HospitalInspections.org

Based on the manner and degree of deficiencies cited, the hospital failed to be in compliance with the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient's rights.

The facility failed to meet the following standards under the Condition of Patient Rights:

Reference Tag A 0166 Restraint or Seclusion:
The facility failed to ensure that when restraints were applied that there was a corresponding written modification to the patient's plan of care.

Reference Tag A 0168 Restraint or Seclusion:
The facility failed to ensure that restraints were used only with the order of a physician or other licensed independent practitioner. This failure resulted in the restraint of a patient without the medical direction that was required.

Reference Tag A 0169 Restraint or Seclusion:
The facility failed to ensure that the use of restraint was never written as an as needed basis (PRN).

Reference Tag A 0175 Restraint or Seclusion:
The facility failed to ensure that the condition of patients in restraints was performed in accordance with the facility's policy.

Based on medical record review, facility policies/procedures, and staff interview the facility failed to ensure that when restraints were applied that there was a corresponding written modification to the patient's plan of care.

This failure resulted in not having a clear plan to respond to the patient's medical and psychiatric needs that necessitated the use of restraints in order to discontinue the use of restraints at the earliest possible time.

Findings:

1. The hospital did not have a process to ensure that the care plans for patients who were restrained had a modification in response to the decision to use restraints.

a. A review of the facility's policy titled "Restraint or Seclusion" which was last updated October 2012 revealed that the hospital did expect that documentation in response to restraints was for staff to "modify the individual's written treatment plan to address the need for restraint, and as appropriate, decrease or prevent its use." The policy did not provide directions for how this was to be documented in the patient's record.

b. An interview was conducted with an registered nurse from the Intensive Care Unit on 04/10/13 at 9:00 a.m. S/he stated that s/he was not able to describe how the patient's care plan was updated to include a modification to the plan in response to restraint use. S/he stated that often restraints were discussed during interdisciplinary rounds that were conducted daily, but that the only documentation of those rounds were completed by the physician and would not always include documentation regarding restraints.

c. During the above interview the record of Sample Patient #18 was concurrently reviewed with the registered nurse. S/he was unable to locate documentation that reflected any modification to the plan of care for the patient in response to restraints. S/he also confirmed that the documentation from the physician of the interdisciplinary rounds did not include documentation of the use of restraints or a modification in response to the use of restraints. The record reflected that Sample Patient #18 was restrained from 03/01/13 at 4:00 p.m. until 03/05/13 at 8:00 a.m.

d. An additional review of Sample Patient #18's record was conducted with the Patient Representative who also confirmed that there was not documentation of a modification to the patient's plan of care in response to the use of restraints.

Based on medical record review and staff interview the facility failed to ensure that restraints were used only with the order of a physician or other licensed independent practitioner. This failure resulted in the restraint of a patient without the medical direction that was required.

Findings:

1. The facility did not have documentation of a physician order for restraints that were applied to 3 (Sample patients #17, 18, and 19) of the 5 patients that were restrained.

a. A facility policy titled "Restraint or Seclusion" last updated October 2012 stated that "a physician, clinical psychologist, or other authorized licensed independent practitioner primarily responsible for the patient's ongoing care orders the use of restraint or seclusion."

b. A review of Sample Patient #17's medical record was conducted from 04/09/13 through 04/10/13. The patient was restrained while s/he was on a mechanical ventilator from 02/23/13 through 02/24/13. The record did not have a physician's order for the use of the restraints.

c. A review of Sample Patient #18's medical record was conducted from 04/09/13 through 04/10/13. The patient was restrained while s/he was on a mechanical ventilator from 03/01/13 through 03/05/13. The record did not have a physician's order for the use of the restraints.

d. A review of Sample Patient #19's medical record was conducted from 04/09/13 through 04/10/13. The patient was restrained while s/he was on a mechanical ventilator for 11 hours on 03/23/13. The record did not have a physician's order for the use of the restraints.

e. The above record reviews were conducted with the facility's Patient Representative. S/he confirmed that the above three records did not contain physician orders for the restraints that were applied to the patients.

Based on medical record review, facility policies/procedures, and staff interview the facility failed to ensure that the use of restraint was never written as an as needed basis (PRN).

This failure had the potential for patients' rights to be free from unnecessary restraints to be violated by not having a physician or licensed independent practitioner determine the appropriateness for each restraint episode.

Findings:

1. The facility did not obtain a new order from a physician when patients were released from restraints as a "trial out" and were not replaced until a later time. This constituted a PRN restraint.

a. The facility's policy titled "Restraint or Seclusion", last updated October 2012, stated that "the hospital does not use standing orders or PRN orders for restraint or seclusion." The policy also stated that at least every two hours staff were to document the justification for continuing restraint or needed to try to remove restraints in a document referred to as a "Trial Out." The policy did not explicitly state that if a patient remained out of restraints for a trial period that a new order would need to be obtained if the staff discontinued the restraint for a period of time.

b. A review of Sample Patient #16's record revealed that the patient was restrained from 01/23/13 at 8:00 p.m. through 01/27/13 at 2:00 p.m. The patient was not restrained on 01/25/13 at 12:00 p.m. for 2 hours, but was replaced in restraints at 2:00 p.m. A notation from the nurse on the "Trial Out" documentation at 12:00 p.m. stated that the patient was extubated and was not pulling at lines and that the restraint was discontinued. A notation at 2:00 p.m. by the nurse stated that the patient was pulling the nasal cannula (that delivered supplemental oxygen to the patient) off frequently and that the nurse had given the "patient a 2 hour break without restraints but" that "reapplication [was] necessary for patient safety." The patient's medical record contained only one physician order for restraints which was written on 01/23/13. The nursing staff had not obtained a new order for the reapplication of restraints that had occurred after the patient was removed from restraints on 01/25/13 at 12:00 p.m.

c. An interview was conducted with the Charge Nurse of the Intensive Care Unit on 04/09/13 at 3:37 p.m. S/he stated that s/he was not aware of a need to receive another order for restraints if a patient was removed from restraints as a "trial out" if the patient's behavior was the same. S/he confirmed that the documentation in Sample Patient #16's record reflected that the restraints were removed by staff for 2 hours and then replaced.

d. An interview was conducted with the facility's Director of Quality Resources/Risk Management on 04/09/13 at 4:12 p.m. S/he stated that s/he was not aware that a "trial release" was considered a PRN use of restraints by CMS. A concurrent review of the interpretive guidance was conducted which revealed that "Staff cannot discontinue a restraint or seclusion intervention, and then re-start it under the same order. This would constitute a PRN order. A 'trial release' constitutes a PRN use of restraint or seclusion, and, therefore, is not permitted by this regulation." S/he stated that s/he had thought that this regulation only pertained to the use of restraint for violent or self destructive patients.

2. The facility did not obtain a new order from a physician when staff placed a patient in restraints 11 hours after the order had been signed by the physician. This constituted a PRN restraint.

a. A review of Sample Patient #20's record revealed that the patient was restrained from 03/27/13 at 8:00 a.m. through 03/28/13 at 10:00 a.m. The patient's record contained only one order for restraints which stated that restraints were started on 03/26/13 at 6:00 p.m. and the order was signed by the attending physician on 03/26/13 at 9:00 p.m. The order was written and signed 11 hours prior to the patient being placed in restraints.

b. An interview was conducted with the Intensive Care Unit's Nurse Manager on 04/10/13 at 10:34 a.m. S/he confirmed the above documentation and stated that s/he thought that the order had been written in expectation that the restraints may be needed. S/he stated that s/he was not aware that not obtaining a new order for restraints when the restraints were actually applied would be considered a PRN or a standing order for restraints.

Based on medical record review, facility policies/procedures, and staff interview the facility failed to ensure that the condition of patients in restraints was performed in accordance with the facility's policy.

This failure had the potential for patient harm due to staff not monitoring patient's while immobilized in restraints.

Findings:

1. The facility did not ensure that staff adhered to the facility's established policy for the monitoring of patients in restraints for 2 (Sample Patients #16 and #20) of 5 patients records who were restrained.

a. The facility's policy titled "Restraint or Seclusion", last updated October 2012, stated that for patients in restraints that were non-violent and not self destructive that staff were to monitor the patients "every 15 minutes and document hourly" in the patient's record.

b. A review of Sample Patient #16's record revealed that the patient was restrained from 01/23/13 at 8:00 p.m. through 01/27/13 at 2:00 p.m. The patient was not restrained on 01/25/13 at 12:00 p.m. for 2 hours, but was replaced in restraints at 2:00 p.m. Documentation of observations of the patient were not done hourly and rather were documented approximately every 2 hours from the initiation of restraints on 01/23/13 at 8:00 p.m. through 01/26/13 at 6:00 a.m. There was not documentation from nursing staff that the patient was monitored while in restraints for the following 24 hours until 01/27/13 at 6:00 a.m. The documentation of monitoring was then, again, approximately every two hours until restraints were removed on 01/27/13 at 2:00 p.m.

c. A review of Sample Patient #20's record revealed that the patient was restrained from 03/27/13 at 8:00 a.m. through 03/28/13 at 10:00 a.m. Documentation of observations of the patient were done hourly except from 03/27/13 at 10:00 a.m. when the next check was documented at 12:00 p.m. reflecting that the check at 11:00 a.m. had not been documented or completed.

d. The review of the above records was conducted with the Patient Representative who confirmed the above gaps in documentation.

e. An interview was conducted with the facility's Director of Quality Resources/Risk Management on 04/09/13 at 3:23 p.m. S/he stated that the expectation of staff was to document the monitoring of patients every hour. S/he confirmed that the documentation for Sample Patient #16 did not meet the expectations of the facility.