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Based on record review and interview the facility failed to assess opportunity for removal/discontinuation of restraints at the earliest possible time, and when the patient's actions no longer warrant the need for restraints in 2 of 10 patient medical records reviewed (Patients #1, 2), failed to protect and promote patient rights by failure to initiate a care plan problem when restraints were applied in 2 of 10 patient medical records reviewed (Patients #1, 6), failed to obtain physician orders for restraints to be used in 4 of 10 patient medical records reviewed (Patients #1, 2, 9, 10), and failed to assess and monitor patients in restraints in 4 of 10 patient medical records reviewed (Patients #1, 2, 6, 10).

Findings:

The facility failed to ensure patients are free from restraints by failing to discontinue restraints at the earliest possible time, and when the need for restraints are no longer warranted. See Tag A-0154.

The facility failed to follow their policy to ensure a care plan problem was initiated when restraints were applied to a patient. See Tag A-0166.

The facility failed to ensure that a physician's order was present for every 24 hour period that there was a restraint in use per facility policy. See Tag A-0173.

The facility failed to ensure that a restraint assessment was completed every 2 hours for patients in restraints per facility policy. See Tag A-0175.

Based on record review and interview, the facility failed to assess opportunity for removal/discontinuation of restraints at the earliest possible time, and when the patient's actions no longer warrant the need for restraints in 2 of 10 patient medical records reviewed (Patients #1, 2) out of a total universe of 10 medical records reviewed.

Findings include:

A review of the facility policy titled, "Patient Rights and Responsibilities", effective 03/14/2020, revealed: "...15. Be assured of reasonable safety within the care setting, including the right to be free from mental, physical, sexual and verbal abuse, neglect, mistreatment..."

Review of the facility policy titled, "Restraint/Seclusion" #8430173 dated 08/18/2020 revealed,"...E. The RN is responsible for reassessing the patient's behavior and readiness for seclusion/restraint discontinuation or need for continued seclusion/ restraint...V. DISCONTINUATION AND REMOVAL OF RESTRAINTS A. Restraints should be ended at the earliest possible time...C. Patients in Non Violent/Non Destructive Restraints will be assessed for opportunity for removal of restraints. This assessment should be documented at least every 2 hours. Restraints should be discontinued when the clinical treatment is discontinued or the patient's actions no longer warrant the need for restraint...VI. DOCUMENTATION A. RN [registered nurse] Responsibilities...Documentation of restraint usage will include:...Ongoing assessments demonstrate that the restrain [sic]/seclusion intervention is needed..."

Review of Patient (Pt.) #1's medical record revealed an admission on 02/06/2023 - 02/17/2023 for dementia and failure to thrive.

The record revealed the following provider orders for non-violent/non-self destructive restraints: 4 point restraints (both wrists and both ankles held down on the bed preventing movement) on 02/06/2023 at 11:53 PM for unable to follow safety plan and interference with medical treatment.

A review of progress note dated 02/06/2023 at 11:56 PM revealed, "Patient attempting to get out of bed, very agitated wanting to get up to go home. Patient unable to be redirected, attempting to swing at staff. 4 point restraints applied, patient continuing trying to hit and kick staff ..."

Pt. #1's restraint flowsheet indicates a restraint assessment on 02/07/23 at 2:00 AM. Patient condition noted as "confused." Restraints remain in place. There are no progress notes as to safety issues with Pt. #1. There is no evidence that patient's condition still warranted restraints.

Pt. #1's restraint flowsheet indicates a restraint assessment on 02/07/23 at 4:00 AM, patient's condition noted as "confused." Restraints remain in place. There are no progress notes as to safety issues with patient. There is no evidence that patient's condition still warranted restraints.

A review of progress note dated 02/07/2023 at 4:00 AM revealed, "Remains in 4pt soft restraints as pt uncooperative. Stutters and cannot make complete statements. No skin alterations but remains a risk. When pt awake after cares was not hitting out at staff." Patient remained in restraints.

Restraint assessments on 02/07/2023 at 6:00 AM and at 8:30 AM (greater than 2 hours between assessments) revealed patient's condition noted as "confused." Restraints remain in place. There are no progress notes as to safety issues with Pt. #1. There is no evidence that patient's condition still warranted restraints.

Pt. #1's medical record indicates restraints discontinued on 02/07/2023 at 10:26 AM (total time in restraints 10.5 hours).

On 02/07/2023 at 3:13 PM, Pt. #1's medical record revealed an order for vest restraint (holds patient's torso and upper body to a surface such as a chair or bed) for unable to follow safety plan.

A review of progress note on 02/07/2023 at 3:14 PM reveals, "Patient has been in the chair since this morning, offered to walk in the hall, provide crayons and coloring sheets. 4 point restraints have been off this this morning, now ordered a vest restraint. Patient keeps standing up and not able to communicate what he wants to do." Note does note reveal a threat to patient's safety or safety of others.

Documentation in the record indicates 4-point restraints added on 02/07/2023 at 3:35 PM. There was no physician order found for this restraint. The restraint flowsheet indicates "confused, agitated." There is no progress note to describe the need for the restraint or threats to the safety of Pt. #1 or others.

Late progress note on 02/08/2023 at 1:21 AM revealed, "Patient remains confused, disoriented and aggressive at times. Patient ripped off vest restraint at 1535 (3:35 PM), 4 point restraints applied. Patient hit right hand over bedside rail, PIV (peripheral IV) dislodged ..." It is unclear if bedrails were up at this time as a secondary restraint.

Pt. #1 continued in 4 point restraints from 02/07/2023 at 3:35 PM until 02/10/2023 at 8:30 AM - a total of 65 hours.

Pt. #1's restraint flowsheet revealed, "Pt. [patient] Observations" for Pt. #1 were documented as confused, agitated and/or restless at assessment times with missed documentation to support the restraint type needed, and no documentation for possible opportunity to discontinue restraints throughout his/her total restraint time.

During a telephone interview with Family Member (FM) B on 07/06/2023 at 10:35 AM regarding the care of patient #1 (B's spouse), FM B stated that the first day that she went to visit, FM B saw restraints on pt #1's bed. When FM B asked about the reason for restraints, was told it was for pt #1's "benefit from walking around." FM B stated that on two additional visits she (FM B) found pt #1 in restraints and had to remove the restraints to assist pt #1 to eat. FM B felt that staff were not checking on pt #1 when restraints were on.

Review of Pt. #2's medical record revealed an admission on 06/19/2023 for altered mental status and confusion. The patient is currently an inpatient.

The record revealed the following provider orders for non-violent/non-self destructive restraints: 4 point restraints and 4 side rails on 06/21/2023 at 1:00 PM for interference with medical treatment and unable to follow safety plan.

Restraint assessments on 06/21/2023 at 3:00 PM and at 5:00 PM revealed patient's condition noted as "confused." 4 point restraints remain in place. There are no progress notes as to safety issues with Pt. #2. There is no evidence that patient's condition still warranted restraints.

A review of progress note dated 06/21/2023 at 7:00 PM revealed, "...Patient confused at times with delayed responses...Patient pleasant with writer and easily redirected...Patient able to feed self with supervision."

Restraint assessments on 06/21/2023 at 9:00 PM and 11:00 PM and on 06/22/2023 at 1:00 AM revealed patient's condition noted as "Restless" or "Drowsy." 4 point restraints and 4 side rails remain in place. There are no progress notes as to safety issues with Pt. #2. There is no evidence that patient's condition still warranted restraints.

Restraint assessment on 06/22/2023 at 3:00 AM revealed patient's condition noted as "Drowsy" with a progress note that revealed, "Remains alert but confused at times, needs constant redirection and reminders...Several attempts to pull his Tele [Telemetry] monitor and attempted to pull off his 4 pt restraints..." 4 point restraints and 4 side rails remain in place.

Restraint assessment on 06/22/2023 at 5:00 AM revealed patient's condition noted as "Restless." 4 point restraints and 4 side rails remain in place. There are no progress notes as to safety issues with Pt. #2. There is no evidence that patient's condition still warranted restraints.

Restraint assessment on 06/22/2023 at 8:00 AM (greater than 2 hours between assessments) revealed patient's condition noted as "confused" with a progress note that revealed, "Restraints off wrist for patient to feed self with supervision...Restraints reapplied." 4 point restraints and 4 side rails remained in place until 06/22/2023 at 10:00 AM.

Pt. #2 continued in 4 point restraints from 06/21/2023 at 1:00 PM until 06/22/2023 at 10:00 AM - a total of 21 hours.

Pt. #2's restraint flowsheets revealed, "Pt. [patient] Observations" for Pt. #2 were documented as confused, restless and/or drowsy at assessment times with missed documentation to support the restraint type needed, and no documentation for possible opportunity to discontinue restraints throughout his/her total restraint time other than to allow Pt. #2 to feed self - then restraints reapplied.

The record revealed the following provider orders for non-violent/non-self destructive restraints: 4 point restraints on 06/24/2023 at 10:03 AM for interference with medical treatment.

Restraint assessments (every 2 hours) from 06/24/2023 at 12:00 PM until discontinued on 06/25/2023 at 9:45 AM revealed patient's condition noted as, "Confused, Agitated, Restless or Drowsy." 4 point restraints remained in place. There were no progress notes as to safety issues with Pt. #2. There was no evidence that patient's condition still warranted restraints. There was missed documentation to support the restraint type needed, with no documentation for possible opportunity to discontinue restraints throughout his/her total restraint time.

Pt. #2 continued in 4 point restraints from 06/24/2023 at 10:00 AM until 06/25/2023 at 9:45 AM - a total of 23 hours 45 minutes.

Based on record review and interview the facility staff failed to follow their policy to ensure a care plan problem was initiated when restraints were applied in 2 of 10 patient medical records reviewed (Patients #1, 6) out of a total universe of 10 medical records reviewed.

Findings include:

Review of the facility policy titled, "Restraint/Seclusion" #8430173 dated 08/18/2020 revealed,"...VI. DOCUMENTATION A RN (Registered Nurse) Responsibilities: Document in the medical record. Documentation of restraint usage will include:...10. Plan of care/treatment plan includes restr [sic]/seclusion..."

Record review of Patient (Pt.) #1 revealed an admission on 02/06/2023 - 02/17/2023 for dementia and failure to thrive. The record revealed the following provider orders for non-violent/non-self destructive restraints: 4 point restraints on 02/06/2023 for unable to follow safety plan and interference with medical treatment, a vest/jacket restraint on 02/07/2023 for unable to follow safety plan, and 4 point restraints on 02/09/2023 for unable to follow safety plan. There was no documented care plan in the medical record for the use of restraints.

On 07/11/2023 at 12:42 PM in an interview with Clinical Nurse Leader (CNL) H, CNL H confirmed that there was no care plan updates for the use of restraints for Pt. #1 and stated, "There were no new add-ons to the care plan."



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Record review of Pt. #6 revealed an admission on 07/06/2023 for a change in mental status and confusion. The patient is currently an inpatient. The record revealed an order for bilateral wrist restraints on 07/09/2023 for pulling at medical devices and inability to redirect. There was no documented care plan in the medical record for the use of restraints.

On 07/11/2023 at 12:45 PM in an interview with Quality C, Quality C confirmed that there was no care plan update for the use of restraints and stated, "There should be."

Based on record review and interview the facility failed to ensure that a physician's order was present for every 24 hour period that there was a restraint in use per facility policy in 4 of 10 patient medical records reviewed (Patients #1, 2, 9, 10) out of a total universe of 10 medical records reviewed.

Findings include:

Review of the facility policy titled, "Restraint/Seclusion" #8430173 dated 08/18/2020 revealed, "...II. Physician Orders A. This policy requires that a physician or other authorized LIP (licensed independent provider)...order restraints or seclusion prior to the application of restraint or seclusion..in emergency application situations, the order must be obtained either during the emergency application of the restraint or seclusion or immediately afterwards...1. Restraints for non-violent/non-destructive behavior: Orders are in effect for up to 24 hours. If the patient remains in restraints for more than 24 hours, then a new order must be obtained by midnight the following day..."

Review of Patient (Pt.) #1's medical record revealed an admission on 02/06/2023 - 02/17/2023 for dementia and failure to thrive. The record revealed the following provider orders for non-violent/non-self destructive restraints: 4 point restraints on 02/06/2023 at 11:53 PM for unable to follow safety plan and interference with medical treatment, vest/jacket restraint on 02/07/2023 at 3:13 PM for unable to follow safety plan, and 4 point restraints on 02/09/2023 at 5:02 AM for unable to follow safety plan. The restraint flowsheet revealed nursing documentation of 4 point restraints in use on 02/07/2023 at 3:35 PM through 02/09/2023 at 4:00 AM, and bilateral wrist restraints in use on 02/09/2023 at 12:00 PM through 02/10/2023 at 8:30 AM; there was no documentation of a physician's order for 4 point restraints applied on 02/07/2023 at 3:35 PM until 02/09/2023 at 5:02 AM, and no order for bilateral wrist restraints applied on 02/09/2023 at 12:00 PM until discontinued on 02/10/2023 at 8:30 AM.

In an interview on 07/11/2023 at 2:02 PM with Clinical Nurse Leader (CNL) H, CNL H confirmed that the 4 point restraints order on 02/06/2023 at 11:53 PM expired on 02/07/2023. CNL H also confirmed that bilateral wrist restraints were in use for Pt. #1 on 02/09/2023 and 02/10/2023 and stated, "There should have been orders that match the restraint that was replaced."

Review of Pt. #1's medical record revealed a 2nd admission on 02/24/2023 - 03/20/2023 for aggressive behavior, dementia and failure to thrive. The record revealed a physician's order for non-violent/non-self destructive 2 point bilateral wrist restraints on 03/06/2023 at 11:00 PM for interference with medical treatment. The restraint flowsheet revealed nursing documentation of 4 side rails up, bilateral wrist and ankle restraints and a vest applied on 03/06/2023 at 11:00 PM - all restraints were discontinued on 03/07/2023 at 10:00 AM. There was no documentation of a physician order for 4 side rails up, bilateral ankle restraints and a vest on 03/06/2023 at 11:00 PM prior to or immediately after the application of these restraints.

In an interview on 07/11/2023 at 2:44 PM with Clinical Nurse Leader (CNL) H, CNL H confirmed that on 03/06/2023 side rails, soft bilateral ankle restraints and a vest were put in use for Pt. #1 and stated, "No orders for side rails, vest, and ankles."

Review of Pt. #2's medical record revealed an admission on 06/19/2023 for altered mental status and confusion. The patient is currently an inpatient. The record revealed a physician's order for non-violent/non-self destructive right hand mitt restraint on 07/08/23 at 7:36 PM for interference with medical treatment and unable to follow safety plan. The restraint flowsheet revealed nursing documentation of 4 side rails up on 07/09/2023 at 1:00 PM and discontinued on 07/10/2023 at 8:01 PM. There was no documentation of a physician order for 4 side rails up on 07/09/2023 prior to or immediately after the application of these restraints.

In an interview on 07/12/2023 at 10:10 AM with Clinical Nurse Leader (CNL) H, CNL H confirmed that side rail restraints were in use for Pt. #2 on 07/09/2023 - 07/10/2023 and stated, "No order for side rails, but documented side rails on the flowsheet."


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Review of Pt. #9's medical record revealed an admission on 02/23/2023 for hypoxia (low oxygen) and pneumonia. The record revealed a restraint flowsheet with a physician order and documentation of bilateral wrist restraints applied on 02/25/2023 for agitation and confusion. The record revealed discontinuation of the restraints upon Pt. #9's discharge from the hospital on 02/27/2023. There was no order for continuation of the restraints on 02/26/2023.

In an interview on 07/11/2023 at 3:00 PM with Quality C, Quality C confirmed that restraints were in use for Pt. #9 on 02/26/2023 and there was no order for them and stated, "Of course there should have been."

Review of Pt. #10's medical record revealed an admission on 03/31/2023 for failure to thrive and alzheimers. The record revealed bilateral mitts, 4 siderails up and a vest restraint applied on 04/01/2023 at 10:00 PM for confusion and pulling at lines. The record revealed the first order for restraints was placed by the provider on 04/02/2023 at 4:59 AM, 7 hours after application of the restraints.

In an interview of 07/11/2023 at 3:20 PM with Quality C, Quality C confirmed the late timing of the order and stated, "They should have gotten an order right away."

Based on record review and interview the facility failed to ensure that a restraint assessment was completed every 2 hours for patients in restraints per facility policy in 4 of 10 patient medical records reviewed (Patients #1, 2, 6, 10) out of a total universe of 10 medical records reviewed.

Findings include:

Review of the facility policy titled, "Restraint/Seclusion" #8430173 dated 08/18/2020 revealed, "...IV. MONITORING...B. Non-violent/non destructive Restraints: Patients are monitored every 2 hours with documentation occurring every 2 hours..."

Review of Patient (Pt.) #1's medical record revealed a 2nd admission on 02/24/2023 - 03/20/2023 for aggressive behavior, dementia and failure to thrive. The record revealed non-violent/non-self destructive 4 point restraints and a vest/jacket restraint were ordered on 02/27/2023 at 9:09 PM for unable to follow safety plan and in use on 02/28/2023 at 9:30 PM. Review of the restraint flowsheet revealed no documented RN assessments on 02/28/2023 from 5:30 AM until 9:00 AM - a period of 3.5 hours between documented restraint assessments. The record revealed non-violent/non-self destructive 4 side rails up and 4 point restraints were ordered on 03/04/2023 at 11:30 PM for unable to follow safety plan and aggressive behavior and in use on 03/04/2023 at 11:05 PM. Review of the restraint flowsheet revealed no documented RN assessments on 03/05/2023 from 6:00 AM until 8:00 PM (a period of 14 hours between documented restraint assessments) and no documentation on the restraint flowsheet that restraints were discontinued.

The above findings were confirmed on 07/11/2023 at 2:54 PM during medical record review with Clinical Nurse Leader (CNL) H who stated, "There are no nursing notes to justify lack of documentation on 02/28/2023." CNL H also stated that on 03/05/2023 there was a nursing note that restraints were re-ordered for patient safety, "but no checks on [his/her] shift..."

Review of Pt. #2's medical record revealed an admission on 06/19/2023 for altered mental status and confusion. The patient is currently an inpatient. The record revealed non-violent/non-self destructive 4 side rails up and 4 point restraints were ordered and in use on 06/22/2023. Review of the restraint flowsheet revealed no documented assessments on 06/22/2023 from 5:00 AM until 8:00 AM - a period of 3 hours between documented restraint assessments. The record revealed non-violent/non-self destructive 4 side rails up and bilateral wrist restraints were ordered and in use on 06/23/2023. Review of the restraint flowsheet revealed no documented assessments on 06/23/2023 from 6:00 AM until 11:48 AM - a period of 5 hours 48 minutes between documented restraint assessments. The record revealed non-violent/non-self destructive bilateral wrist restraints were ordered and in use on 07/07/2023. Review of the restraint flowsheet revealed no documented assessments on 07/07/2023 from 5:09 AM until 8:10 AM - a period of 3 hours 1 minute and on 07/07/2023 from 8:10 AM until 12:45 PM - a period of 4 hours 35 minutes between documented restraint assessments. The record revealed non-violent/non-self destructive right mitt restraint was ordered and in use on 07/09/2023. Review of the restraint flowsheet revealed no documented assessments on 07/09/2023 from 1:00 PM until 5:20 PM - a period of 4 hours 20 minutes between documented restraint assessments. The record revealed non-violent/non-self destructive 4 side rails up and right mitt restraint in use on 07/09/2023. Review of the restraint flowsheet revealed no documented assessments on 07/09/2023 from 5:20 PM until 1:40 AM - a period of 8 hours and 20 minutes.

The above findings were confirmed on 07/12/2023 at 10:10 AM during medical record review with Clinical Nurse Leader (CNL) H who stated, "I agree, no checks were done by the nursing staff and should have been documented on the flowsheet."


41126

Review of Pt. #6's medical record revealed an admission on 07/06/2023 for altered mental status. Pt. #6 is a current inpatient. The record revealed bilateral wrist restraints were ordered and in use on 07/10/2023. Review of the restraint flowsheet revealed no assessment on 07/10/2023 from 2:00 AM until 8:00 AM - a period of 6 hours between restraint assessments.

Review of Pt. #10's medical record revealed an admission from 03/31/2023 - 04/06/2023 for failure to thrive and alzheimers. The record revealed an order for the use of all 4 side rails up on 04/03/2023 with no assessment from 9:00 AM to 8:00 PM - a period of 11 hours between restraint assessment. The record revealed soft wrist and ankle restraints in use on 04/5/2023 with no assessment documented from 4:00 PM until 8:00 PM - a period of 4 hours between restraint assessments.

The above findings were confirmed on 07/11/2023 at 3:30 PM during medical record review with Quality C who stated, "We need to do better, it needs to be every 2 hour assessments."