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Based on records reviewed and interviews the Hospital failed for 1 (Patient #8) of 3 records reviewed of patients placed in restraint in a total sample of 10 to assure modification to Patient #8's plan of care the use of restraint.

Findings included:

Hospital policy titled Restraint and Seclusion, dated 10/14/09, indicated the patient's written plan of care reflected updates to the use of restraint and decision to discontinue restraint.

The Restraint Log, dated 4/3/17, indicated that Patient #8 was in soft limb restraints while cared for in the Intensive Care Unit.

Admission History & Physical Examination, dated 4/3/17, did not indicate a plan for restraint.

Physician Notes, dated 4/3/17-4/7/17, did not indicate a plan for restraint.

Nursing Assessment Restraint Monitoring Notes, dated 4/4/17 at 2:00 A.M. through 4/5/17 at 8:00 P.M. indicated Patient #8 was in restraint.

Patient #8's Plan of Care, dated 4/4/17-4/5/17, indicated no documentation to indicate nurses updated the Plan of Care with the use of restraint and decision to discontinue restraint.

Based on records reviewed and interviews the Hospital failed for 1 (Patient #8) of 3 records reviewed of patients placed in restraint in a total sample of 10 to ensure an appropriate physician order for the restraint according to Hospital policy and regulatory requirements.

Findings included:

Hospital policy titled Restraint and Seclusion, dated 10/14/09, indicated a definition of a mechanical restraint as a mechanical device, material or equipment that immobilized or reduced the ability of a patient to move his/her arms, legs, body or head freely. The Restraint and Seclusion Policy indicated that a Soft Limb Restraint was secured around one or more limbs with ties that were secured to a bed frame and used for patients at high potential for jeopardizing medical healing by dislodging or removing invasive lines and tubes (breathing tube).

The Restraint Log, dated 4/3/17, indicated that Patient #8 was in Soft Limb Restraints while cared for in the Intensive Care Unit.

The Restraint and Seclusion Policy indicated that an order for restraint included:

a.) The reason for restraint,
b.) Type of restraint devise,
c.) Maximum duration of the order,
d.) Date and time, and
e.) Physician or Licensed Independent Practitioner signature.

Physician order sheet, dated 4/4/17 at 4:40 A.M., indicated a nurse received a physician order by telephone for restraints. The telephone physician order indicated no documentation to indicate:

a.) The reason for restraint,
b.) Type of restraint devise or
c.) Maximum duration of the order.

The Restraint and Seclusion Policy indicated that Physician orders for restraint were documented in the Hospital's Computerized Physician Order Entry (CPOE) system and that the patient's plan of care included use and discontinuation of restraints.

The Hospital did not provide documentation to indicate that the physician entered into the Hospital CPOE system an order and renewal order for Patient #8's restraint or documentation of Patient #8's plan of care included use and discontinuation of restraints.

The Restraint and Seclusion Policy indicated that telephone orders for an initial restraint had a duration of one day and that restraint renewal orders were required daily.

The Hospital did not provide documentation to indicate that a physician provided a renewal restraint order consistent with Hospital policy.

Based on records reviewed and interviews the Hospital failed for 1 (Patient #8) of 3 records reviewed of patients placed in restraint in a total sample of 10 to ensure that a physician renewed Patient #8's restraint order in accordance with Hospital policy.

Findings included:

Hospital policy titled Restraint and Seclusion, dated 10/14/09, indicated restraint renewal orders were required daily.

The Hospital did not provide documentation to indicate that a physician provided a renewal restraint order consistent with Hospital policy.

Nursing Assessment Restraint Monitoring Notes, dated 4/4/17 at 2:00 A.M. through 4/5/17 at 8:00 P.M. indicated Patient #8 was in restraint for longer than one day.

Based on records reviewed and interviews the Hospital failed for 1 (Patient #8) of 3 records reviewed of patients placed in restraint in a total sample of 10 to ensure documentation in Patient #1's medical record a description of the Patient #1's behavior and the intervention used.

Findings included:

Hospital policy titled Restraint and Seclusion, dated 10/14/09, indicated a soft limb restraint as a mechanical device, material or equipment that immobilized or reduced the ability of a patient to move his/her arms, legs freely. The Restraint and Seclusion Policy indicated that a soft limb restraint was secured around one or more limbs with ties that were secured to a bed frame and used for patients at high potential for jeopardizing medical healing by dislodging or removing invasive lines and tubes (breathing tube).

The Restraint Log, dated 4/3/17, indicated that Patient #8 was in soft limb restraints while cared for in the Intensive Care Unit.

The Restraint and Seclusion Policy indicated nursing documentation included:
1.) Patient behavior and
2.) Type of restraint device.

Nursing Assessment Restraint Monitoring Notes, dated 4/4/17 at 2:00 A.M. through 4/5/17 at 8:00 P.M. indicated Patient #8 was in restraint. The Nursing Assessment Restraint monitoring Notes indicated no documentation to indicate:
1.) Patient #1's behavior or
2.) Type of restraint device used.

The Restraint and Seclusion Policy indicated nursing documentation included:

a.) Patient behavior
b.) Criteria used to determine the need for restraint
c.) Alternative interventions used
d.) Type of restraint device
e.) Circulation and Range of Motion assessment
f.) Ordering physician name, time and date.

Nursing Assessment Restraint Monitoring Notes, dated 4/4/17 at 2:00 A.M. through 4/5/17 at 8:00 P.M. indicated Patient #8 was in restraint. The Nursing Assessment Restraint Monitoring Notes indicated no documentation to indicate:

a.) Patient behavior
b.) Criteria used to determine the need for restraint
c.) Alternative interventions used
d.) Type of restraint device
e.) Circulation and Range of Motion assessment
f.) Ordering physician name, time and date.

Based on records reviewed and interviews the Hospital failed for 1 (Patient #8) of 3 records reviewed of patients placed in restraint in a total sample of 10 to ensure documentation in the Patient #8's medical record of alternatives or other less restrictive interventions were attempted.

Findings included:

The Restraint Log, dated 4/3/17, indicated that Patient #8 was in soft limb restraints while cared for in the Intensive Care Unit.

Hospital policy titled Restraint and Seclusion, dated 10/14/09, indicated nursing documentation included alternative interventions to restraint used.

Nursing Assessment Restraint Monitoring Notes, dated 4/4/17 at 2:00 A.M. through 4/5/17 at 8:00 P.M. indicated Patient #8 was in restraint. The Nursing Assessment Restraint Monitoring Notes did not indicate alternative interventions to restraint were used.

Based on records reviewed and interviews Hospital A failed to ensure operations of the Nursing Service were consistent with a single Nursing Service for Registered Nurses in four (4) areas of Hospital A. This failure resulted in the Chief Nursing Officer (CNO) being responsible for Nursing Services of nurses not employed by Hospital A.

Findings included:

The organizational chart for Nursing Services at Hospital A titled Hospital Nursing, dated 4/6/2017, indicated a Chief Nursing Officer (CNO) with the Director of Clinical Education responsible to the CNO and Clinical Educators from Hospital A and hospital B responsible to the Director of Clinical Education.

The organizational chart for Nursing Services at Hospital A titled Hospital Nursing, dated 4/26/2017, indicated a CNO with the following four Directors responsible to the CNO:

-Clinical Education,
-Clinical Resource Management (Case Management),
-Quality Improvement and
-Infection Prevention.

1.) The Job Description, dated 7/14/15, indicated that the Director of Clinical Education reported to the CNO at Hospital A. The Job Description indicated the Director of Clinical Education was responsible for Clinical Educators at Hospital A and hospital B and organized and supervised system-wide (the Corporation of Hospital A and hospital B) programs and initiatives. The Job Description indicated a license to practice Nursing was a requirement for the position of Director of Clinical Education.

The Surveyor interviewed the CNO at 9:15 A.M. on 4/14/17. The CNO said that the Director of Clinical Education reported to the Corporation and that she (the CNO) was responsible for the Clinical Education Department. The CNO said that Hospital A employed the Clinical (Nurse) Educators from Hospital A and that hospital B employed the Clinical Educators from hospital B. The CNO said that she did not know why the Nursing Service at Hospital A was responsible for hospital B Clinical Educator employees as demonstrated on the organizational chart for Nursing Services at Hospital A, dated 4/6/2017.

The Surveyor interviewed the CNO at 9:15 A.M. on 4/14/17 and 8:00 A.M. on 4/26/17. The CNO said Clinical Education staff included the Wound Care Nurse and that the Wound Care Nurse did surveillance (patient inspections of wounds) at both Hospital A and hospital B.

The Surveyor interviewed the CNO at 2:30 P.M. on 4/26/17. The CNO said the Clinical Educators for hospital B were employees of hospital B and that she as the CNO at Hospital A was responsible for the Clinical Education Service and nursing practice of the Clinical Educators at hospital B with the CNO of hospital B. The CNO said that the Clinical Educators reported to the Director of Clinical Education. The CNO said the Director of Clinical Education reported to her, as the CNO at Hospital A and that the Director of Clinical Education was an employee of the Corporation. The CNO said the Clinical Educators at Hospital A have taught the Crisis Prevention Institute (CPI, education that specialized in the safe management of people with disruptive and assaultive behavior) at hospital B. The CNO said Clinical Educators at hospital B have taught the CPI education at Hospital A. The CNO said that Clinical Educators of Hospital A have taught educational programs applicable to both Hospitals at hospital B and Clinical Educators of hospital B have taught those programs Hospital A.

2.) The Job Description, dated 11/25/14, indicated that the Director of Case Management reported to the Hospital-Wide System (the Corporation, parent company of Hospital A and hospital B). The Job Description did not indicate that the Director of Case Management was responsible to Hospital A's Nursing Service.

The Job Description indicated the Director of Case Management was responsible for:

a.) System-wide patient care Case Management,
b.) System-wide Clinical Documentation Management,
c.) Health care reports to each facility (Hospital A and hospital B)
d.) System-wide contract review for denial and authorization of patient care services,
e.) Utilization management at each facility
f.) Provide consultation and direction to any entity within the Hospital-Wide System on issues related to continuum of patient care activities.

The Job Description indicated a license to practice Nursing was a requirement for the position of Director of Case Management.

3.) The Job Description, dated 11/29/14, indicated that the Director of Quality Improvement was responsible to the Hospital-Wide System. The Job Description did not indicate that the Director of Quality Improvement was responsible to Hospital A's Nursing Service.

The Job Description indicated the Director of Quality Improvement was responsible for:

a.) Hospital A and hospital B's Quality Department Staff,
b.) Provided oversite for all quality activities within Hospital A and hospital B and
c.) Interfaced with all levels of management at Hospital A and hospital B.

The Job Description indicated a license to practice nursing was a requirement for the position of Director of Quality Improvement.

The CNO said the Director of Quality Improvement had Hospital A employees and hospital B employees reporting and responsible to the Director of Quality Improvement.

4.) The Job Description, undated, indicated that the Director of Infection Prevention reported to the Hospital-Wide System. The Job Description did not indicate that the Director of Infection Prevention was responsible to Hospital A's Nursing Service.

The Job Description indicated the Director of Infection Prevention was responsible for:

a.) Infection Preventionist at Hospital A,
b.) Infection Preventionist at hospital B,
c.) Providing oversight and consultation to the Corporation entities (Hospital A and hospital B),
d.) Designing, implementing and directing a System-Wide infection Control Program.
e.) Management of Hospital A and hospital B Infection Prevention Departments,
f.) Oversight of Infection Prevention and control functions at the CCHC (Cape Cod Health Care Visiting Nurse Association, CCH JML Care Center, Hospital A Pain Management Center, hospital B Pain Management Center,
g.) Provides Infection Prevention consultation to the (MAAC) Practices and other CCH affiliates,
h.) Serves as a resource to CCH leadership, physicians and staff on Infection Prevention,
i.) Serves as the Center for Disease Control (CDC) administrator for Hospital A and hospital B,
j.) Distributes facility specific healthcare associated infection to the Board of Trustees and administrators and
k.) Represents infection prevention in planning new construction or renovation of existing facilities.

The Job Description indicated a license to practice nursing was a requirement for the position of Director of Infection Prevention.

The CNO said that the Directors of Case Management, Clinical Education, Quality Improvement and Infection Prevention reported to the Corporation and that the Directors of Case Management, Clinical Education, Quality Improvement and Infection Prevention had staff that were shared with Hospital A and hospital B.