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Based on observation, interview, clinical record and document review, the facility failed to ensure that restraints were used only when alternative methods were not sufficient to protect the Patient (1) or others from injury.

Findings:

On 7/26/10, review of the medical record indicated Patient 1 was admitted from a Board and Care to the facility on 7/24/10 at 11 p.m. with diagnoses of confusion, hallucinations, Alzheimers disease, and chronic back pain. Review of the emergency department report indicated the physical examination with diagnostic studies was unremarkable with the exception of a low potassium level. Patient 1,"says she has had both auditory and visual hallucinations although it is difficult for her to elaborate ...Denies homicidal or suicidal ideation." Patient 1 lived independently in her home until 10 days ago when she had "confusion and hallucinations and started hitting her family members including her daughter. She was moved to a board and care home 6 days ago where she "developed hallucinations and combativeness."

Review of the nursing notes dated 7/25/10 at 8:35 a.m. indicated Patient 1 was placed in a posey vest for "increased wandering in hall and almost combative with staff." At 8:45 a.m., immediately after being placed in a posey vest, Patient 1 was "throwing things, trying to scratch nurse, screaming and crying." The nursing note at 2 p.m. indicated "patient sitting in chair in doorway starting cursing, yelling and getting anxious. Pulled chair back in room, patient started hitting and kicking, family came in just as staff started to put wrist restraints on..."

Review of the facility Restraints policy identified "restraints shall be used only when necessary and when less restrictive interventions have been determined to be ineffective and never a substitute for surveillance ...Because a patient's movement and ability to care for certain needs while in restraint is more limited, alternatives to restraint use must be attempted prior to application and on an ongoing basis while in restraint. If alternatives are unsuccessful, a clear rationale for the use must be documented. Examples of alternatives to restraints include, but are not limited to:..checking patient frequently, ...decreasing stimulation, having family/significant other in attendance, addressing comfort measures (pain management, noise level, etc.), consider PRIMO (patient requiring increased management and observation) assignment ..."

Review of the facility Patients Requiring Increased Management and Observation (PRIMO) policy indicated the RN was to assess the patient's behavior, initiate alternative interventions, consult with shift coordinator/clinical manager on need for PRIMO assignment, and directly supervise PRIMO assignment staff member. The policy also identified those patients who may have benefited from a PRIMO assignment including "those who have attempted, or is a risk, to injure self or others, confused or delirious patients, and those exhibiting unpredictable behavior." The PRIMO assignment included "direct observation of the patient, feeding and meal assistance, bathing, grooming, ... toileting needs, ...maintaining activity orders ..., comfort measures."

Review of the patient assessment record and care notes form dated 7/25/10, during the period between 7a.m. and 3p.m., alternative interventions of diversion, increase reasoning, decrease stimulation, and pain relief were checked. However, there was no documented evidence in the medical record of specific interventions for diversion, stimulation or reasoning. There was no evidence in the medical record that staff attempted to modify the care and treatment plan, environment, staff approach, or enlist family member support prior to initiating 5 point restraints. At 7 a.m. on 7/25/10 Patient 1 had no restraints. At 3 p.m., Patient 1 had 2 wrist restraints, 2 ankle restraints, a posey vest and all 4 siderails of the bed used as an additional restraint.

During an interview on 7/26/10 at 1:45 p.m., RN 1 reviewed the medical record. RN 1 stated, "She was in 5 point restraints this morning." After RN 1's assessment and observations, she indicated she removed the wrist and leg restraints at 9 a.m. RN 1 indicated Patient 1 had not required the restraints since the removal. She stated, "She is being assisted to the bathroom, and has been cooperative. She is still confused." RN 1 indicated the patient had been confused since admission and required frequent monitoring. When asked about the policy for restraints, RN 1 stated, "I couldn't tell you what it says but this is just what I do."

During an interview on 7/26/10 at 2:15 p.m., the RN manager was asked to review the restraint procedure and protocol. She confirmed there was no evidence of least restrictive methods documented prior to the initiation of 5 point restraints for Patient 1. She stated her expectations were for nurses to follow the least restrictive methods, notify the supervisor on duty when a PRIMO assignment is needed. The RN manager stated, "The supervisor on duty will notify the manager." She stated, "I was not notified about this patient."