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Based on record reviews and interviews, the facility failed to assure they protected and promoted patient rights by the inappropriate use of restraints for 1 (Patient #1) patient; failure to document specific behaviors and attempts to utilize the least restrictive methods prior to placing 4 (Patients #1, #2, #3, and #4) of 4 patients in an enclosed bed; failure to have a physician's order for the restraints utilized; failure to have orders renewed in a timely manner; failure to have a face-to-face evaluation by the physician when initiatin and renewing orders.

These failures present a substantial probability of adversely affecting all patients' health, safety, and wellbeing.

The findings include:

Based on observation, record review, review of hospital policies and procedures for restraint and seclusion, the facility failed to ensure the appropriate use of restraints for 2 (Patients #1 and #4) of 5 sampled patients. The facility failed to ensure the appropriate restraints were in place for the behaviors identified for Patient #4 as well as applied restraints to both of the patients wrists for 2 days without a physician's order. Patient #1 was restrained in an enclosed bed for behaviors without a policy for that use.

Please see A-0159 for additional information.

Based on observation, record review and interview, the facility failed to implement the least restrictive interventions for restraint use for 2(Patients #1 and #2) of 5 sampled patients. Nursing staff failed to demonstrate the specific behaviors of Patient #2 warranted the use of an enclosed bed and failed to document the rational for not using lesser alternatives.

Please see A-0164 for additional information.

Based on observation, record review, review of hospital policies and procedures for restraint and seclusion, the facility failed to ensure the appropriate use of restraints for 2 (Patients #1 and #4) of 5 sampled patients. The facility failed to ensure the appropriate restraints were in place for the behaviors identified for Patient #4 as well as applied restraints to both of the patient's wrists for 2 days without a physician's order. Patient #1 was restrained in an enclosed bed for behaviors without a policy for that use.


The findings include:

1. Observation during tour of the fifth floor of the hospital on 12/14/10 at 10:32 a.m. revealed Patient #4 in a "net bed" with the left and right sides of the bed open. Both of the patient's wrists were restrained to the sides of the bed. The patient's eyes were closed and he was lying still on his back. An NG (Nasogastric) tube was observed in his nose. The patient's wife was at the bedside on the phone.

Interview with the patient's primary nurse at this time revealed the net bed was "supposed to be exchanged today for a regular bed." She stated she "only had the patient for the past 2 days on her assignment" and could not specifically indicate why the bed was in place; however, she indicated the patient was confused and disoriented. She confirmed the wrist restraints were in place to prevent the patient from pulling out the NG tube; however, did not indicate why both wrists had to be restrained while the patient was sleeping and wife was present at the bedside.

Clinical record review on 12/14/10 revealed the patient was admitted to the hospital on 12/09/10 with diagnoses including, not limited to, pneumonia, emesis, and dementia.

Review of the nursing admission assessment for 12/09/10 revealed the patient as confused at times, with a history of falls, incontinent, with decreased muscle coordination, dizzy, impulsive behavior and was placed on fall precautions which included falls alert signage, non-slip footwear, bed alarm, toileting program and moving "poles" to exit side of bed as well as securing tubing.

Record review revealed a physician's order dated 12/09/10 at 1115 for an "enclosed bed" due to the patient "attempting to pull out medically necessary tubes/devices" and the clinical need was "alternative methods failed." The restraint was to be reordered "each calendar day;" and not "every 24 hours." There was no indication why placing a patient in an enclosed bed would alleviate the behavior of "pulling out medically necessary tubes/devices" as the patient would still be able to pull out medically necessary tubes if he could freely move his arms and legs while in the bed.

There was no prior documentation related to the patient's behavior which would warrant an order for the enclosed bed. At 1200 on 12/09/10, 45 minutes later, nursing documents the patient's behavior as "mobility against tx (treatment) plan and the patient as agitated and unable to comprehend as well as disoriented and confused. There was no specific note by the nurse to explain what the "treatment plan" was the patient was not following. The nurse documents the type of restraint to be used as "non violent" for this non specific behavior and at 1206, nursing then documents "attempts to remove device," but does not specifically indicate "which" device the patient is attempting to remove and why placing a patient in an "enclosed bed" for this type of behavior would prevent the patient from removing a "device."

Review of subsequent nursing notes revealed the patient continued to remain in the enclosed bed for "mobility against tx plan" and fluctuating behaviors of "attempts to remove device." There was no specific note indicating what "unsafe mobility" the patient was exhibiting for the use of the enclosed bed or "what devices" the patient was attempting to remove.

On 12/10/10 at 0700, orders for an enclosed bed and bilateral (left and right) wrists restraints were ordered by the physician for the behavior of "climbing out of bed/chair/wandering" due to "alternative methods failed." The order did not specify "which" behavior the patient was exhibiting or whether it was all three behaviors while the patient remained in the enclosed bed. There was no indication the resident had fallen. Nursing notes at 12/10/10 at 0622 reveal the wife wished for her husband to be in wrist restraints; however, nursing notes on 12/10/10 at 0000, 0200, 0400, and 0600 do not reveal evidence the patient was attempting to remove IV (intravenous) lines.

At 1130 on 12/10/10, 4 1/2 hours after the physician's order, bilateral wrist restraints were placed on the patient as nursing documents the patient is "handling wounds/dressings." The enclosed bed was discontinued. The order was to be renewed, "the next calendar day."

At 1600 on 12/10/10, nursing documents the patient's vital signs as "deferred" as the patient was sleeping; however, nursing documentation is in conflict as it further revealed the restraints were appropriately intact as the patient is "not following commands" and "attempts to remove device" while also "sleeping." At 1800, nursing documents the same assessment. There was no indication either wrist restraint was released while the patient was sleeping.

Physician orders dated 12/11/10 at 1130 were renewed for bilateral wrist restraints due to "imminent danger of pulling out medically necessary tubes/devices." The order was to be renewed, "the next calendar day." The patient continued with bilateral wrist restraints and orders dated 12/12/10 at 7:45 a.m. revealed a wrist restraint was ordered; however, it did not indicate whether right or left or "both" wrist restraints were necessary. On 12/13/2010, the physician signed an order for restraints; however, there was no indication for what type of restraints were to be used, for what behavior, and if any alternatives to restraint use were attempted.

Nursing notes for 12/12/10 from 0200 through 12/14/2010 at 1000 revealed the application of bilateral wrist restraints to the patient for 2 days without a specific physician's order.

Interview with the clinical director of the fifth floor on 12/14/10 at 4:20 p.m. confirmed the nursing staff was applying bilateral wrist restraints to the patient without a physician's assessment or order.

Review of the hospital policy and procedures entitled, "Restraints and Seclusion" under "i", directs the staff to ensure that the least restrictive method of restraint possible is used for the least amount of time. Staff are to reassess and terminate restraint use at the earliest possible time. The policy also indicates a "LIP/physician order is required for restraints. The initial order must be time limited, not to exceed twenty-four (24) hours, specify clinical justification for the restraint, the date and time ordered, duration of use, the type of restraint to be used, and behavior-based criteria for release." The LIP/physician order is required for restraints. When a patient is in restraint for longer than 24 hours, the LIP/physician must document his/her assessment supporting the decision to continue restraint; and a new written order for restraint. A new physician order must be written no less often than once each calendar day. The order must be time limited, not to exceed a calendar day and must include clinical justification and the type of restraint to be used.

2. Review of clinical record on 12/14/10 for Patient #1 revealed she had been admitted to the facility on 5/12/10 for complaints of back pain. She was also in renal failure. According to nursing notes dated 5/13/10 at 2000 (8:00 p.m.), the patient was also legally blind.

On 5/13/10 at 2330 (11:30 p.m.) the patient was placed in an enclosed bed (a bed that completely encloses the bed making it impossible for the patient to get out of bed. They are sometimes called a net or web bed). She had become combative, kicking, and scratching staff. Son-in-law and daughter were notified.

Further review of the clinical record revealed orders for the use of restraints documented on a form "Patient Safety Device Order" as follows:

5/13/10 at 2000 (8:00 p.m.) States "alternative methods failed" - no attempt at alternative methods are documented in the clinical record. This order was a verbal order via telephone. Behavioral restraints call for a face-to-face assessment. This order form states "Physician signature represents the completion of a face-to-face assessment and indicates this patient requires continued safety devices to maintain patient safety."

5/14/10 at 9:00 a.m. states "alternative methods failed" - no attempt at alternative methods are documented in the clinical record.

5/15/10 at 2200 (10:00 p.m.) fails to have a clinical need documented. This order was a verbal order via telephone. No face-to-face assessment by the physician to determine the continued need for enclosed bed.

5/16/10 at 0525 (5:25 a.m.) fails to have a clinical need documented. This order was a verbal order via telephone. No face-to-face assessment by the physician to determine the continued need for enclosed bed.

5/17/10 has an order which is blank except for the date and physicians signature. 5/17/10 at 9:15 a.m. signed by a different physician than above.

Review of the policy and procedure fails to find mention of the enclosed bed as a restraint. Review of the policy and procedure for falls prevention states under "Fall Risk Evaluation" page 3 of 5 - under High Risk Fall Precautions Interventions" 4. (c) Consider using an enclosed bed.

The enclosed bed use for this patient was utilized for behaviors, not fall risks. No alternatives were tried prior to the bed placement. No face-to-face was completed by the physician prior to the bed placement.

A review of nursing notes revealed the following:
5/13/10 at 1620 (4:20 p.m.) - "level of sedation" - "Coop/oriented/tranquil
5/13/10 at 1710 (5:10 p.m.) - as above
5/13/10 at 1850 (6:50 p.m.) - "Pt confused and agitated, trying to climb oob (out of bed), unable to reorient to place and situation. Resisting staff assistance. Call out to Dr. _____.
5/13/10 at 1913 (7:13 p.m.) - "Pt is awake, alert and confused. Pt is oob to bs (bedside) commode with max assistance. Pt voids on bedside commode. Incontinent at times, no BM (bowel movement) this shift"
5/13/10 at 2000 (8:00 p.m.) - Shift Evaluation -
LOC (level of consciousness) - alert/awake.
Oriented - N (no)
Behaviors - Anxious, combative, hostile, restless, uncooperative
Falls Precautions Comment - Enclosed bed
Special equipment - Enclosed bed - bed alarm
5/13/10 at 2100 (9:00 p.m.) - Restraint Monitor - behavior - attempts to remove device - alternatives decrease stim/quiet area, orientation and bed alarm.
5/13/10 at 2330 (11:30 p.m.) - nurses note: 1093 received pt. very restless, confused, trying to get out of bed and pulling bedside rails and bed sheets. Threatens staff, biting and very non-compliant. Refused all her meds. Claimed staff trying to give her the wrong medicine. Dr.__was called x 2. Next of kin _______ and ______notified. Placed on enclosed bed and cont. to be restless. Screaming.

5/14/10 enclosed bed continues. No alternatives documented. No other type of restraint attempted.

5/14/10 at 1838 (6:38 p.m.) nurses note: Pt continues hallucinations: "I am being robbed and everyone is out to murder me." Reassurance given. Reoriented pt to person, time, place and situation. Spoke with son-in-law today who agreed with the enclosed bed. Reassured son-in-law of his mother-in-laws wellbeing.

No trial of release or of alternative devices documented.

5/15/10 enclosed bed continues. No alternatives documented. No other type of restraint attempted.

5/15/10 at 1037 (10:37 a.m.) - nurses notes: Pt. screaming, swearing, out of control. Kicking this nurse in the abdomen. Scratching anyone who gets near her. Incontinent for large amt urine. Diaper changed with much difficulty. Pt flailing arms sustained large skin tear right forearm, not allowing nurse to dress wound. Verbally abusive to staff. Pt has multiple skin tears that are bleeding unable to treat these wounds as pt is extremely combative."

No trial of release or of alternative devices documented.

5/16/10 enclosed bed continues. No alternatives documented. No other type of restraint attempted.

No documented behaviors in nurses notes. No trial of release or of alternative devices documented.

5/17/10 at 1000 (10:00 a.m.) nurses notes - MD order to DC enclosed bed.

5/18/10 at 1703 (5:03 p.m.) nurses notes - Patient discharged.

Based on observation, record review and interview, the facility failed to implement the least restrictive interventions for restraint use for 2 (Patients #1 and #2) of 5 sampled patients. Nursing staff failed to demonstrate the specific behaviors of Patient #2 that warranted the use of an enclosed bed and failed to document the rational for not using lesser alternatives. Nursing failed to document the attempt at the least restrictive prior to implementing the enclosed bed for Patient #1. Failed to try and or document trial releases.


The findings include:


1. Observation on 12/14/10 at 10:37 a.m. during the tour of the fourth revealed Patient #2 in an enclosed "net" bed. The nurse was in with the patient preparing to administer medications.

Interview with the nurse at this time revealed the patient was alert, oriented and cooperative and had been admitted to the hospital with a history of alcohol abuse. She stated the patient had "tried to smoke in her bathroom and was unsteady on her feet." She further stated the "patient had alcohol in her purse when she was admitted, was very cooperative and is on alcohol protocol." When asked why the patient was in an enclosed bed, the nurse stated, "We need to keep her safe...she has periods of confusion and gets mixed up using the phone."

The nurse confirmed the patient no longer had alcohol in her purse and did not try and smoke in the bathroom.

Review of the clinical record on 12/14/10 revealed the 63 year old patient was admitted to the hospital on 12/10/10 with diagnoses including, not limited to, pancreatitis.

Clinical record review revealed the patient was ordered delirium tremors protocol while in the ICU (Intensive Care Unit) on 12/10/10. After stabilization, she was transferred to the medical/surgical floor on 12/11/10.

Review of the physician's orders dated 12/13/10 and timed 1955 revealed an enclosed bed was ordered for the behavior of "climbing out of bed, chair/wandering." The specific behavior was not identified. This "new order" needed to be "re-ordered" each calendar day. On 12/14/10, the physician signed the same type of order; however, the "time" of the order was not documented.

Review of the nursing notes for 12/12 through 12/14/10 failed to reveal the nursing assessment of the patient's specific behavior which warranted the use of an enclosed bed was "mobility against treatment plan" however, it did not specify what behavior the patient was exhibiting. In addition, documentation failed to reveal least restrictive, alternative interventions other than placing the patient in an enclosed bed failed to protect her from.

Despite nursing indicating the patient was "alert and cooperative" there was no documentation to support the nursing staff attempted restraint reduction.

During an interview with the clinical manager of the unit on 12/14/10 at 4:20 p.m., she could not provide documentation to support the patient exhibited behaviors which warranted her placement in an enclosed bed. In addition, she confirmed the physician's order for 12/14/10 did not specify the time the order was to be implemented.

Review of the hospital's policy and procedures for Restraint/Seclusion reveals "Restraint standards for medical and post-surgical purposes apply when the primary reason for use directly supports medical healing. Clinical justification is guided by "clear" criteria present in practice guidelines, etc. Behavioral health reasons for the use of restraint or seclusion are primarily to protect the patient against injury to self or others because of an emotional or behavioral disorder.

The facility failed to demonstrate the specific behavior of the patient which warranted the use of the enclosed bed.


2. Review of clinical record on 12/14/10 for Patient #1 revealed she had been admitted to the facility on 5/12/10 for complaints of back pain. She was also in renal failure. According to nursing notes dated 5/13/10 at 2000 (8:00 p.m.), the patient was also legally blind.

On 5/13/10 at 2330 (11:30 p.m.) the patient was placed in an enclosed bed (a bed that completely encloses the bed making it impossible for the patient to get out of bed. They are sometimes called a net or web bed). She had become combative, kicking, and scratching staff. Son-in-law and daughter were notified.

Further review of the clinical record revealed orders for the use of restraints documented on a form "Patient Safety Device Order" as follows:

5/13/10 at 2000 (8:00 p.m.) States "alternative methods failed" - no attempt at alternative methods are documented in the clinical record. This order was a verbal order via telephone. Behavioral restraints call for a face-to-face assessment. This order form states "Physician signature represents the completion of a face-to-face assessment and indicates this patient requires continued safety devices to maintain patient safety."

5/14/10 at 9:00 a.m. states "alternative methods failed" - no attempt at alternative methods are documented in the clinical record.

5/15/10 at 2200 (10:00 p.m.) fails to have a clinical need documented. This order was a verbal order via telephone. No face-to-face assessment by the physician to determine the continued need for enclosed bed.

5/16/10 at 0525 (5:25 a.m.) fails to have a clinical need documented. This order was a verbal order via telephone. No face-to-face assessment by the physician to determine the continued need for enclosed bed.

5/17/10 has an order which is blank except for the date and physicians signature. 5/17/10 at 9:15 a.m. signed by a different physician than above.

Review of the policy and procedure fails to find mention of the enclosed bed as a restraint. Review of the policy and procedure for falls prevention states under "Fall Risk Evaluation" page 3 of 5 - under High Risk Fall Precautions Interventions" 4. (c) Consider using an enclosed bed.

The enclosed bed use for this patient was utilized for behaviors, not fall risks. No alternatives were tried prior to the bed placement. No face-to-face was completed by the physician prior to the bed placement.

A review of nursing notes revealed the following:

5/13/10 at 1620 (4:20 p.m.) - "level of sedation" - "Coop/oriented/tranquil
5/13/10 at 1710 (5:10 p.m.) - as above
5/13/10 at 1850 (6:50 p.m.) - "Pt confused and agitated, trying to climb oob (out of bed), unable to reorient to place and situation. Resisting staff assistance. Call out to Dr. _____.
5/13/10 at 1913 (7:13 p.m.) - "Pt is awake, alert and confused. Pt is oob to bs (bedside) commode with max assistance. Pt voids on bedside commode. Incontinent at times, no BM (bowel movement) this shift"
5/13/10 at 2000 (8:00 p.m.) - Shift Evaluation -
LOC (level of consciousness) - alert/awake.
Oriented - N (no)
Behaviors - Anxious, combative, hostile, restless, uncooperative
Falls Precautions Comment - Enclosed bed
Special equipment - Enclosed bed - bed alarm
5/13/10 at 2100 (9:00 p.m.) - Restraint Monitor - behavior - attempts to remove device - alternatives decrease stim/quiet area, orientation and bed alarm.
5/13/10 at 2330 (11:30 p.m.) - nurses note: 1093 received pt. very restless, confused, trying to get out of bed and pulling bedside rails and bed sheets. Threatens staff, biting and very non-compliant. Refused all her meds. Claimed staff trying to give her the wrong medicine. Dr.__was called x 2. Next of kin _______ and ______notified. Placed on enclosed bed and cont. to be restless. Screaming.

5/14/10 enclosed bed continues. No alternatives documented. No other type of restraint attempted.

5/14/10 at 1838 (6:38 p.m.) nurses note: Pt continues hallucinations: "I am being robbed and everyone is out to murder me." Reassurance given. Reoriented pt to person, time, place and situation. Spoke with son-in-law today who agreed with the enclosed bed. Reassured son-in-law of his mother-in-laws wellbeing.
No trial of release or of alternative devices documented.

5/15/10 enclosed bed continues. No alternatives documented. No other type of restraint attempted.

5/15/10 at 1037 (10:37 a.m.) - nurses notes: Pt. screaming, swearing, out of control. Kicking this nurse in the abdomen. Scratching anyone who gets near her. Incontinent for large amt urine. Diaper changed with much difficulty. Pt flailing arms sustained large skin tear right forearm, not allowing nurse to dress wound. Verbally abusive to staff. Pt has multiple skin tears that are bleeding unable to treat these wounds as pt is extremely combative."
No trial of release or of alternative devices documented.

5/16/10 enclosed bed continues. No alternatives documented. No other type of restraint attempted.

No documented behaviors in nurses notes. No trial of release or of alternative devices documented.

5/17/10 at 1000 (10:00 a.m.) nurses notes - MD order to DC enclosed bed.

5/18/10 at 1703 (5:03 p.m.) nurses notes - Patient discharged.

Based on observation, record review, interview and review of the facility's policies and procedures for Restraints and Seclusion, nursing staff failed to consistently and effectively supervise the nursing care for 3 (Patients #1, #2, and #4) of 5 sampled patients. Nursing failed to ensure the appropriate restraints were in place for the behaviors identified for the patients, failed to ensure physician's orders for restraints were accurate for the types of restraints used and failed to effectively demonstrate lesser alternatives to enclosed beds were attempted.

The findings include:

1. Observation during tour of the fifth floor of the hospital on 12/14/10 at 10:32 a.m. revealed Patient #4 in a "net bed" with the left and right sides of the bed open. Both of the patient's wrists were restrained to the sides of the bed. The patient's eyes were closed and he was lying still on his back. An NG (Nasogastric) tube was observed in his nose. The patient's wife was at the bedside on the phone.

Interview with the patient's primary nurse at this time revealed the net bed was "supposed to be exchanged today for a regular bed." She stated she "only had the patient for the past 2 days on her assignment" and could not specifically indicate why the bed was in place; however, she indicated the patient was confused and disoriented. She confirmed the wrist restraints were in place to prevent the patient from pulling out the NG tube; however, did not indicate why both wrists had to be restrained while the patient was sleeping and wife was present at the bedside.

Clinical record review on 12/14/10 revealed the patient was admitted to the hospital on 12/09/10 with diagnoses including, not limited to, pneumonia, emesis, and dementia.

Review of the nursing admission assessment for 12/09/10 revealed the patient as confused at times, with a history of falls, incontinent, with decreased muscle coordination, dizzy, impulsive behavior and was placed on fall precautions which included falls alert signage, non-slip footwear, bed alarm, toileting program and moving "poles" to exit side of bed as well as securing tubing.

Record review revealed a physician's order dated 12/09/10 at 1115 for an "enclosed bed" due to the patient "attempting to pull out medically necessary tubes/devices" and the clinical need was "alternative methods failed." The restraint was to be reordered "each calendar day" and not "every 24 hours." There was no indication why placing a patient in an enclosed bed would alleviate the behavior of "pulling out medically necessary tubes/devices" as the patient would still be able to pull out medically necessary tubes if he could freely move his arms and legs while in the bed.

There was no prior documentation related to the patient's behavior which would warrant an order for the enclosed bed. At 1200 on 12/09/10, 45 minutes later, nursing documents the patient's behavior as "mobility against tx (treatment) plan and the patient as agitated and unable to comprehend as well as disoriented and confused. There was no specific note by the nurse to explain what the "treatment plan" was the patient was not following. The nurse documents the type of restraint to be used as "non violent" for this non specific behavior and at 1206, nursing then documents "attempts to remove device" but does not specifically indicate "which" device the patient is attempting to remove and why placing a patient in an "enclosed bed" for this type of behavior would prevent the patient from removing a "device."

Review of subsequent nursing notes revealed the patient continued to remain in the enclosed bed for "mobility against tx plan" and fluctuating behaviors of "attempts to remove device." There was no specific note indicating what "unsafe mobility" the patient was exhibiting for the use of the enclosed bed or "what devices" the patient was attempting to remove.

On 12/10/10 at 0700, orders for an enclosed bed and bilateral (left and right) wrists restraints were ordered by the physician for the behavior of "climbing out of bed/chair/wandering" due to "alternative methods failed." The order did not specify "which" behavior the patient was exhibiting or whether it was all three behaviors while the patient remained in the enclosed bed. There was no indication the resident had fallen. Nursing notes at 12/10/10 at 0622 reveal the wife wished for her husband to be in wrist restraints; however, nursing notes on 12/10/10 at 0000, 0200, 0400, and 0600 do not reveal evidence the patient was attempting to remove IV (intravenous) lines.

At 1130 on 12/10/10, 4 1/2 hours after the physician's order, bilateral wrist restraints were placed on the patient as nursing documents the patient is "handling wounds/dressings." The enclosed bed was discontinued. The order was to be renewed, "the next calendar day."

At 1600 on 12/10/10, nursing documents the patient's vital signs as "deferred" as the patient was sleeping; however, nursing documentation is in conflict as it further revealed the restraints were appropriately intact as the patient is "not following commands" and "attempts to remove device" while also "sleeping." At 1800, nursing documents the same assessment. There was no indication either wrist restraint was released while the patient was sleeping.

Physician orders dated 12/11/10 at 1130 were renewed for bilateral wrist restraints due to "imminent danger of pulling out medically necessary tubes/devices." The order was to be renewed, "the next calendar day." The patient continued with bilateral wrist restraints and orders dated 12/12/10 at 7:45 a.m. revealed a wrist restraint was ordered; however, it did not indicate whether right or left or "both" wrist restraints were necessary. On 12/13/10, the physician signed an order for restraints; however, there was no indication for what type of restraints were to be used, for what behavior, and if any alternatives to restraint use were attempted.

Nursing notes for 12/12/10 from 0200 through 12/14/20 at 1000 revealed the application of bilateral wrist restraints to the patient for 2 days without a specific physician's order.

Interview with the clinical director of the fifth floor on 12/14/10 at 4:20 p.m. confirmed the nursing staff was applying bilateral wrist restraints to the patient without a physician's assessment or order.

Review of the hospital policy and procedures entitled, "Restraints and Seclusion", under "i" directs the staff to ensure that the least restrictive method of restraint possible is used for the least amount of time. Staff are to reassess and terminate restraint use at the earliest possible time. The policy also indicates a "LIP/physician order is required for restraints. The initial order must be time limited, not to exceed twenty-four (24) hours, specify clinical justification for the restraint, the date and time ordered, duration of use, the type of restraint to be used and behavior-based criteria for release." The LIP/physician order is required for restraints. When a patient is in restraint for longer than 24 hours, the LIP/physician must document his/her assessment supporting the decision to continue restraint; and a new written order for restraint. A new physician order must be written no less often than once each calendar day. The order must be time limited, not to exceed a calendar day and must include clinical justification and the type of restraint to be used.

2. Observation on 12/14/10 at 10:37 a.m. during the tour of the fourth revealed Patient #2 in an enclosed "net" bed. The nurse was in with the patient preparing to administer medications.

Interview with the nurse at this time revealed the patient was alert, oriented and cooperative and had been admitted to the hospital with a history of alcohol abuse. She stated the patient had "tried to smoke in her bathroom and was unsteady on her feet." She further stated the "patient had alcohol in her purse when she was admitted, was very cooperative and is on alcohol protocol." When asked why the patient was in an enclosed bed, the nurse stated, "We need to keep her safe...she has periods of confusion and gets mixed up using the phone."

The nurse confirmed the patient no longer had alcohol in her purse and did not try and smoke in the bathroom.

Review of the clinical record on 12/14/10 revealed the 63 year old patient was admitted to the hospital on 12/10/10 with diagnoses including, not limited to, pancreatitis.

Clinical record review revealed the patient was ordered delirium tremors protocol while in the ICU (Intensive Care Unit) on 12/10/10. After stabilization, she was transferred to the medical/surgical floor on 12/11/10.

Review of the physician's orders dated 12/13/10 and timed 1955 revealed an enclosed bed was ordered for the behavior of "climbing out of bed, chair/wandering." The specific behavior was not identified. This "new order" needed to be "re-ordered" each calendar day. On 12/14/10, the physician signed the same type of order; however, the "time" of the order was not documented.

Review of the nursing notes for 12/12 through 12/14/10 failed to reveal the nursing assessment of the patient's specific behavior which warranted the use of an enclosed bed was "mobility against treatment plan"; however, it did not specify what behavior the patient was exhibiting. In addition, documentation failed to reveal least restrictive, alternative interventions other than placing the patient in an enclosed bed failed to protect her from.

Despite nursing indicating the patient was "alert and cooperative" there was no documentation to support the nursing staff attempted restraint reduction.

During an interview with the clinical manager of the unit on 12/14/10 at 4:20 p.m., she could not provide documentation to support the patient exhibited behaviors which warranted her placement in an enclosed bed. In addition, she confirmed the physician's order for 12/14/10 did not specify the time the order was to be implemented.

Review of the hospital's policy and procedures for Restraint/Seclusion reveals "Restraint standards for medical and post-surgical purposes apply when the primary reason for use directly supports medical healing. Clinical justification is guided by "clear" criteria present in practice guidelines, etc. Behavioral health reasons for the use of restraint or seclusion are primarily to protect the patient against injury to self or others because of an emotional or behavioral disorder.

The facility failed to demonstrate the specific behavior of the patient which warranted the use of the enclosed bed and failed to demonstrate less restrictive interventions were ineffective prior to the use of this type of restraint. In addition, there was no indication restraint reduction was attempted in lieu of nursing indicating the resident's behavior had stopped and was "alert, oriented and cooperative."

3. Review of clinical record on 12/14/10 for Patient #1 revealed she had been admitted to the facility on 5/12/10 for complaints of back pain. She was also in renal failure. According to nursing notes dated 5/13/10 at 2000 (8:00 p.m.), the patient was also legally blind.

On 5/13/10 at 2330 (11:30 p.m.) the patient was placed in an enclosed bed (a bed that completely encloses the bed making it impossible for the patient to get out of bed. They are sometimes called a net or web bed). She had become combative, kicking and scratching staff. Son-in-law and daughter were notified.

Further review of the clinical record revealed orders for the use of restraints documented on a form "Patient Safety Device Order" as follows:

5/13/10 at 2000 (8:00 p.m.) States "alternative methods failed" - no attempt at alternative methods are documented in the clinical record. This order was a verbal order via telephone. Behavioral restraints call for a face-to-face assessment. This order form states "Physician signature represents the completion of a face-to-face assessment and indicates this patient requires continued safety devices to maintain patient safety".

5/14/10 at 9:00 a.m. States "alternative methods failed" - no attempt at alternative methods are documented in the clinical record.

5/15/10 at 2200 (10:00 p.m.) fails to have a clinical need documented. This order was a verbal order via telephone. No face-to-face assessment by the physician to determine the continued need for enclosed bed.

5/16/10 at 0525 (5:25 a.m.) fails to have a clinical need documented. This order was a verbal order via telephone. No face-to-face assessment by the physician to determine the continued need for enclosed bed.

5/17/10 has an order which is blank except for the date and physicians signature.
5/17/10 at 9:15 a.m. signed by a different physician than above.

Review of the policy and procedure fails to find mention of the enclosed bed as a restraint. Review of the policy and procedure for falls prevention states under "Fall Risk Evaluation" page 3 of 5 - under High Risk Fall Precautions Interventions", 4. (c) Consider using an enclosed bed.

The enclosed bed use for this patient was utilized for behaviors, not fall risks. No alternatives were tried prior to the bed placement. No face-to-face was completed by the physician prior to the bed placement.

A review of nursing notes revealed the following:
5/13/10 at 1620 (4:20 p.m.) - "level of sedation" - "Coop/oriented/tranquil
5/13/10 at 1710 (5:10 p.m.) - as above
5/13/10 at 1850 (6:50 p.m.) - "Pt confused and agitated, trying to climb oob (out of bed), unable to reorient to place and situation. Resisting staff assistance. Call out to Dr. _____.
5/13/10 at 1913 (7:13 p.m.) - "Pt is awake, alert and confused. Pt is oob to bs (bedside) commode with max assistance. Pt voids on bedside commode. Incontinent at times, no BM (bowel movement) this shift"
5/13/10 at 2000 (8:00 p.m.) - Shift Evaluation -
LOC (level of consciousness) - alert/awake.
Oriented - N (no)
Behaviors - Anxious, combative, hostile, restless, uncooperative
Falls Precautions Comment - Enclosed bed
Special equipment - Enclosed bed - bed alarm
5/13/10 at 2100 (9:00 p.m.) - Restraint Monitor - behavior - attempts to remove device - alternatives decrease stim/quiet area, orientation and bed alarm.
5/13/10 at 2330 (11:30 p.m.) - nurses note: 1093 received pt. very restless, confused, trying to get out of bed and pulling bedside rails and bed sheets. Threatens staff, biting and very non-compliant. Refused all her meds. Claimed staff trying to give her the wrong medicine. Dr.__was called x 2. Next of kin _______ and ______notified. Placed on enclosed bed and cont. to be restless. Screaming.

5/14/10 enclosed bed continues. No alternatives documented. No other type of restraint attempted.

5/14/10 at 1838 (6:38 p.m.) nurses note: Pt continues hallucinations: "I am being robbed and everyone is out to murder me." Reassurance given. Reoriented pt to person, time, place and situation. Spoke with son-in-law today who agreed with the enclosed bed. Reassured son-in-law of his mother-in-laws wellbeing.
No trial of release or of alternative devices documented.

5/15/10 enclosed bed continues. No alternatives documented. No other type of restraint attempted.

5/15/10 at 1037 (10:37 a.m.) - nurses notes: Pt. screaming, swearing, out of control. Kicking this nurse in the abdomen. Scratching anyone who gets near her. Incontinent for large amt urine. Diaper changed with much difficulty. Pt flailing arms sustained large skin tear right forearm, not allowing nurse to dress wound. Verbally abusive to staff. Pt has multiple skin tears that are bleeding unable to treat these wounds as pt is extremely combative."
No trial of release or of alternative devices documented.

5/16/10 enclosed bed continues. No alternatives documented. No other type of restraint attempted.

No documented behaviors in nurses notes. No trial of release or of alternative devices documented.

5/17/10 at 1000 (10:00 a.m.) nurses notes - MD order to DC enclosed bed.

5/18/10 at 1703 (5:03 p.m.) nurses notes - Patient discharged.