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Based on record review and interview the hospital failed to promote patient rights by the use of restraints without a physician order and not utilizing the least restrictive device on 6 patients in a standard survey of 20 patients. (Patient identifiers are #1, #2, #3, #4, #5, and #6.)

Findings include:

Review of medical records for patient #4, #5, and #6 revealed the use of pelvic holder while in geri chair/recliner on the GPU (Geriatric Psychiatric Unit). The assessment of patient need for the use of two restraints was not documented in the patient record nor was there documentation of these restraints being the least restrictive.

Further review of the medical record specifically the Restraint Flowsheet revealed that 6 patients, #1, #2, #3, #4, #5, and #6, had 4 side rails up when placed in bed for the night. There is no documented evidence as to why the side rails were up and a physician order for the use of siderails was not documented.

Interview on 5/19/14 with Staff A (Risk Manager), Staff B (Director of Critical Care) and Staff C (Clinical Leader Gero Psych) confirmed the documentation does not reveal why the double restraint was used on 3 patients or why 4 siderails were used on 6 patients without a physician order or documentation of the behaviors identified that support the need.

Cross reference to 154, 159, 164, 165, 167, 168,174, and 186

Based on record review and interview it was determined that the Hospital failed to properly use physical restraints or assess and monitor restraint usage in their Quality Program on 6 out of 20 patients in a selected sample group. (Patient identifiers are #1,#2,#3,#4,#5,and #6)

Findings include:

Review of medical records revealed that the use of physical restraints occurred on two separate units of the hospital. These two units are the ICU (Intensive Care Unit) and GPU (Geriatric Psychiatric Unit). On review of the medical record for the 3 patients on the ICU, Patient #1, #2, and #3 all had full side rails at night with no physicians orders. On further review of the records 3 patients on the GPU, Patients #4, #5,and #6 also had physical restraints. These three patients had both pelvic holders while in a Geri chair /recliner and side rails. Patients #4, #5,and #6 had orders of the use of the pelvic holders but no orders for the use of side rails. These findings were shown to Staff A (Risk Manager) at the time of finding who agreed there were no orders for the use of full side rails at night causing all 6 residents to be restrained.

Interview on 5/19/14 with Staff A (Risk Manager), Staff B (Director of Critical Care) and Staff C (Clinical Leader Gero psych) revealed that the Hospital leadership had established a policy and procedure for the use of restraints. The policy defined the use of restraints as related to patient rights. Assessment and monitoring of restraint usage was completed on the GPU (Gero Psychiatric Unit) however, staff was not able to articulate how the data was used, or if any hospital wide analysis was completed. Staff C reported that the hospital Quality Group did not review restraint usage. There was no indication that similar data was collected by the ICU. There was no documented evidence of hospital oversight of restraint usage.

Based on record review and interview it was determined that the Hospital failed to consider a mechanical device (Geri chair/recliner) as a restraint for 3 out of 20 patients in the survey selection. (Patient identifiers are #4, #5, and #6.)

Findings include:

Review of record revealed that 3 patients (#4, #5, and #6) on the GPU (Gero Psychiatric Unit) were placed in geri chairs/recliners with a pelvic holder. The geri chair/recliners become restraints if the patient cannot easily get out of the chair on his own. The patients in the geri chair/recliners with the use of pelvic holder constitutes a double restraint.

Interview on 5/19/14 with Staff A (Risk Manager), Staff B (Director of Critical Care, and Staff C (Clinical Leader Gero Psych) confirmed that the 3 patients on the GPU were placed in geri chairs/recliners with a pelvic holder. Staff A, Staff B and Staff C failed to recognize the usage of the geri chair/recliner and the pelvic holder as a double restraint.


Cross refer tag: 164 and 165

Based on record review and interview it was found that the Hospital failed to have any documentation to show that other devices or interventions were ineffective prior to using the type of restraints on 6 patients in a standard survey of 20 patients. (Patients identifiers are #1, #2, #3, #4, #5, and #6.)

Findings include:

During review of the 6 patient records on the GPU (Geriatric Psychiatric Unit) and the ICU (Intensive Care Unit) patients #1, #2, #3, #4, #5, and #6, it was confirmed through interview with Staff A (Risk Manager), Staff B (Head of Critical Care) and Staff C (Clinical Leader Gero psych) that there was no documentation to show that other attempts were made with a lessor restraint to show that it was ineffective prior to using the more restrictive devices on the these 6 Patients.

Based on record review and interview it was found that the Hospital failed to have any documentation to show that the devices used was the most effective restraints to be used on 6 patients in a standard survey of 20 Patients (Patients are #1, #2, #3, #4, #5, and #6.)

Findings include:

During review of the 6 patients records on the GPU (Geriatric Psychiatric Unit) and the ICU (Intensive Care Unit) patients #1, #2, #3, #4, #5, and #6, it was confirmed through interview with Staff A (Risk Manager), Staff B (Head of Critical Care) and Staff C (Clinical Leader Gero psych) that there was no documentation to show that the restraint used was the most effective to protect the 6 patients or others from harm.

Based on policy review and interview the hospital failed to implement safe and appropriate restraint usage according to hospital policy.

Finding include:

Review of hospital Restraint policy with effective date of 9/89 and last revised date of 2/2014, revealed that the hospital considers "...Side-rails on beds that are up in a manner that prevents a patient from exiting the bed normally and freely are to be considered restraint and all the documentation that is required for restraints is needed. This is usually when all four half rails are up or both full rails are up. Use of siderails should be assessed on a case-by-case basis. If all side-rails are used this is considered a restraint...". A physician order was not obtained for the use of siderails on 6 patients, #1, #2, #3, #4, #5, and #6, nor was there documentation of least restrictive devices being used. Documentation relating to assessment of Patient need and rationale for use was not documented.

Interview on 5/19/14 with Staff A (Risk Manager), Staff B (Director of Critical Care) and Staff C (Clinical Leader Gero Psych) confirmed the lack of a physician order and lack of documentation determining that the least restrictive device was being used.


Cross reference to 164 and 165

Based on record review and interview it was determined that the facility failed to have a physicians order on 6 out of 20 sampled patients who had restraints and became secluded. (Patient identifiers are: #1, #2, #3, #4, #5 and #6.)

Findings include:

During review of all 6 patients medical records, four side rails were being used when patients were in their beds, on two separate units of the hospital. These two units are the ICU (Intensive Care Unit) and GPU (Geriatric Psychiatric Unit). On review of the medical record for the 3 Patients on the ICU, patient #1, 2, and #3 all had four side rails at night secluding them to their beds. On review of the medical records for the 3 patients on the GPU, patient #4, #5, and #6 all had full side rails at night secluding them to their beds. This information was shown to Staff A (Risk Manager), Staff B (Head of Critical Care) and Staff C (Clinical Leader Gero psych) at time of findings. On review of the physician orders sheet none of the 6 patients had an order written for the use of 4 side rails.

Based on record review and interview it was found that the hospital failed to have any documentation to show that the restraints were removed at the earliest possible time for 6 out of the 20 sampled patients. (Patients identifiers are: #1, #2, #3, #4, #5,and #6.)

Findings include:

During review of the 6 patients records on the GPU (Geriatric Psychiatric Unit) and the ICU (Intensive Care Unit) patients #1, #2, #3, #4, #5, and #6, revealed that there was no documentation to show that the restraints used were discontinued at the earliest possible time.

Interview on 5/19/2014 with Staff A (Risk Manager), Staff B (Head of Critical Care) and Staff C (Clinical Leader Gero Psych) confirmed that there was no documentation to show that the restraint used were discontinued at the earliest possible time.

Based on record review and interview the hospital failed to document that alternative or other less restrictive interventions were attempted on 6 of 20 patients in a survey sample of 20. (Patient identifiers are #1, #2, #3, #4, #5, and #6.)

Findings include:

Review of medical record revealed that the documentation lacked an assessment that the restraints in place were the least restrictive or that less restrictive measures had been determined to be ineffective to protect the patient or others from harm.

Interview on 5/19/14 with Staff A (Risk Manager), Staff B (Director of Critical Care) and Staff C (Clinical Leader Gero Psych) confirmed that there was a lack of documentation that would determine that an assessment of the restraints in place were the least restrictive or that less restrictive measures had been determined to be ineffective to protect the patient or others from harm.


Cross reference to 164 and 165