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Based on record review and interview, the facility failed to ensure the safety of one patient (Patient #1) who sustained a fall during a seizure out of seven patient closed emergency department medical records reviewed. The facility census was 128.

Findings included:

1. Review of the Hospital Nursing Clinical Practice Manual policy and procedure on Fall Prevention, last reviewed date of 09/09, showed the following Purpose: "Strive to protect patients from preventable falls and injuries within the hospital setting and minimize the risk of injury when a fall occurs."

Review showed the following Policy (in part): "Patients admitted to the hospital will be assessed by a RN (Registered Nurse) for fall risk factors during admission and as his/her condition warrants."

Review of the Procedure showed the following measures (in part): "Upon admission the RN will assess the patient for fall risk factors utilizing the designated Fall Risk Assessment tool in EMR (electronic medical record). (The Hendrich II risk assessment tool is used.)"

Review showed a list of Fall Precaution measures including a fall risk wristband, a fall risk safety sign, a plan of care addressing the patient's fall risk factors, "patient/family education on fall risk reduction", frequent rounding, and siderails. Review showed: "Any patient may be placed on the Fall Precautions based on the clinical judgment and decision of the nurse and/or Physician (or by patient/family request.)"

Review showed, in part, the following interventions should the patient experience a fall: "a. The Physician will be notified. b. The nurse will document post fall assessment and notification of the physician and the patient's family in the EMR (electronic medical record)."

Review of the Fall Prevention policy and procedure showed no specific fall intervention policies and procedures related to Emergency Department (ED) patients.

2. Review of the section on Seizure Precautions in the Lippincott Manual of Nursing Practice, showed the following (in part): "Assessment of a client's (patient's) need to be placed on seizure precautions cannot be delegated to assistive personnel...Measures to emphasize if a client is at risk for a seizure includes the following:
-the importance of protecting the client from a fall;
-avoiding attempts to restrain client."

Review showed the following equipment for seizure care (in part): "Padding for side rails and headboard."

Review showed the following Assessment steps and rationale (in part): "Inspect client's environment for potential safety hazards if seizure occurs. Prepare bed with padded side rails and headboard, bed in low position, and client in side-lying position when possible." Rationale: "Prevents client from injury sustained by striking head or body on furniture or equipment."

Review showed the following nursing Planning steps and rationale (in part): "1. Expected outcomes following completion of procedure:
-Client remains free of traumatic injury while experiencing seizure." Rationale: "Injury from a fall or from jerking may occur as a (illegible text) onset of seizure activity."
-"Client does not experience a lowered sense of self-esteem following seizure episode." Rationale: "Loss of bowel or bladder control is common in (illegible text) seizures, causing client to feel embarrassment."

Review showed the following nursing Implementation steps and rationale (in part): "11. Following seizure, assist client to position of comfort in bed with padded side rails up and bed in lowest position." Rationale: "Provides for continued safety. Clients are often confused and sleepy following a seizure."

3. Review the Triage Assessment in Patient #1's closed Emergency Department (ED) medical record, dated 12/21/10, showed an ambulance brought the patient to the hospital following a four minute seizure that occurred at home, witnessed by family members. The patient complained of a headache. Review of the nursing assessment showed the patient had a history of epilepsy, grand mal seizures, and petite mal seizures. The patient reported having symptoms of nausea and vomiting on that day and had been unable to take two doses of his/her seizure medications. Nevertheless, review of the initial ED nursing assessment showed staff assessed the patient was not a risk of falls.

Review of the ED nurses notes showed the following (in part):
-12/21/09 at 6:00 P.M.: "Seizure pads on both side rails for safety. Instructed patient of the same."
-12/21/09 at 7:00 P.M.: "Family at bedside with one side rail down. Instructed family that if they leave room to notify staff so we can put side rail up for patient's safety - [family] verbalized understanding. Call light within reach of patient and family with no complaints." (Note: beds in the ER are also called a "gurney", a narrow bed about two-feet in width.)
-12/21/09 at 7:08 P.M.: "Introduced myself [Registered Nurse (RN) U] to the patient and family. Gave patient warm blankets for comfort. Updates given."
-12/21/10 at 8:00 P.M.: "Patient found in room face down on floor. Patient appeared to be disoriented and frightened. Patient restrained for safety and placed on gurney. Patient siderails up [times] 2 and seizure pads in place. Patient was incontinent of urine. Patient linen changed and gown changed. Foley [urinary catheter] placed per [physician] orders."

During an interview at 2:50 P.M. on 03/08/10, RN A, the Vice President of Clinical Practice, said according to the facility policy and procedure elevating both side rails would be defined as implementing a restraint. RN A said the facility had been cited for this practice in the past. However, review of the current interpretive guidelines for Federal Hospital surveys, Appendix A at A-161 states, "Side rails - A restraint does not include methods that protect the patient from falling our of bed. Examples include raising the side rails when a patient is: on a stretcher [such as a gurney in the ER]...."

During an interview at 3:15 P.M. on 03/08/10, RN F, the ED Shift Manager, said staff always place patients with seizures on an ED cart with padded side rails. RN F said the patient requested to have the side rail down. RN F said the patient was feeling better after administration of an intravenous bolus of normal saline and was having a snack. RN F said that according to the nurses' notes the patient had the seizure right after he/she left after finishing his/her shift. RN F said he/she should have left the side rail in the up position.

Based on observation and record review, the facility failed to assess the patient's condition for the least restrictive method of intervention prior to the use of restraints for two patients (Patient #20 and #21) out of five current patients. The facility census was 128.

Findings included:

1. A. Prior to Restraint Use: 1. Before initiating the use of restraints, every attempt to use verbal and behavioral interventions and environmental modifications must be made and documented in the medical record."

2. Observation on 3/10/10 at 8:20 a.m. revealed Patient #20 in bilateral soft wrist restraints.

Record review of the patient's medical record revealed the patient had been admitted to the facility on 3/4/10 after being in a motor vehicle accident.

Record review of the Patient Notes dated 3/6/10 at 5:52 p.m. revealed the following information:
-The patient was intubated (the placement of a tube into the trachea [windpipe] to protect the patient's airway and provide a means of mechanical ventilation) at approximately 2:30 p.m.

Record review of nursing documentation revealed no lesser interventions being implemented before the bilateral soft wrist restraints were applied.

4. Record review of Patient #21's medical chart revealed the patient was admitted to the facility on 3/6/10 for the complaint of shortness of breath.

Record review of the patient's History and Physical dated 3/6/10 revealed in part the following information:
-Past Medical and Surgical History
1. Lung cancer
2. Chronic Obstructive Pulmonary Disease (COPD)

Record review revealed no documentation of lesser interventions being implemented before the application of bilateral soft wrist restraints.

Based on observation, interview and record review, the facility failed to obtain and record timely orders for the use of physical restraints for two patients (Patient #20 and #21) out of five current patients selected for review during the survey. The facility census was 128.

Findings included:

Review of the Hospital Administrative and Nursing Manual policy and procedure on Restraint Use last reviewed on 01/06 in part revealed the following:

B. Physician Orders:
1. The Registered Nurse may initiate the restraint procedure if the patient's actions pose an immediate threat to their medical condition and/or treatment. The nurse must notify the physician within 12 hours of initiation of restraints to secure orders for the restraint which are specific and time limited (PRN (as needed) order is not acceptable).

3. All restraint orders must be renewed within a calendar day after the physician/nurse practitioner has evaluated the patient.
4. If any physician, other than the attending physician orders the restraints, the attending physician shall be notified of the use of restraints within a reasonable time frame."

Review of the Assessment and Documentation requirements for restraints showed the following:
2. Review of the Department of Internal Medicine Meeting Minutes, dated 05/13/09 showed the following Administrative Reports (in part): " Registered Nurse (RN) W, the Nursing Director of Intensive Care "discussed issues in getting physician signatures on restraint orders.
3. Observation on 3/10/10 at 8:20 a.m. revealed Patient #20 in bilateral soft wrist restraints.

Record review of the Patient 20's medical record revealed the patient had been admitted to the facility on 3/4/10 after being in a motor vehicle accident.

Record review of the Patient Notes dated 3/6/10 at 5:52 p.m. revealed the following information:
-The patient was intubated ( the placement of a tube into the trachea [windpipe] to protect the patient's airway and provide a means of mechanical ventilation)at approximately 2:30 p.m.

Record review of the telephone Physician Orders (late entry) dated 3/6/10 at 3:20 p.m. revealed the following order:
-May restrain for PT safety.
-The order had not been authenticated by the physician on the chart or electronically signed.
-During an interview on 3/10/10 at 9:55 a.m. the Director of ICU stated there is no physician signature on the chart or electronic signature of the physician for the restraint initiated on 3/6/10.

4. Record review of Patient #21's medical chart revealed the patient was admitted to the facility on 3/6/10 for complaints of shortness of breath.

Record review of the patient's History and Physical dated 3/6/10 revealed in part the following information:
-Past Medical and Surgical History
1. Lung cancer
2. Chronic Obstructive Pulmonary Disease

Record review of the Patient Notes dated 3/10/10 at 7:15 a.m. documented the following:
-Pt has restraints on upon arrival to shift, there was no longer a need for restraint because pt was resting comfortably and not interfering with equipment. Pt has sitter at bedside at this time to reassure pt of surroundings.

Record review of the Physician's Orders revealed no order for restraints.

During an interview on 3/10/10 at 9:55 a.m. with the spouse of the patient he/she stated the patient had wrist restraints on both arms for just a short time earlier that morning but the patient didn't need them now that she was at the facility.

Based on observation, record review and interview the physician did not document that he/she had seen and assessed one (Patient # 20) for restraints out of five current patients reviewed in the ICU (Intensive Care Unit). The facility census was 128.

Findings included:

1. Observation on 3/10/10 at 8:20 a.m. revealed Patient #20 in bilateral soft wrist restraints.

Record review of the patient's medical record revealed the patient had been admitted to the facility on 3/4/10 after being in a motor vehicle accident.

Record review of the Patient Notes dated 3/6/10 at 5:52 p.m. revealed the following information:
-The patient was intubated (the placement of a tube into the trachea [windpipe] to protect the patient's airway and provide a means of mechanical ventilation)at approximately 2:30 p.m.

Record review of the telephone Physician Orders (late entry) dated 3/6/10 at 3:20 p.m. revealed the following order:
-May restrain for PT [patient] safety.
-The order had not been authenticated by the physician on the chart or electronically signed indicating the physician had not seen or assessed the patient.

During an interview on 3/10/10 at 9:55 a.m. the Director of ICU (intensive care unit) stated there is no signature on the chart or electronic signature for the restraint.

Based on interview and record review, the facility failed to implement a process to provide adequate training to physicians to ensure they adhere to the hospital restraint policies and procedures. The facility census was 128.

Findings included:

- During an interview at 3:00 P.M. on 03/08/10, Physician D, the Chief Medical Officer said he/she did not specifically instruct new physicians on the hospital restraint policies and procedures.
- During an interview at 4:30 P.M. on 03/10/10, Registered Nurse (RN) B, the Administrative Director of Clinical Quality and Measurement, said the Emergency Department Medical Director, Physician X, was not available for interview. RN B said Physician X said he/she orients physicians on verbal orders and the electronic medical record. RN B presented a list from Physician X on items that he/she discusses with new physicians during orientation. Review of the list revealed Physician X shows the new physicians "how to access the Medical Staff Bylaws, Rules and Regulations and Policies on line as well as the UP TO Date reference site." Review of the physician orientation list did not reveal a specific topic on the physician responsibilities for assessing patients and recording orders according to the hospital restraint policies and procedures.

Based on observation, interview and record review, the facility failed to document a description of the patient's behavior and an assessment of the patient's condition when a restraint was used on one patient (Patient #20) out of five current patients. The facility census was 128.

Findings included:

Review of the Assessment and Documentation requirements for restraints showed the following:
"1. The Registered Nurse must document the demonstrated behaviors/actions which led to the implementation of the restraint and initiate the 24 hour restraint flow sheet."

2. Observation on 3/10/10 at 8:25 a.m. revealed Patient #20 was in bilateral soft wrist restraints.

Record review of the patient's medical record revealed the patient had been admitted to the facility on 3/4/10 after being in a motor vehicle accident.

Record review of the Patient Notes dated 3/6/10 at 5:52 p.m. revealed the following information:
-The patient was intubated ( the placement of a tube into the trachea [windpipe] to protect the patient's airway and provide a means of mechanical ventilation)at approximately 2:30 p.m.

Record review of the telephone Physician Orders (late entry) dated 3/6/10 at 3:20 p.m. revealed the following order:
-May restrain for PT safety.

Record review of the Patient Notes revealed the following information:
From 3/3/10 until 3/7/10 at 6:21 a.m., there is no documentation which describes any behavior which would make it necessary to apply bilateral soft wrist restraints.

Based on interview and record review, the facility failed to implement a process to provide non-employee licensed nurses adequate instruction and clinical supervision to ensure they adhere to the hospital policies and procedures, specifically related to the restraint policies and procedures. The facility census was 128.

Findings included:

1. Review of the Hospital Administrative and Nursing Manual policy and procedure on Restraint Use--Medical, last reviewed 01/06, showed the following Purpose: The hospital "recognizes that the patient has the right to be free from seclusion and restraint, in any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff."

Review showed the following Policy (in part): The hospital "is committed to preventing, reducing and striving to eliminate the use of restraint whenever possible, and to facilitating the discontinuation of restraint as soon as possible."

Review of the Procedure for Medical Indications for restraints showed the following (in part): "A Registered Nurse ensures that the application of a restraining device follows the approved policy. The Registered Nurse is responsible for assessing the patient's need for restraints and coordinating the continued monitoring activities."

Review of the Qualified Staff section of the policy and procedure showed the following:
"1. RNs, LPNs, technicians and patient care assistants receive education related to restraints during new employee orientation.
2. Direct care providers receive annual education through skill validation, net learning, unit and hospital based in services."

2. Record review of Registered Nurse (RN) U's employee file showed he/she is a non-employee (agency) licensed nurse employed on 11/22/09 as an Emergency Department (ED) staff nurse. Review of the Documentation Training form in the file showed he/she completed Restraint Flowsheet training on 11/16/09. However, review of the Policies section of the training form did not reveal a section on training on the facility Restraint Policies and Procedures.

Review of the employee file showed agency testing requirements for 2010 that included Patient Restraints. However, review did not reveal that the testing included instruction on the facility Restraint Policies and Procedures or a date of completion.

During an interview at 3:15 P.M. on 03/08/10, RN E, the Interim Nursing Director of the ED, said all new ED employees go through the basic new employee health worker orientation. RN E said ED staff nurses work with a nursing shift supervisor.

During a telephone interview at 10:10 A.M. on 03/09/10, RN U said he/she cared for Patient #1 on 12/21/10. (The patient, admitted to the ER after a seizure, was left on the gurney with side rails not in the "up" position when nursing was not in the room. The patient fell from the gurney to the floor.) RN U said he/she is employed as an agency nurse to work in the Emergency Department. RN U said he/she could not recall if he/she had read the hospital policy and procedures on Medical Restraints.

During an interview at 2:30 P.M. on 03/10/10, Staff O, Senior Training and Development Specialist, and RN P, Education Specialist, said they were responsible for orientation of new employees and ongoing clinical training. RN P said he/she trains new employees on the hospital restraint policies and procedures including hands on demonstration and performance of restraint techniques. RN P said he/she does not provide the same restraint training to non-employee (agency) licensed nurses.

During the interview at 2:30 P.M. on 03/10/10, RN B, the Administrative Director of Clinical Quality and Measurement, said the agency with whom the hospital contracts for nurses is supposed to provide training to their staff on restraints.