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Based on clinical record review and interview, it was determined the Facility failed to update the plan of care for one (#14) of four (#1, #11, #14 and #15) patients reviewed who were placed in restraints. Failure to include the use of restraints in the plan of care did not reflect a process of assessment, intervention and evaluation by the Interdisciplinary Team when restraints were used. The failed practice affected Patient #14 and had the potential to affect all patients who were restrained. The findings follow:

A. Review of Patient #14's clinical record revealed the patient was in restraints from 11/30/16 at 1440 to 12/01/16 at 1200. There was no evidence the patient's plan of care was updated to reflect the use of the restraints.

B. The findings of A were confirmed in an interview with the Transplant Administrator on 01/18/16 at 1300.

Based on clinical record review, policy and procedure review and interview, it was determined the Facility failed to obtain a physician order to continue restraints for violent behavior every one hour for one (#15) of two (#11 and #15) patient placed in restraints for violent behavior. The failed practice did not ensure a physician's input was included in the management of the restraints. The findings follow:

A. Review of the policy "Restraints/Seclusion (System-Wide)" on 01/18/17 revealed, "B. Time Limits for Orders. 2. Violent, Self-Destructive Restraints or Seclusion. i. May not exceed one (1) hour."

B. Review of Patient #15's clinical record on 01/18/17 revealed the patient was in restraints for violent behavior from 12/04/16 at 0438 to 12/05/16 at 0126. There was no evidence of a physician's order to continue restraints for violent behavior every hour from 12/04/16 at 0800 to 12/04/16 at 2300.

C. The findings of A and B were confirmed in an interview with the Transplant Administrator on 01/18/17 at 1240.

Based on clinical record review, policy and procedure review and interview, it was determined a licensed nurse failed to assess the patient's skin integrity, nutrition and hydration, hygiene and elimination (toileting) and circulation every 15 minutes while the patient was in restraints for violent behavior for one (#11) of two (#11 and #15) patient placed in restraints for violent behavior. The failed practice placed the patient at risk of skin breakdown, dehydration and adverse effects related to poor circulation. The failed practice had the potential to affect all patients placed in restraints. The findings follow:

A. Review of the policy "Restraint/Seclusion (System-Wide)" on 01/18/17 revealed, "IX. Assessment/Monitoring/Care of the Patient in Restraint or Seclusion. A. Patients in restraint/seclusion must be monitored/assessed by qualified and trained staff, at a minimum: 1. Every 15 minutes for Violent, Self-Destructive Restraints or Seclusion. B. Patients in restraint/seclusion must be assessed by a licensed nurse for, at a minimum: 1. Skin integrity. 2. Nutrition and hydration. 3. Hygiene and elimination (toileting). 4. Signs of injury or distress. 5. Circulation. 6. To determine if restraints can be discontinued."

B. Review of Patient #11's clinical record on 01/18/17 revealed the patient was in restraints for violent behavior from 01/16/17 at 0330 to 01/17/17 at 0908. There was no evidence the patient was assessed for skin integrity, nutrition and hydration, hygiene and elimination and circulation every 15 minutes from 01/16/17 at 0330 to 01/17/17 at 0700.

C. The findings of A and B were confirmed in an interview with the Transplant Administrator on 01/18/17 at 1355.

Based on clinical record review and interview, it was determined the Facility failed to ensure 3 (#3-#5) of 15 (#1-#15) patient's plans of care reflected what the goal was for each problem listed and/or failed to reflect if the problems were resolved prior to being discharged from the Facility. Failure to provide a goal did not allow the Interdisciplinary Team to adjust the interventions to meet the goal. Failure to indicate if the problems were resolved prior to discharge did not ensure the interventions in place met the patients' goals. The findings follow:

A. Review of Patient #3's clinical record on 01/19/17 revealed a Plan of Care dated 11/26/16 with the identified problems as "Pain, Risk for Infection and Safety." Review of the Plan of Care revealed there were no identified goals listed on the plan of care for the identified problems. The patient was discharged from the Facility on 11/29/16. There was no evidence the problems listed on the Plan of Care were resolved prior to the patient being discharged from the Facility. The findings were confirmed in an interview with the Transplant Administrator on 01/19/17 at 1223.

B. Review of Patient #4's clinical record on 01/19/17 revealed a Plan of Care dated 01/08/17 with the identified problems as "Pain, Burn Injury, Alt (Altered) Nutrition and Decreased ROM (range of motion), functional mobility (01/11/17)." Review of the Plan of Care revealed there was no evidence the problems listed were resolved prior to discharge from the Facility. The findings were confirmed in an interview with the Director of Accreditation on 01/19/17 at 1025.

C. Review of Patient #5's clinical record on 01/19/17 revealed a Plan of Care dated 01/15/17 with the identified problems as "Risk for Resp. (Respiratory) Distress, Pain and Nutrition." Review of the Plan of Care revealed there were no identified goals listed on the plan of care for the identified problems. The patient was discharged from the Facility on 01/17/17. There was no evidence the problems listed on the Plan of Care were resolved prior to the patient being discharged from the Facility. The findings were confirmed in an interview with the Director of Accreditation on 01/19/17 at 1025.