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Based on record review, review of hospital policy, review of manufacturer's guidelines, and staff interview, the Hospital failed to recognize the safe and appropriate use of a net blanket (a full body restraint for total immobilization) and protective hood (a mask or hood to provide protection from a patient who is spitting and/or biting) for 1 of 1 closed patient (Patient #11) record reviewed and failed to check the vital signs of ? of 9 active patients and ? of 11 closed patient records reviewed. Failure of the Hospital to ensure a patient's medical condition did not contraindicate the usage of a net blanket and protective hood violated the rights of Patient #11 and may have contributed to her death. This failure and failure to check patients vital signs before the use of restraints violate the rights of all patients.

Findings include:

Review of the Hospital policy titled "Restraint" occurred on 04/09/13. This undated policy stated, "Rationale: The justification for restraint is for the need to intervene to save life or prevent injury. Definition: Restraint is the use of physical grip or mechanical device to restrain involuntarily the movement of the whole or a portion of the patient's body . . . Procedure: . . . 9) Vital signs should be checked initially (minimally pulse and respirations) and regularly thereafter (every 15 minutes at a minimum, if abnormal). . . ."

Review of the Hospital policy and procedure titled "SECLUSION and RESTRAINT" occurred on 04/09/13. This policy, dated October 2012, stated, "Alternatives to Seclusion and Restraint. Least Restricting Interventions: Medical and Verbal. Rationale: To use the least restrictive method of diffusing a situation and helping a patient be calm. Interventions: 1. Non-provocation and recognition of patient needs. . . . 2. Medication . . . 3. Continuing verbal intervention. . . . 4. Environmental change. . . . Patient choice room/quiet time in a bed-room or other quiet room. . . . 6. Voluntary blanket wrap by request . . .7. If the previous interventions are exhausted then the next more restricting interventions are considered, which are: *Time out in room *Time out in Seclusion Room * Open Door Seclusion * Locked Seclusion Documentation: Document all circumstances leading to the intervention, what intervention was used, and the outcome. This should be documented in the progress notes, (Form 331.) . . ."

Review of the Hospital checklist titled "Net Blanket" occurred on 04/09/13. This document, dated November 2011, stated, ". . . Purpose: To be used on individuals assessed as being in extreme danger of injury to themselves or to others. Description: A full body restraint for total immobilization in a supine position. . . . CONTRADICTIONS TO THE NET BLANKET RESTRAINT: . . . COPD [chronic obstructive pulmonary disease]. ADVERSE REACTIONS: Severe emotional, psychological, and physical problems may occur . . . Individuals may become restless or agitated . . . WARNING: . . . Individuals in a supine position and unable to sit up require extra vigilance as they could have emesis, aspirate, and suffocate."

Review of the manufacturer's guidelines titled "Posey Restraint Net" occurred on 04/09/13. These guidelines, dated 2011, stated, ". . . BEFORE APPLYING ANY RESTRAINT: *Make a complete assessment of the patient to ensure restraint use is appropriate. *Identify the patient's symptoms . . . *Use the restraint only when all other options have failed. Use the least restrictive device, for the shortest time, until you find a less restrictive alternative. Patients have the right to be free from restraint. . . ."

Review of the Hospital policy titled "Protective Hood" occurred on 04/09/13. This policy, dated 2000, stated, "PURPOSE: To provide protection from a patient who is spitting and/or biting during restraint application. SCOPE: To be used ONLY on patients with a history of multiple incidents of spitting and/or biting during restraint application or a patient who is actually spitting while being restrained. CONTRAINDICATIONS: Do not use the protective hood on any patient who is vomiting, having difficulty breathing . . . D. Remove the hood as soon as the restraints have been applied. . . ."

- Review of Patient #11's closed medical record occurred on all days of survey. The record identified an admission date of 01/23/13. Diagnoses included Trisomy 13 syndrome (a chromosome disorder), seizure disorder, reactive airway, and COPD. The medical record identified Hospital staff utilized a net blanket to restrain Patient #11 on 01/31/13, 02/07/13, and 03/28/13 and a protective hood on 03/28/13.

Patient #11's "SECLUSION/RESTRAINT PROGRESS NOTES" (Form 402), dated 01/31/13, identified the behaviors leading up to the net blanket as, "Pt. [patient] was in the hallway striking out at staff, kicking staff, and biting staff. She was tearing her clothes off and staff's clothes off." Alternative methods attempted prior to the net blanket included verbalizing, counseling, limit setting, reassurance, and offered oral medication. The form identified Patient #11 received an injection of Ativan (an antianxiety medication), Benadryl (an antihistamine used for sedation), and Haldol (an antipsychotic) at 7:12 p.m. The form identified the patient's respirations at "labored" but failed to document her respiration rate, pulse, or blood pressure.

Review of the "SECLUSION/RESTRAINT FOR BEHAVIOR" (Form 354), dated 01/31/13, utilized by Hospital staff to document the patient's activity during seclusion or restraint use, identified at 7:07 p.m. Hospital staff placed Patient #11 on gurney with chest straps and transported her to the L100 wing, transferred her onto a bed, and placed her in a net blanket at 7:12 p.m. The Hospital staff removed the net blanket at 9:13 p.m.

Review of Patient #11's "SECLUSION/RESTRAINT PROGRESS NOTES" (Form 402), dated 03/28/13, identified the behaviors leading up to the net blanket as, "Spitting, screaming, banging head." Alternative interventions attempted prior to the use of the net blanket included redirection and change of environment. The form identified the patient's respirations at "labored" but failed to document her respiration rate, pulse, or blood pressure. The Hospital staff applied the net blanket at 9:23 p.m.

Review of the "SECLUSION/RESTRAINT FOR BEHAVIOR" (Form 354), dated 03/28/13, identified the Hospital staff placed Patient #11 in the net blanket at 9:23 p.m. At 9:32 p.m., staff placed a mask on the patient. Patient #11 stopped breathing at 9:35 p.m. and the the staff removed the net blanket. Hospital staff announced "Code Blue" at 9:45 p.m.

Review of the progress notes (Form 331), dated 01/31/13 and 03/28/13, failed to identify Patient #11's response to the calming interventions attempted by Hospital staff; failed to identify less restrictive physical interventions attempted before the net blanket; and failed to identify the patient's vital signs prior to the application of the net blanket.
The Hospital staff utilized the net blanket restraint and protective hood even though the Patient #11's medical condition, facility policy, and manufacture guidelines contraindicated its use.

During an interview on 04/10/13 at 7:55 a.m., an administrative staff member (#) agreed the net blanket should not be the restraint or choice for a patient with COPD and the Hospital staff failed to document other restraint possiblities before placing the net blanket on Patient #11.

- For each of the following episodes of restraint use, the patients' records lacked evidence staff obtained vital signs prior to initiation of the restraints:
*Patient #1: Four point restraints on 01/02/13, 01/06/13, and 01/26/13 and net blanket restraint on 01/03/13
*Patient #4: Four point restraints on 01/09/13 (twice), 02/01/13 (twice), 02/02/03, and 02/08/13 and a net blanket on 02/01/13, 02/02/13, 02/08/13, and 03/26/13
*Patient #8: Four point restraints on 01/01/13 and waist/wrist restraints on 02/12/13, 02/13/13, 02/14/13, 02/15/13, 02/16/13, 02/17/13, 02/21/13, 02/22/13, and 03/08/13
*Patient #12: Four point restraints on 02/09/13 and 02/15/13
*Patient #13: Four point restraints on 01/23/13 and 01/25/13

Cathy needs to add her patients

Interviews related to vital signs?

Based on record review, review of Hospital policy and procedure, and staff interview, the Hospital failed to use the use the less restrictive form of restraint before utilizing a net blanket for 1 of 1 closed patient (Patient #11) record reviewed who required immediate medical attention and later expired. Failure of the Hospital staff to attempt less restrictive interventions/restraints prior to the net blanket and document the interventions/restraints used or attempted and the outcome in the progress notes (Form 331) violated Patient #11's rights and has the potential to violate the rights of all patients.

Findings include:

Review of the Hospital policy and procedure titled "SECLUSION and RESTRAINT" occurred on 04/09/13. This policy, dated October 2012, stated, "Alternatives to Seclusion and Restraint. Least Restricting Interventions: Medical and Verbal. Rationale: To use the least restrictive method of diffusing a situation and helping a patient be calm. . . . Document all circumstances leading to the intervention, what intervention was used, and the outcome. This should be documented in the progress notes, (Form 331.) . . ."

Review of the "SECLUSION/RESTRAINT PROGRESS NOTES" (Form 402), dated 01/31/13, identified the Hospital staff placed a net blanket on Patient #11 at 7:19 p.m. The form listed hands-off calming interventions used prior to the net blanket which included verbalizing, counseling, limit setting, reassurance, redirection, and offered oral medication. Review of the progress notes (Form 331), failed to identify the outcome to the hands-off interventions and what, if any, less restrictive restraints were attempted prior to the net blanket.

Review of the "SECLUSION/RESTRAINT PROGRESS NOTES" (Form 402), dated 03/28/13, identified the Hospital staff placed a net blanket on Patient #11 at 9:23 p.m. The form listed hands-off calming interventions used prior to the net blanket which included verbalizing, redirection, and change of environment. Review of the progress notes (Form 331), failed to identify the outcome to the hands-off interventions and what, if any, less restrictive restraints were attempted prior to the net blanket.

During an interview on 04/10/13 at 7:55 a.m., an administrative staff member (#) agreed Patient #11's medical record lacked documentation of less restrictive interventions attempted by the Hospital staff and their outcome before utilizing the net blanket.

Based on record review, the Hospital failed to ensure the plan of care/treatment plan included

Based on record review and review of policies and procedures, the Hospital failed to ensure a written modification to the plan of care/treatment plan occurred with the use of restraints or seclusion for 2 of 2 sampled closed records of patients restrained or secluded (Patients #11 and #16). Failure to modify plans of care/treatment plans for use of restraint/seclusion limits the staff's ability to manage patients' behavioral issues.

Findings include:

Review of the "Restraint and Seclusion" policy occurred on 02/12/13. The policy, dated 01/14/12, stated,
". . . The use of seclusion or restraint
Is in accordance with a written modification to the patient's plan of care . . ."

- Review of Patient #11's medical record occurred on February 12-14, 2013. Patient #11, an adolescent, received inpatient care from August 3, 2012 to August 18, 2012. The physician's orders showed Patient #11 restrained or secluded the following days: 08/12/12, 08/13/12, 08/15/12, 08/17/12, and 08/18/12.

Patient #11's record lacked evidence of modification of the care plan/treatment plan for use of the restraints/seclusions.

- Review of Patient #16's record occurred on February 12-14, 2013. Patient #16's admission occurred on 12/17/12 and diagnoses included anxiety with depression and Alzheimer's dementia. The record indicated on 01/02/13 at 12:40 a.m. nursing staff implemented a Geri chair with tray as "Pt kept trying to get up and was being aggressive with the CNAs [certified nursing assistants] when they tried to get him to sit so that he wouldn't fall and hurt himself."

Patient #16's Master Treatment Plan narrative, dated 01/03/13, did not include modifications for the use of the Geri chair restraint.

Based on record review and review of Hospital policy, the Hospital failed to follow their policy related to the use of a net blanket (a full body restraint) for 1 of 1 closed patient (Patient #11) record reviewed. Failure to follow Hospital policy violated Patient #11's rights, has to potential to violate all patients' rights, and may have contributed to Patient #11's emergent care and subsequent death.

Findings include:

Review of the Hospital checklist titled "Net Blanket" occurred on 04/09/13. This document, dated November 2011, stated, ". . . Description: A full body restraint for total immobilization in a supine position. . . . CONTRADICTIONS TO THE NET BLANKET RESTRAINT: . . . COPD [chronic obstructive pulmonary disease] . . . WARNING: . . . Individuals in a supine position and unable to sit up require extra vigilance as they could have emesis, aspirate, and suffocate."

Review of the Hospital policy titled "Protective Hood" occurred on 04/09/13. This policy, dated 2000, stated, "PURPOSE: To provide protection from a patient who is spitting and/or biting during restraint application. . . . CONTRAINDICATIONS: Do not use the protective hood on any patient who . . . having difficulty breathing . . . D. Remove the hood as soon as the restraints have been applied. . . ."

Review of Patient #11's closed medical record occurred on all days of survey. Diagnoses included COPD. The medical record identified the Hospital staff used a net blanket to restrain Patient #11 on 01/31/13, 02/07/13, and 03/28/13 and a protective hood on 03/28/13.

Review of the "SECLUSION/RESTRAINT FOR BEHAVIOR" (Form 354), dated 03/28/13, identified the Hospital staff placed a net blanket on Patient #11 at 9:23 p.m. and a "mask" (protective hood) on patient at 9:32 p.m. Patient #11 stopped breathing at 9:35 p.m.

The Hospital failed to follow their policy and placed a net blanket and protective hood on Patient #11 even though her medical condition warranted their use.

Based on record review, review of Hospital policy, and staff interview, the Hospital failed to obtain an order for the placement of a protective hood (provides protection from spitting and/or biting) from the Independent Licensed Practitioner [ILP] for 1 of 1 closed patient (Patient #11) record reviewed. Failure to obtain an order does not give the ILP the opportunity to choose a less restrictive form of protection and violated the rights of this patient.

Findings include:

Review of the Hospital policy titled "Protective Hood" occurred on 04/09/13. This policy, dated 2000, stated, ". . . Procedure: A. Licensed staff obtain an order from the Independent Licensed Practitioner [ILP] for the application of the protective hood . . ."

Review of Patient #11's medical record occurred on all days of survey. Review of the "SECLUSION/RESTRAINT FOR BEHAVIOR" (Form 354), dated 03/28/13, identified the Hospital staff placed a "mask" on Patient #11 at 9:32 p.m. without obtained an order from the ILP.

During an interview on 04/10/13 at 8:10 a.m., an administrative nurse (#) confirmed the Hospital staff failed to obtain an order from the ILP before the utilization of the protective hood.