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Based on observation, interview, record review, and policy review the facility failed to follow its policy to assess a patient to determine any underlying cause of the patient's behavior prior to initiation of physical restraints (enclosure bed). The facility initiated a restraint based on a request by a family member. This failure occurred for one patient (#17) of three enclosure bed restraint records reviewed. The facility census was 201.

Findings included:

1. Record review of a facility policy titled, "Patient Restraints" dated 07/13/10, showed direction for facility staff to perform an initial assessment to determine any underlying medical cause of the patient's behavior prior to initiation of a physical restraint. The assessment should be documented on the 24 hour medical/surgical restraint flow sheet.

2. Observation of Patient #17 on 11/19/13 at 10:45 AM showed the patient in an enclosure bed. The bed was completely enclosed in tent shaped, mesh netting. The netting could be unzipped from outside the bed to access the patient. The netting was secured to the mattress. The patient could not get out of the enclosure bed without staff assistance. The patient was calm, non verbal and non responsive at the time of the observation.

3. Record review of Patient #17's current medical record showed Staff N, Licensed Practical Nurse (LPN), documented on 11/18/13 at 2:32 PM that the patient was confused and continuously tried to get out of bed. At 4:32 PM Staff N documented patient's wife was at the bedside and the patient continuously tried to get out of bed. At 4:35 PM Staff N documented that the patient was disoriented, restless, speech garbled, responded to voice (patient moved head towards the direction of the person speaking) and his bilateral grip strength (measure of how tightly the patient was able to squeeze the nurses hands) was weak. A restraint order written on 11/18/13 at 5:00 PM for an enclosure bed documented it was indicated because the patient attempted to get out of bed unassisted, had an unsteady gait and was disoriented and/or confused. Staff placed the patient in enclosed bed around 5:00 PM.

4. During an interview on 11/20/13 at 9:30 AM, Staff N, stated that from the time the patient arrived on the floor the wife had requested that the patient be "tied down". Staff N stated that the wife stated that the patient got up every night at home and fell down. Staff N stated that she advised the wife that the hospital could get a patient sitter or a low bed to help the patient and the wife refused and stated that wouldn't work. Staff N stated that she did not document any of the conversation with the wife because she didn't feel it was appropriate to put the wife's comments in the medical record.

Based on observation, interview, record review, and policy review the facility failed to follow its policy to utilize alternative interventions prior to initiation of physical restraints (enclosure bed) for two patients (#17 and #35) of three enclosure bed restraint records reviewed. The facility census was 201.

Findings included:

1. Record review of facility policy titled, "Patient Restraints" dated 07/13/10, showed direction for facility staff to:
-Assess the patient to determine if appropriate alternatives (to restraints) have been successful;
-Avoid the use of restraints;
-Attempt alternatives prior to the initiation of restraints;
-encourage the use of non physical interventions such as redirecting the patient's focus;
-Provide 1:1 observation (patient sitter);
-Allow safe wandering;
-Employ all reasonably available efforts to make the patient comfortable and calm.

2. Observation of Patient #17 on 11/19/13 at 10:45 AM, on the neurologic unit, showed the patient in an enclosure bed. The bed was completely enclosed in tent shaped, mesh netting. The netting could be unzipped, from outside the bed, to access the patient. The netting was secured to the mattress. The patient could not get out of the enclosure bed without staff assistance.

3. Record review of Patient #17's current medical record showed Staff N, Licensed Practical Nurse (LPN), documented on 11/18/13 at 2:32 PM that the patient was confused and continuously tried to get out of bed. At 4:32 PM Staff N documented that the patient's wife was at the bedside and the patient continuously tried to get out of bed. The record showed no documentation that a sitter was utilized to redirect the patient when he attempted to get out of bed or to assist the patient to ambulate. The patient was placed in the enclosure bed around 5:00 PM.

4. During an interview on 11/20/13 at 9:30 AM, Staff N, stated that from the time the patient arrived on the floor the wife requested that the patient should be "tied down". Staff N stated that the wife stated that the patient got up every night at home and fell down. Staff N stated that she advised the wife that the hospital could get a patient sitter or a low bed to help the patient but the wife refused and stated that wouldn't work. Staff N stated that she did not document any of the conversation with the wife because she didn't feel it was appropriate to put the wife's comments in the medical record. Staff N stated she obtained a physician's order for the enclosure bed and there was no attempt to utilize a sitter.

5. During a phone interview on 11/20/13 at 4:10 PM, Staff DD, Medical Doctor (MD), Patient #17's attending physician, stated that the patient had profound dementia (loss of memory and ability to think) and had fallen at home. He stated that to his knowledge a sitter was not considered for this patient and he did not suggest a sitter based on staff recommendation of the enclosure bed.

6. Record review of Patient #35's current medical record showed:
-The patient was admitted to the Rehabilitation (Rehab) unit on 11/04/13 with Traumatic Brain Injury (TBI), (an injury that occurs when an external force traumatically injured the brain. Can involve damage to structures other than the brain, such as the scalp and skull).
-Patient had undergone a right craniotomy (a surgical operation in which a bone flap is temporarily removed from the skull to access the brain) on 10/25/13.
-Patient was confused and disoriented on admission;
-Nursing assessed patient as a fall risk;
-Patient was placed in a low bed (a bed that is positioned low to the floor that helps prevent patient falls and related injuries in the hospital setting) with a bed alarm;
-Patient had attempted to get out of bed, without using call light, multiple times throughout the night of admission;
-Patient was re-oriented, side rails up times two;
-Order obtained for enclosure bed, early morning hours of 11/05/13;
-Patient remained in this bed until 11/11/13;
-Patient was using call light appropriately and enclosure bed was discontinued;
-Patient was placed back in the enclosure bed on 11/12/13 until 11/17/13 for safety;
-No documentation that a sitter was attempted.

7. During an interview on 11/20/13 at 2:50 PM, Staff BB, Rehab unit Manager, stated that the Rehab unit uses patient sitters "occasionally". She stated that the Rehab unit was the trial area for the use of enclosure beds and that the facility started using them about one year ago. She stated this type of bed worked well with TBI patients and seemed to calm them.






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Based on observation, interview, record review, and policy review the facility failed to follow its policy to utilize alternative interventions prior to initiation of physical restraints (enclosure bed) for two patients (#17 and #35) of three enclosure bed restraint records reviewed. The facility census was 201.

Findings included:

1. Record review of facility policy titled, "Patient Restraints" dated 07/13/10, showed direction for facility staff to:
-Assess the patient to determine if appropriate alternatives (to restraints) have been successful;
-Avoid the use of restraints;
-Attempt alternatives prior to the initiation of restraints;
-encourage the use of non physical interventions such as redirecting the patient's focus;
-Provide 1:1 observation (patient sitter);
-Allow safe wandering;
-Employ all reasonably available efforts to make the patient comfortable and calm.

2. Observation of Patient #17 on 11/19/13 at 10:45 AM, on the neurologic unit, showed the patient in an enclosure bed. The bed was completely enclosed in tent shaped, mesh netting. The netting could be unzipped, from outside the bed, to access the patient. The netting was secured to the mattress. The patient could not get out of the enclosure bed without staff assistance.

3. Record review of Patient #17's current medical record showed Staff N, Licensed Practical Nurse (LPN), documented on 11/18/13 at 2:32 PM that the patient was confused and continuously tried to get out of bed. At 4:32 PM Staff N documented that the patient's wife was at the bedside and the patient continuously tried to get out of bed. The record showed no documentation that a sitter was utilized to redirect the patient when he attempted to get out of bed or to assist the patient to ambulate. The patient was placed in the enclosure bed around 5:00 PM.

4. During an interview on 11/20/13 at 9:30 AM, Staff N, stated that from the time the patient arrived on the floor the wife requested that the patient should be "tied down". Staff N stated that the wife stated that the patient got up every night at home and fell down. Staff N stated that she advised the wife that the hospital could get a patient sitter or a low bed to help the patient but the wife refused and stated that wouldn't work. Staff N stated that she did not document any of the conversation with the wife because she didn't feel it was appropriate to put the wife's comments in the medical record. Staff N stated she obtained a physician's order for the enclosure bed and there was no attempt to utilize a sitter.

5. During a phone interview on 11/20/13 at 4:10 PM, Staff DD, Medical Doctor (MD), Patient #17's attending physician, stated that the patient had profound dementia (loss of memory and ability to think) and had fallen at home. He stated that to his knowledge a sitter was not considered for this patient and he did not suggest a sitter based on staff recommendation of the enclosure bed.

6. Record review of Patient #35's current medical record showed:
-The patient was admitted to the Rehabilitation (Rehab) unit on 11/04/13 with Traumatic Brain Injury (TBI), (an injury that occurs when an external force traumatically injured the brain. Can involve damage to structures other than the brain, such as the scalp and skull).
-Patient had undergone a right craniotomy (a surgical operation in which a bone flap is temporarily removed from the skull to access the brain) on 10/25/13.
-Patient was confused and disoriented on admission;
-Nursing assessed patient as a fall risk;
-Patient was placed in a low bed (a bed that is positioned low to the floor that helps prevent patient falls and related injuries in the hospital setting) with a bed alarm;
-Patient had attempted to get out of bed, without using call light, multiple times throughout the night of admission;
-Patient was re-oriented, side rails up times two;
-Order obtained for enclosure bed, early morning hours of 11/05/13;
-Patient remained in this bed until 11/11/13;
-Patient was using call light appropriately and enclosure bed was discontinued;
-Patient was placed back in the enclosure bed on 11/12/13 until 11/17/13 for safety;
-No documentation that a sitter was attempted.

7. During an interview on 11/20/13 at 2:50 PM, Staff BB, Rehab unit Manager, stated that the Rehab unit uses patient sitters "occasionally". She stated that the Rehab unit was the trial area for the use of enclosure beds and that the facility started using them about one year ago. She stated this type of bed worked well with TBI patients and seemed to calm them.






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