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Based on medical record review and staff interview the facility failed to ensure staff provided for the personal hygiene needs of an incapacitated patient.

Findings were:

Review of medical record for patient #1 revealed the patient was in restraints from 12/29/14-1/18/15. During this period of time the patient received a complete bath on 1/2/15, 1/6/15, 1/10/15, 1/11/15, 1/13/15, and 1/21/15. Patient received a partial bath on 1/4/15, 1/14/15, and 1/16/15. Per documentation in the patient medical record the patient was restrained for 21 of his 25 days of hospitalization. The patient was noted as incontinent of urine and stool during this period of time. The patient did not receive bathing assistance on a daily and as needed basis and developed excoriation in the groin and buttocks area on 1/3/15 and was still being treated for the excoriation at the time of discharge on 1/21/15. Documentation in the medical record does not provide evidence of toileting needs offered and provided every 2 hours for a restrained patient. On 1/4/15 the toileting needs was deferred at this time from 08:30 until 19:44 on that day. Toileting needs were again deferred from 1/7/15 11:20-1/13/15 at 14:00. On 1/14/15 it was noted diaper intact for toileting needs until 1/14/15 at 20:00 and there was no charting on restraints and toileting needs until 1/15/15 at 08:00.

In an interview with staff #4 she stated the patient should be bathed daily and the linens changed as needed. She concurred there was not evidence in the patient medical record of this need being met. She also stated there was no documentation the patient was checked every 2 hours and findings documented while in restraints.

Based on medical record review, policy review, and staff interview the facility failed to ensure the physician reordered the use of restraints every 24 hours after patient reassessment. The facility did not document the consideration and usage of less restrictive means to control the patient's behavior prior to the use of restraints on an ongoing basis.

Findings were:

Review of medical record for patient # 1 revealed the following:
* Patient was placed in a vest and 4 point restraints per physician order dated 12/29/14 at 16:02. It states "The following de-escalation techniques were unsuccessful: (blank) This intervention is required because of the following behaviors resulting in actual or potential injury to self or others: (blank). This order was discontinued on 1/21/15 at 13:07.
* Patient received Lorazepam IV push at 15:13 as behavioral intervention.
* Physician order of 1/1/15 at 11:55 for 1:1 observation states "Pt to have sitter due to altered mental status, combative and pulling at tubes/lines." This order has a d/c date of 1/6/15 at 16:45 at which time it was made a PRN order until it was discontinued on 1/21/15 at 13:07.
* Physician acknowledges restraints in progress notes on 12/30/14, 1/1/15, 1/4/15, 1/5/15, 1/6/15, 1/7/15, 1/8/15, 1/9/15, 1/10/15.
* Plan on physician progress notes 1/11/15-D/C restraints. 1/12/15 and 1/13/15 no mention of restraints. Physician progress notes indicate in restraints 1/14/15-1/17/15.
* Patient in restraints from 12/29/14-1/11/15; reapplied restraints 1/13/15 at 06:00-1/18/15 at 08:00. One physician order for restraints on 12/29/14 at 16:02. No further renewal of order.

Facility policy titled "Restraint Use" states in part, "Definition: Restraint is: a) any manual method physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely...Non-Psychiatric Restraint is restraint used for non-behavioral health care reasons below. It is used to assist with the provision of medical or surgical care, including symptoms of withdrawal. NOTE: If the main goal is to maintain medical treatment such as ET tube, IVs, or other lines, this type of restraint should be used. ALTERNATIVES TO RESTRAINT include, but are not limited to cover device, decreasing stimulation in environment, diversional activity, frequent observation, moving to room close to desk, medication for pain/anxiety, use of sitter/family, wrap device, and other methods - distraction, moving equipment, etc., as appropriate. Least restrictive means: a. restraint shall not be used when less restrictive interventions would be effective; b. when restraint is indicated, least restrictive methods of restraint shall be chosen. The physician may order initiation of the Non-Psychiatric Restraint Protocol. Use of this Restraint Protocol does not require a daily order. Should alternative or less restrictive interventions become ineffective or not applicable, restraint may be reapplied as long as the enabling restraint order or order for protocol remains in effect. A new order to initiate the protocol will be obtained if restraint use is reinstated after a documented discontinuation."

In an interview with the staff # 1, 2, and 3 all said a restraint order does not need to be rewritten every 24 hours by the physician and this order was ongoing throughout the patient hospitalization. Staff #1 and #2 confirmed all documentation provided did not reveal a physician reassessment for restraint use every 24 hours while in restraints and no other documentation could be provided.

Based on medical record review, policy review, and staff interview the facility failed to ensure the physician reordered the use of restraints every 24 hours after patient reassessment. The order given by the physician was an open and ongoing order with no time frame for discontinuation.

Findings were:

Review of medical record for patient # 1 revealed the following:
* Patient was placed in a vest and 4 point restraints per physician order dated 12/29/14 at 16:02. It states "The following de-escalation techniques were unsuccessful: (blank) This intervention is required because of the following behaviors resulting in actual or potential injury to self or others: (blank). This order was discontinued on 1/21/15 at 13:07. No further order was given when trial release for the patient was ineffective.
* Physician order of 1/1/15 at 11:55 for 1:1 observation states "Pt to have sitter due to altered mental status, combative and pulling at tubes/lines." This order has a d/c date of 1/6/15 at 16:45 at which time it was made a PRN order until it was discontinued on 1/21/15 at 13:07.
* Physician acknowledges restraints in progress notes on 12/30/14, 1/1/15, 1/4/15, 1/5/15, 1/6/15, 1/7/15, 1/8/15, 1/9/15, 1/10/15.
* Plan on physician progress notes 1/11/15-D/C restraints. 1/12/15 and 1/13/15 no mention of restraints. Physician progress notes indicate in restraints 1/14/15-1/17/15.
* Patient in restraints from 12/29/14-1/11/15; reapplied restraints 1/13/15 at 06:00-1/18/15 at 08:00. One physician order for restraints on 12/29/14 at 16:02. No further renewal of order.

Facility policy titled "Restraint Use" states in part, "Definition: Restraint is: a) any manual method physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely...Non-Psychiatric Restraint is restraint used for non-behavioral health care reasons below. It is used to assist with the provision of medical or surgical care, including symptoms of withdrawal. NOTE: If the main goal is to maintain medical treatment such as ET tube, IVs, or other lines, this type of restraint should be used. ALTERNATIVES TO RESTRAINT include, but are not limited to cover device, decreasing stimulation in environment, diversional activity, frequent observation, moving to room close to desk, medication for pain/anxiety, use of sitter/family, wrap device, and other methods - distraction, moving equipment, etc., as appropriate. Least restrictive means: a. restraint shall not be used when less restrictive interventions would be effective; b. when restraint is indicated, least restrictive methods of restraint shall be chosen. The physician may order initiation of the Non-Psychiatric Restraint Protocol. Use of this Restraint Protocol does not require a daily order. Should alternative or less restrictive interventions become ineffective or not applicable, restraint may be reapplied as long as the enabling restraint order or order for protocol remains in effect. A new order to initiate the protocol will be obtained if restraint use is reinstated after a documented discontinuation."

In an interview with the staff # 1, 2, and 3 all said a restraint order does not need to be rewritten every 24 hours by the physician and this order was ongoing throughout the patient hospitalization. Staff #1 and #2 confirmed all documentation provided did not reveal a physician reassessment for restraint use every 24 hours while in restraints and no other documentation could be provided.

Based on medical record review, policy review, and staff interview the facility failed to ensure the physician reordered the use of restraints every 24 hours after patient reassessment. The order given by the physician was an open and ongoing order with no time frame for discontinuation.

Findings were:

Review of medical record for patient # 1 revealed the following:
* Patient was placed in a vest and 4 point restraints per physician order dated 12/29/14 at 16:02. It states "The following de-escalation techniques were unsuccessful: (blank) This intervention is required because of the following behaviors resulting in actual or potential injury to self or others: (blank). This order was discontinued on 1/21/15 at 13:07. No further order was given when trial release for the patient was ineffective.
* Physician order of 1/1/15 at 11:55 for 1:1 observation states "Pt to have sitter due to altered mental status, combative and pulling at tubes/lines." This order has a d/c date of 1/6/15 at 16:45 at which time it was made a PRN order until it was discontinued on 1/21/15 at 13:07.
* Physician acknowledges restraints in progress notes on 12/30/14, 1/1/15, 1/4/15, 1/5/15, 1/6/15, 1/7/15, 1/8/15, 1/9/15, 1/10/15.
* Plan on physician progress notes 1/11/15-D/C restraints. 1/12/15 and 1/13/15 no mention of restraints. Physician progress notes indicate in restraints 1/14/15-1/17/15.
* Patient in restraints from 12/29/14-1/11/15; reapplied restraints 1/13/15 at 06:00-1/18/15 at 08:00. One physician order for restraints on 12/29/14 at 16:02. No further renewal of order.

Facility policy titled "Restraint Use" states in part, "Definition: Restraint is: a) any manual method physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely...Non-Psychiatric Restraint is restraint used for non-behavioral health care reasons below. It is used to assist with the provision of medical or surgical care, including symptoms of withdrawal. NOTE: If the main goal is to maintain medical treatment such as ET tube, IVs, or other lines, this type of restraint should be used. ALTERNATIVES TO RESTRAINT include, but are not limited to cover device, decreasing stimulation in environment, diversional activity, frequent observation, moving to room close to desk, medication for pain/anxiety, use of sitter/family, wrap device, and other methods - distraction, moving equipment, etc., as appropriate. Least restrictive means: a. restraint shall not be used when less restrictive interventions would be effective; b. when restraint is indicated, least restrictive methods of restraint shall be chosen. The physician may order initiation of the Non-Psychiatric Restraint Protocol. Use of this Restraint Protocol does not require a daily order. Should alternative or less restrictive interventions become ineffective or not applicable, restraint may be reapplied as long as the enabling restraint order or order for protocol remains in effect. A new order to initiate the protocol will be obtained if restraint use is reinstated after a documented discontinuation."

In an interview with the staff # 1, 2, and 3 all said a restraint order does not need to be rewritten every 24 hours by the physician and this order was ongoing throughout the patient hospitalization. Staff #1 and #2 confirmed all documentation provided did not reveal a physician reassessment for restraint use every 24 hours while in restraints and no other documentation could be provided.

Based on medical record review and staff interview the facility failed to update and keep the patient plan of care current with new identified needs of the patient.

Findings were:

Medical record review for patient #1 revealed the following deficiencies in care planning:
* The patient was placed in restraints on 12/29/14-no plan of care for restraints was initiated for the patient until 12/31/14.
* Plan of care for potential of injury initiated on 12/31/14 indicates: prevent injuries i.e. falls, skin breakdown. Patient developed skin breakdown starting 1/3/15 and no adjustment to the plan of care was initiated for skin breakdown and wound care.
*Patient was ordered NPO on 1/3/15-1/6/15 with no nutritional plan of care initiated in response to this. Note in chart by dietitian on 1/5/15 indicates patient on 1800 cal ADA, 2 gm Na diet. Patient again NPO from 1/7/15-1/11/15. Note from dietitian on 1/8/15 indicates patient on 1800 cal ADA, 2 gm Na diet.
* Patient started on Clinamix on 1/9/15 with no update in nutrional plan of care by dietitian or nursing. Note by dietitian on 1/9/15 states "oral diet started"; notes in patient chart indicated patient was receiving sips of water from 1/10/15 07:00 until 1/11/15 12:00.
* Patient intubated from 1/7/15-1/8/15 and again 1/8/15-1/9/15 with no plan of care initiated for intubated patient.
* Patient plan of care on 12/31/14 indicates "Refer to PT/OT; High; Once; Done"; no referral was made for Physical Therapy until 1/15/15.

In an interview with staff #4 and #6 on 1/1/15 in the conference room of the facility both indicated a plan of care should have been initiated in response to the skin breakdown and the use of the ventilator. Both reviewed the plan of care documentation given to the surveyor and could find no plan of care initiated in these areas.

Based on medical record review and staff interview the facility did not evaluate the patient for all areas of self-care prior to discharge.

Findings were:

Medical record review for patient #1 revealed the patient was evaluated for placement for in-patient psychiatric management post hospitalization. Patient was cleared for return for psychiatric issues to previous home setting after discharge after evaluation. Discharge planning never addressed the physical needs of the patient in evaluating for post-hospital needs.

In an interview with staff #7 and #8 both stated they did not look at placement for skilled rehabilitation needs post hospital for the patient. They stated they only tried placement for in-patient psychiatric facilities and were denied because of the patient's medical status.