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Based on review of facility policies, medical records (MR) and interview with staff (EMP), it was determined the facility failed to use restraints, in accordance with a written modification to the patient's plan of care, in two (2) of five (5) restraint medical records reviewed (MR15 and MR16).

Findings include:

Review on May 24, 2017, of the facility policy, "Restraint and Seclusion Precaution", dated "Effective" (blank), revealed "Purpose ... To ensure humane use of restraints, the safety of the patient who is to be restrained and for those around patients requiring restraint ... Policy ... Patients have the right to be free from restraints of any form that are not medically necessary ... Authorization for Use of Restraints ... The use of a restraint must be ... 2. In accordance with the order of a physician or other licensed independent practitioner permitted by the State and hospital to order a restraint ... In accordance with a written modification to the patient's plan of care."

Review on May 24, 2017, of the facility policy, "Restraint and Seclusion use on Senior Behavioral Health Unit", dated "5/2017", revealed "Purpose ... To ensure humane use of restraints, the safety of the patient who is to be restrained and for those around patients requiring restraint ... Policy ... Patients have the right to be free from restraints of any form that are not medically necessary ... Procedure ... 4. Use of restraints will be in accordance with the order of a physician or other licensed independent practitioner permitted by the State and hospital to order a restraint ... 6. A nurse is responsible for ensuring documentation is entered in the medical record following application of restraints."

Review on May 24, 2017, of the facility policy, "Restraints or Seclusion", dated "3/15", revealed "I. Purpose ... this facility ensures that restrain and seclusion interventions are safely and appropriately used ... VI. Procedures ... E. Orders For Restraint ... i) The physician or Licensed Independent Practitioners (LIP) responsible for the care of the patient is authorized to order a restraint ... b) Orders should contain a starting and ending time ... I. Documentation ... Each episode of restraint is documented in the patient's medical record, consistent with polices and procedures ... ix) Revisions to the Plan of care."

Review of MR15, on May 25, 2017, revealed the patient was admitted to the hospital on "3/4/17". Further review of MR15 revealed the patient was placed in bilateral upper extremity soft limb restraints on "3/5/17". Further review of MR15 revealed no documented evidence the patient's plan of care was updated to include the use of restraints.

Interview with EMP10, on May 25, 2017, at 8:48 A.M., confirmed there was documented evidence in MR15 the patient was placed in restraints on "3/5/17". EMP10 further confirmed there was no written modification to the patient's plan of care, in MR15, to include the use of restraints.

Review of MR16, on May 25, 2017, revealed the patient was admitted to the hospital on "3/12/17". Further review of MR16 revealed the patient was placed in bilateral upper extremity soft limb restraints on "3/12/17". Further review of MR16 revealed no documented evidence the patient's plan of care was updated to include the use of restraints.

Interview with EMP10, on May 25, 2017, at 8:48 A.M., confirmed there was documented evidence in MR16 the patient was placed in restraints on "3/12/17". EMP10 further confirmed there was no written modification to the patient's plan of care, in MR16, to include the use of restraints.

Based on review of facility policies, medical records (MR) and interview with staff (EMP), it was determined the facility failed to use restraints in accordance with physician or other licensed independent practitioners' orders for one (1) of one (1) medical records reviewed. (MR1).

Findings include:

Review on May 24, 2017, of facility policy, "Patient Rights", dated "02/2015", revealed, "I. Purpose ... Chestnut Hill Hospital's mission calls us to give personalized and compassionate care to patients in ways that respect the dignity of each person ... IV. Related Patient Rights ... To be free from restraints and/or seclusion unless clinically necessary to protect the safety of the patient and/or others."

Review on May 24, 2017, of facility policy, "Restraint and Seclusion Precaution", dated "Effective" (blank), revealed "Purpose ... To ensure humane use of restraints, the safety of the patient who is to be restrained and for those around patients requiring restraint ... Policy ... Patients have the right to be free from restraints of any form that are not medically necessary ... Definitions ... Restraint- either a physical restraint or a drug that is being used as a restraint. A physical restrain is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient's body that he cannot easily remove that restricts freedom of movement or normal access to one's body ... Seclusion - the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving ... B. Open seclusion ... 1:1 provided with staff inside the room with the patient at all times ... Type of Restraints ... 4. Approved restraint devices ... Geri-chairs with locked trays may be used for geriatric patients who require restraints ... 5. Physical restraints include ... geri-chairs with a tray ... Authorization for Use of Restraints ... The use of a restraint must be ... 2. In accordance with the order of a physician or other licensed independent practitioner permitted by the State and hospital to order a restraint ... In accordance with a written modification to the patient's plan of care."

Review on May 24, 2017, of facility policy, "Restraint and Seclusion use on Senior Behavioral Health Unit", dated "5/2017", revealed "Purpose ... To ensure humane use of restraints, the safety of the patient who is to be restrained and for those around patients requiring restraint ... Policy ... Patients have the right to be free from restraints of any form that are not medically necessary ... Definitions ... A) Restraint - Includes devices and techniques designed and used to control acute or episodic aggressive behavior or involuntary movement of patients/residents ... B) Mechanical restraint ... All restraints used in the senior behavioral health unit are to be approved commercial restrains. Approved restraint devices include ... 2) Geri chairs with locked tray: will only be considered used for restraint when tray is being used to restrict movement and not as a table for meals or activities ... D) Seclusion - restricting a child/adolescent/adult in a locked room, and isolating the person from any personal contact by preventing the individual from leaving the room ... E) Exclusion - the removing of the patient from their immediate environment and restricting them to another area ... Procedure ... 4. Use of restraints will be in accordance with the order of a physician or other licensed independent practitioner permitted by the State and hospital to order a restraint ... 6. A nurse is responsible for ensuring documentation is entered in the medical record following application of restrains ... Exceptions ... b) The use of an unlocked time-out/quiet room does not constitute seclusion or exclusion when used to remove a patient from their immediate environment to reduce stimulation and assist the patient to regain self-control."

Review on May 24, 2017, of facility policy, "Restraints or Seclusion", dated "3/15", revealed "I. Purpose ... this facility ensures that restrain and seclusion interventions are safely and appropriately used ... II. Definitions ... Restraint: is any physical or mechanical device, material, medication, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely ... Seclusion: Involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving ... VI. Procedures ... E. Orders For Restrain ... i) The physician or Licensed Independent Practitioners (LIP) responsible for the care of the patient is authorized to order a restraint ... b) Orders should contain a starting and ending time ... I. Documentation ... Each episode of restraint is documented in the patient's medical record, consistent with polices and procedures ... ix) Revisions to the Plan of care."

Review of MR1, on May 24, 2017, revealed the patient was admitted on "7/22/16". Further review of MR1 revealed the patient was sitting in a "Geri-Chair", with a tray table, and was unable to self-release the tray or get out of the chair, unassisted, on "7/23/16", "7/31/16", "8/2/16", "8/5/16", and "8/8/16". Further review of MR1 revealed that there was no documented evidence of a physcian or licensed independent practitioner order for the use of a Geri-Chair.

Interview with EMP3, on May 25, 2017, at 12:10 P.M., confirmed that MR1 had documented evidence that a Geri-Chair was utilized to restrain the patient on "7/23/16", "7/31/16", "8/2/16", "8/5/16", and "8/8/16", that the use of the Geri-Chair met the definition of a restraint by facility policy, and that there is no documented evidence that a physcian, or licensed independent practitioner order for the use of a Geri-Chair, was obtained, as required by facility policy.

Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure that nursing staff failed to keep current the plan of care, for one (1) of one (1) medical records reviewed. (MR1).

Findings include:

Review on May 24, 2017, of the facility policy, "Restraint and Seclusion Precaution", dated "Effective" (blank), revealed "Purpose ... To ensure humane use of restraints, the safety of the patient who is to be restrained and for those around patients requiring restraint ... Policy ... Patients have the right to be free from restraints of any form that are not medically necessary ... Definitions ... Seclusion - the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving ... B. Open seclusion ... 1:1 provided with staff inside the room with the patient at all times."

Review on May 24, 2017, of the facility policy, "Restraint and Seclusion use on Senior Behavioral Health Unit", dated "5/2017", revealed "Purpose ... To ensure humane use of restraints, the safety of the patient who is to be restrained and for those around patients requiring restraint ... Policy ... Patients have the right to be free from restraints of any form that are not medically necessary ... Definitions ... D) Seclusion - restricting a child/adolescent/adult in a locked room, and isolating the person from any personal contact by preventing the individual from leaving the room ... E) Exclusion - the removing of the patient from their immediate environment and restricting them to another area ... Procedure ... 6. A nurse is responsible for ensuring documentation is entered in the medical record."

Review of MR1, on May 24, 2017, revealed the patient was admitted on "7/22/16". Further review of MR1 revealed the patient was placed in seclusion, in a "Quiet" room, on "7/23/16", "7/26/16", and "8/2/16". Further review of MR1 revealed no documented evidence that 1:1 observation was provided, with staff inside the room, and with the patient at all times, as required by facility policy.

Interview with EMP3, on May 25, 2017, at 12:10 P.M., confirmed that MR1 had documented evidence that the patient was in open seclusion, in a "quiet" room, on "7/23/16", "7/26/16", and "8/2/16". EMP3 further confirmed that there is no documented evidence that the patient was being visualized in a 1:1 capacity, while in open seclusion, as required by facility policy.