/21 at 7:15 P.M. The restraints were not discontinued nor a new order obtained by 7:15 P.M. 1/23/21, twenty-four (24) hours later.
1/24/21 at 5:00 P.M. an order for restraints was obtained. The restraints were not discontinued nor a new order obtained to continue the restraints by 5:00 P.M. on 1/25/21.
1/27/21 at 2:30 P.M. an order for restraints was obtained. The restraints were not discontinued nor a new order obtained to continue the restraints by 2:30 P.M. on 1/28/21.
1/29/21 at 12 noon an order for restraints was obtained. The restraints were not discontinued nor a new order obtained to continue the restraints by 12 noon on 1/30/21.
1/31/21 and 2/2/21, no order for restraints was obtained.
2/2/21 at 8:00 A.M. an order for restraints was obtained.

Per documentation in the medical record, Patient #6 restraints remained in place and were not discontinued from 1/22/21 to 2/2/21. Patient #6 was observed in restraints on 2/2/21 at approximately 1:00 P.M. Patient #6's eyes were closed, Patient #6 was not moving and no one was in the room.

During the timeframe reviewed, Patient #6 was restrained for one hundred and eleven and one quarters hours (111.25 hours) from 1/23/22 to 2/2/21 without a physician's order.


Patient #7:
1/27/21 at 2:00 P.M. A physician's order was obtained for soft wrist restraints. The restraints were not discontinued nor a new order obtained to continue the restraints by 2:00 P.M. on 1/28/21. The restraints were continued and an order obtained at 1/29/21 at 7:15 P.M. The restraints were not discontinued nor a new order obtained to continue the restraints by 7:15 P.M. on 1/30/21. The restraints were continued and an order obtained on 2/2/21 at 10:00 P.M.

Patient #7 was observed in restraints on 2/2/21 at approximately 1:00 P.M. Patient #7's eyes were closed, Patient #7 was not moving and no one was in the room.

During the timeframe reviewed, Patient #7 was restrained for a total of one hundred and four and one half hours (104.50 hours) from 1/27/21 to 2/2/21 without a physician's order.

Patient #8:
Patient #8 was placed in bilateral soft wrist restraints on 1/29/21 at 2:00 A.M. A physician's order for the restraints was not obtained until midnight 1/31/21. There were no additional physician's orders for restraints.

Patient #8 was restrained for a total of eighty-eight hours (88 hours) from 1/29/21 to 2/2/21 without a physician's order.

Patient #9:
Patient #9 was admitted to ICU on 1/29/21. The ICU Flowsheet documents Patient #9 was placed in restraints (bilateral wrist) on 1/30/21 at 2:45 A.M. and that a physician's order was given. A physician's order for the restraints was not written until 5:00 A.M. on 1/30/21

Based on documentation and interview, the facility staff failed to ensure a physician, within 24 hours of placing a patient in restraints, documented why the restraints were necessary for four (4) of ten (10) patients, Patients #6, #7, #8 and #9.

The findings include:

The medical records of Patients #6, #7, #8, and #9 were reviewed at various times and dates from 2/4/21 to 2/12/21 and found to not consistently have documentation by the physician as to why restraints were placed and/or continue every twenty-four (24) hours.

Patient #6:
A physician's order for restraints was obtained on 1/19/21 at 6:00 P.M. Medical records included orders on the following dates with no documentation by the physician indicating why restraints were still needed:
1/20/21 at 4:00 P.M.,
1/22/21 at 7:15 P.M.,
1/24/21 at 5:00 P.M.,
1/25/21 at 4:00 P.M.,
1/26/21 at 4:15 P.M.,
1/27/21 at 2:30 P.M.,
1/29/21 at 12 noon,
2/2/21 at 8:00 A.M.

Patient #6 was observed in restraints on 2/2/21 at approximately 1:00 P.M. Patient #6's eyes were closed, Patient #6 was not moving and no one was in the room.

Patient #7:

On 1/27/21 at 2:00 P.M. a physician's order was obtained for soft wrist restraints and Patient #7 remained in wrist restraints to 2/2/21 at 10:00 P.M. There was no documentation by the physician indicating why restraints were still needed every twenty-four (24) hours.

Patient #7 was observed in restraints on 2/2/21 at approximately 1:00 P.M. Patient #7's eyes were closed, Patient #7 was not moving and no one was in the room.


Staff Member #15 provided a written review of Patient #6's medical record and documented, "...We have also identified that a provider assessment was not documented."

Patient #8:
The physician's progress notes in the medical record of Patient #8 dated 1/30/21 and 1/31/21 indicated Patient #8 was in bilateral wrist restraints but the note did not document why they were ordered or continued.

Based on medical record and policy review, the facility staff failed to ensure they removed restraints from two (2) of eight (8) patients, Patient #8 and #9, at the earliest possible time.

The findings include:

Patient #8 was restrained initially on 1/29/21. Documentation on the Intensive Care (ICU) Flowsheets starting on 1/30/21 at 2:00 P.M. until 6:00 A.M. on 2/1/21 stated Patient #8 was resting. At 8:00 A.M. on 2/1/21 until 6:00 P.M. documentation stated Patient #8 was sedated. There was no documentation as to the behavior of Patient #8 from 6:00 P.M. until 2/2/21 at 2:00 A.M. Documentation from 2:00 A.M. until 6:00 A.M. on 2/2/21 indicated Patient #8 was resting/sedated.

Patient #9 was initially restrained on 1/30/21 at 2:45 A.M. From 1/30/21 4:40 A.M. until 2/4/21 at 2:00 P.M. documentation on the ICU Flowsheets indicated Patient #9 was resting, sedated and/or subdued. There was no documentation of Patient #9 being restless or agitated.


Policy titled: "Restraints and/or Seclusion" with a review date of 10/2017 was provided by Staff Member #2 and documented the following:
"Page 10,
H. Discontinuation and Release Criteria
1. Discontinued as Soon as Possible
a. Restraint must be discontinued at the earliest possible time, regardless of the length of time identified in the order
b. The decision to discontinue must be based on as assessment and re-evaluation of the patient's condition determining that the patient's behavior is on longer a threat to self, staff or others...
3. Release Criteria
a. Nonviolent Restraint Release Criteria
i. Line Protection - NO LONGER pulling at or interfering with invasive tubes/lines resulting in injury/harm to self and alternative interventions successful or not needed..."

Based on document review and interview, it was determined that the facility failed to document ongoing assessment and monitoring of the patient's condition per the facility's policy for restraints for five (5) of ten (10) patients, Patients # 1, #3, #6, #7, and #9.

The findings include:

During clinical record review on February 3, 2021 between 9:30 a.m. and 12:00 p.m. the following was revealed:
Patient # 1 was admitted to the facility from the Emergency Department (ED) on January 4, 2021 at 4:50 a.m. with complaint of Covid-19. Documentation revealed the admitting diagnosis was Pneumonia due to Covid - 19 virus. Patient # 1 was deceased at the facility on January 15, 2021 at 5:06 p.m.

Documentation revealed Patient # 1 was in restraints from January 7 - 15, 2021.
Documentation revealed there was no monitoring or assessment for restraints as follows:
January 10 - 11, 2021, 8 p.m. - 2:00 a.m.
January 11 - 12, 2021, 8 a.m.
January 12 - 13, 2021, 8 p.m.

Patient # 3 was admitted to the facility on January 29, 2021 at 8:07 a.m. with complaint of leg pain. Documentation revealed the admitting diagnosis was Acute DVT (deep venous thrombosis). Patient # 3 was deceased at the facility on February 1, 2021 at 6:04 a.m.

Documentation revealed Patient # 3 was in restraints on January 31, 2021.
Documentation revealed there was no monitoring or assessment for restraints on January 31, 2021 at 7:00 a.m.

Documentation of the patient's condition did not occur every two (2) hours while in restraints per the facility's policy.

On February 2, 2021 at 10:00 a.m., a review of the facility policy provided by Staff Member # 2 titled "Restraint and/or Seclusion" reads in part "Maximum Timeframes for monitoring and assessment are: Non-violent Restraints: Every 2 hours. The time frames are not to be exceeded."



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2. Patient #6, #7, and #9's medical records and/or a Non-violent Restraint Documentation Error Log were reviewed on various dates and times from 2/4/21 to 2/12/21. Patient's #6, #7 and #9 were in bilateral soft wrist restraints during the below noted dates and times. There was no documentation of the patients being monitored and reassessed per the facility policy except on dates and times noted .

Patient #6 was placed in soft wrist restraints from 1/19/21 to 2/2/21.
No documented observations of Patient #6 while in restraints were made during the following dates and times:
1/19/21 at 6:00 P.M. until 1/21/21 8:00 A.M.
1/22/21 at 8:00 A.M. until 10:00 P.M.
1/25/21 at 8:00 A.M. until 1/26/21 at 8:00 A.M.
1/27/21 at 8:00 A.M. until 10:00 P.M.
1/29/21 at 8:00 A.M. until 1/31/21 at 10:00 P.M.
2/1/21 at 8:00 A.M. until 10:00 P.M.

Patient #7 was placed in soft wrist restraints from approximately 1/25/21 to 2/2/21.
No documented observations of Patient #7 while in restraints were made during the following dates and times:
1/25/21 at 9:01 P.M. until 1/26/21 7:01 A.M.
1/26/21 at 9:01 A.M. until 7:01 P.M.
1/26/21 at 9:01 P.M. until 1/27/21 at 7:01 A.M.
1/27/21 at 9:01 A.M. until 7:01 P.M.
1/30/21 at 9:01 P.M. until 1/31/21 at 7:01 A.M.
1/31/21 at 9:01 A.M. until 7:01 P.M.
1/31/21 at 9:01 P.M. until 2/1/21 at 7:01 A.M.
2/1/21 at 9:01 A.M. until 2/2/21 at 7:01 A.M.
2/2/21 at 9:01 A.M. until 5:01 P.M.
2/2/21 at 7:01 P.M. until 2/3/21 at 7:01 A.M.
On the Non-violent Restraint Documentation Error Log the following information was documented: Patient #7 was not observed from 2/1/21 at 8:00 A.M. until 8:01 A.M. on 2/2/21 (twenty-four (24) hours) and from 7:00 P.M. on 2/2/21 for eighteen (18) hours.

Patient #9 was initially restrained on 1/30/21 at 2:45 A.M. From 1/30/21 4:40 A.M. until 2/4/21 at 2:00 P.M. documentation on the ICU Flowsheets indicated Patient #9 was resting, sedated and/or subdued.
There was no documented observation of Patient #9 being restless or agitated.


Policy titled: "Restraints and/or Seclusion" with a review date of 10/2017 was provided by Staff Member #2 and documented the following:
"Page 10,
G. Reassessment/Monitoring
2. Frequency
b. Maximum timeframes for monitoring and assessment are:
a. Nonviolent Restraints - Every 2 hours; With exception of vital signs, respiratory status, intake and output, and cardiac status with may be taken as clinically indicated and/or ordered.

3. Monitoring Components - The following components are monitored offered at timeframes as described above:
a. Circulation, b. Nutrition needs, c. Hydration needs, d. Elimination needs, e. Level of distress/agitation, f. Mental Status, g. Cognitive functioning, h. Skin integrity, i. Readiness of discontinuation...
5. Documentation - Documentation of monitoring/assessment will be on the Restraint Assessment Sheet at the timeframes noted above..."


Staff Member #7 was interviewed on 2/2/21 at approximately 1:15 P.M. regarding the use of sitters to decrease the number of restraints being used. Staff Member #7 stated, "To my knowledge there are only two (2) sitters for the whole hospital."

Based on medical record and policy review, the facility failed to ensure less restrictive interventions were attempted and documented prior to placing a patient in restraints for three (3) of eight (8) patients, Patient #6, #7 and #8.

The findings include:

The following medical records were reviewed at various times from 2/4/21 to 2/12/21 and the following information was noted:

Patient #6 was initially seen in the Emergency Department for shortness of breath and coffee ground emesis. Patient #6 was intubated and placed on a ventilator for airway protection.

Patient #6 was sedated with Precedex but able to follow commands.
Patient #6 was placed in soft wrist restraints on 1/19/21 and remained in soft wrist restraints through 2/2/21 (The medical record after this date was not reviewed.) During the days of the restraints there was no documentation of lesser restrictive interventions attempted.

Patient #7 was placed in soft wrist restraints from approximately 1/25/21 to 2/2/21.
There was no documentation in Patient #7's medical record of less restrictive interventions prior to placing Patient #7 in restraints or an alternative to continuing the restraints.

Patient #8 was restrained initially on 1/29/21.
There was no documentation in Patient #8's medical record of less restrictive interventions prior to placing Patient #8 in restraints or an alternative to continuing the restraints.


Policy titled: "Restraints and/or Seclusion" with a review date of 10/2017 was provided by Staff Member #2 and documents the following:
"Page 1 and 2,
2. Use of Restraint is:
c. Only used after least restrictive interventions have failed and/or based on individual patient assessment the use of least restrictive measures is determined to pose a greater risk that the risk of using restraint;...
5. Documentation -
b. A description of the patient's behavior and the intervention used;
c. Alternatives or other less restrictive interventions attempted (as applicable);
d. The patient's condition or symptom(s) that warranted the use of the restraint and/or seclusion;
e. The patient's response to the intervention(s) used, including the rationale for continued use of the intervention;..."

Based on observations, interviews, and documents reviews, it was determined the facility staff failed to ensure the facility implemented the infection control plan by not ensuring Staff changed dirty gloves and performed hand hygiene upon entering and exiting patient rooms, and ensuring Staff performed hand hygiene after touching masks.

Please see Tag 0749 for detailed information.

2. On 2/3/21 at approximately 11:30 A.M. Staff Member #5 was observed approaching the nursing station in a hospital gown, PPE (personal protective equipment), head cover and gloves. Staff Member #5 removed a medical record from the shelf and proceeded to document in the medical record. Staff Member #5 replaced the medical record and then walked down the hallway and entered a patient room.

Staff Member #5 was asked where they had come from with their PPE and gloves on and stated, "I just came out of surgery."

After leaving the patient room, Staff Member #5 removed the PPE and gloves and then performed hand hygiene.


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Based on observations, interviews and document reviews, it was determined that the facility failed to ensure staff performed hand hygiene upon entering and exiting patient rooms for four (4) of ten (10) Staff Members (Staff Members # 5, # 19, # 20 and # 21); and performed hand hygiene after touching masks for three (3) of ten (10) Staff Members (Staff Members # 4, # 7, and # 18) to prevent and control the transmission of infections.

The findings include:

1. On February 2 and 3, 2021 during observations in patient care areas, the following were observed:

February 2, 2021 at 12:30 p.m. during the facility tour, Staff Member # 4 was observed on a "stroke unit", touching the front of mask without performing hand hygiene.

At 12: 42 p.m. Staff Member # 21 (Dietary Staff) was going in and out of patient rooms to pick up trays from the beside. Staff Member # 21 failed to removed dirty gloves and perform hand hygiene between patients.

At 12:52 p.m., Staff Members # 19 and # 20 were observed rolling a cart with red buckets (hazardous waste containers) on it. Staff Members # 19 and # 20 were observed going in and out of Patient rooms wearing gloves, removing "dirty" red buckets and placing "clean" red buckets in the room. Staff Members # 19 and # 20 failed to removed dirty gloves and perform hand hygiene before touching clean buckets and between patient rooms.

At 12:59 p.m., Staff Member # 18 was observed walking down the hallway on the nursing unit. Staff Member # 18 adjusted face mask by touching the front of the mask. Staff Member # 18 failed to perform hand hygiene after touching face mask. Staff Member # 18 was then observed typing on the computer in the hallway. Staff Member # 18 did not clean and disinfect the computer after use.

On February 3, 2021 at 1:30 p.m., Staff Member # 7 was observed going from one nursing unit to another nursing unit while adjusting mask by touching the front of the mask. Staff Member # 7 failed to perform hand hygiene.

During observations on the nursing units, signs were observed posted outside of each room reading "Foam in and out". Along with the signs was foaming hand sanitizer.
An interview with Staff Member # 12 on February 2, 2021 at 1:40 p.m. revealed staff are expected to perform hand hygiene upon entering and exiting the patient rooms. The signs are reminders to staff and visitors.

The facility's policy for infection control was requested on Thursday, February 18, 2021 at 3:50 p.m. and received on Monday, February 22, 2021 at 10:50 a.m.

The facility policy titled "General Standard Precautions" reads in part "Hand hygiene: before and after any patient encounter. Masks: front of mask/respirator is contaminated - do not touch. Keep hands away from face. Perform hand hygiene."