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Based on observation, staff interview and record review, the hospital failed to document evidence that medical restraints ordered for fall prevention were the least restrictive appropriate available treatment for 2 of 2 sampled patients utilizing medical restraints in the certified portion of the psychiatric hospital (#15 and #16).

The findings include:

Patient #15:

Observations were conducted of patient #15 on 6/7/16 at 12:10pm and 2:30pm, on 6/8/16 at 9:15am and 1:00pm and on 6/9/16 at 9:30am. In all observations, patient #15 was seated in a geri-chair with his feet on the floor wearing a Posey vest restraint.

A record review was conducted to review medical restraint indications, orders, and treatment team recommendations.

A review of treatment team notes on 12/2/15 revealed patient #15 was ambulating using a wheelchair.

A review of 'Progress and Event Notes, form 52', was conducted from 3/1/16 to present. On 3/1/16 at 11:57 a nurse documented that patient #15 was offered a physician assessment due to a fall he had on 2/29/16 from a geri chair. Patient #15 declined the visit stating he was okay. On 3/2/16 shortly after midnight at 12:05am, a nurse wrote that patient #15 was on the floor after he attempted in transfer self from wheelchair to gerichair. No injuries noted. Night staff noted that patient #15 prefers to sleep in a geri chair instead of in a bed. No further falls were documented on this form, but on 3/8/16 at 3:05pm a nurse wrote, "due to resident's frequent falls from wheelchair while walking, orders given for geri-chair, Posey Vest and Mini-Pelvic restraint when out of bed."

A review of physician orders revealed that the initial order for medical restraints occurred on 3/8/16 at 2:17pm when the physician ordered a geri-chair, Posey vest and a mini pelvic restraint "to keep resident from falling off wheel and other chairs for patient safety".

The order for geri chair, Posey vest and mini-pelvic restraint was renewed on 3/18/16. On 4/18/16 on the 'monthly treatment orders' the order was changed to geri chair and Posey vest when out of bed. The min-pelvic restraint was not re-ordered. The geri-chair and Posey vest order was renewed on 4/29/16 and 5/18/16. On 4/29/16 the physician wrote, Posey vest with geri- chair when out of bed for safety until team reviews. On 5/22/16 additional restraint orders were received of Posey vest in bed, side rails up x2 until reviewed by treatment team the next day. Rationale was documented as "resident gait unsteady." On 5/23/16, the physician discontinued the Posey vest when in bed.

A review of physician progress notes from March 2016 until present revealed no documentation or discussion about restraint alternatives attempted or how the least restrictive device was assessed.

A further review of nurses notes revealed that nurses documented a monthly restraint summary. On 3/22/16 at 10:13, monthly summary of March 2016 on 7-3 shift, "Due to resident's frequent falls from wheelchair and while walking, orders given for geri-chair, Posey Vest and Mini-Pelvic restraint when out of bed for safety". On 3/26/16 at 1:50pm, a nurse wrote, "Monthly treatment orders have been received for March for Posey vest and mini pelvic restraint with geri-chair when out of bed as safety precaution to decrease risk of injury. Resident has had no injuries since restraint has been initiated and it is recommended to continue orders." On 4/20/16 at 10:38 a nurse wrote, "Monthly treatment orders have been received for April for Posey vest with geri-chair when out of bed as safety precaution to decrease risk of injury. This is a reduction from Mini-pelvic and Posey vest with geri-chair when out of bed. Resident currently has no injuries and it is recommended to continue orders." On 5/19/16 at 9:50am, a nurse wrote, "Monthly treatment orders received on 5/18/16 for May. Orders are for Posey vest with geri-chair when out of bed as safety precaution to decrease the risk of injury. Resident currently has no injuries from falls reported and it is recommended to continue these orders."

The Treatment team (recovery team) meetings were reviewed. Patient #15 had a bi-monthly review on 3/30/16, after the initiation of restraints. There was no mention of the restraint use in the team notes. The annual team meeting occurred on 5/25/16 with updated goals and treatment modalities. Patient #15 had a goal developed for "risk for injury related to unsteady gait due to tardive dyskinesia (neurological disorder of involuntary movements) and verbal/physical aggression". The short and long term goals stated that patient #15 would reduce risk for injury by wearing properly fitting clothes, non-skin shoes and using wheelchair for assistance with ambulation, as evidence by him having no falls or injuries through 12/7/16. There was no mention of restraint usage. The meeting notes were reviewed. There was no mention of the day time use of restraints. The team did mention that the bedtime Posey vest had been discontinued and side rails were being used, and the team agreed with this decision.

Two incidents were documented to have occurred while the patient was in restraints. On 5/3/16 at 11:00pm a nurse wrote that patient #15 was in the hallway by the telephone when staff noticed a chair flipped over and patient #15 stating, "I need a nurse. I'm bleeding." When asked, patient #15 stated that the man in the burgundy jacket hit me. Physician orders were received on 5/4/16 for an X-Ray of facial bones and suture laceration status post being hit by another resident.

On 5/23/16 a nurse documented that at about 4:00pm, the psych ARNP (advanced registered nurse practitioner) observed patient #15 had turned the Geri-chair he was sitting in onto its back. Patient #15 was sitting in the chair as Posey vest was still intact. No injuries noted. Patient #15 was trying to move the geri-chair backward when if flipped over.

On 6/8/16 at 1:10pm, an interview was conducted with the treatment team registered nurse, nurse CC. Nurse CC confirmed that the initial restraint orders occurred on 3/8/16 and were for a geri chair, Posey vest and mini pelvic restraint. this was changed to just a Posey vest on 4/22/16. We do have pommel cushions and lap buddies, but patient #15 is so non-compliant he would just remove them. Nurse CC was asked about the physician restraint order of 4/26/16 when the physician ordered, "Posey Vest with geri chair when out of bed for safety until team reviews." Nurse CC stated that they order team, but it isn't a team decision. If it is medical restraints, then the team is technically the medical doctor. The treatment team reviews restraints after 180 days. There is not 180 day review because patient #15 has not had restraints that long. Nurses review restraints monthly and document in the 52's ( Progress and Event Notes).

Patient #16

Observations were conducted of patient #16 on 6/7/16 at 12:10pm and 2:30pm, on 6/8/16 at 9:12am and 1:00pm and on 6/9/16 at 9:45am. In all observations, patient #16 was seated in a geri-chair with his feet on the floor wearing a Posey vest restraint.

An interview was conducted with the treatment team registered nurse, nurse CC, on 6/8/16 at 9:12am. Nurse CC stated that patient #16 had medical restraints initiated in the past week due to a bad fall with a brain bleed.

Review of the medical record revealed a fall over a month ago on 4/26/16 after which patient #16 was diagnosed with a subdural hematoma. The notes stated that the resident was noted with bradycardia and ventricular bigeminy. On 5/23/16, patient #16 was evaluated by neurology for chronic encephalopathy (brain disorder) recently evaluated for ataxia (a lack of muscle coordination) with recurrent falls. On 5/24/16 there was a transport report which stated that patient #16 was being transferred to acute care to rule out a skull fracture status post fall.

A record review of physician orders, progress notes, and treatment team notes was conducted for treatment plan updates and changes to address the falls. The only identified treatment plan change was the initiation of a Posey vest medical restraint.

A review of physician orders revealed that the initial order for medical restraints occurred on 6/5/16 at 8:45am. The physician ordered to send resident #16 to the emergency room (ER) for evaluation. Posey Vest with wheelchair when out of bed until reviewed by the ward physician on 6/6/16. Rationale, fall, hitting left side of head and complaints of left elbow arm pain. Safety precautions. Upon return from the ER on 6/5/16 at 11:45am, the physician wrote to continue to use Posey Vest with wheelchair/ geri-chair when out of bed. Full side rails up in bed. Ward physician to review in am. Rationale: history of falls, increased risk of injury. On 6/8/16 at 9:30am the ward physician ordered Posey Vest with wheelchair/ geri-chair when out of bed; Side rails up x4 in bed. Add restraint orders to the the monthly treatment orders. Rationale: Increased Risk of injury with history of falls.

A record review was conducted to review how the least restrictive appropriate available treatment for fall prevention was determined.

The Treatment team (recovery team) meetings were reviewed. The most recent Treatment team meeting occurred 5/18/16, prior to the restraint initiation. There was no documentation related to medical restraints.

Medical/Psychiatric Progress notes were reviewed. There was no mention of medical restraints.

A review of 'Progress and Event Notes, form 52', was conducted for May and June 2016. There was no documentation regarding alternatives tried or how the least restrictive device was determined. On 6/5/16 a nurse wrote that at approximately 8:40am, direct care staff reported that resident #16 had fallen in the hallway. Resident #16 complained of head and arm pain, but there were no visible signs of injury noted. The physician was notified and orders were received to send resident to ER for evaluation and Posey Vest with wheelchair when out of bed due to increased risk of injury. On 6/5/16 a nurse wrote that at 12:52pm, the physician changed the order to Posey Vest with wheelchair/ geri-chair when out of bed and side rails up in bed until reviewed by ward physician in the AM.

On 6/9/16 at 10:00am an interview was conducted with the treatment team registered nurse, nurse CC. Nurse CC was unable to locate documentation showing restraint alternatives tried and determination that the restraints chosen were the least restrictive. Nurse CC stated that we do discuss it, but it does not appear to be documented.

Based on record review and staff interview, the hospital failed to clearly document the circumstances of an emergency situation which resulted in the administration of an emergency treatment order (ETO) for 2 of 3 ETOs administered (patient #18).

The findings:

On 6/9/16 at 9:50 am, an interview was conducted with the treatment team registered nurse, nurse CC. Nurse CC stated that according to their log, only 3 Emergency Treatment Orders (ETO) had been administered on the ward to date in 2016. All 3 ETOs were given to patient #18, one each in January, February and May. The behavior necessitating administration of an ETO would be documented in the "52's" (Progress and Event Notes) or in the physician progress notes. Our psychiatric advanced registered nurse practitioner (ARNP) always writes a detailed note.

May ETO:

A record review of physician orders revealed on 5/19/16 at 8:15am a telephone verbal order was received for ETO: Give Ativan 2mg IM (intramuscular injection) now. Rationale was documented as increased agitation; unable to de-escalate or redirect.

A review of 'Progress and Event Notes, form 52', for ETO administration was conducted. On 5/19/16 at 9:26am a nurse wrote that Resident #18 was very demanding during morning medication pass and refused several medications. After resident received her medications, she became increasingly agitated and verbally aggressive with both direct care staff and other residents. Attempted to redirect resident several times with no success, behavior just increased. ETO order given by physician for Ativan 2mg IM now x 1 dose. There was no documentation regarding specific behaviors, length of time the behaviors were occurring, severity of behaviors and whether the personal safety plan was used. The nurse did not define what was meant by agitated and verbally aggressive.

A record review of Medical/Psychiatric Progress notes was conducted. There was no documentation of the ETO.

February ETO:

A record review of physician orders revealed on 2/4/16 at 1:40pm a telephone verbal order was received for ETO: Give Ativan 2mg by intramuscular injection now. Rationale was documented as increased agitation; unable to verbally redirect.

A review of 'Progress and Event Notes, form 52', revealed an entry on 2/4/16 which stated at approximately 11:00am resident #18 was noted as agitated, yelling " my chest hurts, it is a medical emergency, I need to see the doctor now, I want my medicine when I want it, not when he says I can have it. " The physician assessed patient #18 and routine noon medications were administered. Approximately 15 minutes later resident #18 was calm and requesting to go outside. Later on 2/4/16 at 1:48pm the nurse wrote that resident #18 noted with increased agitation, unable to be verbally redirected after multiple attempts by multiple staff members. Telephone order received to give Ativan 2mg IM now x 1 dose. Injection given in the left deltoid (arm). There was no documentation regarding specific behaviors, length of time the behaviors were occurring, severity of behaviors and whether the personal safety plan was used. The nurse did not define what was meant by 'increased agitation'.

A record review of Medical/Psychiatric Progress notes was conducted. There was no documentation of the ETO.

On 6/9/16 at 10:40 am, a follow-up interview was conducted with nurse CC. Nurse CC stated that the psychiatric ARNP did not give the orders for the ETO, which is why she did not write a note. Nurse CC stated that the only other documentation for ETO's was a log (Report of Emergency treatment orders) but it will not describe the specific behaviors. The log will only say what was ordered, who ordered it, and whether the patient received it.

Based on observation, staff interview and clinical record review, the hospital failed to consider alternative means prior to initiating and continuing medical restraints for 2 of 2 sampled patients utilizing medical restraints in the certified portion of the psychiatric hospital (#15 and #16).

The findings include:

Patient #15:

Observations were conducted of patient #15 on 6/7/16 at 12:10pm and 2:30pm, on 6/8/16 at 9:15am and 1:00pm and on 6/9/16 at 9:30am. In all observations, patient #15 was seated in a geri-chair with his feet on the floor wearing a Posey vest restraint.

A record review was conducted to review medical restraint indications, orders, and treatment team recommendations.

A review of treatment team notes on 12/2/15 revealed patient #15 was ambulating using a wheelchair.

A review of 'Progress and Event Notes, form 52', was conducted from 3/1/16 to present. On 3/1/16 at 11:57 a nurse documented that patient #15 was offered a physician assessment due to a fall he had on 2/29/16 from a geri chair. Patient #15 declined the visit stating he was okay. On 3/2/16 shortly after midnight at 12:05am, a nurse wrote that patient #15 was on the floor after he attempted in transfer self from wheelchair to gerichair. No injuries noted. Night staff noted that patient #15 prefers to sleep in a geri chair instead of in a bed. No further falls were documented on this form, but on 3/8/16 at 3:05pm a nurse wrote, "due to resident's frequent falls from wheelchair while walking, orders given for geri-chair, Posey Vest and Mini-Pelvic restraint when out of bed."

A review of physician orders revealed that the initial order for medical restraints occurred on 3/8/16 at 2:17pm when the physician ordered a geri-chair, Posey vest and a mini pelvic restraint "to keep resident from falling off wheel and other chairs for patient safety".

The order for geri chair, Posey vest and mini-pelvic restraint was renewed on 3/18/16. On 4/18/16 on the 'monthly treatment orders' the order was changed to geri chair and Posey vest when out of bed. The min-pelvic restraint was not re-ordered. The geri-chair and Posey vest order was renewed on 4/29/16 and 5/18/16. On 4/29/16 the physician wrote, Posey vest with geri- chair when out of bed for safety until team reviews. On 5/22/16 additional restraint orders were received of Posey vest in bed, side rails up x2 until reviewed by treatment team the next day. Rationale was documented as "resident gait unsteady." On 5/23/16, the physician discontinued the Posey vest when in bed.

A review of physician progress notes from March 2016 until present revealed no documentation or discussion about the initiation, continuation or reduction of restraints. There was no documentation of the alternatives attempted or how the least restrictive device was assessed.

A further review of nurses notes revealed that nurses documented a monthly restraint summary. On 3/22/16 at 10:13, monthly summary of March 2016 on 7-3 shift, "Due to resident's frequent falls from wheelchair and while walking, orders given for geri-chair, Posey Vest and Mini-Pelvic restraint when out of bed for safety". On 3/26/16 at 1:50pm, a nurse wrote, "Monthly treatment orders have been received for March for Posey vest and mini pelvic restraint with geri-chair when out of bed as safety precaution to decrease risk of injury. Resident has had no injuries since restraint has been initiated and it is recommended to continue orders." On 4/20/16 at 10:38 a nurse wrote, "Monthly treatment orders have been received for April for Posey vest with geri-chair when out of bed as safety precaution to decrease risk of injury. This is a reduction from Mini-pelvic and Posey vest with geri-chair when out of bed. Resident currently has no injuries and it is recommended to continue orders." On 5/19/16 at 9:50am, a nurse wrote, "Monthly treatment orders received on 5/18/16 for May. Orders are for Posey vest with geri-chair when out of bed as safety precaution to decrease the risk of injury. Resident currently has no injuries from falls reported and it is recommended to continue these orders."

The Treatment team (recovery team) meetings were reviewed. Patient #15 had a bi-monthly review on 3/30/16, after the initiation of restraints. There was no mention of the restraint use in the team notes. The annual team meeting occurred on 5/25/16 with updated goals and treatment modalities. Patient #15 had a goal developed for "risk for injury related to unsteady gait due to tardive dyskinesia (neurological disorder of involuntary movements) and verbal/physical aggression". The short and long term goals stated that patient #15 would reduce risk for injury by wearing properly fitting clothes, non-skin shoes and using wheelchair for assistance with ambulation, as evidence by him having no falls or injuries through 12/7/16. There was no mention of restraint usage. The meeting notes were reviewed. There was no mention of the day time use of restraints. The team did mention that the bedtime Posey vest had been discontinued and side rails were being used, and the team agreed with this decision.

Two incidents were documented to have occurred while the resident was in restraints. On 5/3/16 at 11:00pm a nurse wrote that patient #15 was in the hallway by the telephone when staff noticed a chair flipped over and patient #15 stating, "I need a nurse. I'm bleeding." When asked, patient #15 stated that the man in the burgundy jacket hit me. Physician orders were received on 5/4/16 for an X-Ray of facial bones and suture laceration status post being hit by another resident.

On 5/23/16 a nurse documented that at about 4:00pm, the psych ARNP (advanced registered nurse practitioner) observed patient #15 had turned the Geri-chair he was sitting in onto its back. Patient #15 was sitting in the chair as Posey vest was still intact. No injuries noted. Patient #15 was trying to move the geri-chair backward when if flipped over.

On 6/8/16 at 1:10pm, an interview was conducted with the treatment team registered nurse, nurse CC. Nurse CC confirmed that the initial restraint orders occurred on 3/8/16 and were for a geri chair, Posey vest and mini pelvic restraint. this was changed to just a Posey vest on 4/22/16. We do have pommel cushions and lap buddies, but patient #15 is so non-compliant he would just remove them. Nurse CC was asked about the physician restraint order of 4/26/16 when the physician ordered, "Posey Vest with geri chair when out of bed for safety until team reviews." Nurse CC stated that they order team, but it isn't a team decision. If it is medical restraints, then the team is technically the medical doctor. The treatment team reviews restraints after 180 days. There is not 180 day review because patient #15 has not had restraints that long. Nurses review restraints monthly and document in the 52's ( Progress and Event Notes).

Patient #16

Observations were conducted of patient #16 on 6/7/16 at 12:10pm and 2:30pm, on 6/8/16 at 9:12am and 1:00pm and on 6/9/16 at 9:45am. In all observations, patient #16 was seated in a geri-chair with his feet on the floor wearing a Posey vest restraint.

An interview was conducted with the treatment team registered nurse, nurse CC, on 6/8/16 at 9:12am. Nurse CC stated that patient #16 had medical restraints initiated in the past week due to a bad fall with a brain bleed.

Review of the medical record revealed a fall over a month ago on 4/26/16 after which patient #16 was diagnosed with a subdural hematoma. The notes stated that the resident was noted with bradycardia and ventricular bigeminy. On 5/23/16, patient #16 was evaluated by neurology for chronic encephalopathy (brain disorder) recently evaluated for ataxia (a lack of muscle coordination) with recurrent falls. On 5/24/16 there was a transport report which stated that patient #16 was being transferred to acute care to rule out a skull fracture status post fall.

A record review of physician orders, progress notes, and treatment team notes was conducted for treatment plan updates and changes to address the falls. The only identified treatment plan change was the initiation of a Posey vest medical restraint.

A review of physician orders revealed that the initial order for medical restraints occurred on 6/5/16 at 8:45am. The physician ordered to send resident #16 to the emergency room (ER) for evaluation. Posey Vest with wheelchair when out of bed until reviewed by the ward physician on 6/6/16. Rationale, fall, hitting left side of head and complaints of left elbow arm pain. Safety precautions. Upon return from the ER on 6/5/16 at 11:45am, the physician wrote to continue to use Posey Vest with wheelchair/ geri-chair when out of bed. Full side rails up in bed. Ward physician to review in am. Rationale: history of falls, increased risk of injury. On 6/8/16 at 9:30am the ward physician ordered Posey Vest with wheelchair/ geri-chair when out of bed; Side rails up x4 in bed. Add restraint orders to the the monthly treatment orders. Rationale: Increased Risk of injury with history of falls.

A record review was conducted to review alternatives attempted prior to the use of medical restraints and team recommendations.

The Treatment team (recovery team) meetings were reviewed. The most recent Treatment team meeting occurred 5/18/16, prior to the restraint initiation. There was no documentation related to medical restraints.

Medical/Psychiatric Progress notes were reviewed. There was no mention of medical restraints.

A review of 'Progress and Event Notes, form 52', was conducted for May and June 2016. There was no documentation regarding alternatives tried or how the least restrictive device was determined. On 6/5/16 a nurse wrote that at approximately 8:40am, direct care staff reported that resident #16 had fallen in the hallway. Resident #16 complained of head and arm pain, but there were no visible signs of injury noted. The physician was notified and orders were received to send resident to ER for evaluation and Posey Vest with wheelchair when out of bed due to increased risk of injury. On 6/5/16 a nurse wrote that at 12:52pm, the physician changed the order to Posey Vest with wheelchair/ geri-chair when out of bed and side rails up in bed until reviewed by ward physician in the AM.

On 6/9/16 at 10:00am an interview was conducted with the treatment team registered nurse, nurse CC. Nurse CC was unable to locate documentation showing restraint alternatives tried and determination that the restraints chosen were the least restrictive. Nurse CC stated that we do discuss it, but it does not appear to be documented.

Based on observation, staff interview and record review, the hospital failed to update the treatment plan to include the use of medical restraints for 1 of 2 sampled patients utilizing medical restraints in the certified portion of the psychiatric hospital (#15).

The findings include:

Observations were conducted of patient #15 on 6/7/16 at 12:10pm and 2:30pm, on 6/8/16 at 9:15am and 1:00pm and on 6/9/16 at 9:30am. In all observations, patient #15 was seated in a geri-chair with his feet on the floor wearing a Posey vest restraint.

A review of physician orders revealed that the initial order for medical restraints occurred on 3/8/16 at 2:17pm when the physician ordered a geri-chair, Posey vest and a mini pelvic restraint "to keep resident from falling off wheel and other chairs for patient safety".

The order for geri chair, Posey vest and mini-pelvic restraint was renewed on 3/18/16. On 4/18/16 on the 'monthly treatment orders' the order was changed to geri chair and Posey vest when out of bed. The min-pelvic restraint was not re-ordered. The geri-chair and Posey vest order was renewed on 4/29/16 and 5/18/16. On 4/29/16 the physician wrote, Posey vest with geri- chair when out of bed for safety until team reviews. On 5/22/16 additional restraint orders were received of Posey vest in bed, side rails up x2 until reviewed by treatment team the next day. Rationale was documented as "resident gait unsteady." On 5/23/16, the physician discontinued the Posey vest when in bed.

The Treatment team (recovery team) meetings and implementation plan were reviewed. Patient #15 had a bi-monthly review on 3/30/16, after the initiation of restraints. There was no mention of the restraint use in the team notes. The annual team meeting occurred on 5/25/16 with updated goals and treatment modalities. Patient #15 had a goal developed for "risk for injury related to unsteady gait due to tardive dyskinesia (neurological disorder of involuntary movements) and verbal/physical aggression". The short and long term goals stated that patient #15 would reduce risk for injury by wearing properly fitting clothes, non-skin shoes and using wheelchair for assistance with ambulation, as evidence by him having no falls or injuries through 12/7/16. There was no mention of restraint usage. The meeting notes were reviewed. There was no mention of the day time use of restraints. The team did mention that the bedtime Posey vest had been discontinued and side rails were being used, and the team agreed with this decision.

On 6/8/16 at 1:10pm, an interview was conducted with the treatment team registered nurse, nurse CC. Nurse CC confirmed that the initial restraint orders occurred on 3/8/16 and were for a geri chair, Posey vest and mini pelvic restraint. this was changed to just a Posey vest on 4/22/16. We do have pommel cushions and lap buddies, but patient #15 is so non-compliant he would just remove them. The treatment team reviews restraints after 180 days. There is not 180 day review because patient #15 has not had restraints that long. Nurses review restraints monthly and document in the 52's ( Progress and Event Notes).

On 6/9/16 at 10:00am a follow-up interview was conducted with nurse CC. Nurse CC reviewed the 'recovery team implementation plan' and confirmed that medical restraints had not been added to the plan. Nurse CC also confirmed that the use of daytime restrains was not included in the team notes.