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Based on document review and interview the facility failed to protect the rights of one of four patients (#1) reviewed for restraints from a total sample of 10 resulting in the potential for all current and future patients to be at risk for loss of their rights. Findings include:

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A-0159 - Failure to employ a definition of physical restraints in use at the facility

A-0165 - Failure to ensure the least restrictive intervention was employed

A-0175 - Failure to ensure the monitoring of a patient in restraints per facility policy

A-0178 - Failure to ensure a physician performed a face to face assessment within the required timeframe

Based on interview and record review, the facility failed to employ a definition of a physical restraint that was consistent with regulatory requirements for one (Patient #1) of 4 patients reviewed for physical restraints out of a total sample of 10, resulting in the potential for unnecessary restriction of movement and patient distress. Findings include:

On 10/17/18 at 1530, Patient #1's clinical record was reviewed with Staff T. The Chief Nursing Officer, Staff D, and the Emergency Department Manager, Staff H were also present, and were interviewed at this time.

Patient #1 was a 63 year old female who resided in an extended care facility (nursing home), and was transferred to the facility Emergency Department (ED) on 9/8/17 at approximately 1215, for a change in mental status and decreased oxygen saturation. The Nursing Home to Hospital Transfer Form, dated 9/8/17 documented that Patient #1 was transferred to the hospital for mental status change and hypoxemia. The form documented the "behavioral issues" as, "yelling, cursing and apologizing, metting her needs", but no violent or self-destructive behaviors. The form also documented that Patient #1 had left sided weakness. Diagnoses indicated that the patient had poor vision with bilateral cataracts and optic nerve atrophy, Dementia, Anxiety and residuals from a stroke. The ambulance record documented that Patient #1 was, "confused but consolable" and obeyed commands. A Physician's consultation report, dated 9/10/17 at 1039 documented that Patient #1 had, "obvious weakness of left upper extremity and left lower extremity.

Review of facility ED Physician's orders for Patient #1 revealed an order dated 9/8/17 at 1828 for Patient #1 to be placed in keyed four point cuff restraints (hard cuffs secured to the stretcher and locked with a key to both wrists and both ankles). The order was noted as "Restraint, Non-violent. keyed cuff x 4, pulling at tubes/dressings, pain relief/comfort measures." The order expiration date, and the date the order was documented as discontinued, was 9/11/17 at 1320, three days later. There was an order for "Restraint, Non-Violent" monitoring, dated 9/8/17 at 1828 to monitor the patient every two hours.

There were two Nursing Notations for this restraint application for Patient #1, dated 9/8/17 at 1830 and 1836. These did not indicate that the patient was pulling at any tubes. Record review revealed that Patient #1 had no dressings or tubes except for oxygen tubing through a nasal cannula, monitoring leads, and a peripheral intravenous access device (IV) with normal saline (salt water).

The Nursing Note on the facility "Adult Restraint Flow Record", dated 9/8/17 at 1830 documented the initiation of the restraints, and noted the reason for physical restraint as, " Patient kicking, yelling, screaming, biting, using profanities, noncompliant. Restraints applied."

A Nursing Note dated 9/8/17 at 1836 documented that the doctor was notified that Patient #1 was "kicking, biting, scratching, pinching, screaming, yelling profanities, alert and oriented x 1 (confused), patient hostile."

On 10/17/17 at approximately 1600 Emergency Department Manager, Staff H was interviewed regarding the lack of monitoring, a three day stop time for the order and lack of a one hour face to face restraint assessment for Patient #1 after the 4 point locked cuff restraints were applied. Staff H stated that a four hour stop time for the order, 15 minute monitoring, restraint loosening at one hour intervals and a one hour face to face assessment were not necessary for a non-violent restraint.

On 10/17/17 at approximately 1605, the Chief Nursing Officer, Staff D was interviewed and stated that non-violent restraints were used to prevent patients from pulling at critical tubings or dressings, and consisted of soft restraints applied to the hands. Staff D stated that a peripheral IV, oxygen tubing and monitor leads were not life threatening if removed by the patient. Staff D stated that locked restraints of both legs and both arms were not necessary to prevent a patient from removing tubings or dressings, but were used for violent behavior management.

On 10/18/17 at 1700, Staff W was interviewed by telephone and stated that she had "been pulled to help out and transfer (Patient #1) to the floor (inpatient unit) because it was really busy on that hallway, and they needed help." Staff W said that she was told that Patient #1 was in non-violent soft restraints on both hands, and had been "shocked" to find that the patient was in 4 point keyed cuff restraints and soaked in urine. When asked, Staff W stated that she had been unable to find out who was assigned to Patient #1's care since shift change at 1900, and could not find any documentation of restraint monitoring or nursing care since shift change at 1900, or an order for violent restraints. Staff W stated that locked cuffed leg restraints were not non-violent restraints, and were not needed to prevent a patient from pulling out tubes and leads, as the patient was not likely to be able to reach them with her feet.

A policy on Physical Restraints, including definitions of restraints was requested. The provided policy, entitled "Restraints", dated 05/01/17 contained no definition of Non-violent versus Violent Restraint. The definition of a physical restraint was noted as, "The involuntary use of any manual method or physical or mechanical device or material or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement, physical activity or normal access to one's body."

Based on interview and record review, the facility failed to ensure that the least restrictive intervention was used for one (Patient #1) of 4 patients reviewed for physical restraints out of a total sample of 10, resulting in the potential for unnecessary restriction of movement and patient distress. Findings include:

On 10/17/18 at 1530, Patient #1's clinical record was reviewed with Staff T. The Chief Nursing Officer, Staff D, and the Emergency Department Manager, Staff H were also present, and were interviewed at this time.

Patient #1 was a 63 year old female who resided in an extended care facility (nursing home), and was transferred to the facility Emergency Department (ED) on 9/8/17 at approximately 1215, for a change in mental status and decreased oxygen saturation. The Nursing Home to Hospital Transfer Form, dated 9/8/17 documented that Patient #1 was transferred to the hospital for mental status change and hypoxemia. The form documented the "behavioral issues" as, "yelling, cursing and apologizing, metting her needs", but no violent or self-destructive behaviors. The form also documented that Patient #1 had left sided weakness but toileted independently with assistance in transferring (to the toilet). Diagnoses indicated that the patient had poor vision with bilateral cataracts and optic nerve atrophy, Dementia, Anxiety and residuals from a stroke. The ambulance record documented that Patient #1 was, "confused but consolable" and obeyed commands. A Physician's consultation report, dated 9/10/17 at 1039 documented that Patient #1 had, "obvious weakness of left upper extremity and left lower extremity.

Review of facility ED Physician's orders for Patient #1 revealed an order dated 9/8/17 at 1828 for Patient #1 to be placed in keyed four point cuff restraints (hard cuffs secured to the stretcher and locked with a key to both wrists and both ankles). The order was noted as "Restraint, Non-violent. keyed cuff x 4, pulling at tubes/dressings, pain relief/comfort measures." The order expiration date, and the date the order was documented as discontinued, was 9/11/17 at 1320, three days later. .

There were two Nursing Notations for this restraint application for Patient #1, dated 9/8/17 at 1830, and at 1836. These did not indicate that the patient was pulling at any tubes. Record review revealed that Patient #1 had no dressings or tubes except for oxygen tubing through a nasal cannula, monitoring leads, and a peripheral intravenous access device (IV) with normal saline (salt water) at a minimal rate. There was no other documentation of behaviors that indicated that Patient #1 was a danger to herself or others.

Patient #1 was assessed by the physician, Staff X on 9/8/17 at 1216, and by another ED Physician on 9/8/17 at 1408. Both physicians documented that the patient was confused, but there was no documentation to indicate that the patient was violent or a danger to herself. The Physician Assessment at 1408 documented that the patient was "resting comfortably in mild distress, writhing on the cart saying she is in pain", and, "she will be admitted to the hospital to (Staff X)'s service, in stable condition" for a diagnosis of, "altered mental status." A History and Physical for Patient #1, signed by Staff X on 9/8/17 at 1821 documented the patient was agitated, but did not indicate that the patient was violent, or at risk for harming herself, or in need of physical restraints.

The Nursing Note on the "Adult Restraint Flow Record" dated 9/8/17 documented that Patient #1 was placed in physical restraints at 1830. The reason for physical restraint was documented as, " Patient kicking, yelling, screaming, biting, using profanities, noncompliant. Restraints applied."

A Nursing Note dated 9/8/17 at 1836 documented the doctor was notified that Patient #1 was "kicking, biting, scratching, pinching, screaming, yelling profanities, alert and oriented x 1 (confused), patient hostile."

There was no documentation of less restrictive interventions attempted, attempts at redirection or attempts to see if Patient #1 was reacting out of unmet care needs. There was no documentation to indicate that Patient #1 had been toileted since arriving in the facility six hours earlier.

On 10/17/17, the ED Manager, Staff H was interviewed and asked to provide documentation of less restrictive interventions attempted. None were recieved by survey exit. When queried, Staff H was unable to explain why a patient with left sided weakness from a stroke would need both ankles and both wrists locked to the stretcher in hard cuffs to prevent her from pulling out tubes/dressings.

On 10/17/17 at approximately 1605, the Chief Nursing Officer, Staff D was interviewed and stated that a peripheral IV, oxygen tubing and monitor leads were not life threatening if removed by the patient. Staff D stated that locked restraints of both legs and both arms were not necessary to prevent a patient from removing tubings or dressings, but were used for violent behavior management.

On 10/18/17 at 1700, Staff W was interviewed by telephone and stated that she had "been pulled to help out and transfer (Patient #1) to the floor (inpatient unit) because it was really busy on that hallway, and they needed help." Staff W said that she was told that Patient #1 was in non-violent soft restraints on both hands, and had been "shocked" to find that the patient was in 4 point keyed cuff restraints and soaked in urine. When asked, Staff W stated that she had been unable to find out who was assigned to Patient #1's care since shift change at 1900, and could not find any documentation of restraint monitoring or nursing care since shift change at 1900, or any order for violent restraints. Staff W stated that locked cuffed leg restraints were not non-violent restraints, and were not needed to prevent a patient from pulling out tubes and leads, as the patient was not likely to be able to reach them with her feet, especially with one sided weakness from an old cerebrovascular accident (CVA- stroke). Staff W stated that Patient #1 was confused and anxious, but was not combative when she changed her sheets and gown and washed her up before transferring her upstairs to the floor.

Record review revealed that during the time frame Staff W was caring for Patient #1, a restraint order, dated 9/8/17 at 2056 was written for, "Restraint-Violent-Renewal: hard keyed x 4, visual supervision, harmful to self, 4 hr. The order was cancelled/discontinued on 9/8/17 at 2106 (12 minutes later, still under Staff W's care). A new restraint order was written on 9/8/17 at 2106 (same time the order for the hard keyed x4 was discontinued). This new order, dated 9/8/17 at 2106 was for, "Restraint-Violent-Renewal: soft limb x 2, Reorientation, verbal reminders, harmful to self, 4 hr."

A policy on Physical Restraints, including definitions of restraints was requested. The provided policy, entitled "Restraints", dated 05/01/17 contained the following notation, "Physical restraint will be initiated only in those instances when a patient threatens to physically harm self or others. The use of restraints must be ...implemented in the least restrictive manner possible, in accordane with safe, appropriate restraining techniques and ended at the earliest possible time. In all instances the use of physical restraint is considered the most restrictive intervention. A patient may be restrained only after less restrictive interventions have been considered and docoumented in the medical record"

Based on interview and record review, the facility failed to ensure that monitoring, assessment, repositioning and loosening of restraints was done at 15 minute intervals per facility policy for one (Patient #1) of four patients reviewed for physical restraints out of a total sample of 10, resulting in the potential for unplanned events and unexpected outcomes. Findings include:

On 10/17/18 at 1530, Patient #1's clinical record was reviewed with Staff T. The Chief Nursing Officer, Staff D, and the Emergency Department Manager, Staff H were also present, and were interviewed at this time.

Patient #1 was a 63 year old female who resided in an extended care facility (nursing home), and was transferred to the facility Emergency Department (ED) on 9/8/17 at approximately 1215, for a change in mental status and decreased oxygen saturation. The Nursing Home to Hospital Transfer Form, dated 9/8/17 documented that Patient #1 was transferred to the hospital for mental status change and hypoxemia. The form documented the "behavioral issues" as, "yelling, cursing and apologizing, metting her needs", but no violent or self-destructive behaviors. The form also documented that Patient #1 had left sided weakness. Diagnoses indicated that the patient had poor vision with bilateral cataracts and optic nerve atrophy, Dementia, Anxiety and residuals from a stroke. The ambulance record documented that Patient #1 was, "confused but consolable" and obeyed commands. A Physician's consultation report, dated 9/10/17 at 1039 documented that Patient #1 had, "obvious weakness of left upper extremity and left lower extremity.

Review of facility ED Physician's orders for Patient #1 revealed an order dated 9/8/17 at 1828 for Patient #1 to be placed in keyed four point cuff restraints (hard cuffs secured to the stretcher and locked with a key to both wrists and both ankles). The order was noted as "Restraint, Non-violent. keyed cuff x 4, pulling at tubes/dressings, pain relief/comfort measures."

There were two Nursing Notations for this restraint application for Patient #, dated 9/8/17 at 1830, and at 1836. These did not indicate that the patient was pulling at any tubes. Record review revealed that Patient #1 had no dressings or tubes except for oxygen tubing through a nasal cannula, monitoring leads, and a peripheral intravenous access device (IV) with normal saline (salt water) at a minimal rate.

The Nursing Note on the "Adult Restraint Flow Record" dated 9/8/17 documented that physical restraints were applied at 1830. The reason for physical restraint was documented as, " Patient kicking, yelling, screaming, biting, using profanities, noncompliant. Restraints applied."

A Nursing Note dated 9/8/17 at 1836 documented the doctor was notified that Patient #1 was "kicking, biting, scratching, pinching, screaming, yelling profanities, alert and oriented x 1 (confused), patient hostile."

An "Adult Restraint Flow Record" for Patient #1 indicated that Patient #1 was monitored every 15 minutes from 1830 until 1900 (Nursing change of shift). There was no other nursing documentation for Patient #1 until 2024. There was no further restraint monitoring, or other documentation that Patient #1 was observed or assessed, or restraints released and repositioning and toileting offered, until 2034.

On 9/8/17 at 2034, ED Staff W documented, "assisting primary nurse".

0n 9/8/17 at 2055, Staff W documented the following comments, "Was asked by the charge nurse to assist with the patient while I was assigned to the E team for my shift tonight. While preparing the patient to be transported upstairs, the patient had a family member arrive by the name of ..., niece of the patient. Patient niece asked to see the charge nurse, upset because the patient has no nurse assigned, bed is wet with urine, no one is able to give an update regarding the patient." Staff W documented on 9/8/17 at 2105, "Assisted niece of the patient by changing the patient's linens, gown and blankets."

On 10/18/17 at 1700, Staff W was interviewed by telephone and stated that she had "been pulled to help out and transfer (Patient #1) to the floor (inpatient unit) because it was really busy on that hallway, and they needed help." Staff W said that she was told that Patient #1 was in non-violent soft restraints on both hands, and had been "shocked" to find that the patient was in 4 point keyed cuff restraints and soaked in urine. When asked, Staff W stated that she had been unable to find out who was assigned to Patient #1's care since shift change at 1900, and could not find any documentation of restraint monitoring or nursing care since shift change at 1900, or an order for violent restraints. There was no documentation to indicate that the patient was assessed by a physician or independent licensed contractor within one hour after the restraints were applied on 9/8/17 at 1830. There was no documentation of any physician assessment from the time the restraints were applied, until the admission history and physical, which was conducted the following morning on 9/9/17.

On 10/17/17 at approximately 1600 Emergency Department Manager, Staff H was interviewed regarding the lack of restraint monitoring and repositioning for Patient #1 after the 4 point locked cuff restraints were applied. When requested at this time during review of the Electronic Medical Record (EMR), Staff T was unable to provide any additional documentation that Patient #1 was assessed, monitored, repositioned or provided nursing care between shift change at 1900 and when Staff W documented at 2034. Staff H was also requested to provide documentation of this, but was unable to provide any additional documentation. When asked about this, Staff H stated that frequent monitoring was not necessary for a non-violent restraint.

On 10/17/17 at approximately 1605, the Chief Nursing Officer, Staff D was interviewed and stated that non-violent restraints were used to prevent patients from pulling at critical tubings or dressings, and consisted of soft restraints applied to the hands. Staff D stated that a peripheral IV, oxygen tubing and monitor leads were not life threatening if removed by the patient. Staff D stated that locked restraints of both legs and both arms were not necessary to prevent a patient from removing tubings or dressings, but were used for violent behavior management.

A policy on Physical Restraints, including definitions of restraints was requested. The provided policy, entitled "Restraints", dated 05/01/17 contained no definition of Non-violent versus Violent Restraint. The definition of a physical restraint was noted as, "The involuntary use of any manual method or physical or mechanical device or material or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement, physical activity or normal access to one's body." Documentation guidelines included, "Hourly offering of fluids during waking hours, Q 15 minute assessment of restraint sites for adequate circulation, assessement of the patient's behavior every 15 minutes (Q15), Description of the rotation of each restraint with passive range of motion to all extremities once every two hours for at least 15 minutes."

Based on interview and record review, the facility failed to ensure that a physician performed a face to face assessment within one hour of the initiation of a physical restraint for one (Patient #1) of four patients reviewed for physical restraints out of a total sample of 10, resulting in the potential for unplanned events and unexpected outcomes. Findings include:

On 10/17/18 at 1530, Patient #1's clinical record was reviewed with Staff T. The Chief Nursing Officer, Staff D, and the Emergency Department Manager, Staff H were also present, and were interviewed at this time.

Patient #1 was a 63 year old female who resided in an extended care facility (nursing home), and was transferred to the facility Emergency Department (ED) on 9/8/17 at approximately 1215, for a change in mental status and decreased oxygen saturation. The Nursing Home to Hospital Transfer Form, dated 9/8/17 documented that Patient #1 was transferred to the hospital for mental status change and hypoxemia. The form documented the "behavioral issues" as, "yelling, cursing and apologizing, metting her needs", but no violent or self-destructive behaviors. The form also documented that Patient #1 had left sided weakness. Diagnoses indicated that the patient had poor vision with bilateral cataracts and optic nerve atrophy, Dementia, Anxiety and residuals from a stroke. The ambulance record documented that Patient #1 was, "confused but consolable" and obeyed commands. A Physician's consultation report, dated 9/10/17 at 1039 documented that Patient #1 had, "obvious weakness of left upper extremity and left lower extremity.

Review of facility ED Physician's orders for Patient #1 revealed an order dated 9/8/17 at 1828 for Patient #1 to be placed in keyed four point cuff restraints (hard cuffs secured to the stretcher and locked with a key to both wrists and both ankles).

The Nursing Note on a facility form entitled, "Adult Restraint flow Record", dated 9/8/17 at 1830 documented the initiation of the restraint. The reason for physical restraint was documented as, " Patient kicking, yelling, screaming, biting, using profanities, noncompliant. Restraints applied."

A Nursing Note dated 9/8/17 at 1836 documented the doctor was notified that Patient #1 was "kicking, biting, scratching, pinching, screaming, yelling profanities, alert and oriented x 1 (confused), patient hostile."

Review of the clinical record revealed no documentation that Patient #1 was assessed by a Physician or other independent licensed practioner within one hour of the restraint application. There was no documentation to indicate that the patient was assessed by a physician or independent llicensed contractor until the admission history and physical conducted the following morning on 9/9/17.

On 10/17/17 at approximately 1600 Emergency Department Manager, Staff H was interviewed regarding the lack of a one hour face to face restraint assessment for Patient #1 after the 4 point locked cuff restraints were applied. When requested at this time during review of the Electronic Medical Record (EMR), Staff T was unable to provide any documentation that a one hour face to face assessment was done for Patient #1 after restraints were applied on 9/8/17 at 1830. . Staff H was also requested to provide documentation of this, but was unable to provide any documentation that a one hour face to face restraint assessment was done after restraints were applied on 9/8/17 at 1830. When asked about this, Staff H stated that a one hour face to face assessment was not necessary for a non-violent restraint.

On 10/17/17 at approximately 1605, the Chief Nursing Officer, Staff D was interviewed and stated that non-violent restraints were used to prevent patients from pulling at critical tubings or dressings, and consisted of soft restraints applied to the hands. Staff D stated that a peripheral IV, oxygen tubing and monitor leads were not life threatening if removed by the patient. Staff D stated that locked restraints of both legs and both arms were not necessary to prevent a patient from removing tubings or dressings, but were used for violent behavior management.

A policy on Physical Restraints, including definitions of restraints was requested. The provided policy, entitled "Restraints", dated 05/01/17 contained no definition of Non-violent versus Violent Restraint. The definition of a physical restraint was noted as, "The involuntary use of any manual method or physical or mechanical device or material or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement, physical activity or normal access to one's body. A Physician, Clinical Psychologist or other licensed independent pratitioner responsible for the are of the patient evaluates the patient in person within one hour of the initiation of restraint or seclusion lused for the management of violent or self-destructive behavior that jeopardizes the physical safety of the patient, staff or others."