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Based on interview and record review the facility failed to ensure restraint orders were received prior to usage of restraints. They failed to ensure complete restraint assessments were performed and alternatives were documented prior to administration of prn psychotropic medications used for aggressive behavior. This deficient practice was found in 1 of 1 patients (Patient #2).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of the EMS (Emergency medical services) report revealed Patient #2 was transferred to the hospital on 05/21/2015 at 9:24 a.m.
Review of the EMS (Emergency medical services) report revealed Patient #2 was a 64 year old female picked up from a nursing home. According to documentation Patient #2 had soft tissue swelling/bruising to the face, upper right arm and chest /thorax. The EMS documented Patient #2 was found in bed with staff holding her down, moaning and combative. Staff reported Patient #2 had a ground level fall last night and was normal until this am. EMS documented Patient #2 had swelling to her lip and multiple bruises on her body from the fall. Enroute Patient #2 was restrained.
Review of the clinical record of Patient #2 revealed she presented to the ED (Emergency Department) on 05/21/2015 at 9:59 a.m.
Review of ED trauma flow sheet dated 05/21/2015 revealed Patient #2 had a skin tear to the back of the left arm.
At 10:05 a.m. there was documentation that Patient #2 had a laceration to the left hip and had altered mental status. Patient #2 was combative and pulling on everything. She had to be physically restrained with wrist restraints pta by ems. Continued upon transfer to the ED bed. One IV (intravenous) in place by EMS in the left hand, Versed (a sedative) was given to calm the patient for treatment and testing. There was documentation that Patient #2 was non-verbal secondary to an old stroke, but normally followed commands. Patient #2 moved all extremities.
Patient #2 was given Versed 2 milligrams IV (intravenous) at 10:15a.m, 10:26 a.m., 10:40 a.m., and 11:40 a.m., for being combative. At 11:45 a.m. the anti-psychotic Geodon was administered IM (intramuscular) for anxiety.
At 1:53 p.m., Patient #2 was pulling against the restraints. No signs of distress, breathing equally, vital signs stable.
At 3:44 p.m. a physician order was written for inpatient admission to telemetry unit for altered mental status and urinary tract infection.
At 4:52 p.m. Patient #2 was given another dosage of Versed for anxiety.
At 5:20 p.m., Patient #2 was taken to the floor (telemetry unit).
At 5:30 p.m. LVN #5 documented Patient #2 had a skin tear to the left arm, busted lips, and scattered bruises to both legs. Review of a copy of the same assessment form revealed two additional areas added (right bruised swollen hand and a Stage I on the coccyx-sacral area). RN #6 initialed off on the form but did not time it to indicate when she was adding the information to the form.
At 5:45 p.m. (over 8 hours from presentation to the ED) was the first documentation of a physician order being written for restraint usage written and initiated by LVN #5. There was no documentation in ED notes of Patient #2 being consistently monitored while in restraints. There was no documentation of what type or how many restraints were being used.
The first documentation of a restraint assessment was on 05/21/2015 and 7:00 p.m.
05/22/2015 at 9:00 a.m. there was no documentation of Releasing and ROM (range of motion), at 1:00 a.m. and 7:00 a.m. there was no documentation of Patient #2's skin being assessed for signs and symptoms of injury. On 05/22/2015 at 10:58 p.m. there was no documentation of skin assessment for signs and symptoms of injury. On 05/22/2015 at 9:00 p.m. there was documentation the restraints were discontinued.
Review of the medication administration record revealed the following psychotropic were administered;
Haldol 5 milligrams=1 (ml) milliliter IV (intravenous) every 4 hours as needed for agitation /restlessness
05/22/2015 at 8:00 a.m.
05/23/2015 at 12:29 a.m.
Lorazepam 1mg=0.5ml, IV every hour as needed for anxiety and agitation
05/23/2015 at 2:47 a.m. and 7:33 p.m.
Haldol 5 milligrams= 1 tablet, every 4 hours as needed for agitation /restlessness
05/23/2015 at 4:19 p.m., 11:05 p.m.,
05/24/2015 at 9:32 a.m.
05/25/2015 at 9:48 a.m.
There was no documentation of the alternatives tried prior to administration of the medication except twice.
During an interview on 08/04/2015 after 12:00 p.m., Staff #1 and 4 confirmed the problems with the restraints and staffing documentation.

Review of a facility policy dated 11/2014 named" Restraint Management for Acute Medical and Surgical Care" revealed the following:
POLICY
...When the use of restraints is necessary, patient care staff must demonstrate through documentation the restraint intervention is used in accordance with a written modification to the patient's plan of care and is least restrictive intervention. The use of restraints is based on individual assessments of the patient with the goal of protecting the patient's safety ...
Section 1
B. Clinical Justification Based on Assessment
a. Restraints are only used in clinically justified situations in which Criteria for Application have been met and less restrictive measures have been ineffective.
b. Restraints are applied based on the initial and on-going assessed need of the patient, using the least restrictive means possible.
C.Restraint Alternatives
a. Positive and less restrictive alternatives are considered and attempted whenever possible prior to use of more restrictive interventions. Such as:
i. Reorientation
ii. Bed Check Alarms
iii. Arranging the family or significant other to remain at the bedside
iv. Moving patient closer to the nurses station,
v. Other creative solutions to avoid using restraints.
b. Restraints are utilized only after appropriate alternative measure have been deemed unsuccessful.
c.The use of less intrusive measures poses a greater risk than the risk of using a restraint.
Section II
B. Chemical Restraint: Medications can also be used as a restraint when staff members decide to sedate a patient who is being difficult. A medication is defined to be a restraint when it is used to manage a patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition ...
Section IV
Obtaining a Medical/Surgical restraint Order:
A.The physician provided an individual order to initiate the use of restraints.
B. If he physician is not available to issue the order, a Registered Nurse (RN) may initiate the restraint use based on the assessment and immediate needs of the patient.
C. If initiate by a RN a verbal or written order is obtained from the physician and entered into the patient's medical record.
D.The attending physician will perform an (in-person) assessment within 24 hours of initiation of the restraint, thereafter at least every calendar day, at which time the restraint will be reordered, or discontinued as appropriate.
F. Orders must specify the date/time and contain the following:
a. Purpose for which the restraints are applied.
b. Type of restraint device and where to apply the device.
c. Time limit on order.

Section VI.
Assessment/Reassessment/Documentation Requirements for Medical and Surgical Restraint Usage
A. In the absence of the physician, a RN determines and documents that other reasonable, less restrictive measures have been found to be ineffective to benefit the patient and promote the delivery of essential medical treatment and care.
B. The RN performs a comprehensive assessment, evaluating what intervention is most appropriate and of the greatest benefit to the patient. When selecting the appropriate restraining device any pre-existing medical conditions, physical disabilities, and limitations that may place the patient at grater risks are evaluated. The RN also addressed specific risk associated with vulnerable patients, such as emergency, pediatric, and cognitively impaired patients.