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Based on review of medical records, policies/procedures and interviews with staff, it was determined the hospital failed to demonstrate for 1 of 3 patients that less restrictive interventions were ineffective prior to placing patient #45 in a Posey Bed as a restraint.

Findings include:

The hospital policy titled Restraint Use Non-Violent Situations, effective, 12/01/10, required: "...All possible alternative measures shall be used prior to use of restraints...Restraints will be used in the least restrictive manner possible...Restraint Availability: Soft limb restraints, mittens that are tied, bed side rails, and Freedom Splints...and enclosed beds will be the only restraints available for non-violent situations...Notify family regarding patient condition and discuss alternatives being considered to reduce necessity for restraint...Consider services of a Patient Care Companion (where applicable)...."

Patient #45 was admitted to the hospital on 12/05/10, with increased leg edema, pancytopenia, symptomatic anemia, gastroesophageal reflux disease, history of hypertension, diabetes type 2, and weakness. On 12/06/10, the physician indicated the number 1 problem was altered level of consciousness, and the following problems were identified: anemia and possible portal gastropathy, Hepatitis C, pancytopenia, urinary tract infection (UTI), diabetes mellitus (DM), hypertension (HTN).
The patient was discharged 4 days later on 12/09/10. The patient was assessed as a fall risk and safety measures were taken.

On 12/06/10 at 1900 hours, nursing documented the patient was confused and unable to follow commands, and the patient was restless, agitated and anxious. At 2100 hours nursing again documented the patient was confused and unable to follow commands and was physically aggressive towards people. At 2131 hours nursing indicated the patient was attempting to hit staff with the phone and to bite staff. Nursing called the physician at 2137 hours to notify of the patients change in condition. The physician called back with the following orders, "S-Bed UHS Posey." The Posey bed was described by employee #35 as an enclosed bed with mesh and zippers to keep the patient safely in bed. According to nursing documentation the patient was placed in an enclosed Posey bed as a restraint on 12/07/10 at 0055 hours. This was confirmed with employee #29 on 02/23/11 at 1103 hours.

On 02/24/11 employee #34 confirmed she did not document her rationale for not attempting the use of a companion/sitter which would have been the least restrictive restraint intervention for patient #45. Employee #29 confirmed on 02/23/11, nursing did not document the use of a companion or why a companion was not attempted.

Based on review of medical records, policies/procedures and interview with staff, it was determined the hospital failed to modify 1 of 3 patients (Pt #45) plan of care after being placed in an enclosed Posey bed as a restraint.

Findings include:

The hospital policy titled Restraint Use Non-Violent Situations, effective, 12/01/10, required: "...Procedural Documentation:...Modification to the patient's plan of care addressing the use of restraints...."

Patient #45 was admitted to the hospital on 12/05/10 and discharged 4 days later on 12/09/10.

According to nursing documentation the patient was placed in an enclosed Posey bed as a restraint on 12/07/10 at 0055 hours. This was confirmed with employee #29 on 02/23/11 at 1103 hours.

Nursing did not modify the patient's plan of care when patient #45 was restrained on 12/07/10.

This was confirmed with employee #29 on 02/23/11 at 1103 hours.

Based on review of medical records, policies/procedures and interview with staff, it was determined the hospital failed to obtain a restraint order for 1 of 3 patients (Pt #45) restrained in a Posey bed for 34 hours prior to a physician's order.

Findings include:

The hospital policy titled Restraint Use Non-Violent Situations, effective, 12/01/10, required: "...Obtain an order for restraint from the physician or other LIP (licensed independent practitioner) as soon as possible after application of restraint...Orders for restraints must be obtained daily or with each new episode or restraint...."

Patient #45 was admitted to the hospital on 12/05/10 and discharged 4 days later on 12/09/10.

According to nursing documentation the patient was placed in an enclosed Posey bed as a restraint on 12/07/10 at 0055 hours. An order for a restraint was obtained on 12/08/10 at 1103 hours.

This was confirmed with employee #29 on 02/23/11 at 1103 hours.

Based on review of policies/procedures, medical record, and interview with staff, it was determined the registered nurse failed to assess and evaluate nursing services for for 4 of 6 patients by providing/offering daily bathing, according to policy (Patients #21, 50, 51, 52).

Findings include:

The hospital policy titled Adult Patient Standards of Care #10135.3 (effective 08/09) requires: "...All patients will be provided an opportunity for personal hygiene at least daily and as condition warrants...."

The policy titled Standards of Care: Medical-Surgical #8354.1 (effective 02/08) requires: "...Patients will be assisted to perform hygiene, as condition allows...Type and frequency of baths/personal hygiene will be tailored to meet the individual need of the patient...Bed bound patients will receive a complete bed bath daily...Oral care is offered/provided daily...."

Four (4) of 6 patients' records reviewed at random for documentation of daily hygiene, did not contain evidence of daily hygiene offered/provided, as follows:

Patient #21, The patient presented to the Emergency Department (ED) on 05/19/10, with bright red rectal bleeding. The patient was discharged to a long term care rehabilitation facility on 06/30/10.

The surveyor requested documented evidence of daily bathing, on 02/18/11. The hospital responded to the request and provided the following Occupational Therapy notes on 02/23/11: Occupation Therapy notes 05/26/10 through 06/20/10, revealed no documentation to confirm the patient was provided, or offered, daily bathing. 05/19/10 through 05/25/10, and 06/21/10 through 06/30/10, were not provided for review.

Patient #50, was admitted on 02/19/11, with anemia, vomiting, and gastrointestinal bleeding. Documentation revealed that daily bathing was not offered or provided, 02/19/11 through 02/23/11 (5 days). ICU RN #32, stated during an interview conducted on 02/24/11 at 1100: "...I know he (the patient) had a bath...I just didn't document it...." The patient was incapacitated at the time of the tour and was not interviewed.

Patient #51, was admitted on 02/21/11, with pneumonia. Documentation revealed that daily bathing was not offered or provided, 02/21/11 through 02/23/11 (3 days). The patient "refused" the bath on 02/24/11. The patient's spouse stated during an interview conducted on 02/24/11 at 1105, "...no one has offered a bath...."

Patient #52, was admitted on 02/07/11, with a respiratory illness. Documentation revealed that 5 of 17 days (02/07/11 - 02/23/11) the patient was not provided or offered bathing. The patient's spouse stated during an interview conducted on 02/24/11 at 1115: "...they (nursing staff) don't offer...I had to ask for a bath - he (the patient) was getting rank...."

Senior Clinical Manager RNs #22 and 31, confirmed during interviews conducted on 02/18/1, and 02/24/11, that the staff are required to document that patients are offered/provided daily bathing.

There was no documented evidence patients were offered/provided daily bathing, according to the policy.