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Based on a review of clinical records, facility documents and interviews, it was determined the facility's LIPs (Licensed Independent Practitioners) failed to ensure restraint orders were correctly identified as addressing violent behaviors, and therefore failed to ensure the restraint orders were renewed as required every four (4) hours, for one (1) of four (4) adult patients (Patient #7).

The findings were:

A review of Patient #7's clinical record took place on 03/13/19 at 10:15 a.m., with the Director of Advanced Clinicals (RN-registered nurse) assisting in navigating the EHR (electronic health record). That review identified the following documentation:
· The registered nurse (RN) documented a summary of patient behaviors and care given, during the 7 a.m. to 7 p.m. shift, on 01/25/19 at 6:38 p.m. That documentation included, in part, the following: "Shift note: patient very combative and non compliant today. patient [sic] placed in 4 point restraints today @ 1330 [1:30 p.m.] following yelling, frequent attempts to throw [him/her]self out of bed by rolling over onto stomach and throwing legs out of the bed and attempting to hit and kick nursing staff."
· The physician documented a restraint order on 01/25/19 at 13:29 [1:29 p.m.]. That order listed the "Level of restraint" as "Non-violent" and the device as "Waist" and "Soft all extremities." The order included "Non-violent Restraint Time Limit 24 hours."

The surveyor reviewed the facility policy titled, "Seclusion, Restraints and Restraint Alternatives" (PolicyStat ID:5021848) with the most recent revision date of 06/2018. That policy included a requirement that "Orders for restraint or seclusion [for the management of violent of self-destructive behavior] must not exceed..Four (4) hours for adults, aged 18 years or older." That requirement was on page 3 of 16 of the policy, under the heading of "Order for Restraint with Violent or Self-Destructive Behavior."

The failure of the facility staff to ensure restraint orders for Patient #7 were correctly identified as addressing 'violent' behaviors and subsequently resulting in the restraint orders not being renewed within the required time limit, was discussed during the record review with the aforementioned navigator as well as the facility's Vice President (VP) of Quality and Compliance. The VP of Quality and Compliance acknowledged the aforementioned nursing documentation (for Patient #7), described violent or self-destructive behaviors. The VP of Quality and Compliance also acknowledged the physician's orders for (Patient #7's) restraints failed to correctly identify the restraints as used to manage violent or self-destructive behaviors.

The surveyor met with the The VP of Quality and Compliance on 03/13/19 at 4:40 p.m., for a review of the Quality Program's oversight of proper use of restraints. The VP of Quality and Compliance stated that restraints were often challenging, however the quality oversight had not identified trends or issues regarding accurate identification of restraints used for the management of violent or self destructive behaviors.

Based on a review of clinical records, facility documents and interviews, it was determined the facility's staff failed to provide a face to face assessment addressing the required elements of evaluation, within one (1) hour of initiation of restraints used to address violent or self-destructive behaviors, for one (1) of four (4) adult patients (Patient #7).

The findings were:

A review of Patient #7's clinical record took place on 03/13/19 at 10:15 a.m., with the Director of Advanced Clinicals (RN-registered nurse) assisting in navigating the EHR (electronic health record). That review identified the following documentation:
· The registered nurse (RN) documented a summary of patient behaviors and care given, during the 7 a.m. to 7 p.m. shift, on 01/25/19 at 6:38 p.m. That documentation included, in part, the following: "Shift note: patient very combative and non compliant today. patient [sic] placed in 4 point restraints today @ 1330 [1:30 p.m.] following yelling, frequent attempts to throw [him/her]self out of bed by rolling over onto stomach and throwing legs out of the bed and attempting to hit and kick nursing staff."
· The physician documented a restraint order on 01/25/19 at 13:29 [1:29 p.m.]. That order listed the "Level of restraint" as "Non-violent" and the device as "Waist" and "Soft all extremities."
· The record failed to contain evidence the restraints were accurately identified as used to address the aforementioned and documented violent/self-destructive behaviors. The record failed to contain evidence the patient received the required face-to-face evaluation within 1 hour of the initiation of the intervention (restraints), to evaluate the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; and the need to continue or terminate the restraint or seclusion.

The surveyor reviewed the facility policy titled, "Seclusion, Restraints and Restraint Alternatives" (PolicyStat ID:5021848) with the most recent revision date of 06/2018. That policy included, in part, the following information/requirements on page 4 and 5 of 16, under the heading of "Face-to-face assessment by a Physician or LIP [Licensed Independent Practitioner."
"A face-to-face assessment by a physician or LIP, RN or physician assistant [PA] with demonstrated competence, must be done within one (1) hour of restraint or seclusion initiation...to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others."
"At the time of the face-to-face assessment, the LIP/physician/RN/PA will:
1. Work with staff and patient to identify ways to help the patient regain control
2. Evaluate the patient's immediate situation
3. Evaluate the patient's reaction to the intervention
4. Evaluate the patient's medical and behavioral condition
5. Evaluate the need to continue or terminate the restraint or seclusion
6. Revise the plan of care, treatment and services as needed."

The failure of the facility staff to ensure restraint orders for Patient #7 were correctly identified as addressing documented violent and self-destructive behaviors, and the subsequent failure to perform the required one (1) hour face to face evaluation/assessment, was discussed during the record review with the aforementioned navigator as well as the facility's Vice President (VP) of Quality and Compliance. The VP of Quality and Compliance acknowledged the aforementioned nursing documentation (for Patient #7), described violent or self-destructive behaviors. The navigator (Director of Advanced Clinicals) acknowledged there was no evidence the required one (1) hour face to face assessment/evaluation was performed.