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Based on medical record review, staff interview, and review of policies and procedures, it was determined the facility failed to ensure all medical restraint requirements were met. There lacked an adequate justification for the use of an enclosure bed restraint and physician orders did not consistently include all required information related to restraint use (A154). The facility did not ensure least restrictive restraint devices were utilized (A165). The facility did not ensure plans of care were modified to address all types of restraint use (A166). There lacked evidence that restraints were used for the least amount of time necessary (A174). The facility did not have evidence that all patients who were restrained were monitored by a physician and other qualified staff (A175). The facility failed to ensure the responses to restraint interventions were monitored for all restrained patients (A188). The cumulative effect of these systems failures resulted in the inability of the facility to ensure that restraint interventions were used only when absolutely necessary, for as short a time as possible, were not used for staff convenience, and with minimal risk to all patients being restrained.

Based on staff interview, medical record review, and review of nursing policies and procedures, it was determined the hospital failed to ensure all nursing requirements were met. There lacked evidence nursing staff provided the necessary assessments, monitoring, and nursing measures to ensure adequate pain management was provided (A395). The hospital did not ensure plans of care were modified to address patient needs as they changed and new interventions were put in place (A396). The combined results of these systems failures resulted in the inability of the hospital to ensure nursing assessments, monitoring and nursing measures were adequately and appropriately provided for all patients.

Based on staff interview, medical record review, and review of the policy and procedure for restraints, the facility failed to ensure restraints imposed for safety reasons were used for an immediate safety need and not used for staff convenience, and that physicians' orders for restraints included all the required information related to restraint use for 2 (#10, #14) of 3 sample patients whose records were reviewed related to enclosure bed restraints. The findings were:

Review of the hospital's own policy and procedure on restraints, revised in January 2009, page 2 documented: "Identified types of Physical Restraints: Bed Enclosures...."

1. Review of the 2/12/10 history and physical for patient #10 showed s/he was a 44 year old patient admitted with diagnoses including critical illness polyneuropathy, muscle weakness, severe malnutrition, chronic obstructive pulmonary disease, degenerative joint disease, pain, and depression. Review of the 2/12/10 admission nursing assessment timed at 3:47 PM showed the patient was identified as a fall risk and was placed on the fall prevention program. Review of the 2/17/10 and the 2/24/10 case conference notes showed the patient was at risk for falls because s/he was impulsive and unpredictable. Review of the nursing shift notes showed a restraint was implemented on 2/17/10 at 6 PM and remained in place daily from 2/17 until 2/25/10 at 6 AM when the patient was transferred out of the facility. The following concerns were identified:
a. Review of physician orders showed the physician ordered an enclosure (net) bed restraint beginning on 2/17/10 at 6 PM as a medical restraint for impulsive behaviors. Review of the entire medical record showed no evidence a surgical, diagnostic or dental procedure was performed.
b. Review of the 2/17 through 2/24/10 nursing notes showed the patient remained in the enclosure bed restraint most of the time on a daily basis. Review revealed the rationale for the enclosure bed was because, at times, the patient attempted to get out of the bed without assistance and there was concern s/he might fall. Review of the physician documentation showed he did not describe the actual behaviors/actions that warranted the use of restraints. In fact, the physician did not make any note regarding the use of the restraint other than the orders. Nursing notes dated 2/22/10 at 2:29 PM showed the patient "feels great anxiety related to the bed net."
c. Review of the 2/19/10, 2/20/10, 2/24/10, and 2/25/10 physician's orders showed the orders did not address the type of restraint being used for this patient and a time limitation. In addition, review of the restraint order form showed the "restraint alternative section," where details of steps taken or interventions used prior to implementation of restraints were to be documented, had been left blank.
d. Review of the 2/21/10, 2/22/10 and an undated physician order revealed the orders failed to document the type of restraint and the time limitation for use.

2. Review of the 7/22/09 physician's history and physical for patient #14 showed s/he had diagnoses including stroke with dominant weakness, neuropathic pain, rheumatoid arthritis, osteoporosis, peripheral vascular disease, depression, and anxiety disorder. Review of the 7/22/09 nursing admission assessment timed at 4:30 PM showed the patient was identified as a fall risk and was placed on the fall prevention program. Review of the nursing shift notes from 7/31 through 8/17/09 showed the patient was at risk for falls because s/he was impulsive and had an unsteady gait. Review of the hospital restraint record showed an enclosure bed was implemented on 7/31/09 at 6 PM. Review of the nursing notes showed the restraints remained in place from 7/31 until 8/17/09 at 3 PM when the patient was transferred out of the facility. Review of the July and August 2009 incident logs and the entire medical record showed that despite the implementation of this enclosure bed restraint, the patient had one fall,which occurred was on 8/1/09. The following concerns were identified:
a. Review of physician orders showed the physician ordered an enclosure (net) bed restraint beginning on 7/31/09 at 6 PM. The sole rationale for the restraint was to prevent the patient from climbing out of bed and falling. The restraint was identified as a medical restraint for "impulsive" behaviors; however, the evidence showed the bed was being used as a safety device, not for medical reasons. Review of the entire medical record showed there was no evidence a surgical, diagnostic or dental procedure was performed during this patient's stay.
b. Review of the 7/31/09 through 8/17/09 nursing shift notes showed the patient remained in the enclosure bed restraint most of the time on a daily basis. Review revealed the rationale for the enclosure bed was because the patient was impulsive and unsteady on his/her feet and there was concern s/he might fall. Review of the physician's documentation showed he did not describe the specific behaviors/actions that warranted the use of restraints. The physician did not make any note regarding the use of the restraint other than the orders.
c. Review of the 8/7/09, 8/11/09, 8/12/09, 8/13/09, 8/1409, and 8/15/09 physician's orders revealed there was no time limitation established for the use of the restraint.
d. Review of the 8/8/09, and 8/17/09 physician's orders failed to document the type of restraint and the time limitation. In addition review of the hospital restraint order form showed the "restraint alternative section" was blank.
e. Review of the 8/9/09 and 8/10/09 physician's orders showed the type of restraint was not indicated, and there was no time limitation indicated.

3. Interview with the director of nurses (DON) on 3/25/10 at 9 AM revealed staff and physicians were educated and trained on the use of restraints during initial orientation and annually thereafter. She stated policies should be followed as written. During an interview on 4/8/10 at 8:40 AM, the DON said the enclosure beds for the two patients noted above, were in fact, used as safety devices to prevent the patients from falling.

4. Review of the restraint policy, revised January 2009, page 4, showed the following instructions: "Obtain a written order from the physician [which] must contain the specific reason for restraint, the date, specific time limit, and the signature of the physician."

5. According to Webster's dictionary, page 557, 2001, the word impulsive means to act on impulse not thought. Impulsive was not defined as a medical condition. Review of the hospital's restraint policy, January 2009, page 2, showed there was a statement "Medical/Surgical restraints are used to limit mobility or temporarily immobilize the patient in direct relation to a medical, surgical, diagnostic or dental procedure."

Based on staff interview, medical record review, and review of policies and procedures, the hospital failed to ensure less restrictive alternative measures were attempted without success prior to implementation of restraints and for continuation of a restraint for 2 (#10, #14) of 3 sample patients who were physically restrained while in the facility. The findings were:

1. Review of physician orders for patient #10 showed the physician ordered an enclosure (net) bed restraint beginning on 2/17/10 at 6 PM as a medical restraint for impulsive behaviors. Review of the nursing notes showed the restraints remained in place daily from 2/17 until 2/25/10 at 6 AM when the patient was transferred out of the facility. Review of the hospital restraint order form showed the "restraint alternative section," which required a description of steps taken or interventions used to assess the need for implementation and continued use of restraints. However, although this section contained a completed check list identifying physiological, psychological, and environmental alternatives attempted, there were no descriptions as to when the alternative measures were attempted, how the patient responded to the alternative measures, or why staff determined the less restrictive alternatives did not protect the patient's safety. Review of the 2/19/10, 2/20/10, 2/24/10, and 2/25/10 physician's restraint orders showed the "restraint alternative section" was left blank.

2. Review of physician orders for patient #14 showed the physician ordered an enclosure (net) bed restraint beginning on 7/31/09 at 6 PM as a medical restraint for impulsive behaviors. Review of the nursing notes showed the restraints remained in place from 7/31 until 8/17/09 at 3 PM when the patient was transferred out of the facility. Review of the July and August 2009 incident logs and the entire medical record showed the patient had one fall, which occurred on 8/1/09. Review of the hospital restraint order form showed the "restraint alternative section" consisted of a check list that had been completed, identified physiological, psychological, and environmental alternatives attempted. However, review revealed there were no descriptions as to when the alternative measures were attempted, how the patient responded to the alternative measures, or why staff determined the less restrictive alternatives did not protect the patient's safety. Review of the 8/8/09, and 8/17/09 physician's restraint orders showed the "restraint alternative section" had been left blank.

3. Interview with the director of nursing on 3/25/10 at 11 AM revealed less restrictive alternatives should be attempted prior to implementation of restraints unless it is determined the alternative would not be appropriate or effective. She said medical restraints should be used to limit or temporarily immobilize a patient during a medical, surgical, or diagnostic procedure. The cases noted above were to prevent the patients from getting out of bed and falling. Review of the hospital's policy and procedure on restraints, revised January 2009, page 4, showed "restraint use must be ended at the earliest possible time."

Based on staff interview, medical record review, and review of hospital policies, the hospital failed to ensure the care plan was modified after an enclosure bed restraint was implemented for 2 of 3 sample patients (#10, #14) who were restrained. The findings were

1. Review of physician orders for patient #10 showed the physician ordered an enclosure (net) bed restraint beginning on 2/17/10 at 6 PM as a medical restraint for impulsive behaviors. Review of the nursing notes showed the restraints remained in place daily from 2/17 until 2/25/10 at 6 AM when the patient was transferred out of the facility. The following concerns were identified:
a. Review of the 2/12/10 patient care plan showed the use of restraints was not included other than a statement that they might be considered in the future. Review of the nursing shift notes for 2/18/10, 2/19/10, 2/20/10, 2/21/10, 2/23/10, and 2/24/10 showed the care plan was not modified to address the implementation of a restraint enclosure bed.
b. Review of the 2/22/10 shift notes, timed at 2:29 PM, showed the care plan was "modified as addressed above." However, review of the entire 2/22/10 shift documentation failed to show what modification was made.
c. Review of the care plan revealed it did not reflect the process of assessment, intervention, and evaluation when the restraint was implemented. In addition, the care plan did not address a time limit for the use of the restraint.

2. Review of physician orders for patient #14 showed the physician ordered an enclosure (net) bed restraint beginning on 7/31/09 at 6 PM as a medical restraint for impulsive behaviors. Review of the 7/31/09 through 8/17/09 nursing shift notes showed the patient remained in the enclosed bed restraint most of the time on a daily basis. The following concerns were identified:
a. Review of the care plan, originally developed 7/22/09, showed restraint usage was not addressed. Review of the nursing shift notes for 7/31 through 8/17/09 failed to show a modification to the care plan was made when the enclosure bed restraint was implemented.
b. Review of the care plan showed it did not reflect the process of assessment, intervention, and evaluation when the restraint was implemented. In addition, the care plan did not incorporate a time limit for the use of the restraint.

3. Review of the January 2009 hospital policy and procedure for restraints, page 3, showed: "Upon completion of the assessment, written modification will be made to the patient's plan of care appropriate to the findings. The problem must be included on the patient plan of care with the determination of appropriate interventions/alternatives and goals. Additional interventions(s) and or goals should be added or deleted as the patients condition and response to treatment changes." Interview with the director of nursing on 3/25/10 at 11 AM revealed hospital policy requires the care plan to be modified or updated whenever a patient's condition changes in order to address the new interventions.

Based on staff interview, medical record review, and review of hospital policy, the hospital failed to ensure staff identified the behaviors that required continued use of an enclosure restraint bed for 2 (#10, #14) of 3 sample patients who were restrained. The findings were:

1. Review of physician orders for patient #10 showed the physician ordered an enclosure (net) bed restraint beginning on 2/17/10 at 6 PM as a medical restraint for impulsive behaviors. Review of the nursing notes showed the restraints remained in place daily from 2/17 until 2/25/10 at 6 AM when the patient was transferred out of the facility. Review of the restraint record flow sheets from 2/17 at 6 PM through 2/23/10 at 6 AM documented the nurse who performed the every two hour checks initialed that the checks were done. However, the nurse did not address or describe the need for continued use of the restraint.

2. Review of physician orders for patient #14 showed the physician ordered an enclosure (net) bed restraint beginning on 7/31/09 at 6 PM as a medical restraint for impulsive behaviors. Review of the 7/31/09 through 8/17/09 nursing shift notes showed the patient remained in the enclosure bed restraint most of the time on a daily basis. Review of the restraint record flow sheets from 7/31 at 6 PM until 8/5/10 at 6 AM, from 8/7 at 8 AM until 8/12/10 at 8 AM, and from 8 PM on 8/13 until 8 AM on 8/15 showed the nurse who performed the every two hour checks initialed that the checks were completed. However, the nurse did not address or describe the need for continued use of the restraint.

3. Review of the policy and procedure on restraints, revised January 2009, page 4, showed instructions that restraint use must be ended at the earliest possible time. In addition, on page 5 of the same policy instructions documented: "Patients in restraints will be continually assessed for the readiness to discontinue restraints. Patients may qualify for a trial release if one or more of the following criteria are met: a. Patient is co-operative and willing/able to follow directions. b. Patient is no longer causing harm or injury to self or others. c. The treatment warranting restraints is discontinued. d. Least restrictive/alternative measures have been successful." Interview with the director of nursing on 3/25/10 at 11 AM revealed staff must follow the education, training, and policies on restraints as described by the hospital. She stated restraints must be discontinued as soon as possible based on the assessments performed.

Based on staff interview and medical record review, the hospital failed to ensure monitoring was relevant, was reflective of the patient's condition, described the patient's mental status, and showed adequate justification for the restraint for 2 of 3 sample patients (#10, #14) who were restrained. The findings were

1. Review of the 2/17/10 through 2/24/10 nursing notes showed patient #10 remained in the enclosure bed restraint most of the time on a daily basis for impulsive and unpredictable behaviors. The following concerns were identified:
a. Review of the hospital restraint assessment and monitoring flow sheet for 2/17/10 from 6 PM through 6 AM on 2/22/10 showed the nurse initialed a series of monitoring/assessment parameters including mental status (behavior) and the need for continued use. However, there was no description of what the mental status of the patient was, nor was there a description of the rationale for the continued need of the restraint, only the nurse's initials. Review of the 2/22/10 and 2/23/10 monitoring/assessment flow sheets showed the time slots from 8 AM until 6 PM were completely blank.
b. Review of the nursing shift notes from 2/17 through 2/24/10 showed there were periods of time when the patient was in therapy, at the nursing station or the net was unzipped; however, the documentation and times were not consistent with the restraint monitoring/assessment flow sheets.

2. Review of the physician's orders for patient #14 showed he ordered an enclosure bed restraint for impulsive behaviors on 7/31/09 at 6 PM. Review of the nursing notes showed the restraints remained in place from 7/31 until 8/17/09 at 3 PM when the patient was transferred out of the facility. Review of the 7/31/09 through 8/17/09 nursing shift notes showed the patient remained in the enclosure bed restraint most of the time on a daily basis. The following concerns were identified:
a. Review of the restraint record flow sheets for 8/1 at 8 AM until 8/6/10 at 8 AM, and from 8/7 at 8 AM until 8/12/10 at 6 AM showed the nurse performed a series of monitoring/assessments including mental status (behavior) and the need for continued restraint use every two hours. Further review revealed, however, there was no description of what the mental status of the patient was and there was no description of the rationale for the continued need for restraints, only the nurse's initials that monitoring was performed.
b. Review of the nursing shift notes from 7/31 through 8/17/09 showed there were periods of time when the patient was in therapy, at the nursing station, family was present, or the net was unzipped, however, the documentation and times were not consistent with the restraint monitoring/assessment flow sheets.

3. Interview with the director of nursing on 3/25/10 at 11 AM revealed behaviors and the continued need for a restraint should be documented as outlined in the policy. Review of the restraint policy, revised January 2009, page 5, showed the following instructions: "Daily reassessment includes assessment of current condition, behavior of patient, interventions and success of alternatives, patient's response to intervention with alternatives and re-intervention as necessary. Monitoring results and patient care provided will be documented."

Based on staff interview and medical record review, the hospital failed to ensure monitoring the patients response to the restraint and the rationale for continued use was documented in the medical record for 2 of 3 sample patients (#10, #14) who were restrained. The findings were:

1. Review of the 2/17 through 2/24/10 nursing notes showed the patient #10 remained in the enclosure bed restraint most of the time on a daily basis for impulsive and unpredictable behaviors. Review of the entire medical record revealed there was only one entry, 2/22/10 at 2:29 PM, that described the patient's response to the enclosure bed restraint and that documented response was negative. Review of these nursing notes showed the patient "feels great anxiety related to the bed net. [S/he] stated that [sh/e] felt afraid if [s/he] ever needed something from [his/her] bedside table and wouldn't be able to get it." Further review of the notes showed the staff placed the call light within the patient's reach and provided education about the net bed to the patient as the intervention. Continued review showed the patient said "[S/he] still feels anxious about the net bed." Review showed there was no documented justification for the continued use of the net bed restraint.

2. Refer to Federal citation A174 for details related to the lack of recording the patient's response and continued need for restraint use for patient #14. Refer to the same citation for details regarding the hospital policy on the need for continued use of a restraint.

3. Interview with the director of nursing on 3/25/10 at 11 AM revealed staff must follow the education, training, and policies on restraints as described by the hospital. She said restraints must be discontinued as soon as possible based on the assessments performed

Based on staff interview and medical record review, the hospital failed to ensure staff provided adequate pain management for 1 (#12) of 14 sample patients who experienced pain. The findings were:

Review of the 1/28/10 history and physical for patient #12 showed s/he was admitted on that date for rehabilitation after experiencing a fifty percent full thickness thermal burn over both lower extremities, the abdomen, and the lower back. The patient had undergone multiple surgical procedures, including skin grafting at an acute care hospital. In addition, the patient's acute care hospital stay had been complicated by poorly controlled pain. Upon admission to this facility from the acute care hospital, the patient continued to have pain. According to the nursing shift note on 2/1/10 timed at 3:35 PM, the patient had leg pain most of the time. Review of the 2/3/20 case conference notes showed pain was the problem that was impeding the patient's progress and was a barrier to discharge. The plan to resolve this problem was to assess the patient for pain using the pain scale, administer PRN (as needed) pain medications, and evaluate the effectiveness of the medication in relieving the patient's pain. Review of the 1/28/10 physician's orders showed the patient was prescribed a narcotic pain medication (Norco 7.5/325 mg) every four hours as needed for a pain level of 3 to 4. For a pain level of 5 to 10, the physician prescribed Norco 15/650 mg every four hours as needed. The following issues were noted in regard to management of the patient's pain.
1. Review of the PRN intervention form and the 2/1/10 medication administration record (MAR) showed the patient received two Norco 15/650 mg tablets at 5 AM on 2/1/10 for complaint of pain described as 6 out of 10 (6/10), with 10 being the worst. The following concerns were identified:
a. Review of the PRN intervention form and nursing shift notes showed the patient's pain was not reassessed to determine the effectiveness of this medication. The next time pain was addressed was by the occupational therapist who documented in her progress notes on 2/1/10 at 12:16 PM, 7 hours and 15 minutes after the pain medication was administered, that the patient's pain level was 6.5/10. Review of the 2/1/10 MAR and the PRN intervention form, confirmed by the 2:10 PM nursing shift notes, showed that by 1:45 PM the patient's pain level was up to 9/10 and required administration of two more Norco 15/650 mg tablets.
b. Interview with the director of nursing (DON) on 4/8/10 at 8:40 AM revealed this patient almost always said his/her pain was at a high level of severity.
c. Review of information she provided on 4/1/10 showed the 2/1/10 physician's progress notes timed at 10:45 AM showed the patient's pain was "controlled overall." However, this note did not address the patient's specific leg pain or the pain rating of 6 out of 10 earlier that morning. The physician progress note addressed pain as a general problem.
2. Review of the 2/3/10 nursing shift notes timed at 3:28 PM showed the patient had been experiencing throbbing pain to both legs for about an hour (2:30 PM ). The patient stated his/her pain level was 8/10. The patient was told by the nurse it was too soon for him/her to receive more pain medication because s/he had received two Norco 15/650 mg tablets at 11:30 AM (3 hours earlier), and the physician's order was for every four hours as needed. The following concerns were identified:
a. Review of the 2/3/10 MAR showed the patient did not receive pain medication again until 8:10 PM that evening, 5 hours and 40 minutes after stating his/her pain level was 8/10. According to the physician's order, the patient could have been administered pain medication at 3:30 PM. However, review of the medical record showed no evidence the patient's pain was reassessed by nursing between 2:30 PM when the patient's pain started and 8:10 PM when s/he received a PRN pain medication.
b. Review of a physical therapy note on 2/3/10 timed at 4:44 PM showed the patient continued to have pain in both extremities at the burn sites, however, no assessment of the pain was performed and the patient received no pain medications at that time.
c. Information provided by the DON on 4/1/10 showed the nursing shift note for 2/3/10 timed at 4:53 PM referenced the patient's pain during the shift. The note was "Pt [patient] has asked for pain medication x 1 for pain to [his/her] bilateral feet at 9/10. No other acute issues noted at this time." Interview with the DON on 4/8/10 at 8:40 AM revealed the 4:53 PM shift note was a summary of what occurred during the entire shift so she did not know if the reference to the pain was for the 11:30 AM episode or the 2:30 PM complaint of pain. Regardless of what time the shift note referenced, the patient only received pain medications at 11:30 AM and 8:10 PM (8 hours and 40 minutes between times) on 2/3/10, according to the MAR. Review of the medical record revealed the patient's complaint of pain at a severity level of 8/10 at 2:30 PM was not addressed.

Review of the hospital policy on medication administration, PS 090, revised October 2008, page 3 showed instructions that the patient's response to medications should be documented in the medical record, including but not limited to as needed medications and scheduled pain medications. Review of the hospital policy on reassessment, PC 090, revised December 2008, page 2, showed instructions that a patient should be reassessed when changes occur in condition (i.e., pain) and/or in response to care (i.e., administration of pain medication). Interview with the DON on 3/25/10 at 1 PM showed she would expect a patient's pain level would be reassessed within 1 hour of the administration of pain medication. This time frame for reassessment of pain was reiterated by the DON during an interview on 4/8/10 at 8:45 AM.

Based on staff interview, medical record review, and review of hospital policies, the hospital failed to ensure the care plan was modified after an enclosure bed restraint was implemented for 2 (#10, #14) of 3 sample patients who were in restraints. The findings were

Refer to Federal citation A166 for details regarding the lack of modification of the care plan after implementation of an enclosure bed restraint for patients #10 and #14.