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Based on record review, policy review and interviews with key personnel on January 8, 2013 and January 9, 2013, it was determined that the hospital failed to renew restraint orders every twenty four (24) hours.

The findings include:

1. Five (5) records were randomly chosen from the "restraint log". 4/5 records failed to indicate on the "RESTRAINT ASSESSMENT AND PHYSICIAN ORDER" forms that restraint orders were renewed within twenty four (24) hours of the original order.

2. Record FFF;
a. Restraint initiated 2/29/12 at 02:40, renewed 3/1/12 at 03:15.
b. Restraint initiated 3/5/12 at 00:40, renewed 3/6/12 at 03:45.
c. Restraint initiated 3/17/12 at 01:00, renewed 3/18/12 at 04:30.
d. Restraint initiated 3/20/12 at 03:10, renewed 3/21/12 at 04:00.
i. No documentation was available in the record indicating the aforementioned restraints were discontinued at any time.

3. Record HHH:
a. Restraint initiated 6/21/12 at 01:30, renewed 6/22/12 at 02:30.
b. Restraint initiated 6/22/12 at 02:30, renewed 6/23/12 at 03:50.
c. Restraint initiated 6/23/12 at 03:50, renewed 6/24/12 at 18:00.
i. No documentation was available in the record indicating the aforementioned restraints were discontinued at any time.

4. Record III:
a. Restraint initiated 2/19/12 at 08:00, renewed 2/20/12 at 12:35.
b. Restraint initiated 2/21/12 at 00:35, renewed 2/22/12 at 12:00.
c. Restraint initiated 2/22/12 at 12:00, renewed 2/23/12 at 14:00.
i. No documentation was available in the record indicating the aforementioned restraints were discontinued at any time.

5. Record JJJ:
a. Physician note indicates "patient in enclosure - still confused".
b. No physician order noted in record between dates November 27, 2012 and November 30, 2012.

6. These findings were confirmed during an interview with the Chief Nursing Officer on January 9, 2013.

Based on record review, policy review and interviews with key personnel on January 8, 2013 and January 9, 2013, it was determined that the hospital failed to implement/renew patient restraints per hospital policy.

Findings include:

1. Five (5) records were randomly chosen from the "restraint log". 5/5 records failed to have the "ASSESSMENT" section of the "RESTRAINT ASSESSMENT AND PHYSICIAN ORDER" form completed. 4/5 records failed to contain documentation of notification to the Licensed Independent Practitioner (LIP) during or immediately following application of emergency restraint.

2. Department of Nursing policy "Standard #: 1.6.1", "Patient Safety: Use of Restraints" stated ... " 7. Completion of the "Restraint Assessment and Physician Order" Form is as follows:...
i. "ASSESSMENT: write down the risks that triggered the possible use of restraints ...
ii. NON-RESTRAINT INTERVENTIONS CONSIDERED/ATTEMPTED: Check all that apply. "

3. HEALTHSOUTH policy number "Risk Management 669", (which is referred to in Standard #: 1.6.1 above), stated in section " II. PROCEDURE: A. restraints may only be initiated aftercare assessment of the patient and a determination that alternatives to the use of restraint have proved to be ineffective or pose a greater safety threat than the use of restraints."

4. In the table outlining procedural steps for non-violent/self-destructive versus violent/self-destructive restraints indicated: (non-violent/self-destructive table will be quoted as no behavioral restraints were ordered).
a. Assessment:
i. Daily by LIP.
ii. Daily by RN ....
b. Order/renewal:
i. Clinical justification required.
ii. Requires LIP reorder every 24 hours.
iii. May be initiated based on our and assessment in emergent situations with notification to the LIP occurring during or immediately following application.
iv. Documentation of the subsequent verbal or written order as given is required.
v. An LIP must examine the patients within 24 hours of initiation of the restraint intervention.
c. Content of order/renewal:
i. orders will contain the
1. Type of restraint.
2. Reason for restraint.
3. Time limitations for restraint-NO PRN orders allowed.
4. Documentation must also include findings from the physician assessment of the patient's clinical needs supporting the continued use of restraints.

5. Record FFF
a. Eighteen (18) "RESTRAINT ASSESSMENT AND PHYSICIAN ORDER" forms were reviewed.
b. 18/18 forms failed to contain any documentation in the "assessment" or "least restrictive alternatives" sections of the form.
c. 3/18 forms failed to contain documentation of the time that the RN assessment determining need for restraint was completed.
d. 14/18 forms failed to contain documentation indicating notification of the LIP occurring during or immediately following application of the restraint.
i. 3/18 records the notification time could not be determined as no assessment time had been noted.
e. The record failed to contain daily documentation by the LIP on all the days where a restraint order had been noted.

6. Record GGG
a. Contained a physician order for restraints written on June 23, 2012 at 10:30.
b. The order stated "pelvic restraints", "4 side rails up" ...
c. The order failed to contain the reason for restraint or time limitation for the restraint.
d. Four (4) "RESTRAINT ASSESSMENT AND PHYSICIAN ORDER" forms were reviewed.
e. 4/4 forms failed to contain any documentation in the "assessment" or "time limit" sections of the form.

7. Record HHH
a. Five (5) "RESTRAINT ASSESSMENT AND PHYSICIAN ORDER" forms were reviewed.
b. 5/5 forms failed to contain any documentation in the "assessment" section of the form.
c. 1/5 forms failed to contain signature, date or time of the RN completing the form.
d. 5/5 forms failed to contain documentation indicating notification of the LIP occurring during or immediately following application of the restraint.

8. Record III
a. Five (5) "RESTRAINT ASSESSMENT AND PHYSICIAN ORDER" forms were reviewed.
b. 5/5 forms failed to contain any documentation in the "assessment" or "least restrictive alternatives" sections of the form.
c. 4/5 forms failed to contain documentation indicating notification of the LIP occurring during or immediately following application of the restraint.

9. Record JJJ
a. Eleven (11) "RESTRAINT ASSESSMENT AND PHYSICIAN ORDER" forms were reviewed.
b. 11/11 forms failed to contain any documentation in the "assessment" section of the form.
c. 6/11 forms failed to contain any documentation in the " least restrictive alternatives" section of the form.
d. The record failed to contain daily documentation by the LIP on all the days where a restraint order had been noted.

10. These findings were confirmed during an interview with the Chief Nursing Officer and the charge nurse on January 9, 2013.

Based on record review and interviews with key personnel on October 25, 2012, November 1, 2012, January 8, 2013 and January 9, 2013, it was determined that the hospital failed to provide adequate numbers of nursing staff to ensure that assessments were completed, physician orders were implemented and policies were followed.

Findings include:

Failure to Complete Assessments

1. Physician A had ordered that Patient A (from the survey of October 25, 2012) have neurological checks every hour at 0600 on October 9, 2012. Additionally, the Medical Record of Patient A documented that on October 10, 2012 at 0955, Physician C ordered "resume neuro checks every 1 hour." In addition, there were no orders in Patient A's Medical Record instructing nursing to discontinue neurological checks.

2. The 'Neurological Monitoring Form' dated October 9, 2012 documented neurological checks at only 0545, 0600, 0700, 0800 and 1700. The 'Neurological Monitoring Form' dated October 10, 2012 documented neurological checks at only 1000 and 1100, and partial neurological checks at 1300, 1400 and 1800. The 'Interdisciplinary Daily Documentation (IDD)' forms for October 9, 2012 at 1445 and October 10, 2012 at 1930 also contained some nursing documentation of neurological assessments. This represented twelve (12) neurological assessments during forty-two (42) hours.

3. On January 2, 2012, Physician E had ordered that Patient F, have vital signs done every four (4) hours and to notify Physician F.

4. The treatment sheet for Patient F indicated that vital signs were done every four (4) hours, however, they were only done at 0800, 1200, and 1600 [4:00 PM] on January 2, January 3, and January 4, 2013. After that date, vital signs were only recorded as done at 1600 on January 5, 7, 8, 2013.

5. The above finding was confirmed in an interview with the Nurse Manager of Unit R1 on January 9, 2013.

6. On January 7, 2013 Physician G ordered "orthostatic BP/P daily" (blood pressure/pulse) for Patient DD.

7. The treatment sheet for Patient DD indicated that orthostatic BP/P were not done on January 8, 2013.

8. The above finding was confirmed by the Charge Nurse on Unit R2 on January 9, 2013, who stated, "they are done on days and I wasn't told about them."

9. Based on review of the daily nursing assignment for July 4, 2012, November 10, 2012 and December 21, 2012, it was determined that staffing had variances (failed to meet core staffing requirements) on six (6) shifts on two (2) units.

10. On July 4, 2012 Unit R1 during the 11-7 shift, there was a variance of -0.5 (lack of 1/2 staffing, i.e. one staff person only working four (4 ) hours when one staff for eight (8) hours was needed). Also, during the 3-11 shift, there was a variance of one (1) staff person needed on both the R1 and R2 Units.

11. On November 10, 2012, a week end day, during the 3-11 shift on both R1 and R2 Units, there was a variance of one (1) extra staff person needed on both Units.

12. On December 21, 2012, a week day, during the 3-11 shift on Unit R1, there was a variance of one (1) extra staff person needed on that Unit and also a person for half of the shift.

13. The above findings were confirmed by the Chief Nursing Officer on January 9, 2013.

14. In interviews with twelve (12) staff persons, nurses and C.N.A.'s (certified nursing assistants) from two (2) shifts, five (5) of the staff stated that they felt they needed more staff on the units. One staff person stated that he/she felt they needed another person on during medication passes so they could get all the medications out in a timely manner.

15. Daily Nursing Assignment for January 2, 2013 through January 9, 2013, to document sufficient staff for documentation of vital signs for Patient E, or sufficient staff to document orthostatic BP/P for Patient DD, indicated that sufficient staff was available for the documentation required. This finding was confirmed by the Chief Nusing Officer on January 11, 2013.

See Tag A-0392 for additional information regarding the documentation of following physician's orders in medical records.

Based on observation and interviews on January 8 and 9, 2013, it was determined that the hospital failed to maintain facilities, supplies and equipment to ensure safety and quality.

Findings include:

1. The paint was peeling from the wall in Room 2170. The wall was painted before the end of the survey.
2. A cabinet in the closet of Room 2172 had a rusty metal top. This was removed before the end of the survey.
3. There were holes in the ceiling in Room 2176. These were repaired during the survey
4. There was no signage indicating the location of an eyewash station on the first floor. Signs were installed during the survey.
5. Paint was worn from the arms of a chair in the Dialysis Room. This was removed during survey.
6. The floor was cracked outside the Briggs Conference Room and in the rear hallway of the same area.
7. Paint was peeling from the wall in the "A" stair landing on the first floor. This wall was painted during the survey.
8. These findings were discussed with and confirmed with the Director of Engineering and the Director of Quality Management.