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This CONDITION is not met as evidenced by:

Based on review of clinical records review of facility policies and procedures, hospital documentation and interviews with facility personnel, the facility failed to promote the rights of eleven (11) of eleven (11) patients reviewed for restraint usage (Patient's # 1, # 2, #3, #4, #5, #6, #7, #8, #9, #10 and # 11). The findings include:

The facility failed to protect patients and to promote each resident's rights as is exhibited by the failure to ensure that the least restrictive restraints were utilized, that the patient ' s plan of care was modified to include restraint use, restraints were instituted based on physician's order, restraints were removed at the earliest possible time and that the facility failed to monitor patients in restraints in accordance with hospital policies.

Cross Reference A165, 166, 168, 171, 175 and 179

Based on review of the clinical records review of policies and procedures and interviews with facility personnel for eleven of eleven sampled patients reviewed for restraint usage (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11), the facility failed to ensure that the least restrictive restraints were utilized. The findings include:

1. Patient #1 was admitted to the hospital on 9/28/13 with Congestive Heart Failure (CHF). Patient #1 was identified as a Fall Risk on 9/28/13 and had identified behaviors of agitation, confusion and delirium. Review of the physician's orders dated 9/29/13 identified that the patient was to have an Enclosure Bed and Geri-Chair due to confusion and the least restrictive interventions were insufficient. Review of nursing documentation dated 9/29/13 identified that the patient was in the Enclosure Bed from 9/29/13 at 4:00 am - 9/29/13 at 10:00 pm. (18 hours). Further review identified that although a bed alarm was utilized, the facility failed to identify other least restrictive measures that were attempted prior to using an Enclosure Bed and Geri-Chair.

2. Patient #2 was admitted to the hospital on 10/20/13 with weakness. Patient #2 was identified as a Fall Risk on 10/20/13 and had behaviors identified that included agitation, confusion and delirium. Review of the physician's orders dated 10/21/13 at 9:00 pm identified that the patient was to have an Enclosure Bed for risk of self-injury and interference with the medical plan of care. On 10/22/13 at 1:40 am, the physician's order identified that the patient was put in a vest and four point restraints due to behaviors of restlessness and pulling at tubes. On 10/22/13 at 4:55 am, the patient was changed to four point restraints. On 10/23/13, Patient#2 was put in a two point restraint. Further review identified that although a bed alarm was utilized, the facility failed to identify other least restrictive measures were attempted prior to adding a vest restraint and four point restraints.

3. Patient #3 was admitted to the hospital on 9/5/13 with altered mental status. Patient #3 had a recent history of falls and had behaviors of restlessness and jumping out of bed. Review of the physician's orders dated 9/5/13 at 9:00 pm identified that the patient was to have an Enclosure Bed due to the least restrictive interventions were insufficient. Patient #2 remained in the Enclosure Bed until 9/8/13 at 4:00 am. Further review identified that although a bed alarm was utilized, the facility failed to identify other least restrictive measures were attempted prior to placing the patient in an Enclosure Bed.

4. Patient #4 was admitted to the hospital on 9/17/13 with left arm pain. Patient #4 has a history of mentally challenged, bipolar and schizo-effective. Review of the physician's orders dated 9/17/13 identified that the patient was to have an Enclosure Bed and a 1:1 sitter due to the least restrictive interventions were insufficient. On 9/18/13 at 9:00 pm, Patient #4 was placed in four point restraints and remained in restraints until 9/21/13. Further review identified that although a bed alarm was utilized, the facility failed to identify that other least restrictive measures were attempted prior to placing the patient in an Enclosure Bed.

5. Patient #5 was admitted to the hospital on 9/18/13 with left shoulder pain after a fall. Patient #5 was identified as a fall risk on 9/18/13 and had behaviors of agitation and confusion. Review of the physician's orders dated 9/18/13 at 2:27 pm identified that the patient was to have a Enclosure Bed due to risk of self-injury or interference with medical plan of care. Review of the clinical record dated 9/18/13-9/19/13 identified that the patient remained in the Enclosure Bed until 9/19/13 at 11:06 am. Further review identified that although a bed alarm was utilized, the facility failed to identify that other least restrictive measures were attempted.

6. Patient #6 was admitted to the hospital on 9/23/13 with an exacerbation of Chronic Obstructive Pulmonary Disease (COPD). Patient #5 was identified as a fall risk on 9/23/13 and had behaviors identified of restlessness and confusion. Review of the physician's order dated 9/23/13 at 5:00 pm identified that the patient was to have an Enclosure Bed due to risk of self-injury and interference with medical care. Review of the clinical record identified that the patient remained in the Enclosure Bed until 9/24/13 at 5:55 am. Further review identified that although a bed alarm was utilized, the facility failed to identify that other least restrictive measures were attempted.

7. Patient #7 was admitted to the hospital on 7/20/13 for a Laparoscopic Ileocolectomy. Patient #7 had behaviors of restlessness and pulling at tubes. Review of the physician orders dated 7/20/13 at 3:00 am identified that the patient was put into four point restraints for risk of self-injury and interference with medical plan of care. On 7/20/13 at 7:24 am, Patient #7 was put in a Enclosure Bed. On 7/22/13 at 4:39 pm., Patient #7 was put in two point restraints and remained in restraints until 7/31/13. Further review identified that although a bed alarm was utilized, the facility failed to identify that other least restrictive measures were attempted prior to placing the patient in four point restraints and then an Enclosure Bed.

8. Patient #8 was admitted to the hospital on 7/6/13 with Seizures. Patient #8 had behaviors agitation, confusion and delirium. Review of the physician's orders dated 7/6/13 at 6:24 pm identified that an Enclosure Bed was ordered for risk of self-injury or interference with medical plan of care. Review of the clinical record dated 7/6/13 identified the patient remained in the Enclosure Bed until 7/7/13 at 10:30 am. Further review identified that although a bed alarm was utilized, the facility failed to identify that the other least restrictive measures were attempted.


9. Patient #9 was admitted to the hospital on 7/12/13 with altered mental status and psychosis. Patient #9 had behaviors of being combative and self-destructive behaviors. Review of the physician's orders dated 7/12/13 at 6:49 pm identified that the patient was to be put in four point restraints. On 7/13/13 at 9:01pm, Patient #9 was to have an Enclosure Bed. On 7/14/13 at 7:13 pm, Patient #9 was to have a vest restraint for risk of self-injury. Patient #9 remained in behavior restraints with either a vest restraint and/or an Enclosure Bed until 7/19/13. Further review identified that although a bed alarm was utilized, the facility failed to identify that other least restrictive measures were attempted.

10. Patient #10 was admitted to the hospital on 7/16/13 after a fall at home. Patient #10 was identified as a fall risk on 7/16/13 and had behaviors of agitation and restlessness. Review of the physician's orders dated 7/19/13 identified the patient was put in two point restraints for risk of self-injury or interference with the medical plan of care. Further review identified that the Enclosure Bed was ordered on 7/19/13 at 6:25 am. Review of the clinical record dated 7/19/13-7/21/13 identified that Patient #19 remained in restraints until 7/21/13. Further review identified that although a bed alarm was utilized, the facility failed to identify that other least restrictive measures were attempted.

11. Patient #11 was admitted to the hospital on 7/24/13 with dementia and atrial fibrillation. Patient #11 was a fall risk and had behaviors of restlessness and confusion. Review of the physician's orders dated 7/24/13 at 7:41pm identified that the patient was to have an Enclosure Bed for risk of self-injury and interference with the medical plan of care. Further review of physician's orders dated 7/26/13 at 9:43pm identified that the patient had the Enclosure bed in addition to a bed alarm and personal alarm. Review of the clinical record dated 7/24/13-7/27/13 identified that the patient remained in restraints until 7/27/13. Further review identified that although a bed alarm was utilized, the facility failed to identify that other least restrictive measures were attempted.

Review of hospital policy identified that attempts should be made to correct, modify, or eliminate underlying causes for altered behaviors. Restraints may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, staff member or others from harm and should not be used as a means of coercion, discipline, convenience or staff retaliation. When a restraint is clinically justified and used as a last resort, it shall be implemented in the least restrictive manner possible and the patient shall not be maintained in the restraint longer than absolutely necessary.

Interview with the Director of Quality and multiple staff members on 10/24/13 identified that the staff were directed to utilize the Enclosure Beds for patients who are elderly, have dementia and who are a fall risk before implementing 1:1 sitters.

Based on clinical record reviews, review of policies and procedures and interviews with facility personnel for eleven of eleven sampled patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11), reviewed for restraint usage, the facility failed to develop a plan of care when restraints were implemented. The findings include:

1. Patient #1 was admitted to the hospital on 9/28/13 with CHF. Patient #1 was identified as a Fall Risk on 9/28/13 and had behaviors of agitation, confusion and delirium. Review of the physician's orders dated 9/29/13 identified that the patient was to have an Enclosure Bed and Geri-Chair due to confusion and the least restrictive interventions were insufficient. Review of nursing documentation dated 9/29/13 identified that the patient was in the Enclosure Bed from 9/29/13 at 4:00 am-9/29/13 at 10:00 pm. (18 hours). Review of the clinical record failed to identify that a care plan was developed to address the use of restraints.

2. Patient #2 was admitted to the hospital on 10/20/13 with weakness. Patient #2 was identified as a Fall Risk on 10/20/13 and had behaviors of agitation, confusion and delirium. Review of the physician's orders dated 10/21/13 at 9:00 pm identified that the patient was to have an Enclosure Bed for risk of self injury and interference with the medical plan of care. On 10/22/13 at 1:40 am, the physician's order identified that the patient was put in a vest and four point restraints due to behaviors of restlessness and pulling at tubes. On 10/22/13 at 4:55 am, the patient was changed to four point restraints. On 10/23/13, Patient#2 was put in a two point restraint. Review of the clinical record failed to identify that a care plan was developed to address the use of restraints.

3. Patient #3 was admitted to the hospital on 9/5/13 with altered mental status. Patient #3 has a recent history of falls and had behaviors of restless and jumping out of bed. Review of the physician's orders dated 9/5/13 at 9:00 pm identified that the patient was to have a Enclosure Bed due to less restrictive interventions insufficient. Patient #2 remained in the Enclosure Bed until 9/8/13 at 4:00 am. Review of the clinical record failed to identify that a care plan was developed to address the use of restraints.

4. Patient #4 was admitted to the hospital on 9/17/13 with left arm pain. Patient #4 has a history of mentally challenged, bipolar and schizo-effective. Review of the physician's orders dated 9/17/13 identified that the patient was to have a Enclosure Bed. On 9/18/13 at 9:00 pm, Patient #4 was placed in four point restraints and remained in restraints until 9/21/13. Review of the clinical record failed to identify that a care plan was developed to address the use of restraints.

5. Patient #5 was admitted to the hospital on 9/18/13 with left shoulder pain after a fall. Patient #5 was identified as a fall risk on 9/18/13 and had behaviors of agitation and confusion. Review of the physician's orders dated 9/18/13 at 2:27 pm identified that the patient was to have a Enclosure Bed due to risk of self injury or inteference with medical plan of care. Review of the clinical record dated 9/18/13-9/19/13 identified that the patient remained in the Enclosure Bed until 9/19/13 at 11:06 am. Review of the clinical record failed to identify that a care plan was developed to address the use of restraints.

6. Patient #6 was admitted to the hospital on 9/23/13 with COPD exacerbation. Patient #5 was identfied as a fall risk on 9/23/13 and had behaviors of restlessness and confusion. Review of the physician's order dated 9/23/13at 5:00pm identified that the patient was to have an Enclosure Bed due to risk of self injury and interference with medical care. Review of the clincal record identified that the patient remained in the Enclosure Bed until 9/24/13 at 5:55am. Review of the clinical record failed to identify that a care plan was developed to address the use of restraints.

7. Patient #7 was admitted to the hospital on 7/20/13 for a Laparoscopic Ileocolectomy. Patient #7 had behaviors of restlessness and pulling at tubes. Review of the physician orders dated 7/20/13 at 3:00 am identified that the patient was put into four point restraints for risk of self-injury and interference with medical plan of care. On 7/20/13 at 7:24 am, Patient #7 was put in a Enclosure Bed. On 7/22/13 at 4:39 pm., Patient#7 was put in two point restraints and remained in restraints until 7/31/13. Review of the clinical record failed to identify that a care plan was developed to address the use of restraints.

8. Patient #8 was admitted to the hospital on 7/6/13 with seizures. Patient #8 had behaviors agitation, confusion and delirium. Review of the physician's orders dated 7/6/13 at 6:24 pm identified that an Enclosure Bed was orders for risk of self-injury or interference with medical plan of care. Review of the clinical record dated 7/6/13 identified the patient remained in the Enclosure Bed until 7/7/13 at 10:30 am. Review of the clinical record failed to identify that a care plan was developed to address the use of restraints.
9. Patient #9 was admitted to the hospital on 7/12/13 with altered mental status and psychosis. Patient #9 had behaviors of being combative and self destructive behaviors. Review of the physician's orders dated 7/12/13 at 6:49 pm identified that the patient was to be put in four point restraints. On 7/13/13 at 9:01pm, Patient #9 was to have an Enclosure Bed. On 7/14/13 at 7:13pm, Patient #9 was to have a vest restraint for risk of self injury. Patient #9 remained in behavior restraints with either a vest restraint and/or an Enclosure Bed until 7/19/13. Review of the clinical record failed to identify that a care plan was developed to address the use of restraints.

10. Patient #10 was admitted to the hospital on 7/16/13 after a fall at home. Patient #10 was identified as a fall risk on 7/16/13 and had behaviors of agitation and restlessness. Review of the physician's orders dated 7/19/13 identified the patient was put in two point restraints for risk of self-injury or interference with the medical plan of care. Further review identified that the Enclosure Bed was ordered on 7/19/13 at 6:25 am. Review of the clinical record dated 7/19/13-7/21/13 identified that Patient #19 remained in restraints until 7/21/13. Review of the clinical record failed to identify that a care plan was developed to address the use of restraints.

11. Patient #11 was admitted to the hospital on 7/24/13 with dementia and atrial fibrillation. Patient #11 was a fall risk and had behaviors of restlessness and confusion. Review of the physician's orders dated 7/24/13 at 7:41pm identified that the patient was to have an Enclosure Bed for risk of self-injury and interference with the medical plan of care. Further review of physician's orders dated 7/26/13 at 9:43 pm identified that the patient had the Enclosure Bed in addition to a bed alarm and personal alarm. Review of the clinical record dated 7/24/13-7/27/13 identified that the patient remained in restraints until 7/27/13. Review of the clinical record failed to identify that a care plan was developed to address the use of restraints.

Review of hospital policy identified that all direct care providers are expected to document a plan of care which includes assessment information, interventions and outcomes using the Sunrise Clinical Manager (SCM).

Based on clinical record reviews, review of policies and procedures and interviews with facility personnel for three of eleven sampled patients reviewed for restraint usage (Patient #3, #4, and #7), the facility failed to ensure that restraints were applied with a physician's order. The findings include:

1. Patient #3 was admitted to the hospital on 9/5/13 with altered mental status. Patient #3 has a recent history of falls and had behaviors of restless and jumping out of bed. Review of the physician's orders dated 9/5/13 at 9:00 pm identified that the patient was to have an Enclosure Bed due to less restrictive interventions insufficient. Patient #2 remained in the Enclosure Bed until 9/8/13 at 4:00 am. Review of the clinical record failed to identify a physician order for the continuation of restraints from 9/6/13-9/7/13.

2. Patient #4 was admitted to the hospital on 9/17/13 with left arm pain. Patient #4 has a history of mentally challenged, bipolar and schizo-effective. Review of the physician's orders dated 9/17/13 identified that the patient was to have an Enclosure Bed and a 1:1 sitter due to least restrictive interventions were insufficient. On 9/18/13 at 9:00 pm, Patient #4 was placed in four point restraints and remained in restraints until 9/21/13. Review of the clinical record failed to identify a physician order for the continuation of restraints from 9/20/13.

3. Patient #7 was admitted to the hospital on 7/20/13 for a Laparoscopic Ileocolectomy. Patient #7 had behaviors of restlessness and pulling at tubes. Review of the physician orders dated 7/20/13 at 3:00 am identified that the patient was put into four point restraints for risk of self-injury and interference with medical plan of care. On 7/20/13 at 7:24 am, Patient #7 was put in a Enclosure Bed. On 7/22/13 at 4:39 pm., Patient#7 was put in two point restraints and remained in restraints until 7/31/13. Review of the clinical record failed to identify a physician order for the continuation of restraints on 7/21/13 and 7/27-7/28/13.

Review of hospital policy identified that a physician is notified and the order is obtained within 12 hours of initiation of restraints for non-violent patients.

Based on clinical record reviews, review of policies and procedures and interviews with facility personnel for one of eleven sampled patients reviewed for restraint usage (Patient #9), the facility failed to ensure that restraints were applied or continued with a physician's order. The findings include:

1. Patient #9 was admitted to the hospital on 7/12/13 with altered mental status and psychosis. Patient #9 had behaviors of being combative and self-destructive behaviors. Review of the physician's orders dated 7/12/13 at 6:49 pm identified that the patient was to be put in four point restraints. On 7/13/13 at 9:01pm, Patient #9 was to have an Enclosure Bed. On 7/14/13 at 7:13pm, Patient #9 was to have a vest restraint for risk of self-injury. Patient#9 remained in behavior restraints with either a vest restraint and/or an Enclosure Bed until 7/19/13. Review of the clinical record failed to identify a physician order for the initiation and/or the continuation of restraints for violent behavior was obtained.

Review of hospital policy identified that for violent behaviors, the physician is immediately notified and an order is obtained and the physician needs to evaluate the patient within one hour and subsequently every 4 hours to evaluate the reaction to interventions, medical and behavioral condition and need to continue or terminate the restraint violent behaviors.

Based on clinical record reviews, review of policies and procedures and interviews with facility personnel for two of eleven sampled patients (Patient #1and Patient #2), reviewed for restraint usage, the facility failed to ensure patients were monitored in accordance with hospital policy. The findings include:

1. Patient #1 was admitted to the hospital on 9/28/13 with CHF. Patient #1 was identified as a Fall Risk and had behaviors of agitation, confusion and delirium. Review of the physician's orders dated 9/29/13 identified that the patient was to have an Enclosure Bed and Geri-Chair due to confusion and the least restrictive interventions were insufficient. Review of nursing documentation dated 9/29/13 at 10:00 pm to 9/30/13 at 8:01am failed to identify that the patient's two hour monitoring check was completed in accordance with hospital policy.

2. Patient #2 was admitted to the hospital on 10/20/13 with weakness. Patient #2 was identified as a Fall Risk and had behaviors of agitation, confusion and delirium. Review of the physician's orders dated 10/21/13 at 9:00 pm identified that the patient was to have an Enclosure Bed for risk of self-injury and interference with the medical plan of care. On 10/22/13 at 1:40 am, the physician's order identified that the patient was put in a vest and four point restraints. On 10/22/13 at 4:55 am, the patient was changed to four point restraints. On 10/23/13, Patient#2 was put in a two point restraint. Review of nursing documentation dated 10/22/13 at 6:00 pm to 10/23/13 5:39 am failed to identify that the patient's two hour monitoring check was completed in accordance with hospital policy.

Review of hospital policy identified that every two hour monitoring includes type of restraint, behavior actions, comfort and dignity and circulation/skin checks.

Based on clinical record reviews, review of policies and procedures and interviews with facility personnel for eleven of eleven sampled patients reviewed for restraint usage, (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10 and P #11), the facility failed to ensure that a one to one evaluation was completed with the initiation and/or continuation of restraints. The findings include:

1. Patient #1 was admitted to the hospital on 9/28/13 with CHF. Patient #1 was identified as a Fall Risk and had behaviors of agitation, confusion and delirium. Review of the physician's orders dated 9/29/13 identified that the patient was to have an Enclosure Bed and Geri-Chair due to confusion and the least restrictive interventions were insufficient. Review of the progress notes dated 9/29/13-9/30/13 failed to identify that a one to one evaluation was conducted with the placement of restraints. Review of nursing documentation dated 9/29/13 identified that the patient was in the Enclosure Bed from 9/29/13 at 4:00 am-9/29/13 at 10:00 pm. (18 hours).

2. Patient #2 was admitted to the hospital on 10/20/13 with weakness. Patient #2 was identified as a Fall Risk and had behaviors of agitation, confusion and delirium. Review of the physician's orders dated 10/21/13 at 9:00 pm identified that the patient was to have an Enclosure Bed for risk of self-injury and interference with the medical plan of care. On 10/22/13 at 1:40 am, the physician's order identified that the patient was put in a vest and four point restraints. On 10/22/13 at 4:55 am, the patient was changed to four point restraints. On 10/23/13, Patient #2 was put in a two point restraint. Review of the progress notes dated 10/21/13-10/23/13 failed to identify that a one to one evaluation was conducted with the initiation and/or continuation of restraints.

3. Patient #3 was admitted to the hospital on 9/5/13 with altered mental status. Patient #3 has a recent history of falls and had behaviors of restless and jumping out of bed. Review of the physician's orders dated 9/5/13 at 9:00 pm identified that the patient was to have a Enclosure Bed due to the less restrictive interventions being insufficient. Patient #2 remained in the Enclosure Bed until 9/8/13 at 4:00 am. Review of the progress notes dated 9/5/13-9/6/13 failed to identify that a one to one evaluation was conducted with the initiation and/or continuation of restraints.

4. Patient #4 was admitted to the hospital on 9/17/13 with left arm pain. Patient #4 has a history of mentally challenged, bipolar and schizo-effective. Review of the physician's orders dated 9/17/13 identified that the patient was to have an Enclosure Bed and a 1:1 sitter due to least restrictive interventions were insufficient. On 9/18/13 at 9:00pm, Patient #4 was placed in four point restraints and remained in restraints until 9/21/13. Review of the progress notes dated 9/17/13-9/21/13 failed to identify that a one to one evaluation was conducted with the initiation and/or continuation of restraints.

5. Patient #5 was admitted to the hospital on 9/18/13 with left shoulder pain after a fall. Patient #5 was identified as a fall risk and had behaviors of agitation and confusion. Review of the physician's orders dated 9/18/13 at 2:27pm identified that the patient was to have an Enclosure Bed due to risk of self-injury or interference with medical plan of care. Review of the clinical record dated 9/18/13-9/19/13 identified that the patient remained in the Enclosure Bed until 9/19/13 at 11:06 am. Review of the progress notes dated 9/18/13-9/19/13 failed to identify that a one to one evaluation was conducted with the initiation of restraints.

6. Patient #6 was admitted to the hospital with COPD exacerbation. Patient #5 was identified as a fall risk and had behaviors of restlessness and confusion. Review of the physician's order dated 9/23/13at 5:00 pm identified that the patient was to have an Enclosure Bed due to risk of self-injury and interference with medical care. Review of the clinical record identified that the patient remained in the Enclosure Bed until 9/24/13 at 5:55 am. Review of the progress notes dated 9/23/13-9/24/13 failed to identify that a one to one evaluation was conducted with the initiation of restraints.

7. Patient #7 was admitted to the hospital on 7/20/13 for a Laparoscopic Ileocolectomy. Patient #7 had behaviors of restlessness and pulling at tubes. Review of the physician orders dated 7/20/13 at 3:00 am identified that the patient was put into four point restraints for risk of self-injury and interference with medical plan of care. On 7/20/13at 7:24 am, Patient #7 was put in an Enclosure Bed. On 7/22/13 at 4:39 pm., Patient #7 was put in two point restraints and remained in restraints until 7/31/13. Review of the progress notes dated 7/20/13-7/31/13 failed to identify that a one to one evaluation was conducted with the initiation and/or continuation of restraints.

8. Patient #8 was admitted to the hospital on 7/6/13 with seizures. Patient #8 had behaviors agitation, confusion and delirium. Review of the physician's orders dated 7/6/13 at 6:24pm identified that an Enclosure Bed was orders for risk of self-injury or interference with medical plan of care. Review of the clinical record dated 7/6/13 identified the patient remained in the Enclosure Bed until 7/7/13 at 10:30am. Review of the progress notes dated 9/23/13-9/24/13 failed to identify that a one to one evaluation was conducted with the initiation of restraints.

9. Patient #9 was admitted to the hospital on 7/12/13 with altered mental status and psychosis. Patient #9 had behaviors of being combative and self-destructive behaviors. Review of the physician's orders dated 7/12/13 at 6:49 pm identified that the patient was to be put in four point restraints. On 7/13/13 at 9:01pm, Patient #9 was to have an Enclosure Bed. On 7/14/13 at 7:13pm, Patient #9 was to have a vest restraint for risk of self-injury. Patient #9 remained in behavior restraints with either a vest restraint and/or an Enclosure Bed until 7/19/13. Review of the progress notes dated 7/12/13-7/19/13 failed to identify that a one to one evaluation was conducted with the initiation and/or continuation of behavior restraints. Review of hospital policy identified that the face to face evaluation by the physician need to be completed with one hour of initiation and repeated at least every 8 hours.

10. Patient #10 was admitted to the hospital on 7/16/13 after a fall at home. Patient #10 was a fall risk and had behaviors of agitation and restlessness. Review of the physician's orders dated 7/19/13 identified the patient was put in two point restraints for risk of self-injury or interference with the medical plan of care. Further review identified that the Enclosure Bed was ordered on 7/19/13 at 6:25 am. Review of the clinical record dated 7/19/13-7/21/13 identified that Patient #19 remained in restraints until 7/21/13. Review of the progress notes dated 7/19/13-7/21/13 failed to identify that a one to one evaluation was conducted with the initiation and/or continuation of restraints.

11. Patient #11 was admitted to the hospital on 7/24/13 with dementia and atrial fibrillation. Patient #11 was a fall risk and had behaviors of restlessness and confusion. Review of the physician's orders dated 7/24/13 at 7:41pm identified that the patient was to have an Enclosure Bed for risk of self-injury and interference with the medical plan of care. Further review of physician's orders dated 7/26/13 at 9:43pm identified that the patient had the Enclosure bed in addition to a bed alarm and personal alarm. Review of the clinical record dated 7/24/13-7/27/13 identified that the patient remained in restraints until 7/27/13. Review of the progress notes dated 7/24/13-7/27/13 failed to identify that a one to one evaluation was conducted with the initiation and/or continuation of restraints.

Review of hospital policy identified that a one to one evaluation needs to be conducted within twenty-four hours of initiation of restraints for non-violent patients and repeated daily. Interview with the Director of Quality on 10/24/13 identified that the one to one physician assessment was not completed per hospital policy.