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Based on observation, interview, record review, and facility policy review, the facility failed to protect and promote each patient's rights for 4 of 4 (Patients 4, 6, 7, and 8) patients reviewed for restraints.

Findings Include:

1. The hospital failed to identify hand mitts as a restraint, even though the hand mitts greatly reduced the patient's ability to use their hands and the patient would not be able to easily remove the mitts in the same manner they were applied by the staff. Specifically, this deficient practice resulted in the staff's failure to obtain restraint orders, perform restraint assessments, and conduct the restraint monitoring required when physical restraints were utilized. (Refer to A-0161)

2. The hospital failed to ensure restraints were used only in accordance with a physician's or other authorized licensed practitioner's order. Specifically, this deficient practice had the likelihood of resulting in the inappropriate use of restraints. (Refer to A-0168)

Based on observation, interview, record review, and facility policy review, the facility failed to identify hand mitts as a restraint, even though the hand mitts greatly reduced the patient's ability to use their hands and the patient would not be able to easily remove the hand mitts in the same manner they were applied by the staff for 1 (Patient 8) of 1 patient observed with hand mitts. Specifically, this deficient practice resulted in the staff's failure to obtain restraint orders, perform restraint assessments, and conduct the restraint monitoring required when physical restraints were utilized.

Findings Include:

A facility policy titled, "Patient Rights and Responsibilities," revised 09/07/21, revealed the section titled "Patient Rights" indicated "9. The right to be free from corporal punishment, restraint or seclusion of any form."

A facility policy titled, "Standard Process Description: Restraint initiation, orders and documentation," revised 02/27/23, revealed the section titled "Common medical devices and intervention" indicated "Hand mitts would no [sic] be considered a restraint as long as the device is easily removed by a patient." The policy also indicated, "Hand mitts that are pinned or attached to the bedding, or applied so tightly that the patient's hand or fingers are immobilized, or if the mitts are so bulky that the patient's ability to use their hands is greatly reduced, would be considered a restraint."

A facility policy titled, "Restraints and Seclusion Patient Care Management Policy," revised 03/06/23, revealed the section titled "Definitions" indicated "Non-violent Behavior: behavior that threatens a patient's safety, healing and well-being by pulling on or removing lines, tubes, and medical devices that are necessary for care of treatment." The policy revealed the section titled "Initiating Restraints/Seclusion," included "1. A physician order is required to initiate restraints or seclusion. EXCEPTION: during an emergency event, e.g. [exempli gratia, for example] self-extubation. In these events, the RN [registered nurse] may initiate restraints and then obtain an order immediately." The policy revealed, "3. The physician order includes: a. Indication for restraint/seclusion b. Type of restraint c. Duration for use of restraint/seclusion." The policy revealed, "Maximum duration for patient in restraints for non-violent restraint should not exceed 24 hours." The policy revealed the section titled "Face to Face Assessment," indicated "Required assessment and monitoring times vary depending on type of restraint/seclusion ordered. 1. Non-Violent restraints a. Every two (2) hours."

During observation on 10/02/24 at 4:22 PM, Patient 8 was observed in the medical intensive care unit (MICU) with bilateral hand mitts applied. The patient was observed in bed and appeared to be sedated. The mitts were observed closed on the top. During a concurrent interview, RN 12 stated that Patient 8 had mitts on because of the patient's impulsivity to pull at their medical devices. RN 12 stated Patient 8 could follow commands at times but at other times the patient could not. RN 12 stated that the mitts were open when Patient 8's family was at the bedside, so the family was able to hold the patient's hand, but, after the family left, staff closed the top of the mitts. RN 12 stated they liked to keep the mitts open when possible because Patient 8's hands become sweaty and "smelly" when the mitts were closed. RN 12 stated they performed circulation checks every couple of hours. RN 12 stated the mitts were helpful because they were "least restrictive," and they were "not a restraint."

Review of Patient 8's "Hospitalist History and Physical," dated 10/01/24, revealed Patient 8 was admitted on 10/01/24 for cardiac arrest.

Review of Patient 8's "Safety Interventions" flowsheet revealed that Patient 8 had mittens documented for the first time on 10/01/24 at 8:00 PM. Patient 8's flowsheets revealed mitts were documented again on 10/02/24 at 8:00 AM, 10:00 AM, 12:00 PM, 12:26 PM, and 2:00 PM.

Further review of Patient 8's medical record revealed no evidence of an order for restraints, restraint documentation, or restraint assessments.

During an interview on 10/02/24 at 9:32 AM, RN 3 stated that orders were needed for soft restraints, any locked restraints, or anything that required the physician to assess the patient within a certain amount of time. RN 3 stated the mitts utilized at the facility were not considered restraints. RN 3 stated the mitts slipped on the patient, and there was a closure strip at the base of the mitt because they were one-size-fits-all. RN 3 stated the mitts opened at the top and could be left open, but there was also a cover to close the top.

During an interview on 10/02/24 at 2:07 PM, Clinical Simulation Educator (CSE) 11 stated that restraint classes were provided for most patient-facing staff. CSE 11 stated nurses also received education during skills class. CSE 11 stated staff were taught how to apply mitts properly and were educated on how the policy did not consider mitts restraints and did not require the same physician face-to-face as restraints. CSE 11 stated the use of mitts still needed to be documented. CSE 11 stated she believed the mitts were documented under restraints but only that the mitts were on or off. CSE 11 stated the staff education on application of mitts included how to leave two finger widths of space when securing the mitts. CSE 11 stated staff were shown how to close the top of the mitts, but the mitts did not have to be closed. CSE 11 stated she could be wrong and would follow up with someone. CSE 11 stated her manager had responded to a message and told her that staff were educated to close the tops of the mitts.

During an interview on 10/02/24 at 2:09 PM, the DRM requested CSE 11 to get clarification on mitt education including the top being closed because, if they were closed, that "would be a restraint."

During an interview on 10/02/24 at 3:16 PM, CSE 11 stated the clarification for closed or open mitts was based on what was the least necessary for the patient. CSE 11 stated there was nothing in the policy that specifically stated that closed mitts were a restraint.

During an interview on 10/02/24 at 4:03 PM, RN 4 stated that she had personally utilized mitts on a patient in the Emergency Department (ED). RN 4 stated the mitts she had utilized had not required an order in the past, but she did not know if that policy had changed. RN 4 stated having the mitts open or closed on the top would depend on the goal of the mitts and how they were applied. RN 4 stated, if she was at the point of putting mitts on a patient, the goal would to be to apply the mitts closed because, at that point, the patient's safety was kept in mind, and they were applying the mitts so that the patient was prevented from pulling out any necessary medical devices.

During an interview on 10/03/24 at 12:55 PM, RN 12 stated that 10/02/24 was his first day as Patient 8's nurse. RN 12 stated Patient 8 had mitts on when he took over the patient's care. RN 12 stated his "best guess" was that the mitts were on Patient 8 for "possibly" 12 to 16 hours prior to him taking over the patient's care. RN 12 stated the mitts were able to come off once the patient was extubated. RN 12 stated the only alternative to the mitts would have been to use wrist restraints, but those were more restrictive. RN 12 stated there were no non-restraint alternatives to the mitts. RN 12 stated he was not qualified to say if the mitts were a restraint or not. RN 12 stated patients could not do things such as utilize the call light, use the phone, or make a call if the mitts were closed on the top. RN 12 stated, because mitts were not a restraint, they would not be documented under the restraint flowsheet and would not require a provider's order. RN 12 stated he could not recall when mitts were determined to not be a restraint anymore.

Based on interview, record review, and facility policy review, the Hospital failed to ensure restraints were used only in accordance with a physician's or other authorized licensed practitioner's order for 3 of 4 (Patients 4, 6, and 7) patients reviewed for restraints. Specifically, this deficient practice had the likelihood of resulting in the inappropriate use of restraints.

Findings Include:

A facility policy titled, "Restraints and Seclusion Patient Care Management Policy," revised 03/06/23, revealed the section titled, "Initiating Restraints/Seclusion," included "1. A physician order is required to initiate restraints or seclusion. EXCEPTION: during an emergency event, e.g. [for example] self-extubation. In these events, the RN [registered nurse] may initiate restraints and then obtain an order immediately." The policy also indicated, "3. The physician order includes: a. Indication for restraint/seclusion b. Type of restraint c. Duration for use of restraint/seclusion."

Patient 4

Review of Patient 4's "Hospitalist History and Physical," dated 09/01/24, revealed Patient 4 was admitted to the hospital on 09/01/24 for respiratory distress.

Review of Patient 4's "Restraint Type" flowsheet revealed Patient 4 had non-violent restraints on 09/05/24 at 2:00 PM and 4:00 PM. The record revealed the type of non-violent restraint was not documented.

Review of Patient 4's "Reason for Restraint" flowsheet, dated 09/05/24 at 2:00 PM and 4:00 PM, revealed staff documented Patient 4 was pulling at their nasogastric tube.

Further review of Patient 4's medical record did not reveal an order for restraints.

During an interview on 10/01/24 at 1:34 PM, Quality Program Manager (QPM) 7 stated that they did not see reference to the non-violent restraints in medical record notes for Patient 4. QPM 7 stated that, if the patient were in mitts, there would not have needed to be an order. QPM 7 stated that the type of restraint should have been documented in the flowsheet, and it was unknown what type of restraint it was, because all that was documented was non-violent and there was no order found.

Patient 6

Review of Patient 6's "Hospitalist History and Physical," dated 09/18/24, revealed Patient 6 was admitted on 09/17/24 for aggressive behavior.

Review of Patient 6's "Violent Behavior Restraint Adult" order, dated 09/17/24 at 11:32 PM, revealed a physical hold restraint was ordered for Patient 6 due to aggression and was continuous for three hours.

Review of Patient 6's "Four Way Locking" flowsheet revealed Patient 6 had four-way locking restraint started continuously on 09/17/24 at 11:45 PM until being discontinued on 09/18/24 at 1:30 AM.

A physician's order for Patient 6, dated 09/18/24 at 12:31 AM, indicated a 5 milligram (mg) injection of midazolam (a benzodiazepine used for sedation). The record indicated the midazolam was administered on 09/18/24 at 12:40 AM.

A "Chemical Restraint" flowsheet revealed Patient 6 had a chemical restraint started on 09/18/24 at 12:40 AM and discontinued on 09/18/24 at 1:30 AM.

Further review of Patient 6's record did not reveal an order for either the chemical restraint or the four-way locking restraints and no documentation of the physical hold restraint.

During an interview on 10/01/24 at 1:14 PM, Quality Program Manager (QPM) 7 stated that there was no restraint documentation for a physical hold for Patient 6. QPM 7 stated that there was no order for a chemical restraint or four-point locked restraints. QPM 7 stated that the only order was for a physical hold. QPM 7 stated that midazolam was administered at 12:40 AM, the same time as the chemical restraint was documented on the restraint flowsheet, but it did not specify in the order that the midazolam was for a chemical restraint. QPM 7 stated that the assumption could be that the nurse documented a chemical restraint for Patient 6 because that was when they medicated the patient, but there was no order for a chemical restraint. QPM 7 stated that it could have also been confusion on the provider's part.

During an interview on 10/02/24 at 4:03 PM, Registered Nurse (RN) 4 stated that four-point restraints did require an order. RN 4 stated that she was not as familiar with the policy for chemical restraints, but for a nurse to give it, the doctor would need to put the order in. RN 4 stated that she did not recall if the order for a chemical restraint specified chemical restraint or just the medication, but, if she needed to clarity, she could ask the provider. RN 4 stated that there was a spot in the record to document restraints, which was where a physical hold restraint would be documented.

Patient 7

Review of Patient 7's "ED [Emergency Department] Provider Note[s]," dated 08/16/24, revealed Patient 7 was admitted for altered mental status.

Patient 7's "ED Notes," dated 08/17/24 at 5:45 AM, revealed Patient 7 continued to yell and kick staff. The notes revealed Patient 7 was physically held by staff members to restrain the patient from assaulting staff. The notes revealed the ED provider was at Patient 7's bedside, and an order for four-point restraints was placed.

Review of Patient 7's "Violent Behavior Restraint Adult" order, dated 08/17/24 at 5:55 AM, revealed locking restraints were ordered for Patient 7 due to the patient being combative and violent. The record indicated the order was continuous for three hours.

Review of Patient 7's "Restraint Type" flowsheet revealed Patient 7 was placed in violent restraints on 08/17/24 at 5:50 AM. The record did not indicate what type of violent restraint was used for Patient 7.

Further review of Patient 7's record revealed there was no order for a physical hold restraint.

During an interview on 10/01/24 at 1:45 PM, Quality Program Manager (QPM) 7 stated that restraint documentation for Patient 7 did not indicate what type of violent restraints the resident was placed in. QPM 7 stated tthat it appeared the nurse did not open that section of documentation. QPM 7 stated that there was no order or restraint documentation for a physical hold for Patient 7, and based on the wording of the nurse's note they would expect to see one. QPM 7 stated that if the note had been worded that the patient had to be held for the restraints to be applied, they would not expect to see an order or documentation of a physical hold. QPM 7 stated based on the nurse's note, "There are missing pieces."