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Based on review of the facility policy, medical staff and quality committee meeting minutes, medical records, and staff interviews, the governing body failed to ensure that the medical staff was accountable to the governing body for the quality of` care provided to patients. The medical staff and quality committee failed to keep track of the use of restraints or give reports to the governing body concerning the use of restraints within the facility from May 2021 - March 2022.

Cross-Reference A0063 as it relates to the Governing Body 's failure to ensure that the medical staff was accountable to the governing body for the quality of` care provided to patients.

Based on review of the facility policy, medical staff and quality committee meeting minutes, medical records, and staff interviews, the governing body failed to ensure that the medical staff was accountable to the governing body for the quality of` care provided to patients. The medical staff and quality committee failed to keep track of the use of restraints or give reports to the governing body concerning the use of restraints within the facility from May 2021 - March 2022.

Review of the Governing Body bylaws effective 11/17/1999 revealed that the Board of Trustees would have supervision, control, and direction of the management, affairs, and property of the corporation. Review of the Board of Trustees Minutes from 10/22 to 12/21 revealed the meetings were held monthly. There was no discussion concerning the use of restraints.

Review of the Medical Staff Bylaws revealed the medical staff was accountable to the Board of Trustees for the safety, quality, and efficiency of patient care provided by those authorized to practice in the hospital and would provide the Board of Trustees with regular reports and recommendations on quality improvement and outcome management. The Medical Staff was to be actively involved in the measurement, assessment, and improvement of medical assessment and treatment of patients. Review of the Medical Executive Committee Meeting minutes from 9/21 to 2/22 revealed the meetings were held monthly except 12/21. The minutes failed to reveal discussion regarding restraints.

Review of Quality Meeting minutes from 9/21 to 2/22 revealed there was no discussion or data regarding restraints.

Review of the "Patient Rights and Responsibilities," policy #R1-01-01, effective 7/16, revealed that patients had a right to be free from the use of restraints and/or seclusion unless clinically necessary.

Review of the "Restraints and Seclusion" policy #RI-40-01, published 7/21/21, revealed that each episode of restraint or seclusion would be reviewed for quality assurance. Restraint orders, assessment, and monitoring would be assessed by the nurse manager for policy adherence. The nurse manager would aggregate data for tracking and trending purposes, and report Restraint/Seclusion use as required for facility performance improvement standards.

An interview took place with the Accreditation Coordinator (AC) (OO) on 3/17/22 at 3:14 p.m. in the Conference Room. AC OO said there were random audits of restraints prior to July 2021 and no audits during COVID -19 surges. AC OO said every time the audits would get started, another surge would hit. AC OO said order and documentation reports were completed in 1/22 and 2/22, and the reports would be presented to the Quality Review Committee on 3/22/22. AC OO said restraint audits were being put back on the quality scorecard, and the facility did not realize there was nothing about restraints on the scorecard. AC OO said the facility started talking about restraints in 1/22 so the unit leaders could start running reports and monitoring restraints to make sure there was a current order and no missing documentation. AC OO said there had not been quality discussion regarding restraints since 5/21. There were mock surveys in 12/21 and 2/22 that focused on restraint documentation.

Medical record review for P#1, 2, 4, 5, 8, revealed that all five patients had four siderails up and did not have physicians' orders for four siderails. In addition, review of the medical record failed to reveal that alternatives to restraints were implemented prior to raising all four siderails.

Based on a review of the facility policies, observations made at the facility, review of medical records, and interviews with staff, it was determined that the facility used restraints without an order by a physician or other licensed practitioner responsible for the patient's care for 4 out of 8 patients sampled (P#1, P#2, P#4, P#5).

Cross-reference A0166 as it relates to the use of restraints failed to be in accordance with a written modification to the patient's plan of care.

Cross-reference A0168 as it relates to the facility's use of restraints without an order by a physician or other licensed practitioner responsible for the patient's care.

Cross-reference A0186 as it relates to the facility use of restraints without documenting attempted alternatives or other less restrictive interventions.

Based on a review of the facility policies and medical record review, the use of restraints failed to be in accordance with a written modification to the patient's plan of care for 4 out of 8 patients sampled (P#1, P#2, P#4, P#5).

A review of a policy titled "Patient Rights and Responsibilities," Policy #R1-01-01, 7/16, revealed that patients had a right to be free from the use of restraints and/or seclusion unless clinically necessary.

A review of a policy titled "Restraints and Seclusion" Policy #RI-40-01, published 7/21, revealed that restraints included the use of four side rails up to confine a patient when the patient could not release the side rails. Four side rails would not be considered a restraint when used for patients with a potential for falling out of bed. The nurse would assess the patient for identification of physical or psychological problems that may be causing the behavior. The plan of care would be modified as indicated by the assessment. Restraints may have been avoided by addressing needs identified during an assessment and early interventions. The patient/family would be educated on alternatives to restraints.

A review of the medical record for P#1 revealed that a Nursing Note by Registered Nurse (RN) CC on 3/15/22 at 5:43 p.m. said that P#1 insisted that all four side rails were up. P#1 could not hold herself up properly in the bed and stated, "Put all the rails up. That is what they are there for." A review of the plan of care failed to reveal that the use of restraints was included.

A medical Record review for P#2 revealed that notes by Physical Therapist (PT) QQ on 3/11/22 at 3:54 p.m. and 3/14/22 at 5:00 p.m. said that P#2 had all four side rails up. P#2 was a fall risk and had a bed alarm. P#2 was oriented to person only and disoriented to place, time, and situation. P#2 had decreased strength in upper and lower extremities, decreased coordination, and impaired functional mobility, gait, and balance. P#2 could not ambulate or complete high-level activities of daily living.

A review of a Nurse Note by RN CC on 3/15/22 at 5:23 p.m. revealed that the family had requested all four side rails be up while the family was not in the room. The family feared that P#2 would try to get out of bed and fall. The bed alarm was on and would alarm if the patient moved to the side of the bed. The family was still not comfortable with leaving one side rail down. A review of the flowsheets revealed that there were four side rails up on 3/15/22 at 6:00 p.m. A review of the plan of care failed to reveal that the use of restraints was included.

A review of the medical record for P#4 revealed that P#4 was confused and disoriented to situation.
A review of a note by PT UU on 3/8/22 at 4:30 p.m. revealed that four side rails were up. P#4 was a fall risk. Precautions included not leaving P#4 unattended on the edge of the bed or while out of bed.

A review of the Speech-Language Pathologist (SLP) notes on 3/11/22 at 3:00 p.m. revealed that restraints were in place with four side rails up. A review of PT notes on 3/14/22 at 10:08 a.m. revealed that P#4 was on fall precautions and four side rails were up. P#4 required maximum assistance with rolling, scooting and sitting up. A review of the plan of care failed to reveal that the use of restraints was included.

A review of the medical record for P#5 revealed that 4/4 side rails were documented on the flowsheets on 3/16/22 at 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m., and 8:00 a.m. P#5 required moderate assistance until transported to the ICU on 3/15/22. A review of nurses' notes/flowsheets failed to reveal if alternatives were attempted prior to restraints.

A review of the medical record for P#8 revealed that an assessment by PT QQ on 2/9/22 at 10:32 a.m. said that P#8 had impaired functional mobility limited by pain, fatigue, and decreased upper extremity strength. A plan of care was initiated on 2/9/22 at 3:43 p.m. that included safety/falls. A review of a note by PT VV on 2/11/22 at 5:00 p.m. revealed that P#8 was on fall precautions and had four side rails up. A review of the plan of care failed to reveal that the use of restraints was included.

Based on a review of the facility policies, observations made at the facility, review of medical records, and interviews with staff, it was determined that the facility used restraints without an order by a physician or other licensed practitioner responsible for the patient's care for 4 out of 8 patients sampled (P#1, P#2, P#4, P#5).

A review of the policy titled "Patient Rights and Responsibilities," Policy#R1-01-01, effective 7/16, revealed that patients had a right to be free from the use of restraints and/or seclusion unless clinically necessary.

A review of the policy titled "Restraints and Seclusion," Policy #RI-40-01, published 7/21, revealed that restraints included the use of four side rails up to confine a patient when the patient could not release the side rails. Four side rails would not be considered a restraint when used for patients with a potential for falling out of bed. The physician would evaluate the reason for restraints, and an order would be obtained from the provider prior to the application of restraints. In an emergency, the order would be obtained during or immediately after the restraints were applied.

A review of the medical record for Patient (P) #1 revealed that nursing notes by Registered Nurse (RN) CC on 3/15/22 at 5:43 p.m. said that P#1 insisted that all four side rails were up. P#1 could not hold herself up properly in the bed and stated, "Put all the rails up. That is what they are there for."
A review of the physician orders failed to reveal an order for side rails.

A medical record review for P#2 revealed that notes by Physical Therapist (PT) QQ on 3/11/22 at 3:54 p.m. and 3/14/22 at 5:00 p.m. said that P#2 had all four side rails up. P#2 was a fall risk and had a bed alarm. P#2 was oriented to person only and disoriented to place, time, and situation. P#2 had decreased strength in upper and lower extremities, decreased coordination, and impaired functional mobility, gait, and balance. P#2 could not ambulate or complete high-level activities of daily living.

A review of a Nurse Note by RN CC on 3/15/22 at 5:23 p.m. revealed that the family had requested all four side rails be up while the family was not in the room. The family feared that P#2 would try to get out of bed and fall. The bed alarm was on and would alarm if the patient moved to the side of the bed. The family was still not comfortable with leaving one side rail down. A review of the flowsheets revealed that there were four side rails up on 3/15/22 at 6:00 p.m. A review of physician orders failed to reveal an order for side rails.

A review of the medical record for P#4 revealed that P#4 was confused and disoriented to situation.
A review of a note by PT UU on 3/8/22 at 4:30 p.m. revealed that four side rails were up. P#4 was a fall risk. Precautions included not leaving P#4 unattended on the edge of the bed or while out of bed.

A review of the Speech-Language Pathologist (SLP) notes on 3/11/22 at 3:00 p.m. revealed that restraints were in place with four side rails up. A review of PT notes on 3/14/22 at 10:08 a.m. revealed that P#4 was on fall precautions and four side rails were up. P#4 required maximum assistance with rolling, scooting and sitting up. A review of the physician orders failed to reveal an order for side rails.

A review of the medical record for P#5 revealed that 4/4 side rails were documented on the flowsheets on 3/16/22 at 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m., and 8:00 a.m. P#5 required moderate assistance until transported to the ICU on 3/15/22. A review of the physician orders failed to reveal an order for side rails.

A review of the medical record for P#8 revealed that an assessment by PT QQ on 2/9/22 at 10:32 a.m. said that P#8 had impaired functional mobility limited by pain, fatigue, and decreased upper extremity strength. A plan of care was initiated on 2/9/22 at 3:43 p.m. that included safety/falls. A review of a note by PT VV on 2/11/22 at 5:00 p.m. revealed that P#8 was on fall precautions and had four side rails of the bed up. A review of the physician orders failed to reveal an order for side rails.

An interview was conducted with RN AA on 3/15/22 at 4:04 p.m. in the Conference Room. RN AA stated the only time all four side rails of a bed would be up without a need for restraint would be if the patient requested the rails. RN AA said P#5 was worried about rolling out of bed and felt more secure with side rails. RN AA stated four side rails would not be up without an order unless the patient requested it. RN AA said an order would be given for confused, agitated, or high fall risk patients.

An interview was conducted with RN BB on 3/15/22 at 4:20 p.m. in the Conference Room. RN BB stated P#2 had four side rails up on the bed because of the daughter's preference. The daughter was afraid P#2 would fall out of bed. RN BB said she knew that four side rails were considered a restraint, and there were no orders to keep the rails up. RN BB did not think there was a risk of P#2 falling out of bed.

An interview was conducted with RN CC on 3/15/22 at 4:36 p.m. in the Conference Room. RN CC stated the daughter requested all the side rails up for P#2. When the nurses would take the bedrails down, the daughter would put them back up, especially when the daughter left the room. RN CC said P#2 was confused. There was always a chance of P#2 falling out of bed, but P#2 did not move much. RN CC said P#2 could not put up or remove any side rails on her own.

RN CC explained P#1 preferred all four bedside rails to be up because she was a right below knee amputee (BKA) and had a left ischemic (inadequate blood supply) foot. P#1 was missing a leg and would slide to one side. All four rails provided the safety of not falling out of bed. P#1 was alert and oriented and wanted the rails up since she could not keep her body straight without the rails.

An interview was conducted with RN DD on 3/15/22 at 4:53 p.m. in the Conference Room. RN DD stated P#4 came to the facility with cardiac arrest. P#4 was in a lot of pain and did not move his arms much. P#4 needed assistance with activities and did about 25 percent of the work. RN DD said P#4 did not have an order for restraints, and an order was required to have all four side rails up.

An interview was conducted with RN EE on 3/15/22 at 5:09 p.m. in the Conference Room. RN EE stated P#5 wanted the side rails up. P#5 would ask RN EE to bring the rail back up whenever RN EE would lower a side rail. P#5 had items that would fall out of the bed due to the patient's size if the side rails were down. RN EE said P#5 was awake and oriented. When RN EE tried to put P#5's things on a table, P#5 did not like the items on the table. RN EE said there was no order to keep the side rails up.

An interview was conducted with Chief Nursing Officer (CNO) GG on 3/17/22 at 11:15 a.m. in the Conference Room. CNO GG stated four side rails were considered a restraint. Four side rails were not supposed to be up unless there was an order by a physician, documentation that the patient/representative had requested four side rails, or if the patient was on seizure precautions, comatose, or intubated. Regardless of the reason for four bedside rails, an order was still required. CNO GG further stated that if a patient were alert and oriented and requested all four side rails up, there would not typically be an order because the patient would understand to call for help. If a patient insisted on having all four side rails up, it would be important to explain that it was not the facility's policy and would be considered a restraint.

An interview was conducted with the Director of Acute Care (DAC) TT on 3/17/22 at 1:42 p.m. in the Conference Room. DAC TT stated that four side rails were a form of restraint. If a patient asked for four side rails to feel comfortable, there would have to be a note in the medical record or an order from the physician. DAC TT said that if a family member asked for the side rails to be up or if a patient was at risk of falling out of bed, there would need to be a physician order.

During a tour of the Medical-Surgical Units on 3/15/22 with the Manager of Accreditation (MA) MM, it was observed that P#1, 2, 4, 5 were in bed with four side rails up.

A review of the Complaint/Grievance Log revealed a grievance related to nurses' failure to respond to call lights for P#8 on 2/11/22. The complainant mentioned that there were four side rails up at the time of the complaint.

Based on a review of the facility policies, medical record review, and interviews with staff, it was determined that the facility used restraints without documenting attempted alternatives or other less restrictive interventions for 4 out of 8 patients sampled (P#1, P#2, P#4, P#5).

A review of the policy titled "Patient Rights and Responsibilities," Policy #R1-01-01, effective 7/16, revealed that patients had a right to be free from the use of restraints and/or seclusion unless clinically necessary.

A review of the policy titled "Restraints and Seclusion" Policy #RI-40-01, published 7/21, revealed that restraints included the use of four side rails up to confine a patient when the patient could not release the side rails. Four side rails would not be considered a restraint when used for patients with a potential for falling out of bed. The nurse would assess the patient for identification of physical or psychological problems that may be causing the behavior. The least restrictive intervention would be used to maintain safety. The nurses would attempt alternatives to restraints unless the patient's behavior presented an immediate danger to self or others. Restraints may have been avoided by addressing needs identified during an assessment and early interventions. The patient/family would be educated on alternatives to restraints.

A review of the medical record for P#1 revealed that a Nursing Note by RN CC on 3/15/22 at 5:43 p.m. said that P#1 insisted that all four side rails were up. P#1 could not hold herself up properly in the bed and stated, "Put all the rails up. That is what they are there for." A review of nurses' notes/flowsheets failed to reveal if alternatives were attempted prior to restraints.

A medical Record review for P#2 revealed that notes by the Physical Therapist (PT) QQ on 3/11/22 at 3:54 p.m. and 3/14/22 at 5:00 p.m. said that P#2 had all four side rails up. P#2 was a fall risk and had a bed alarm. P#2 was oriented to person only and disoriented to place, time, and situation. P#2 had decreased strength in upper and lower extremities, decreased coordination, and impaired functional mobility, gait, and balance. P#2 could not ambulate or complete high-level activities of daily living.

A review of a Nurse Note by RN CC on 3/15/22 at 5:23 p.m. revealed that the family had requested all four side rails be up while the family was not in the room. The family feared that P#2 would try to get out of bed and fall. The bed alarm was on and would alarm if the patient moved to the side of the bed. The family was still not comfortable with leaving one side rail down. A review of the flowsheets revealed that there were four side rails up on 3/15/22 at 6:00 p.m. A review of nurses' notes/flowsheets failed to reveal if alternatives were attempted prior to restraints.

A medical record review for P#4 revealed that P#4 was confused and disoriented to situation.
A review of a note by PT UU on 3/8/22 at 4:30 p.m. revealed that four side rails were up. P#4 was a fall risk. Precautions included not leaving P#4 unattended on the edge of the bed or while out of bed.

A review of Speech-Language Pathologist (SLP) notes on 3/11/22 at 3:00 p.m. revealed that restraints were in place with four side rails up. A review of PT notes on 3/14/22 at 10:08 a.m. revealed that P#4 was on fall precautions and four side rails were up. P#4 required maximum assistance with rolling, scooting and sitting up. A review of nurses' notes/flowsheets failed to reveal if alternatives were attempted prior to restraints.

A review of the medical record for P#5 revealed that 4/4 side rails were documented on the flowsheets on 3/16/22 at 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m., and 8:00 a.m. P#5 required moderate assistance until transported to the ICU on 3/15/22.A review of nurses' notes/flowsheets failed to reveal if alternatives were attempted prior to restraints.

A review of the medical record for P#8 revealed that an assessment by PT QQ on 2/9/22 at 10:32 a.m. said that P#8 had impaired functional mobility limited by pain, fatigue, and decreased upper extremity strength. A plan of care was initiated on 2/9/22 at 3:43 p.m. that included safety/falls.
A review of a note by PT VV on 2/11/22 at 5:00 p.m. revealed that P#8 was on fall precautions and had four side rails up. A review of nurses' notes/flowsheets failed to reveal if alternatives were attempted prior to restraints.

An interview was conducted with RN AA on 3/15/22 at 4:04 p.m. in the Conference Room. RN AA stated that alternatives for raising all four side rails would be to move patients closer to the nurses' station within the line of sight, provide a one-to-one sitter, and give medications to calm agitation. Restraints would be the last resort, and RN AA said the nurses tried not to use restraints. RN AA further said that the bedrails could make it more dangerous for patients trying to climb out of bed.

An interview was conducted with RN EE on 3/15/22 at 5:09 p.m. in the Conference Room. RN EE said P#5 wanted the side rails up. P#5 would ask RN EE to bring the rail back up whenever RN EE would lower a rail. P#5 had items that would fall out of the bed due to the patient's size if the rails were down. RN EE said P#5 was awake and oriented. When RN EE tried to put P#5's things on a table, P#5 did not like the items on the table. RN EE said alternatives to putting all four side rails up would be to move a patient closer to the nurses' station, keep an eye on them, or get a sitter.
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During a tour of the Medical-Surgical units on 3/15/22 with the Manager of Accreditation (MA) MM, it was observed that P#1, 2, 4, 5 were in bed with four side rails up.

A review of the Complaint/Grievance Log revealed a grievance related to nurses' failure to respond to call lights for P#8 on 2/11/22. The complainant mentioned that there were four side rails up at the time of the complaint.

Based on medical record review, facility policy, QAPI committee meeting minutes, and staff interviews, the facility failed to ensure that the QAPI program duly considered and addressed the proper use of restraints. The QAPI committee failed to track and trend restraint data from May 2021 to March 2022.

A review of the "Restraints and Seclusion" policy #RI-40-01, published 7/21/21, revealed that each episode of restraint or seclusion would be reviewed for quality assurance. Restraint orders, assessment, and monitoring would be assessed by the nurse manager for policy adherence. The nurse manager would aggregate data for tracking and trending purposes, and report Restraint/Seclusion use as required for facility performance improvement standards.

A review of Quality Meeting minutes from September 2021 to February 2022 revealed there was no discussion or data regarding restraints.

An interview took place with the Accreditation Coordinator (AC) (OO) on 3/17/22 at 3:14 p.m. in the Conference Room. AC OO said there were random audits of restraints prior to July 2021 and no audits during COVID -19 surges. AC OO said every time the audits would get started, another surge would hit. AC OO said order and documentation reports were completed in 1/22 and 2/22, and the reports would be presented to the Quality Review Committee on 3/22/22. AC OO said restraint audits were being put back on the quality scorecard, and the facility did not realize there was nothing about restraints on the scorecard. AC OO said the facility started talking about restraints in 1/22 so the unit leaders could start running reports and monitoring restraints to make sure there was a current order and no missing documentation. AC OO said there had not been quality discussion regarding restraints since 5/21. There were mock surveys in 12/21 and 2/22 that focused on restraint documentation.

A medical record review for P#1, 2, 4, 5, 8, revealed that all five patients had four siderails up and did not have physicians' orders for four siderails. In addition, review of the medical record failed to reveal that alternatives to restraints were implemented prior to raising all four siderails.