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Based on record review and interview the facility failed to protect and promote patient rights by obtaining orders for restraints to be used on a PRN basis, failed to assess and monitor the use of restraints every 2 hours per facility policy, and failed to obtain a new restraint order when discontinuing then reapplying restraints.

Findings:

The facility utilized "standing orders" for restraints in 8 of 13 records reviewed. See Tag A-0169.

The facility failed to assess and monitor patients in restraints every 2 hours per facility policy in 4 of 13 records reviewed. See Tag A-0175.

The facility failed to provide documentation for the need of the use of restraints in 3 of 13 records reviewed where a restraint was ordered. See Tag A-0187.

Based on interview and record review the facility failed to ensure restraint orders are not standing orders per policy for 8 of 13 medical records reviewed of patients who had restraints (Patients # 2, 3, 4, 5, 6, 7, 11,15).

Findings include:

Review of facility policy "HSHS Restraint and Seclusion Policy" last revised 6/7/18 revealed under "V. General Restraint Information A. "... PRN restraint orders or "standing orders" for restraints are not permitted. B. "A trial release constitutes a PRN use of restraints or seclusion and therefore is not permitted. When restraint or seclusion is ended the hospital staff has no authority to reinstitute the intervention without a new order..."

Patient #2
Review of Patient #2's medical record on 9/16/2020 revealed admission on 8/23/2020 for altered mental status (confusion.) Record revealed an order for restraints for "jacket/vest and enclosed net bed" on 8/25/2020 at 12:27 PM for "violent or self-destructive behavior." Reason given, "Danger to self or others." Nurses note on 8/25/2020 at 7:04 PM revealed "chest restraint has been off since 2:30 PM- pt has been cooperative-talkative." Confirmed in interview with Manager D on 9/16/2020 at 3:40 PM that the net bed was ordered "in case we needed it." The net bed was never implemented. Manager D stated, "I remember this patient and we had law enforcement at her bedside 1:1 on the 25th before her discharge to a mental health hospital - she was on an emergency hold." Manager D confirmed that there was no documentation in the medical record of the 1:1 supervision.

Patient # 3
Review of Patient #3's medical record on 9/16/2020 revealed an admission on 9/3/2020 to the in-patient Rehab unit following neck surgery. Orders revealed a verbal order received on 9/5/2020 at 8:45 PM for "enclosed net bed and lap belt" for "interference with medical treatment" and a second order on 9/5/2020 at 8:45 PM for "right and left wrist soft restraints" for "interference with medical treatment." The "Restraint Documentation Flowsheet" revealed the lapbelt as "continuous" until 5:33 PM on 9/10/2020 then not again until 3:20 PM on 9/12/2020. Documentation in the nurses notes revealed that the net bed was discontinued on 9/16/2020 at 9:36 AM. Manager D confirmed that the soft wrist restraints were never used and the lap belt used "sporadically."

Patient # 4
Review of Patient #4's medical record on 9/16/2020 revealed an admission on 2/12/2020 to the in-patient Rehab unit with a diagnosis of a subarachnoid bleed (bleeding into the brain.) Orders revealed restraint orders for "net bed and mitt" on 2/12/2020 and a second order on 2/12/2020 for a lapbelt. There was no documentation in the "Restraint Flowsheet"of use of a lapbelt until 2/15/2020 at 7:30 AM five days after the initial order was written. Confirmation of lack of documentation in interview with Manager D on 9/17/2020 at 8:55 AM.

Patient #5
Review of Patient #5's medical record on 9/16/2020 revealed an admission on 7/26/2020 to the Intensive Care Unit (ICU) for sepsis and pneumonia. The History and Physical on admission dated/timed 7/26//2020 at 9:38 AM revealed, "he is oriented to person, place and time. No distress. ...resting in ICU bed, no acute distress." Orders revealed restraint orders written on 7/26/2020 at 4:10 PM for "interference with medical treatment" for "jacket/vest and right and left soft wrist restraints." The "Restraint Flowsheet" revealed use of right and left soft restraints beginning on 7/27/2020 at 00:30 AM. There was no documentation of a jacket/vest being utilized during the hospitalization.

Patient # 6
Review of Patient #6's medical record on 9/16/2020 revealed an admission on 7/5/2020 at 7:05 PM to the Intensive Care Unit for a drug overdose. Nursing assessment revealed on admit to ICU the patient was sedated, "unresponsive and intubated" (a tube to assist with breathing.) The nursing assessment revealed under "Motor Response" "no movement to painful stimuli." Orders revealed a restraint order written on 7/5/2020 at 7:01 PM for "interference with medical treatment" for "jacket/vest and right and left soft wrist restraints." In interview with ICU Manager C on 9/17 at 7:35 AM when asked why a restraint order would be written for an unresponsive sedated patient, ICU Manager C responded, "when patients wake up they sometimes wake up agitated so we need to have those orders if we need them." When asked about the perception of the order being written as PRN ICU Manager C responded, "it is part of our standard ICU admission orders."

Patient #7
Review of Patient #7's medical record on 9/16/2020 revealed an admission on 7/8/2020 to in-patient Rehab following a psychotic episode. Orders revealed restraint orders written on 7/8/2020 at 2:30 PM for "interference with medical treatment" for "right and left soft wrist restraints." The "Restraint Flowsheet" revealed discontinuation of the soft wrist restraints on 7/14/2020 at 3:15 AM. On 7/29/2020 at 8:00 PM the "Restraint Flowsheet" revealed right and left wrist restraints. There was no new order for the use of restraints. On 7/17/2020 at 1:40 PM there was an order for a net bed for "attempts to get out of bed." The "Restraint Flowsheet" did not reveal any documentation regarding its use. On 7/30/2020 at 8:30 PM the "Restraint Flowsheet" revealed the wrist restraints are discontinued. On 8/3/2020 the "Restraint Flowsheet" revealed right and left wrist restraints. There was no new order for the use of restraints on that date. In interview with Critical Care Manager C on 9/17/2020 at 7:35 AM Critical Care Manager C stated, "nurses know that they should be getting new orders if they take them off."

Patient #11
Review of Patient #11's electronic medical record revealed admission on 08/27/20 for colon surgery. Record revealed an order for "right and left soft wrist restraints" on 9/05/20 at 5:33 AM for "non-violent or non-self destructive behavior." Reason given, "interference with medical treatment." The medical record revealed no documentation that restraints were placed and no documentation on the "Restraint Assessment" flowsheet of restraint checks. Per interview with Manager of Critical Care U on 09/16/20 at 1:30 PM, U stated "I see that restraints were ordered but nothing I can see for documentation that they were placed, this was an oversight."

Patient #15
Review of Patient #15's electronic medical record revealed an admission on 08/28/20 for seizures and hydrocephalus (water on the brain.) On 08/29/20 at 8:55 AM the order set "HSPS IP ICU Ventilator Bundle/ Vent Weaning Medications" was placed, the order stated "non-violent restraint will remain in effect until the patient or situation no longer requires the use of restraint to protect the patient from harm, or the indications for discontinuation are met." There was an additional order placed for restraints on 08/29/20 at 8:55 AM that included right and left soft wrist restraints. Patient was intubated on 08/29/20 at 11:41 AM. Nurse's note on 8/30/20 at 6:37 PM revealed "restraints not needed." The Restraint Flowsheet revealed that right and left wrist restraints were placed 8/31/20 at 8:15 AM and discontinued on 8/31/20 at 6:08 PM. ICU Manager C confirmed that it "is not clear when restraints were placed."

Review of a report from the vendor who supplies the net beds revealed the use of 40 net beds as a restraint in the past 12 months. In interview with Quality A when questioned regarding the use of net beds responded, "I have seen an increase in their usage over the years." When questioned regarding a sitter program as an alternative to restraints Quality A responded, we had a sitter program for a short period of time but it was difficult to staff and the program was cut. We try to use sitters whenever we can and staffing allows."


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Based on record review and interview the facility failed to assess and monitor 4 out of 13 patients in restraints per the facility policy. (Patients #2, 4, 5, 7)

Findings:

Review of the facility policy "HSHS Restraint and Seclusion Policy" last revised 6/7/2018 revealed under VI. "Restraint Procedure" "6. Patients in either violent restraints or seclusion shall be monitored on an ongoing basis for safety by staff members. Observations for safety shall be documented at a minimum frequency of 15 minutes." "7. "Monitoring and assessment: the RN responsible for the patient will determine the frequency of monitoring and assessment at intervals at minimum frequency of two (2) hours..." "

Patient #2
Review of Patient #2's medical record on 9/16/2020 revealed an order on 8/25/2020 at 12:27 PM for "jacket/vest and enclosed net bed" for "danger to self and others." The order was entered as "Restraint for Violent or Self-destructive." Review of the "Restraint Flowsheet" revealed no 15 minute documentation of safety per facility policy. "Nurses note" on 8/25/2020 at 7:04 PM revealed "chest restraint has been off since 2:30 PM pt has been cooperative and talkative with staff."

In interview with Inpatient Manager D on 9/17 at 3:40 PM when asked about 15 minute checks for restraints for violent behavior stated, "this patient actually had a 1:1 police officer with her until she was discharged later that day." Inpatient Manager D confirmed that there was not any documentation of the 1:1 in the medical record.

Patient #4
Review of Patient #4's medical record on 9/17/2020 revealed restraint usage from 2/12/2020 to 2/17/2020. Review of the "Restraint Flowsheet" revealed missing restraint documentation without assessments on 2/12/2020 from noon to 8:30 PM, on 2/14/2020 from 11:00 AM to 6:15 PM, on 2/15/2020 from 12:45 PM to 6:15 PM, on 2/16/2020 from 12:20 PM to 5:45 PM, and on 2/17/2020 from 4:40 PM to 9:10 PM. Lack of every 2 hour documentation was confirmed by Infomatacist J at time of review.

Patient #5
Review of Patient #5's medical record on 9/16/2020 revealed restraint usage from 7/30/2020 to 8/2/2020. Review of the "Restraint Flowsheet" revealed missing restraint documentation without assessments on 8/1/2020 from 2:00 PM to 8:00 PM. Lack of every 2 hour documentation was confirmed by Infomatacist J at time of review.

Patient # 7
Review of Patient #7's medical record on 9/16/2020 revealed intermittent restraint usage from 7/7/2020 to 8/16/2020. Review of the "Restraint Flowsheet" revealed missing restraint documentation without assessments on 7/10/2020 at 6:00 AM to 7:30 PM, 7/16/2020 from 6:00 AM to 3:00 PM, 7/25/2020 from 9:00 AM to 6:00 PM, 7/31/2020 from 8:30 AM to 4:00 PM, on 8/1/2020 from 10:00 PM to 8/2/2020 at 3:30 PM, on 8/2/2020 from 6:30 PM to midnight, on 8/3/2020 from 6:00 AM to 3:39 PM, on 8/4/2020 from 9:00 AM to 4:00 PM, on 8/7/2020 from 2:00 PM to 8:00 PM, on 8/11/2020 from 9:30 AM to 3:00 PM.

In interview with Manager C on 9/17/2020 at 7:35 when asked about the missing documentation stated, "we could have done better - we already discussed this at our morning huddle."

Based on record review and interview the facility failed to provide adequate justification for obtaining orders for restraints in 3 of 13 medical records of patients in restraints reviewed. (Patient #'s 5, 6, 14)

Findings:

Review of facility policy HSHS Restraint and Seclusion Policy" last revised 6/7/18 revealed the following, "X. Documentation C. Documentation shall include the following: 1. A description of the patient's behavior and interventions used 2. alternatives or other less restrictive interventions attempted (as applicable) 3. the patient's condition or symptoms that warranted the use of restraint..."

Patient #5
Review of Patient #5's medical record on 9/16/2020 revealed an admission on 7/26/2020 to the ICU. The History and Physical on admission dated/timed 7/26//2020 at 9:38 AM revealed, "he is oriented to person, place and time. No distress. ...resting in ICU bed, no acute distress." Orders revealed restraint orders written on 7/26/2020 at 4:10 PM for "interference with medical treatment" for "jacket/vest and right and left soft wrist restraints." There is no documentation of restraint use until 7/27/2020. There was no description of the behavior that warranted restraint use and no documentation of less restrictive interventions used prior to restraint use.

Patient #6
Review of Patient #6's medical record on 9/16/2020 revealed an admission on 7/5/2020 to the ICU. Nursing assessment on admission revealed the patient was sedated, "unresponsive and intubated." The nursing assessment revealed under "Motor Response" "no movement to painful stimuli." Orders revealed a restraint order written on 7/5/2020 at 7:01 PM for "interference with medical treatment" for "jacket/vest and right and left soft wrist restraints." There was no evidence of the use of this restaint order.

Patient #14
Review of Patient #14's electronic medical record revealed an admission on 07/18/20 at 11:57 PM for seizure activity, and encephalopathy (damage or disease that affects the brain) needing intubation (breathing tube). Orders revealed a restraint order for "right and left soft wrist restraints" on 07/18/20 at 11:52 PM and a second order for "jacket/vest" on 7/20/20 at 9:58 AM. The "Restraint Assessment" Flowsheet revealed the right and left soft wrist restraints were placed on 7/18/20 at 11:45 PM. There was no description of the behavior that warranted restraint use and no documentation of less restrictive interventions used prior to restraint use.When asked about lack of documentation for the use of the additional jacket/vest restraint on 7/20/20, ICU Manager C responded "we used the jacket because this patient was agitated and restless."

In interview with Critical Care Manager C on 9/17/2020 at 7:40 AM when asked about the "standing orders" for restraints stated, "they are part of the admit admission order set because sometimes patient's awake with a start and need them." When questioned regarding asking for the order at the time they are needed Manager C responded, "we have always done it this way."


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