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Based on record review and interview the facility failed to avoid writing as needed orders for restraints. This failed practice is likely to cause physical harm to the patient and staff by the release and then the reinstitution of the restraints without a new order.

Findings are:

A. Record review of P#7 medical chart revealed:
1."Physician Order - Restraint" dated 11/09/20 at 3:30 am for Non-Behavioral Restraint with indication for restraint, "unable to comprehend or follow directions to refrain from activities that can injure self", signed by S#19 (Medical Doctor) dated 11/09/20 at 8:00 am.
2. "Progress Note", dated 11/09/2020 at 3:50 am by S#19 revealed "Will restrain as needed to prevent self harm".
3. "Progress Note", dated 11/09/20 at 11:58 am by S#19 revealed no documentation of P#7 in restraints and the general physical exam noting P#7 as "alert and oriented, well nourished, no acute distress".
4. "Progress Note", dated 11/09/20 at 12:06 pm by S#19 revealed "Acute Delirium (Confused thinking): Patient noted today attempting to walk out of the hospital early this morning about 2 am. Is currently on haloperidol (a behavioral medication) 2.5mg (Milligrams) as needed which appears to be helping. Agitation and delirium is thought to be related to possible dementia (persistent disorder of the mental process) ". No documentation that patient is in restraints and no documentation that the restraints had been discontinued.
5. "Progress Note", dated 11/09/20 at 1:51pm by S#19 revealed "Will restrain as needed to prevent self harm".
6. "Physician Order - Restraint" dated 11/10/20 at 4:30 am for Non-Behavioral Restraint with indication for restraint, "unable to comprehend or follow directions to refrain from activities that can injure self", order signed by S#19 dated 11/09/20 at 8:00 am.
7. "Progress Note", dated 11/10/20 at 10:18 am by S#19 revealed "Still requiring restraints and sedation (Administering of a sedative drug to produce a state of calm or sleep) ".
8. "Physician Order - Restraint" dated 11/11/20 at 8:00 am for Non-Behavioral Restraint with indication for restraint, "unable to comprehend or follow directions to refrain from activities that can injure self, Impulsive, Observed trying to climb out of bed, Unsteady will not ask for assistance", order signed by S#19 at 8:00 am.
9. "Discharge Summary", dated 11/11/20 at 9:53 am by S#19 revealed "Discharge Disposition - Patient is being discharged home along with his son who will take care of him at home. He is to follow up with his primary care provider when he is out of isolation". No documentation of the Restraint order being discontinued.

B. On 11/18/20 at 12:00 pm during interview with S#1 (Director of Quality) confirmed that in P#7's medical chart that the patient was placed into restraints on 11/09/20 and was taken out of restraints on 11/11/20 when patient was discharged home. S#1 also confirmed that there was no order to discontinue the restraints for P#7.

Based on record review and interview the facility failed to document a restraint patient's response to the intervention and the rationale for continued use of the intervention. This failed practice would likely cause physical and/or emotional harm to the patient because the impact of the restraints were not documented.

Findings are:

A. Record review of P#7 medical chart revealed:

1. "Progress Note", dated 11/09/20 at 11:58 am by S#19 (Medical Doctor) revealed in the Assessment/Plan section of the progress note there was no detailed assessment of how P#7 was responding to the restraints or any reason to continue the use of restraints.
2. "Progress Note", dated 11/09/20 at 12:06 pm by S#19 revealed "Acute Delirium: Patient noted today attempting to walk out of the hospital early this morning about 2 am. Is currently on haloperidol (a behavioral medication) 2.5mg (Milligrams) as needed which appears to be helping. Agitation and delirium is thought to be related to possible dementia". No documentation that patient was in restraints and no documentation that the restraints had been discontinued or any reason for the continued use of the restraints.
3. "Progress Note", dated 11/10/20 at 10:18 am by S#19 revealed "Still requiring restraints and sedation" and no detailed assessment of how P#7 was responding to the restraints, any reason to continue the use of the restraints or a plan to discontinue the restraints.
4. "Discharge Summary", dated 11/11/20 at 9:53 am by S#19 revealed the patient was being discharged home with his son but no documentation of the Restraint order being discontinued or the impacted the restraints had on P#7.

B. On 11/18/20 at 12:00 pm during interview with S#1 (Director of Quality) confirmed that in P#7's medical chart that the patient was discharged home with family from the facility on 11/11/20. S#1 also confirmed that there was no documentation in P#7 medical chart that indicated a detailed assessment of how P#7 responded to being in restraints.

Based on record review and interview the facility failed to complete a discharge planning process at an early stage of hospitalization for P#1 -P#5 and P#7- P#10 of records reviewed. This failed practice could cause patients to suffer adverse health consequences upon discharge due to the absence of adequate discharge planning.

The findings are:

A. On 11/17/2020 at 11:30 am during interview S#3 (Administrator) confirmed the facility does not currently have a Discharge Planner in place and the House Supervisor is in charge of discharge planning. S#3 further confirmed the facility is currently seeking a Social Worker/Case Manager to work PRN (as needed) until such time as the position is required full time.

B. Record Review of inpatient charts for P#1 -P#5 and P#7- P#10 initial discharge planning reveals:

1. Record Review for P#1 MR# (medical record number), date of admission 11/12/2020 reveals no Initial Discharge Assessment on file. Patient is a current patient in the facility.
2. Record Review for P#2 MR#, date of admission 11/12/2020 reveals no Initial Discharge Assessment on file. Patient is a current patient in the facility.
3. Record Review for P#3 MR#, date of admission 11/12/2020 reveals no Initial Discharge Assessment on file. Patient is a current patient in the facility.
4. Record Review for P#4 MR#, date of admission 11/3/2020 reveals no Initial Discharge Assessment on file.
5. Record Review for P#5 MR#, date of admission 11/4/2020 reveals no Initial Discharge Assessment on file.
6. Record Review for P#7 MR#, date of admission 11/6/2020 reveals no Initial Discharge Assessment on file.
7. Record Review for P#8 MR#, date of admission 11/9/2020 reveals no Initial Discharge Assessment on file.
8. Record Review for P#9 MR#, date of admission 10/13/2020 reveals no Initial Discharge Assessment on file.
9. Record Review for P#10 MR#, date of admission 10/13/2020 reveals no Initial Discharge Assessment on file.

C. Record review of inpatient charts for P#4, P#5, P#7, P#8, P#9 & P#10 discharge documentation reveals Patient P#1, P#2, P#3 were present patients in the facility.
1. Record Review for P#4 date of discharge 11/4/2020 reveals Physician Order for follow up appointment dated 11/4/2020 at 12:22 pm. "Hospital Discharge Instructions Discharge Follow Up Appoints: follow up with PCP (primary care provider) in 1 week", no appointment provided.
2. Record Review for P#5 date of discharge 11/6/2020 reveals "Hospital Discharge Instructions Discharge Follow Up Appointments: Blank". "Discharge Summary Follow Up: PCP within 1 week", no appointment provided
3. Record Review for P#7 date of discharge 11/11/2020 reveals "Hospital Discharge Instructions Discharge Follow Up Appointments: follow up with PCP in 1 week", no appointment provided,
4. Record Review for P#8 date of discharge 11/14/2020 reveals "Physician Order dated 11/14/2020 3:13 pm Home Health, Need home PT (Physical Therapy) and Home O2 (oxygen) at 21/min (2 liters per minute),Consult Indicator (consult orders) ". Hospital Discharge Instructions Follow Up Appointments: Follow up with specialist, name and info provided", no appointment provided. Nurse Progress note shows referral to Home Health and Request for O2 completed but not communicated to patient.
5. Record Review for P#9 date of discharge 10/15/2020 reveals on Discharge Summary "Patient afraid of partner: Yes", "Usual hours of sleep: 2 hours", "Alcohol/Substance Abuse: yes". Discharge Plan: discharge to home. Hospital Discharge Instructions Problem "Ongoing: Alcohol binge and Major Depressive Disorder, (a mental disorder characterized by a persistently depressed mood and long term loss of pleasure or interest in life) Historical: Suicidal Ideation (thinking about, considering, or planning suicide) ", "Follow Up Appointments: Follow up with PCP within 5 to 7 days, Question: Why? provided answer: Make PCP appointment when you get home today", no appointment provided.
6. Record Review for P#10 date of discharge 10/15/2020 reveals no plan for discharge other than "Follow Up Appointments: Return to referring provider", no appointment provided.