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Based on staff interviews, medical record review, and facility document reviews it was determined the facility staff failed to modify the plan of care to address restraint use in one (1) of six (6) sampled patients that had restraints used while a patient at the facility. (Patient #5).

The findings were:

Patient #5's electronic medical record was reviewed along with a facility navigator during the morning of 1/31/18 and revealed the patient had restraints ordered, applied, and monitored according to policy every day from 1/08/18 through 1/11/18. The care plan included restraints in the problem list for those days too but did not indicate the restraint concern was resolved until the patient was discharged on 1/16/18.

The nursing documentation indicated Patient #5 was transferred from the intensive care unit (ICU) to a medical/surgical floor on 1/11/18 at approximately 5:27 p.m. The last documented restraint monitoring was on 1/11/18 at 4:00 p.m., prior to the patient's transfer to the floor and noted soft left and right wrist restraints were continued at that time. The receiving nurse (on the floor the patient was transferred to) documented, in part, at 1/11/18 at 5:27 p.m. "Pt (patient) transferred to Med Surg from ICU to (room # noted)... Nonviolent restraints ordered, 1:1 Sitter at bedside. Report received from ICU nurse." The medical record contained no evidence of restraint documentation after the patient arrived on the medical/surgical floor.

The facility's clinical manager of the cardiac intermediate unit who was also the "restraint process owner" was interviewed on 1/31/18 at 2:15 p.m. regarding Patient #5's restraint documentation. The manager acknowledged the patient's record did not provide evidence of when the restraints were discontinued either in the monitoring flowsheet, the care plan or anywhere else. The manager acknowledged the restraint problem in the care plan had been resolved on the same day the patient was discharged from the facility and upon discharge, all care plan problems are resolved if they hadn't been before.

On 1/31/18 at approximately 4:45 p.m., one of the facility's quality department team members, staff member (SM) #12, approached one surveyor about Patient #5's restraint documentation. SM #12 said he/she had spoken with both the transferring nurse from the ICU as well as the floor nurse who received Patient #5 on 1/11/18 and that today, both nurses documented an addendum to their note from 1/11/18 related to the patient's transfer and restraint usage. Both nurses' addendums were reviewed with SM #12. The ICU nurse's addendum was dated 1/31/18 at 1:16 p.m. and read, "Late entry for 1/11/2018 pt (patient) transfer to M/S (medical/surgical) unit. Pt transferred to M/S tele [sic] on active restraint order and on restrains because pt remained agitated and impulsively trying to get out of bed. Sitter accompany [sic] nurse. Receiving nurse updated on pt's current status. Last restraint documentation at 1600 (4:00 p.m.) prior to pt leaving ICU." The receiving nurse's addendum was dated 1/31/18 at 1:55 p.m. and added the sentence, "Pt (patient) received without restraints, restraints not continued" to the progress note dated 1/11/18 at 5:27 p.m. The facility's restraint process owner was interviewed regarding the nurses' addendums on 1/31/18 at approximately 5:15 p.m. and acknowledged the evidence in the medical record failed to identify when the restraints were removed and that the ICU nurse's documentation and the medical/surgical nurse's documentation were at odds.

The facility's procedure titled, "Restraint and Seclusion Management: NON-Violent or Self destructive Behavior in Non Behavioral Health Areas" had a revision date of May 2016 and was reviewed throughout the survey. The procedure read, in part, "19. Modify the Plan of Care to include Restraint use."

Based on staff interviews, medical record reviews, and facility document review it was determined the facility staff failed to consistently monitor patients according to facility policy for patients in restraints for one (1) of six (6) patients sampled. (Patient #5).

The findings were:

1. Patient #5's electronic medical record was reviewed along with a facility navigator during the morning of 1/31/18 and revealed the patient had restraints ordered, applied, and monitored according to policy every day from 1/08/18 through 1/11/18. The last documented restraint monitoring was on the flowsheet and dated 1/11/18 at 4:00 p.m. Soft left and right wrist restraints were continued at that time. The nursing documentation indicated Patient #5 was transferred from the intensive care unit (ICU) to a medical/surgical floor on 1/11/18 at approximately 5:27 p.m. The receiving nurse (on the floor the patient was transferred to) documented, in part, at 1/11/18 at 5:27 p.m. "Pt (patient) transferred to Med Surg from ICU to (room # noted)... Nonviolent restraints ordered, 1:1 Sitter at bedside. Report received from ICU nurse." There was no documentation regarding restraints after the patient arrived on the medical/surgical floor. No restraint orders or monitoring were documented throughout the remainder of the patient's stay. Patient #5 was discharged on 1/16/18.

The facility's clinical manager of the cardiac intermediate unit who was also the facility's "restraint process owner" was interviewed on 1/31/18 at 2:15 p.m. regarding Patient #5's restraint documentation. The manager acknowledged the patient's record did not provide evidence of when the restraints were discontinued either in the monitoring flowsheet, the care plan or anywhere else. The last restraint order was a renewal order dated 1/11/18 at 10:38 a.m. that would expire on 1/12/18 at 11:59 p.m. (one calendar day).

On 1/31/18 at approximately 4:45 p.m., one of the facility's quality department team members, staff member (SM) #12, approached one surveyor about Patient #5's restraint documentation. SM #12 said he/she had spoken with both the transferring nurse from the ICU as well as the floor nurse who received Patient #5 on 1/11/18 and that today, both nurses documented an addendum to their note from 1/11/18 related to the patient's transfer and restraint usage. Both nurses' addendums were reviewed with SM #12. The ICU nurse's addendum was dated 1/31/18 at 1:16 p.m. and read, "Late entry for 1/11/2018 pt (patient) transfer to M/S (medical/surgical) unit. Pt transferred to M/S tele [sic] on active restraint order and on restraints because pt remained agitated and impulsively trying to get out of bed. Sitter accompany [sic] nurse. Receiving nurse updated on pt's current status. Last restraint documentation at 1600 (4:00 p.m.) prior to pt leaving ICU." The receiving nurse's addendum was dated 1/31/18 at 1:55 p.m. and added the sentence, "Pt (patient) received without restraints, restraints not continued" to the progress note dated 1/11/18 at 5:27 p.m. (referenced above). The facility's restraint process owner was interviewed regarding the nurses' addendums on 1/31/18 at approximately 5:15 p.m. and acknowledged the evidence in the medical record failed to identify when the restraints were removed and that the ICU nurse's documentation was that the restraints continued upon transfer to the floor and the medical/surgical nurse's documentation indicated Patient #5 was received without restraints.

The facility's procedure titled, "Restraint and Seclusion Management: NON-Violent or Self destructive Behavior in Non Behavioral Health Areas" had a revision date of May 2016 and was reviewed throughout the survey. The procedure read, in part, "18. Monitor and document restraint safety according to patient need. Monitoring shall be documented at least every 1.5 - 2.5 hours and may need to be more often; Adjust to more often according to patient need" and "21. Take action based on result assessment/reassessment... Continue monitoring and reassessment, if continued restraint is indicated..."