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Based on review of facility policy, medical records (MR), and interviews with staff (EMP), it was determined the facility failed to obtain a physician or other licensed independent practitioner order for the use of restraints for two of 10 restraint medical records reviewed (MR6 and MR12).

Findings include:

Review on December 27, 2013, of facility policy "Restraint Use," revised March 2013 revealed " ... III. Restraint for Non-Violent/Non Self-Destructive Behaviors ... B. Restraint Order 1. There is a written/electronic, time-limited, order for restraints ... 4. Restraint use may be initiated by a registered nurse on an emergent basis. A physician is notified to obtain an order during the emergent application or immediately after restraint application, not normally to exceed one hour."

Review on December 27, 2013, of MR6 revealed nursing documentation that indicated the patient had a soft waist restraint applied on October 23, 2013, at 6:29 AM. Review of physician orders for MR6 revealed no documentation for a restraint order until October 24, 2013, at 4:14 PM.

Review on December 27, 2013, of MR12 revealed nursing documentation that indicated that the patient had soft limb restraints applied to both wrists on November 1, 2013, at 9:15 PM. Review of physician orders for MR12 revealed no documentation for restraint orders until November 2, 2013, at 7:00 AM.

Interview on December 27, 2013, at 2:30, with EMP3 confirmed that a physician order had not been obtained prior to the application of restraints for MR6 and MR12.

Based on review of facility policy, medical records and interview with staff (EMP), it was determined that the facility failed to provide therapeutically effective nursing care related to the monitoring of intake and nutrition for one of four medical records (MR1).

Findings include:

Review on December 27, 2013, of facility policy "Patient Care Process: Including Admission, Assessment/Reassessment and Patient Plan of Care," revised January 2013, revealed " D. Plan of Care: Plan of Care will be documented via the appropriate documentation vehicle; electronic or paper. 1. The RN will coordinate the planning, implementation, and evaluation of the plan of care. Patient outcomes, whenever possible, will be mutually set with the patient and family. These outcomes will be realistic, measurable and consistent with the medical plan of care. 2. The plan of care will be reviewed/ revised as patient care needs are identified and or when the patient's needs change. 3. The RN will evaluate and record the patient's progress toward the outcome(s) per the plan of care. E. Documentation: 1. Will be completed utilizing the facility specific mechanism. a. For facilities utilizing computerized documentation, a printed copy of the Health Summary will be placed in the medical record binder... The Registered Nurse is responsible for screening the nutritional status of each patient within 24 hours of the patient's admission. Clinical nutrition staff is notified for all patients identified at nutritional risk per screening tool. ... B. Reassessment 1. Policies and General Instructions: a. An RN must perform an assessment a minimum of every 24 hours. b. Reassessments or partial assessments are done more frequently at the RN's discretion based on; 1) patient's diagnosis 2) significant changes in the patient's condition...c. It is the responsibility of the RN to analyze the assessment data to determine and prioritize patient care needs ...d. Based on the reassessment, the RN will modify/ revise the patient's problems/needs and patient's plan of care, when appropriate."

Request on December 27, 2013, was made for a policy related to "Intake and Output" monitoring protocols. None was provided.

Review of MR1 revealed that the patient was admitted to the facility on October 25, 2013. Review of a physician's order dated October 25, 2013, revealed daily "I&O" (Intake and Output) and document. Further review of MR1 revealed that upon admission the patient's weight was measured at 48.7 KG (107.14 LBS).

Review of MR1 "I&O Summary Flowsheet," revealed the following: October 26, 2013, total intake 120 cc and October 27, 2013, total intake 50 cc. On October 28, 29, and 30 2013, revealed no documented evidence that the patient's intake was monitored and recorded. On October 31, 2013, total intake 120 cc. On November 1, 2013, revealed no documented evidence that the patient's intake was monitored and recorded.

Review on MR1 "Nutrition Flowsheet," revealed no documented evidence that the patient's nutrition was monitored and recorded on October 26, 2013. On October 27, 2013 amount eaten 35% breakfast, 0% lunch. On October 28, 29, 30, 2013 revealed no documented evidence that the patient's nutrition was monitored and recorded. Further review of "Nutrition Flowsheet," dated October 31, 2013 revealed amount eaten 10% and that the patient had "very poor appetite." Review of "BMI Flowsheet," dated October 31, 2013 revealed that the patient's weight was measured at 45.1 KG (99.22 LBS)

Interview on December 27, 2013, at 2:00 PM with EMP9 confirmed there were days when the patient's intake was not documented. Further review of MR1 revealed no documented evidence that nursing followed the physician's order for the daily monitoring and documenting of the patient's Intake and Output. Further review of MR1 revealed no documented evidence that nursing adequately monitored and reassessed the patient's care needs related to a decrease in intake, nutrition and weight loss. Correspondence received on January 14, 2014, at 9:34 AM, from EMP1, confirmed that the Registered Dietician did not assess this patient.