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Based on interview and record review, the facility failed to ensure performance improvement data collected for monitoring of one patient in restraints was accurate (Patient 9).

This failed practice resulted in a missed opportunity to improve restraint monitoring and overall patient safety.

Findings:

A review of Patient 9's record was conducted on July 16, 2019. Patient 9 presented to the ED on January 1, 2019, for combative behavior. The restraint flowsheet indicated bilateral wrist and ankle soft restraints were placed on Patient 9 on January 1, 2019, for combative behavior.

There was no evidence the nursing staff monitored the patient for safety while in restraints.

An interview was conducted with the Infection Control Nurse (ICN) on July 16, 2019, at 11:45 a.m. The ICN stated there was no evidence Patient 9 was monitored every 15 minutes while he was in bilateral soft wrist and ankle restraints for behavioral management.

A review of the facility policy and procedure titled, "Safe and Effective use of Restraints (Review Date 03/19)," was conducted on July 17, 2019. The procedure addressed patients who were in restraints for behavior management reasons and indicated, "Every 15 minutes, the patient will be assessed for the need for vital signs, signs of injury associated with the use of restraints, nutrition/hydration, circulation and range of motion in the extremities, hygiene and elimination, physical and psychological status and comfort, and readiness for discontinuation of restraint. This is documented on the Behavior Management Restraint Monitoring form."

A review of quality data was conducted with the Chief Nursing Officer (CNO) on July 17, 2019, at 11:20 a.m. The data indicated for the 1st quarter of 2019, there was 100% compliance with the indicators being monitored, and staff were documenting their monitoring on the restraint flowsheet every 15 minutes for patients in behavioral restraints.

In a concurrent interview, the CNO stated during the first quarter of data collection (2019), which included nursing assessments/monitoring, the nursing staff were not implementing the every fifteen minute monitoring as they were supposed to on patients in behavioral restraints.

The CNO further stated the quality indicator data did not reflect the lack of patient monitoring by the nursing staff.

A review of the policy and procedure, "Quality Assessment and Performance Improvement Plan (QAPI) (Review Date 5/19)," was conducted on July 17, 2019. The purpose indicated, "The plan supports a comprehensive, coordinated, and integrated approach, using available and human technological resources for: Improving health outcomes for patients; Minimizing risk and threats to patient safety; Utilizing data to identify changes that will lead to improved performance and increase safety..."

Based on interview and record review, the facility failed to ensure bilateral soft wrist and ankle restraints were ordered by a physician before being placed on one of five patients who were restrained (Patient 9).

This failed practice resulted in the potential for inappropriate use of the restraints.

Findings:

On July 16, 2019, at 11:45 a.m., Patient 9's record was reviewed with the Infection Control Nurse (ICN). Patient 9 was seen in the Emergency Department (ED) on January 1, 2019, for combative behavior.

The Restraint Flowsheet indicated Patient 9's restraints were initiated on January 1, 2019, at 10:30 p.m., and the type of restraints used were the following:

- "...siderails up x (times) 4 (four);

- bilateral wrist soft restraint;

- bilateral ankle soft restraint..."

The Physician's Order, dated January 1, 2019, at 10:30 p.m., indicated, "...side rails x 4..."

There was no evidence bilateral soft wrist and ankle restraints were ordered by the physician.

In a concurrent interview, the ICN stated there should have been a physician's order for the use of bilateral soft wrist and ankle restraints on Patient 9.

A review of the facility policy titled, "Safe and Effective use of Restraints," dated March 2019, indicated, "...A written order for restraint is required by a physician and must be time-limited to 24 hours or less. The specific type of restraint to be used must be specified as part of the order..."

Based on interview and record review, the facility failed to ensure three of five patients placed in restraints (Patients 6, 7, and 9) were monitored for safety when:

1. Patient 6 had no evidence of monitoring while the patient was in bilateral soft wrist and ankle restraints for behavioral management;

2. Patient 7 had no evidence of 1:1 monitoring by a sitter while the patient was in bilateral soft wrist and ankle restraints for behavioral management; and

3. Patient 9 had no evidence of monitoring while the patient was in bilateral soft wrist and ankle restraints for behavioral management.

These failures resulted in the potential for injury or death.

Findings:

1. On July 16, 2019, at 11:15 a.m., Patient 6's record was reviewed with the Infection Control Nurse (ICN). Patient 6 was seen in the Emergency Department (ED) on July 3, 2019, for depression.

The ED notes dated July 4, 2019, at 3:24 a.m., indicated Patient 6 became aggressive and violent to the staff, and restraints were initiated.

A Physician's Order, dated January 4, 2019, indicated the following:

- "...soft wrist restraint...bilateral...reason: destructive and violent behavior..."; and,

- "...soft ankle restraint...bilateral...reason: destructive and violent behavior..."

The Restraint Flowsheet documentation did not have a 15 minute check monitoring of Patient 6 while in restraints.

In a concurrent interview, the ICN stated there was no evidence every 15 minute monitoring was conducted while the patient was in bilateral soft wrist and ankle restraints for behavioral management.

On July 16, 2019, at 11:42 a.m., the Chief Nursing Officer (CNO) was interviewed. The CNO stated she needed to reeducate the nurses regarding the importance of monitoring patients when they were in restraints.

2. On July 16, 2019, at 10:15 a.m., Patient 7's record was reviewed with the Infection Control Nurse (ICN). Patient 7 was seen in the Emergency Department (ED) on March 15, 2019, for agitation, anxiety, confusion, and disorientation.

A Physician's Order, dated March 15, 2019, at 1:30 a.m., indicated, "...soft wrist restraint...bilateral...reason: destructive and violent behavior...include bilateral soft ankle restraints..."

There was no evidence of 1:1 monitoring while Patient 7 was in behavioral restraints.

In a concurrent interview, the ICN stated there was no evidence 1:1 monitoring was provided while the patient was in bilateral soft wrist and ankle restraints for behavioral issues.

On July 16, 2019, at 11:42 a.m., the Chief Nursing Officer (CNO) was interviewed. The CNO stated when a patient was put in restraints for behavioral management, a 1:1 sitter would be provided for continuous patient monitoring.

3. On July 16, 2019, at 11:45 a.m., Patient 9's record was reviewed with the Infection Control Nurse (ICN). Patient 9 was seen in the Emergency Department (ED) on January 1, 2019, for combative behavior.

The Restraint Flowsheet indicated Patient 9 's restraints were initiated on January 1, 2019, at 10:30 p.m., and the type of restraints used were the following:

- "...siderails up x (times) 4 (four);

- bilateral wrist soft restraint;

- bilateral ankle soft restraint..."

The Restraint Flowsheet documentation did not include every 15 minute monitoring of Patient 9 while in behavioral restraints.

In a concurrent interview, the ICN stated there was no evidence every 15 minute monitoring was conducted while the patient was in bilateral soft wrist and ankle restraints for behavioral management.

The ICN stated Patient 9 should have been monitored every 15 minutes while in behavioral restraints.

A review of the facility policy titled, "Safe and Effective use of Restraints," dated March 2019, indicated, "...Patients who are in restraints for behavioral management reasons will be continuously monitored by 1:1 observation including the following...

Every 15 minutes, the patient will be assessed for the need for vital signs, signs of injury associated with the use of restraints, nutrition/hydration, circulation and range of motion in the extremities, hygiene and elimination, physical and psychological status and comfort, and readiness for discontinuation of restraint. This is documented on the Behavioral Management Restraint Monitoring form..."