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Based on record review, document review, and interview, the facility failed to:

A. follow federal regulations, their own policy's definition of a grievance and the appropriate procedure to address a grievance in 1 (patient #1) of 8 (#1 (2 complaint/grievances), #2, #3, #4, #5, #6 (2 complaint/grievances) reviewed.
Refer to tag: A118


B. ensure nursing staff was assessing, monitoring, and reporting changes in the condition of the patient's skin and implementing skin breakdown preventative practices, such as turning immobile patients every 1-2 hours and elevating patient's heels off of bed, to prevent pressure on bony prominences such as the coccyx, heels, and occiput in 1 (patient #1) of 6 (patients #1 through #6) records reviewed.

Refer to tag: A144


C. ensure patients were safe from chemical restraints used to restrict the patient's freedom of movement and were only used when less restrictive interventions had been determined to be ineffective in 1 (patient #1) of 6 (patient #1 through #6) records reviewed.
Refer to tag: A160


D. obtain a signed physician's order for the use of chemical and physicial restraints in 1 (patient #1) of 6 (patient #1 through #6) records reviewed. The facility failed to have a physician's order in patient #1's record for 4 of 27 days (24 hour period) patient #1 was restrained.
Refer to tag: A168


E. ensure the attending physician was consulted when another physician ordered a patient restraint in 1 (patient #1) of 6 (patient #1 through #6) records reviewed.

Refer to tag: A170



F. ensure their staff was following their facility's policy for reassessment and monitoring patients that were being restrained in 1 (patient #1) of 6 (patient #1 through #6) records reviewed.
Refer to tag: A175

Based on record review, document review, and interview, the facility failed to follow federal regulations, their own policy's definition of a grievance and the appropriate procedure to address a grievance in 1 (patient #1) of 8 (#1 (2 complaint/grievances), #2, #3, #4, #5, #6 (2 complaint/grievances) reviewed.

Review of the facility's Complaint Log revealed 2 incident entries related to patient #1. The first entry listed an "Incident Report Date" of 9/24/2015. A "Brief Description of Issue(s) "stated, "Brother c/o (complained of) patient has skin breakdown buttocks after being in ICU (Intensive Care Unit)". The log report further describes the entry as a complaint that was received verbally, and was resolved at the patient's bedside on 9/24/2015.

An interview with staff #1 confirmed patient #1's brother made 2 separate complaints. Staff #1 reported the first complaint was made verbally to staff #1 via phone call on 9/24/2015, and the information was documented in the facility's computerized incident reporting system. Staff #1 reported the complaint was NOT handled as a grievance and therefore, no investigation was conducted and no follow up, verbal or in writing, was provided to the patient's brother (representative).

Review of the printed documentation from the incident reporting system revealed an incident report date of 9/22/2015. The report stated the following information: "Patient Relations Case Type: Grievance...Intake Method: Phone Call...Event Description: Patient's brother called and reported patient has a 'large bed sore' on his back that 'he got in ICU because they didn't turn him.'"

Although the incident reporting system showed discrepancies with the Complaint Log, staff #1 confirmed that there was only 1 complaint received from patient #1's brother in reference to the patient not being turned while in ICU and the complaint was never treated as a grievance.

Review of the facility's policy titled, "Complaint and Grievance Policy Guidelines" revealed the following: "DEFINITIONS....Grievance - A written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoP).

2. If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is proposed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purposes of these requirements.

6. Patient complaints that become grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding their patient care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or more CoPs, or other CMS requirements.

7. All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements are considered a grievance for the purposes of these requirements."

Based on record review, document review, and interviews, the facility failed to:

A. Assess, monitor and report changes in the condition of the patient's skin in 1 (patient #1) of 6 (patient #1 through #6) records reviewed.

Review of patient #1's record revealed an admission date of 8/26/2015, and a discharge date of 10/6/2015, a total of 42 days. Just prior to his admission, patient #1 sustained a hemorrhagic (bleeding) stroke on the left side of his brain which caused right sided body paralysis. The patient was unable to move the right side of his body and was documented as "completely immobile" and confined to the hospital bed throughout the hospital stay.

The nursing staff at the facility worked 2, 12 hour shifts per day. The day shift worked from 7:00 a.m. to 7:00 p.m. and the night shift worked from 7:00 p.m. until 7:00 a.m.

Review of patient #1's skin assessments revealed there was NO skin breakdown documented prior to 8/29/2015, at 7:30 a.m., when staff #7 documented, "small coccygeal decub (tailbone area bedsore)". The following shift skin assessment (8/29/2015, at 7:00 p.m.) documentation did NOT contain any skin breakdown information. On 8/30/2015, at 7:30 a.m., staff #7 documented, "small coccygeal decub". There was NO further documentation related to the coccygeal decubitis found in the record until 9/2/2015, when the physician ordered a wound care consult.

Review of the documentation by staff #8 (Wound Care Nurse) on 9/2/2015, at 9:48 a.m., stated, "Skin Breakdown....Stage 2 to coccyx. Deep tissue injuries to heels. Recommend and order for duoderms (moisture retentive wound dressing) to affected areas. This will provide a barrier, reduce friction and shear, and provide a moist healing environment. Off loading (keeping weight off areas) also recommended at all times."

Review of information from the "American Association of Critical Care Nurses" revealed a stage 2 decubitus is defined as, "Partial-thickness skin loss (limited to the epidermis) that may be described as a clear fluid-filled blister or shallow wound with a pink-red wound base.... Practices that prevent pressure on bony prominences such as the coccyx, trochanters, heels, and occiput have traditionally been minimized by using turning schedules every 2 hours and elevating patients' heels off of the mattress".


Further review of patient #1's record revealed the skin assessments documented each shift (2 shifts daily) from the time of the Wound Care Nurse consult on 9/2/2015, at 9:48 a.m., until 9/4/2015, at 7:30 a.m., there were 3 skin assessments in the record that did NOT contain any documentation related to the coccygeal decubitis.


Review of the facility's policy titled, "Skin Assessment" revealed the following information:

"PROCEDURE

1. Upon admission patients will be assessed for pressure ulcer risk by a Registered Nurse (RN).

2. All 'HOT SPOTS' (heels, occiput (back of head), toes, sacrum, posterior buttocks, over bony prominences....) will be assessed for skin integrity and circulatory impairment....

4. The assessment will be documented in the medical record and significant findings reported to the physician....

5. Reassessment will occur at least every twelve-hour shift and at transfer or discharge."


B. ensure nursing staff was implementing skin breakdown preventative practices, such as turning immobile patients every 1-2 hours and elevating patient's heels off of bed, to prevent pressure on bony prominences such as the coccyx, heels, and occiput in 1 (patient #1) of 6 (patients #1 through #6) records reviewed.


Review of patient #1's record revealed an admission date of 8/26/2015, and a discharge date of 10/6/2015, a total of 42 days. Just prior to his admission, patient #1 sustained a hemorrhagic (bleeding) stroke on the left side of his brain which caused right sided body paralysis. The patient was unable to move the right side of his body and was documented as "completely immobile" and confined to the hospital bed throughout the hospital stay.


Review of the Physical Therapy Notes revealed the following statements:

"10/03/15 13:11(1:11 p.m.)...Pt (patient) is total assist for all transitional movement; supine (lying on back) to sit, rolling...

10/06/15 13:51 (1:51 p.m.)...Pt very lethargic (sluggish, inactive, lifeless) nd (and) not responding to any instructions".

An interview with staff #1 revealed the facility approved and was currently using "Lippincott Procedures" as their guidance reference for pressure ulcer prevention.


Review of "Lippincott Procedures - Pressure Ulcer Prevention" revealed the following information:

"When a pressure ulcer develops despite preventive efforts, treatment includes methods to decrease pressure, such as frequent repositioning to shorten pressure duration and the use of special equipment to reduce pressure intensity. Treatment mayalso involve pressure redistribution devices, such as specialty beds, mattresses, mattress overlays, and chair cushions."


Patient #1 should have been turned or repositioned 12 times in each 24 hour period.


Review of patient #1's "Assessment/Interventions Flowsheets" revealed the patient was NOT turned or repositioned in bed every 2 hours. The following documentation related to turning and/or repositioning the patient was found:
8/26/2015 - the patient was "turned right" 1 time.
8/27/2015 - the patient was "repositioned" 1 time.
8/28/2015 - the patient was "repositioned" 3 times.
8/29/2015 - the patient was "repositioned" 6 times.
8/30/2015 - the patient was "repositioned" 6 times.
8/31/2015 - the patient was "repositioned" 3 times.
9/01/2015 - the patient was "repositioned" 12 times.
9/02/2015 - the patient was "repositioned" 11 times.
9/03/2015 - the patient was "repositioned" 12 times.
9/04/2015 - the patient was "repositioned" 12 times.
9/05/2015 - the patient was "repositioned" 12 times.
9/06/2015 - the patient was "repositioned" 12 times.
9/07/2015 - the patient was "repositioned" 8 times.
9/08/2015 - the patient was "repositioned" 3 times.
9/09/2015 - the patient was "repositioned" 7 times.
9/10/2015 - the patient was "repositioned" 12 times.
9/11/2015 - the patient was "repositioned" 8 times.
9/12/2015 - the patient was NOT turned or repositioned.
9/13/2015 - the patient was "repositioned" 11 times.
9/14/2015 - the patient was "repositioned" 11 times.
9/15/2015 - the patient was "repositioned" 2 times.
9/16/2015 - the patient was "repositioned" 4 times.
9/17/2015 - the patient was NOT turned or repositioned.
9/18/2015 - the patient was NOT turned or repositioned.
9/19/2015 - the patient was NOT turned or repositioned.
9/20/2015 - the patient was NOT turned or repositioned.
9/21/2015 - the patient was "repositioned" 2 times.
9/22/2015 - the patient was "repositioned" 7 times.
9/23/2015 - the patient was "repositioned" 9 times.
9/24/2015 - the patient was "repositioned" 12 times.
9/25/2015 - the patient was "repositioned" 6 times.
9/26/2015 - the patient was "repositioned" 8 times.
9/27/2015 - the patient was "repositioned" 9 times.
9/28/2015 - the patient was "repositioned" 9 times.
9/29/2015 - the patient was "repositioned" 12 times.
9/30/2015 - the patient was "repositioned" 8 times.
10/1/2015 - the patient was NOT turned or repositioned.
10/2/2015 - the patient was NOT turned or repositioned.
10/3/2015 - the patient was NOT turned or repositioned.
10/4/2015 - the patient was "turn ....total lift" 2 times.
10/5/2015 - the patient was NOT turned or repositioned.
10/6/2015 - the patient was NOT turned or repositioned.
The patient discharged 10/6/2015 at 5:50 p.m.

According to the nursing documentation, patient #1 was NOT repositioned by staff in compliance with the facility's policy 34 out of 42 days.

An interview with staff #9 (Director of Intensive Care Unit) revealed the ICU unit has a total of 16 beds. 5 of the 16 beds were "rotation beds" that were owned by the hospital. Staff #9 was not able to determine if a rotation bed was used by patient #1 since no records are kept as to which patients or patient rooms had the rotation beds in use.

Based on record and document review, the facility failed to ensure patients were safe from chemical restraints used to restrict the patient's freedom of movement and were only used when less restrictive interventions had been determined to be ineffective in 1 (patient #1) of 6 (patient #1 through #6) records reviewed.

Review of patient #1's record revealed the following information:

Patient #1 suffered an unwitnessed fall from bed on 10/2/2015, at 2:40 a.m. At 7:40 a.m., the nurse documented the patient was "confused....uncooperative wanders" and "continually trying to climb over rails. Gave Ativan". There was NO documentation of other less restrictive methods considered or attempted to stop the patient from climbing over the bed rails prior to giving the Ativan.

Review of the facility's policy titled, "Use of Restraint or Seclusion" revealed the following information:

"DEFINITIONS
Restraint - Restraint is defined as:...
A. Chemical restraint - A drug or medication, when it is used as a restriction, to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition....

PROCEDURE
A. LEAST RESTRICTIVE ALTERNATIVES
Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member or others from harm."

Based on record review and document review, the facility failed to:

A. obtain a signed physician's order for the use of restraints in 1 (patient #1) of 6 (patient #1 through #6) records reviewed. The facility failed to have a physician's order in patient #1's record for 4 of 27 days (24 hour period) patient #1 was restrained.

Review of patient #1's record revealed the patient's left wrist was restrained from 8/27/2015 until 9/23/2015. Patient #1's left wrist was first restrained with a soft wrist restraint on 8/27/2015 at 6:30 p.m. The preprinted restraint order dated 8/27/2015 at 6:30 p.m. was NOT signed by a physician. The preprinted restraint order dated 8/28/2015 at 12:00 a.m. was NOT signed by a physician. There was NO restraint order found in the record for 9/18/2015 and 9/20/2015.

Review of the facility's policy titled, "Use of Restraint or Seclusion" revealed the following statement:

"C. INITIATION OF RESTRAINT BY PHYSICIAN ORDER
1. The use of restraint or seclusion must be in accordance with the order of a physician who is responsible for the care of the patients and authorized to order restraint or seclusion....
7. Non-Violent/Non-Self Destructive Restraints - Orders must not exceed one calendar day."


B. obtain a signed physician's order for the use of a chemical restraint in 1 (patient #1) of 6 (patient #1 through #6) records reviewed.

Review of patient #1's record revealed the following information:
Patient #1 suffered an unwitnessed fall from bed on 10/2/2015 at 2:40 a.m. At 7:40 a.m., the nurse documented the patient was "confused....uncooperative wanders" and "continually trying to climb over rails. Gave Ativan". There was no order in the record for Ativan to be given as a means to restrain the patient.

Review of the facility's policy titled, "Use of Restraint or Seclusion" revealed the following statement:

"C. INITIATION OF RESTRAINT BY PHYSICIAN ORDER
1. The use of restraint or seclusion must be in accordance with the order of a physician who is responsible for the care of the patients and authorized to order restraint or seclusion."

Based on record review and document review the facility failed to ensure the attending physician was consulted when another physician ordered a patient restraint in 1 (patient #1) of 6 (patient #1 through #6) records reviewed.

Review of patient #1's record revealed the patient's left wrist was first restrained with a soft wrist restraint on 8/27/2015 at 6:30 p.m. The preprinted restraint order dated 8/27/2015 at 6:30 p.m. was NOT signed by a physician and did not list a physician's name. The preprinted restraint order dated 8/28/2015 at 12:00 a.m. was NOT signed by a physician and did not list a physician's name. The first restraint order that contained a physician's name was dated 8/29/2015 at 4:52 a.m. and was documented as a "telephone" order received from staff #5.
Review of patient #1's "Admitting Facesheet" revealed the attending physician was staff #6. There was NO documentation the attending physician (staff #6) was consulted or notified that patient #1 had been placed in restraint.

Review of the facility's policy titled, "Use of Restraint or Seclusion" revealed the following statement:
"C. INITIATION OF RESTRAINT BY PHYSICIAN ORDER
2. The attending physician must be consulted as soon as possible if the attending physician did not order the restraint or seclusion."

Based on record and document review, the facility failed to ensure their staff was following their own facility's policy for reassessment and monitoring patients that were being restrained in 1 (patient #1) of 6 (patient #1 through #6) records reviewed.

Review of patient #1's record revealed an admission date of 8/26/2015 and a discharge date of 10/6/2015, a total of 42 days. Patient #1's left wrist was placed in a soft wrist restraint on 8/27/2015 at 7:30 p.m. and remained restrained until 9/22/2015 at 8:55 a.m. for a total of 25 days, 13 hours and 25 minutes. There was NO documentation found that reflected the release of the restraint or any range of motion exercises were done with patient #1's left upper extremity.

Review of the facility's policy titled, "Use of Restraint or Seclusion" revealed the following information:
"PROCEDURE....
REASSESSMENT/MONITORING....The following components for Nonviolent/Non-Self Destructive Restraints are reassessed/monitored/offered:...
Ongoing Monitoring.....Range of motion, one extremity at a time....Time Frame....5 minutes for each extremity continuously every 2 hours....Documentation....Every 2 hours".

Based on record review, document review and interviews, the facility failed to:

A. Assess, monitor and report changes in the condition of the patient's skin in 1 (patient #1) of 6 (patient #1 through #6) records reviewed.
Review of patient #1's record revealed an admission date of 8/26/2015, and a discharge date of 10/6/2015, a total of 42 days. Just prior to his admission, patient #1 sustained a hemorrhagic (bleeding) stroke on the left side of his brain which caused right sided body paralysis. The patient was unable to move the right side of his body and was documented as "completely immobile" and confined to the hospital bed throughout the hospital stay.
The nursing staff at the facility worked 2, 12 hour shifts per day. The day shift worked from 7:00 a.m. to 7:00 p.m. and the night shift worked from 7:00 p.m. until 7:00 a.m.
Review of patient #1's skin assessments revealed there was NO skin breakdown documented prior to 8/29/2015 at 7:30 a.m. when staff #7 documented, "small coccygeal decub (tailbone area bedsore)". The following shift skin assessment (8/29/2015 at 7:00 p.m.) documentation did NOT contain any skin breakdown information. On 8/30/2015 at 7:30 a.m., staff #7 documented, "small coccygeal decub". There was NO further documentation related to the coccygeal decubitis found in the record until 9/2/2015 when the physician ordered a wound care consult.

Review of the documentation by staff #8 (Wound Care Nurse) on 9/2/2015 at 9:48 a.m. stated, "Skin Breakdown....Stage 2 to coccyx. Deep tissue injuries to heels. Recommend and order for duoderms (moisture retentive wound dressing) to affected areas. This will provide a barrier, reduce friction and shear, and provide a moist healing environment. Off loading (keeping weight off areas) also recommended at all times."

Review of information from the "American Association of Critical Care Nurses" revealed a stage 2 decubitus is defined as, "Partial-thickness skin loss (limited to the epidermis) that may be described as a clear fluid-filled blister or shallow wound with a pink-red wound base.... Practices that prevent pressure on bony prominences such as the coccyx, trochanters, heels, and occiput have traditionally been minimized by using turning schedules every 2 hours and elevating patients' heels off of the mattress".

Further review of patient #1's record revealed the skin assessments documented each shift (2 shifts daily) from the time of the Wound Care Nurse consult on 9/2/2015 at 9:48 a.m. until 9/4/2015 at 7:30 a.m. there were 3 skin assessments in the record that did NOT contain any documentation related to the coccygeal decubitis.

Review of the facility's policy titled, "Skin Assessment" revealed the following information:
"PROCEDURE
1. Upon admission patients will be assessed for pressure ulcer risk by a Registered Nurse (RN).
2. All 'HOT SPOTS' (heels, occiput (back of head), toes, sacrum, posterior buttocks, over bony prominences....) will be assessed for skin integrity and circulatory impairment....
4. The assessment will be documented in the medical record and significant findings reported to the physician....
5. Reassessment will occur at least every twelve-hour shift and at transfer or discharge."


B. ensure nursing staff was implementing skin breakdown preventative practices, such as turning immobile patients every 1-2 hours and elevating patient's heels off of bed, to prevent pressure on bony prominences such as the coccyx, heels, and occiput in 1 (patient #1) of 6 (patients #1 through #6) records reviewed.

Review of patient #1's record revealed an admission date of 8/26/2015, and a discharge date of 10/6/2015, a total of 42 days. Just prior to his admission, patient #1 sustained a hemorrhagic (bleeding) stroke on the left side of his brain which caused right sided body paralysis. The patient was unable to move the right side of his body and was documented as "completely immobile" and confined to the hospital bed throughout the hospital stay.

Review of the Physical Therapy Notes revealed the following statements:
"10/03/15 13:11(1:11 p.m.)...Pt (patient) is total assist for all transitional movement; supine (lying on back) to sit, rolling...
10/06/15 13:51 (1:51 p.m.)...Pt very lethargic (sluggish, inactive, lifeless) nd (and) not responding to any instructions".

An interview with staff #1 revealed the facility approved and was currently using "Lippincott Procedures" as their guidance reference for pressure ulcer prevention.

Review of "Lippincott Procedures - Pressure Ulcer Prevention" revealed the following information:
"When a pressure ulcer develops despite preventive efforts, treatment includes methods to decrease pressure, such as frequent repositioning to shorten pressure duration and the use of special equipment to reduce pressure intensity. Treatment may also involve pressure redistribution devices, such as specialty beds, mattresses, mattress overlays, and chair cushions."

Patient #1should have been turned or repositioned 12 times in each 24 hour period.

Review of patient #1's "Assessment/Interventions Flowsheets" revealed the patient was NOT turned or repositioned in bed every 2 hours. The following documentation related to turning and/or repositioning the patient was found:
8/26/2015 - the patient was "turned right" 1 time.
8/27/2015 - the patient was "repositioned" 1 time.
8/28/2015 - the patient was "repositioned" 3 times.
8/29/2015 - the patient was "repositioned" 6 times.
8/30/2015 - the patient was "repositioned" 6 times.
8/31/2015 - the patient was "repositioned" 3 times.
9/01/2015 - the patient was "repositioned" 12 times.
9/02/2015 - the patient was "repositioned" 11 times.
9/03/2015 - the patient was "repositioned" 12 times.
9/04/2015 - the patient was "repositioned" 12 times.
9/05/2015 - the patient was "repositioned" 12 times.
9/06/2015 - the patient was "repositioned" 12 times.
9/07/2015 - the patient was "repositioned" 8 times.
9/08/2015 - the patient was "repositioned" 3 times.
9/09/2015 - the patient was "repositioned" 7 times.
9/10/2015 - the patient was "repositioned" 12 times.
9/11/2015 - the patient was "repositioned" 8 times.
9/12/2015 - the patient was NOT turned or repositioned.
9/13/2015 - the patient was "repositioned" 11 times.
9/14/2015 - the patient was "repositioned" 11 times.
9/15/2015 - the patient was "repositioned" 2 times.
9/16/2015 - the patient was "repositioned" 4 times.
9/17/2015 - the patient was NOT turned or repositioned.
9/18/2015 - the patient was NOT turned or repositioned.
9/19/2015 - the patient was NOT turned or repositioned.
9/20/2015 - the patient was NOT turned or repositioned.
9/21/2015 - the patient was "repositioned" 2 times.
9/22/2015 - the patient was "repositioned" 7 times.
9/23/2015 - the patient was "repositioned" 9 times.
9/24/2015 - the patient was "repositioned" 12 times.
9/25/2015 - the patient was "repositioned" 6 times.
9/26/2015 - the patient was "repositioned" 8 times.
9/27/2015 - the patient was "repositioned" 9 times.
9/28/2015 - the patient was "repositioned" 9 times.
9/29/2015 - the patient was "repositioned" 12 times.
9/30/2015 - the patient was "repositioned" 8 times.
10/1/2015 - the patient was NOT turned or repositioned.
10/2/2015 - the patient was NOT turned or repositioned.
10/3/2015 - the patient was NOT turned or repositioned.
10/4/2015 - the patient was "turn ....total lift" 2 times.
10/5/2015 - the patient was NOT turned or repositioned.
10/6/2015 - the patient was NOT turned or repositioned.
The patient discharged 10/6/2015 at 5:50 p.m.

According to the nursing documentation, patient #1 was NOT repositioned by staff in compliance with the facility's policy 34 out of 42 days.
An interview with staff #9 (Director of Intensive Care Unit) revealed the ICU unit has a total of 16 beds. 5 of the 16 beds were "rotation beds" that were owned by the hospital. Staff #9 was not able to determine if a rotation bed was used by patient #1 since no records are kept as to which patients or patient rooms had the rotation beds in use.


C. ensure their staff was following their own facility's policy for reassessment and monitoring patients that were being restrained in 1 (patient #1) of 6 (patient #1 through #6) records reviewed.

Review of patient #1's record revealed an admission date of 8/26/2015 and a discharge date of 10/6/2015, a total of 42 days. Patient #1's left wrist was placed in a soft wrist restraint on 8/27/2015 at 7:30 p.m. and remained restrained until 9/22/2015 at 8:55 a.m. for a total of 25 days, 13 hours and 25 minutes. There was NO documentation found that reflected the release of the restraint or any range of motion exercises were done with patient #1's left upper extremity.
Review of the facility's policy titled, "Use of Restraint or Seclusion" revealed the following information:
"PROCEDURE....
REASSESSMENT/MONITORING....The following components for Nonviolent/Non-Self Destructive Restraints are reassessed/monitored/offered:...
Ongoing Monitoring.....Range of motion, one extremity at a time....Time Frame....5 minutes for each extremity continuously every 2 hours....Documentation....Every 2 hours".