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Based on interview and document review, it was determined that nursing staff failed to modify the plan of care to reflect the use of restraints for one (1) of five (5) patients sampled. (Patient #18)

The findings included:

On April 5, 2019, Staff Member #24 navigated Patient #18's electronic medical record (EMR) with the surveyor. Patient #18's EMR documented the patient was seen in the facility's Emergency Department [ED] on January 28, 2019, with a chief complaint of behavioral changes. Patient #18's EMR documented while within the ED, the patient's aggressive behaviors escalated. Patient #18 was assessed and deemed "a harm to self and others." Patient #18's EMR documented the patient was placed in "four-point [bilateral wrist and bilateral ankle]" artificial leather restraints. Patient #18's EMR documented the patient was in "four-point" artificial leather restraint from 8:20 a.m. through 8:45 a.m. and in "bilateral" wrist artificial leather restraints from 8:45 a.m. through 9:00 a.m. on January 28, 2019.

Staff Member #24 and the surveyor reviewed Patient #18's plan of care. The plan of care did not include a modification for restraints. Staff Member #24 reviewed other potential areas within Patient #18's EMR for potential documentation reflecting the modification of the plan of care to include restraints. Staff Member #24 stated, "The care plan wasn't modified for restraints." The surveyor requested the facility's policy for restraints.

A review of the facility's policy titled "Restraints and Seclusion" that read in part "... This policy applies to the application of any and all physical and chemical restraints used in both the medical, post-surgical, as well as the emergency use of restraints and seclusion including those used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member, or others. This includes medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition ... 9.16. Documentation [-] Initiation and on-going use of restraints will be documented in the nursing notes, on the Restraint Documentation and in the Plan of Care ..."

During the end of the day meeting on April 5, 2019 at 3:18 p.m., the surveyor informed Staff Members #1, #2, #4, #23, #24, #29, and #30 of the findings. Staff Member #24 verified the findings.

Based on interview and document review, it was determined that nursing staff failed to apply the type of restraint ordered by the physician for one (1) of five (5) patients sampled. (Patient #11)

The findings included:

On April 5, 2019 from 10:22 a.m. through 10:50 a.m., Staff Member #24 navigated Patient #11's electronic medical record (EMR) with the surveyor. Staff Members #1 and #2 were present during the medical record review.

A review of the physician orders for restraints revealed two (2) orders for November 17, 2018. The first restraint order at 8:15 a.m., continued the utilization of bilateral hand mitts. Patient #11's EMR documented the patient was assessed by a physician and a new restraint order was placed at 10:15 a.m. on November 17, 2018, for bilateral wrist restraints.

Staff Member #24 and the surveyor reviewed the nursing assessment and restraint documentation for Patient #11 on November 17, 2018. The nursing restraint documentation revealed Patient #11 continued in bilateral mitts. Staff Member #24 and the surveyor reviewed nursing documentation for clarification or notification of the physician regarding the continued use of bilateral mitts rather than the physician ordered bilateral wrist restraints. Staff Member #24 acknowledged the nursing documentation on November 17, 2018 did not reflect the reason Patient #11 continued in bilateral mitts. Staff Member #24 verified the nurse failed to document the reason the physician ordered bilateral wrist restraints were not applied.

Staff Member #2 verified when the physician performed his/her assessment and ordered bilateral wrist restraints at 10:15 a.m., that order would supersede the 8:15 a.m. order for bilateral mitts. The surveyor requested the facility's policy for restraints.

Review of the facility's policy titled "Restraints and Seclusion" that read in part "... This policy applies to the application of any and all physical and chemical restraints used in both the medical, post-surgical, as well as the emergency use of restraints and seclusion including those used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member, or others. This includes medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition ... 9.16 Documentation [-] The use of a restraint and/or seclusion requires documenting the situation thoroughly in the patient's medical record. The documentation will include: 1. All orders relevant for the use of restraint or seclusion ... 12. Type of restraint to be used (soft wrist, hard ankle, etc.) 9.10. Physician Order [-] ... If the time period of the order is still in effect and the behavior improved, then less restrictive alternative must be attempted and evaluated ..."

During the end of the day meeting on April 5, 2019 at 3:18 p.m., the surveyor informed Staff Members #1, #2, #4, #23, #24, #29, and #30 of the findings. Staff Members #1 and #24 verified the findings.

Based on observation, interview and document review, it was determined that nursing staff for two (2) of five (5) patients restrained failed to:

1. document monitoring and reassessing a patient in restraints. (Patient #1), and;

2. cease documentation of performing reassessments when the patient was not observed and off the unit for surgery (Patient #8)

The findings included:

An entrance conference was held from 1:20 p.m. through 1:44 p.m. on April 2, 2019 with Staff Member #1, and at approximately 1:30 p.m., Staff Member #2 joined the conference. The surveyor requested a list of all currently restrained patients. At approximately 2:08 p.m., Staff Member #2 reported the facility had only one (1) restrained patient (Patient #1).

An observation conducted on April 2, 2019 at 2:37 p.m. with Staff Members #4 and #5, revealed Patient #1 had bilateral soft wrist restraints in place. Staff Member #5 briefed the surveyor and carried out the steps for reassessing Patient #1 bilateral restraints.

On April 5, 2019 from 9:26 a.m. through 10:07 a.m., Staff Member #24 navigated Patient #1's electronic medical record (EMR) with the surveyor. Staff Members #1 and #2 were present during the medical record review. A review of nursing documentation on the restraint flowsheet for April 2, 2019, revealed at 2:00 a.m. Patient #1 had been placed in restraints. The April 2, 2019 restraint flowsheet documentation stopped at 8:00 a.m. on and did not restart until 8:00 p.m. Staff Member #24 verified the restraint flowsheet documentation for April 2, 2019 included an eleven (11) hour gap in monitoring and reassessing Patient #1's bilateral wrist restraints.

A review of Patient #1's EMR did not have documentation the bilateral wrist restraints had been removed during the eleven (11) hour gap in restraint flowsheet documentation. A review of the nurse's note for the day shift on April 2, 2019, did not include information whether Patient #1 remained in bilateral soft wrist restraints. A physician's note timed at 1:25 p.m., documented observation of Patient #1 in continued "mechanical restraints." The observation by the surveyor on April 2, 2019 at 2:37 p.m. revealed the patient remained in bilateral soft wrist restraints. Staff Member #24 reported he/she could not find documentation to explain the eleven (11) hour gap in charting. The surveyor requested the facility's policy for restraints.

On April 5, 2019 starting at 11:38 a.m., Staff Member #24 navigated Patient #8's electronic medical record (EMR) with the surveyor. Staff Members #1 and #2 were present during the medical record review. The review revealed Patient #8 had daily physician orders for bilateral soft wrist restraints from February 16 through February 24, 2019. The review revealed on February 22, 2019 Patient #8 went to surgery at 1:15 p.m., related to an incision and drain of an abscess. Nursing documented on Patient #8's restraint flowsheet at 1:15 p.m. "surgery." A review of the restraint flowsheet documentation revealed the nurse reassessed Patient #8 at 2:00 p.m. and 4:00 p.m. The documentation at 2:00 p.m. and 4:00 p.m. verified the patient's restraints were visualized, the patient's "Psychological Status [-] Sedate", "Circulation [:] NS [normal status]", "Range of Motion [:] P [Performed]", "Fluids [:] N [None]", "Food/Meal [:] TF, NPO [Tube feeding/Nothing by Mouth]" and the patient's elimination status.

A nursing notation revealed Patient #8 returned to the unit from surgery at 4:45 p.m., on February 22, 2019. The surveyor inquired if the nurse documenting the reassessment of Patient #8 accompanied the patient to surgery. Staff Member #24 reviewed other documentation by the nurse and reported there was no evidence the nurse accompanied the patient to surgery. The surveyor inquired if the nurse was listed on the surgical timeout- since all staff and visitors in the surgical suite had to be included.

Staff Member #2 contacted the surgical department for assistance. On April 5, 2019 at 1:42 p.m., Staff Member #31 arrived to navigate the surgical documentation. Staff Member #31 displayed the surgical timeout documentation. Staff Member #31 identified the staff listed in Patient #8's surgical timeout as "only surgical staff."

Staff Member #1 requested that Staff Member #24 hover over the documentation for the 2:00 p.m. and 4:00 p.m. restraint reassessments to determine the documentation entry time, in case it had been a mistaken late entry. Staff Member #24 followed Staff Member #1's directions. The displayed entry time revealed it was performed at the time indicated 2:00 p.m. and 4:00 p.m. on February 22, 2019.

During the end of the day meeting on April 5, 2019 at 3:18 p.m., the surveyor informed Staff Members #1, #2, #4, #23, #24, #29, and #30 of the findings. Staff Members #1 and #24 verified the findings. Staff Member #5 reported an investigation of the nursing documentation for Patient #8, revealed correction charting. Staff Member #4 reported the nurse that entered the restraint assessment had been in orientation and his/her preceptor caught the error and corrected it. The surveyor inquired why the visible documentation did not appear to have a strike through or a change of entry time. Staff Member #4 reported the documentation would be reviewed with the surveyor on Monday, April 8, 2019.

An interview conducted on April 8, 2019 at 12:36 p.m., with Staff Member #5. Staff Member #5 reported the documentation in Patient #8's EMR related to the restraint reassessments at 2:00 p.m. and 4:00 p.m., while Patient #8 was off the unit, were as the surveyor had read them. The nurse documented the restraint reassessments without Patient #8 being on the unit and without the nurse actually performing the task.

Review of the facility's policy titled "Restraints and Seclusion" that read in part "... This policy applies to the application of any and all physical and chemical restraints used in both the medical, post-surgical, as well as the emergency use of restraints and seclusion including those used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member, or others. This includes medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition ... 9.13. Documentation and Reassessment of Non-Violent, Non-Behavioral (Medical and Surgical) Restraints [:] Reassess at least every 2 hours or more frequently based on the patient needs. Continual reassessment / monitoring determines 1. The physical and emotional well-being of the patient; 2. The patient's rights, dignity and safety are maintained; 3. Whether least restrictive methods are possible; 4. Changes in the patient's behavior or clinical condition needed to initiate the removal of restraints; 5. Whether the restraint has been appropriately applied in a safe manner, removed or reapplied ..."