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Based on observations, interviews and document reviews, the facility failed to protect the rights of all patients and/or patient representatives receiving care resulting in the potential for loss of their rights. Findings include:

---the facility failed to send a final written resolution letter to 2 of 4 patients reviewed who had filed a grievance with the facility (See A-123),
---the facility failed to identify the use of a psychotropic medication as a chemical restraint (See A-160),
---the facility failed to use the least restrictive type of restraint (See A-165)
---the facility failed to complete modifications/updates to patient's plans of care addressing the use of medical restraints (See A-166)
---the facility failed to document the continued need for restraints for 1 of 9 (#1) patients reviewed (See A-174)
---the facility failed to ensure that the patient was seen face to face by a physician, physician assistant or nurse practitioner (providers) for 3 of 4 patients (#17, #18, #19) placed into restraints (See A-178)
---the facility failed to ensure that a physician, physician assistant or nurse practitioner (providers) completed the one hour face to face evaluation for 3 of 4 patients (#17, #18, #19) placed into restraints related to violent behavior (See A-184).

Based on document review and interview, the facility failed to send a final written resolution letter to 2 of 4 patients reviewed (#8, #9) who had filed a grievance with the facility resulting in the potential for a loss of patients' rights. Findings include:

On 12/02/2014 at 1100, during a review of grievances that had been received at the facility revealed that patient #8 had phoned the facility and filed a complaint/grievance on 06/27/2014 regarding care during her previous hospital admission.

In an interview on 12/02/2014 at 1105 Staff L stated, "We did not send a resolution letter to the patient to the patient because we only considered this to be a point of service complaint."

On 12/02/2014 at 1115, a review was conducted of a complaint/grievance that was filed via telephone on 07/13/2014 by the grandfather of patient #9 (seven (7) year old minor). A list of "Grievances and POS (Point of Service) Complaints" dated 06/01/2014-08/31/2014 revealed that the patient was discharged from the facility on 07/12/2014. The grandfather was upset that the facility staff did not review the patient's discharge instructions with him before discharge since he did not feel that the patient's mom was able to understand what the staff was telling her.

In an interview on 12/02/2014 at 1130 Staff L stated, "We did not send a resolution letter to the patient's grandfather because he was not the patient's legal guardian. When queried as to if there had been a letter sent to the patient's family (parents), Staff L stated, no, because again we considered this to be a point of service complaint."

Review of the facility's policy titled, "Patient/Representative Complaint/Grievance Management System" #06-01-005, revised 10/2012 revealed that a grievance is "A verbal complaint that is made to (Facility A) by a patient, or the patient's representative, when a patient issue cannot be resolved promptly by the staff present. Whenever the patient or patient's representative request their complaint to be handled as a formal complaint/grievance or when the patient request a response from the hospital, then the complaint is a grievance. Any written complaint is considered a grievance. Comments on patient satisfaction surveys are considered a grievance when the identified patient request a response or if no response is requested, the comment is something that is normally handled as a grievance."

Based on document review and interview, the facility failed to identify the use of a psychotropic medication, administered to 1 of 1 patients (#1), as a chemical restraint resulting in a loss of the patient's right for the use of the "least restrictive" restraint. A total universe of 9 patients were reviewed for restraints. Findings include:

On 12/01/2014 at 1500 a review of the medical record for patient #1 revealed that he was presented to the facility's Emergency Department (ED) on 06/03/2014 with a fractured right ankle and was noted to be cognitively impaired. He remained at the facility in observation status until 06/06/2014 at 0001. The patient was then admitted as an in-patient and was moved from the observation unit to the 6 th floor. On 06/07/2014 at 0609, nursing staff placed the patient into 4 point soft limb restraints and administered 2 mg (milligrams) of Haldol intramuscular (IM) at 0617. The nurse administering the medication documented on the medication administration record, "patient combative, unable to scan barcode." There was no prior documentation in the record of behavioral issues for 06/07/2014 from 0001 when he was transferred to the unit until 0600 when he was placed into the restraints. At 0600, the nurse removed the patient's saline lock (IV{intravascular access}). The order for the administration of Haldol does not contain information regarding what the medication was being administered for. The record review confirmed that Haldol was not a part of the standard treatment for the patient's medical or psychiatric condition. The patient's record does not contain documentation of the events leading up to the use of restraints or alternative interventions attempted prior to the application of them. Once the patient went into restraints, the nurse documented at 0630 the reason for restraints as "unable to follow instructions and at risk for injury related to behavior." The nursing documentation did not identify what the "behavior" was. Nursing staff also charted that alternatives such as, "Frequent observation; environment, verbal limits/redirection; cover/disguise lines/drains/wounds; Diversional activities were attempted prior to applying restraints and that they tried to, "Decrease Stimulation; Adjust lighting; Adjust temperature; Provide bedside commode; Clear space; Distraction; Cognitive Stimulation; Repetitive activities. "The patient's only "line (IV)" had been removed at 0600. The record does not contain documentation that the patient was making any attempts to get out of bed.

In an interview with the patient's mother/guardian on 12/11/30/2014 at 1600, revealed, "my son has never required restraints and has never been given Haldol before in his life. I would have been OK if they would have given him Ativan, he was already getting that."

On 12/02/2014 at 0800, staff B was queried as to why the patient was given the Haldol injection. Staff B replied, "I believe it was given to help relax him." When queried as to why he was not given the Ativan that was already ordered for the patient "for anxiety" at the time of the incident, staff B stated, "I do not know why they didn't give it." When queried if the Haldol would be considered a chemical restraint staff B replied, "It was given to help calm the patient down."

On 12/02/2014 at 0900, review of the facility's policy titled, "Restraint for Non-Violent, Non-Self-Destructive Behavior, Policy 62-01-001, approved 6/10/10" read in the section IV titled "Guiding Principles A. Patient Rights and Safety, 5. (Facility A) does not use any pharmacological agent as a chemical restraint. Medications are only prescribed in accordance with treatment goals. Medications that are used as part of the patient's standard medical or psychiatric treatment and are considered within the standard dosage for the patient's condition are not chemical restraint."

Based on document review and interview, the facility failed to use the least restrictive type of restraint for 1 of 1 (#1) patients resulting in the loss of the patient's right to be free from restraint at the earliest possible time. A total universe of 9 patients were reviewed for restraint use. Findings include:

On 12/01/2014 at 1500, during review of the medical record for patient #1 revealed that the patient was a 36 year old cognitively impaired person with a fractured right ankle. The patient came to the emergency department on 06/03/2014 and had remained in the observation unit until being transferred up to the 6 th floor on 06/06/2014 at 0001. At 0600 the Registered Nurse (RN) obtained an order for the patient to be placed into 4 point soft limb medical restraints. Review of the documentation for 06/07/2014 from 0001 to 0600 does not identify any unsafe behavior that the patient had exhibited. At 0609, the patient was placed into 4 point soft limb restraints. The RN documented in the patient's medical record at 0630 that the patient was "unable to follow instructions and at risk for injury related to behavior." The nursing documentation failed to identify the "behavior." The medical record also did not make any mention of the patient making any attempts to get out of bed. At 0617, the patient was administered Haldol 2 mg intramuscular (IM). The medication order did not state the reason for the medication nor indication for use. The patient's medical record lacked documentation of the staff's reason for the giving the medication. It was noted during the medical record review, that the Haldol was not ordered for the patient prior to "the behavior" occurring.

On 12/02/2014 at 0800, staff B was queried as to why the patient was given the Haldol injection. Staff B replied, "I believe it was given to help relax him." When queried as to why he was not given the Ativan that was already ordered for the patient at the time of the incident, staff B stated, "I do not know why they did not give it (Ativan)." When queried as to why they would both put on restraints and give the patient a psychotropic medication, staff B stated, "I can not speak to why they did that. We try hard to not use restraints on any patient." When queried if the Haldol would be considered a chemical restraint staff B replied, "It was given to help calm the patient down."

On 12/02/2014 at 0810, review of the facility's policy titled, "Restraint for Non-Violent, Non-Self-Destructive Behavior, Policy 62-01-001, approved 6/10/10" reads in the section IV titled, "Guiding Principles A. Patient Rights and Safety, 5. (Facility A) does not use any pharmacological agent as a chemical restraint. Medications are only prescribed in accordance with treatment goals. Medications that are used as part of the patient's standard medical or psychiatric treatment and are considered within the standard dosage for the patient's condition are not chemical restraint."

Based on document review and interview, the facility failed to complete modifications/updates to 4 of 4 (#2-#5) current in-patients and 1 of 1 (#1) discharged patient's plans of care addressing the use of medical restraints resulting in the potential for unmet and/or unidentified patient needs. A total universe of 9 patients were reviewed for restraint use. Findings include:

On 12/01/2014 between 1055-1300, observations were conducted for four(4) current in-patients that were in medical restraints. Patients #2 was in the cardio vascular intensive care unit (CV-ICU) and per record documentation the patient required medical restraints for pulling at tubes/lines. Patient #2 was observed at 1110 when staff were providing care. The staff were getting ready to place the patient back into bed. The nurse had the patients right hand restraint untied and the patient was observed reaching for a tube that was inserted into the right nostril and needed to be redirected.

In an interview on 12/01/2014 at 1115 with staff F (Charge Nurse-CV-ICU), when queried to see the update/documentation for restraints in the patient's plan of care, staff F stated, "We don't have a plan of care for medical restraints. So there really is not an update to the plan of care for restraints. Staff would do all their documentation on the flow sheets."

On 12/01/2014 at 1130 observation and interview was conducted for patient #3 who was in medical restraints. When staff G was queried as to what the staff document in the patient's plan of care regarding the patient's need for restraints, staff G replied, "The documentation is done hourly and goes onto the nursing flow sheet." At 1145 observation and record review was conducted for patient #4 and at 1725 for patient #5. The record reviews all lacked updates to the patients' plans of care regarding restraints.

On 12/01/2014 at 1500, during review of the medical record for patient #1 revealed a lack of updates to the plan of care regarding the use of 4-point restraints.

In an interview with staff B on 12/01/2014 at 1730, she stated, "We have some work to do on the care plans. We have a plan of care for behavioral restraints but not for medical restraints. I think they address everything on the nursing flow sheet it is just not updated as part of the patient's plan of care."

Based on document review and interview, the facility failed to document the continued need for restraints for 1 of 9 (#1) patients reviewed resulting in the potential for the a loss of the patient's right to be released from restraints at the earliest possible time. Findings include:

On 12/01/2014 at 1500, during review of the medical record for patient #1 revealed that the patient was placed into medical restraints on 06/07/2014 at 0609. The Registered Nurse (RN) documented at 0630 on the nursing flow sheet in the section titled, "Assessment/Intervention 'unable to follow instructions and at risk for injury related to behavior.'" The nursing documentation does not identify what the "behavior" was, that placed the patient at risk for injury. The patient's IV access had been removed at 0600 just prior to the application of restraints. The patient still had a splint/cast on the right lower leg. The RN documented the patients behavior at 0704 as "unable to follow instructions and at risk for injury related to behavior." The next entry related to the patients behavior was at 1222 where the RN documented the patient's behavior as, "unable to follow instructions and actively reaching for/or pulling at lines/tubes/devices." The next RN documented "Assessment/Intervention" on the nursing flow sheet was at 1434. A through review of all the nursing documentation was conducted revealing that none of it contained documentation of attempts to release the patient from the restraints. The record also lacked documentation identifying what behavior the patient had exhibited that put him at risk and required the use of restraints for 470 minutes. The patient was released from the restraints at 1359.

In an interview with staff B on 12/02/2014 at 1145, when queried regarding how often staff are supposed to document on patient's who are in "medical restraints," she stated, "It is supposed to be every hour." Staff B confirmed that the staff did not document on the patient every hour. When queried if the staff are supposed to document attempted releases of the patient from the restraints, she stated, "They should be." When queried if she could locate in the patient's (#1) medical record where attempts to release the patient were documented, she stated, "I do not see any in there." When queried if she could locate in the record the continued behavior of the patient that warranted the continued use of restraints for up to 470 minutes, she stated, "the nurse documented that he was "unable to follow instructions and actively reaching for/or pulling at lines/tubes/devices." The IV had been discontinued nine minutes before the restraints were applied.

Based on document review and interview, the facility failed to ensure that the patient was seen face to face by the physician, physician assistant or nurse practitioner (providers) for 3 of 4 patients (#17, #18, #19) placed into restraints related to violent behavior resulting the potential for unidentified patient needs. A total universe of 9 patients were reviewed for restraint use.
Findings include:

On 12/02/2014 at 0900, a review was conducted of the electronic medical record for patient #17 . The record revealed that the patient went into 4 point leather restraints for aggressive behavior at 0438 per telephone order. The record did not contain documentation to support that the provider had seen the patient within one hour of the initiation of restraints.

On 12/02/2014 at 0915 a review was conducted of the electronic medical record for patient #18. The record revealed that telephone order was obtained for 4 point leather restraints for aggressive behavior at 0507. The record contained a physician's note documented at 0708 (2 hours later) that did not speak to the patient being in restraints. The patient was not released from restraints until 0745.

On 12/02/2014 at 0930, a review was conducted of the electronic medical record for patient #19 . The record revealed that a telephone order was obtained for 4 point leather restraints for aggressive behavior at 2145. The record did not contain documentation to support that the provider had seen the patient within one hour of the initiation of restraints.

In an interview with staff B on 12/02/2014 at 0940, she confirmed that the electronic records did not contain documentation to support that the patients were seen by the providers within one hour of the initiation of the restraints. Staff B stated, "They (providers) know that they are supposed to see them within one hour."

On 12/02/2014 at 0950 a review of the facility's policy titled, "Restraint and Seclusion for Management of Violent or Self-Destructive Behavior, #62-01-002, Revised 3/13" read, "6. Restraint/Seclusion authorized by phone shall continue only until the physician can personally examine the patient within 1 hour of initiation of restraint/seclusion."

Based on document review and interview, the facility failed to ensure that a physician, physician assistant or nurse practitioner (providers) completed and documented the one hour face to face evaluation for 3 of 4 patients (#17, #18, #19) placed into restraints related to violent behavior resulting in the potential for unidentified patient needs. A total universe of 9 patients were reviewed for restraint
Findings include:

On 12/02/2014 at 0900, a review was conducted of the electronic medical record for patient #17. The record revealed that the patient had 4 point leather restraints applied for aggressive behavior at 0438 per telephone order. The first documentation in the record was at 0513 by the Registered Nurse (RN). The record lacked documentation of the one hour face to face evaluation by a provider.

On 12/02/2014 at 0915, a review was conducted of the electronic medical record for patient #18. The record revealed that telephone order was obtained for 4 point leather restraints for aggressive behavior at 0507. The record contained a physician's note documented at 0708 (2 hours later) that did not contain the evaluation nor documentation related to the patient being in restraints. The patient was not released from restraints until 0745.

On 12/02/2014 at 0930, a review was conducted of the electronic medical record for patient #19. The record revealed that a telephone order was obtained for application of 4 point leather restraints for aggressive behavior at 2145. The record lacked documentation of the one hour face to face evaluation by a provider.

In an interview with staff B on 12/02/2014 at 0940, she confirmed that the electronic records did not contain documentation of the 1 hour face to face evaluations by the providers. When queried if the providers are supposed to complete and document an assessment of the patient within one hour of the initiation of the restraints for behavioral, she stated, "Yes, they are."

On 12/02/2014 at 0950 a review of the facility's policy titled, "Restraint and Seclusion for Management of Violent or Self-Destructive Behavior, #62-01-002, Revised 3/13" read, "6. Restraint/Seclusion authorized by phone shall continue only until the physician can personally examine the patient within 1 hour of initiation of restraint/seclusion."