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Based on interview and record review the facility failed to meet the Condition of Participation for Patient Rights by failing to ensure the use of restraints for 1 of 5 patients (#1) was done on the order of a physician resulting in the potential for loss of patient #1's rights.

Findings include:

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A-0169 - Failure to obtain physicians orders for each episode of restraints

Based on record review and interview, the facility failed to ensure that physician orders were obtained daily for each episode of restraints for 1 of 5 patients (#1) reviewed for restraints out of a total of 10 sampled patients and failed to ensure their non-behavioral restraint policy included obtaining physician orders for each episode of restraints resulting in the potential for patient #1's loss of rights.
Findings include:

Medical record review on 8/26/19 at 1300 revealed patient #1 presented to the Emergency Department (ED) on 7/25/19 at 1032 from a group home for a psych evaluation due to behavioral changes. The patient remained in the ED until his admission on 7/31/19 with diagnoses that included Rhabdomyolysis. The patient had a previous medical history Schizophrenia, Dementia, Hypertension, Diabetes, Anxiety, and Thyroid disorder.

A physicians order for patient #1 dated 7/25/19 at 1230 documented: "non-violent soft left and right wrist restraints and soft left and right ankle restraints due to the patient's cognitive impairment that interfered with his medical care and the patient's attempts to ambulate independently; unsafe to do so. Q (every) 2 hours monitoring."

A review of restraint flow sheets revealed patient #1 was restrained with bilateral soft upper and bilateral lower limb restraints on the following dates and times for agitation/anxiety and/or confusion and monitored every 2 hours.
On 7/25/19 at 1230 through 7/31/19 at 0400.
On 7/31/19 at 0800 through 8/1/19 at 1800.
On 8/1/19 at 1900, a lap belt restraint were added and the right wrist restraint was removed.
On 8/1/19 at 2100 through 8/2/19 at 0100, the patient's bilateral wrists and bilateral ankles were restrained with soft limb restraints, the lap belt restraint remained in use.
On 8/2/19 at 0300 through 8/2/19 at 0700, the right ankle soft limb restraint was removed. The lap belt remained in use.
On 8/2/19 at 0900 through 8/3/19 at 0100, soft bilateral wrist restraints and soft bilateral ankle restraints were applied for agitation and anxiety. The lap belt was removed.
On 8/3/19 at 0305 through 8/3/19 at 1100, soft bilateral wrist restraints were in use.
On 8/3/19 at 1300 through 8/4/19 at 0904, soft bilateral wrist and soft bilateral ankle restraints were in use.
On 8/4/19 at 0911, there were no restraints in use.
On 8/4/19 at 1100 through 8/5/19 at 0500, soft bilateral wrist and soft bilateral ankle restraints were reapplied and in use.
On 8/5/19 at 0808 the bilateral soft ankle restraints were removed.

A physicians order for patient #1 dated 8/5/19 at 08:10 with a stop date for 8/16/19 at 0236 am documented: "non-violent restraints for agitation have been evaluated and documented."

On 8/5/19 at 0900 through 8/6/19 at 1500, soft bilateral wrist restraints were reapplied and in use.
On 8/6/19 at 1618 the restraints were removed.
On 8/6/19 at 1900 through 8/7/19 at 0100, soft bilateral wrist restraints were reapplied and in use.
On 8/7/19 at 0205, soft bilateral ankle restraints were reapplied and in use and the bilateral soft wrist restraints were removed.
On 8/7/19 at 0300 through 8/8/19 at 0700, soft bilateral wrist were reapplied and in use.
On 8/8/19 at 0900 through 8/8/19 at 1300, soft bilateral wrist and soft bilateral ankle restraints were in use.
On 8/8/19 at 1500 through 8/8/19 at 0300, the soft bilateral ankle restraints were removed and the bilateral soft wrist restraints remained in use.
On 8/9/19 at 0400 through 8/9/19 at 0700, the bilateral soft wrist restraints remained in use.
On 8/9/19 at 0900 through 8/9/19 at 1700, the soft bilateral wrist and soft bilateral ankle restraints were removed.
On 8/9/19 at 1900 soft bilateral wrist and soft bilateral ankle restraints were reapplied and in use.
On 8/9/19 at 2100 through 8/11/19 at 1000, soft bilateral ankle restraints were removed and the bilateral soft wrist restraints remained in use.
On 8/11/19 at 1200 through 8/12/19 at 0900, the bilateral soft wrist restraints remained in use. The lap belt was reapplied.
On 8/12/19 at 1400 the restraints were removed.
On 8/12/19 at 1900 the lap belt and bilateral soft wrist restraints were reapplied and in current use.
On 8/12/19 at 2100 through 8/13/19 at 0507, the bilateral soft wrist restraints were in current use.
On 8/13/19 at 0732 through 8/13/19 at 1100, the lap belt and bilateral soft wrist restraints were reapplied and in current use.
On 8/13/19 at 1300 the bilateral soft wrist restraints and the soft left ankle restraint was reapplied and in current use.
On 8/13/19 at 1424 the restraints were removed.
On 8/13/19 at 1500 through 8/13/19 at 1900, the bilateral soft wrist restraints and soft left ankle restraints were reapplied.
On 8/13/19 at 2057 the bilateral soft wrist restraints, the soft left ankle restraint were in use. The right soft ankle restraint was reapplied. The lap belt was reapplied.
On 8/13/19 at 2300 through 8/14/19 at 0100, the bilateral soft wrist restraints remained in use. The bilateral soft ankle restraints were removed.
On 8/14/19 at 0319 the bilateral soft wrist restraints remained in use. The soft bilateral ankle restraints were reapplied. The lap belt was reapplied.
On 8/14/19 at 0500 through 8/15/19 1700, the bilateral soft wrist restraints remained in use.
The bilateral soft ankle restraints were removed and lap belt were removed.
On 8/15/19 at 1900 there were no restraints in current use.

A review of physician progress notes dated 7/25/19 through 8/20/19 documented the following:
The patient was seen daily for examination and treatment. The patient had a sitter at all times. The physicians' documented the patient was observed with and without restraints. The patient was observed making frequent attempts to get out and bed. The patient was observed agitated and not sleeping. The patient required antianxiety medications for agitation, and sedation for a Cat Scan of the brain and for a brain scan to rule out seizure disorder. The patient was observed at times pulling at medical devices, hitting his bed rails and flailing his arms in all directions when not restrained. The patient was observed not sleeping well as reported by nursing staff. The patient was noted to be intermittently agitated, restless and impulsive. The patient's speech remained gibberish. The patient was not understanding addressed. The patient was not responding to verbal command. The patient was later observed at times being able to follow commands and responding to changes with the medication regime resulting in reduction in restraints and as needed antianxiety medications. The patient was unpredictable at times and was observed following restraint reduction with impulsive aggression, kicking, swinging at staff unpredictably. As the patient's condition improved he became more cooperative following commands, oriented to person, age and where he lived. His speech improved but remained somewhat impaired prior to discharge.

An interview was conducted with Nurse Manager Staff M on 8/26/19 at 1400. Staff M explained she recalled the patient. She said the patient flapped his arms around a lot. She said he had a lot of involuntary movements. She said his speech was gibberish. She explained the patient (#1) was restrained for "Safety". She said the patient's restraints were trialed off and on everyday and throughout the day. Staff M said the patient had a sitter around the clock for additional safety until he discharged. Staff M said the patient was unpredictable most of the time. She said he would hit on the side rails. He pulled an IV (intravenous) line out. Staff M said she required 2-3 staff team members present when repositioning the patient, or cleaning the patient up for safety. When further queried regarding the facility's protocol for restraints Staff M said we have a recent policy for "Safety" for patient's that are not on the "Behavioral Unit."

An interview was conducted with Patient Care Technician Staff N on 8/26/19 at 1557. Staff N said she recalled the patient. She said she was assigned to sit with him once. She said he was aggressive, he would kick, holler and she said he tried to kick her. She said he was unpredictable. She said because of his aggression they always made sure to have 2 or 3 staff to repostion him or clean him up becauses he would swing at staff or try and pull his IV out.

On 8/26/19 at 1645 an interview was conducted with Patient Care Technician Staff R. She explained the patient was in her "set". She said he was combative, resistant had outbursts and his speech was mumbled. She said the patient never slept. She said he always had a sitter. She said he was restrained at times on the occassions that she was assigned to him.

On 8/27/19 at 1030 an interview was conducted with Emergency Nurse Staff R. She explained she recalled taking care of the patient. She said he (#1) was in the ED for a few days after being initially petitioned by the group home. She said he wasn't always in restraints. She said he had a sitter around the clock in effort to keep him out of restraints. She said his gait was unsteady. She said the patient's speech was mumbled and said things that "didn't make sense."

She said it was their policy to obtain physcian orders for each episode of restraint. She said restraints are used for behaviors whereas the patient may be a threat to self or others
She said the doctor has to evaluate the patient as well to ensure the reason for the restraints meet their criteria for restraints. She said the order is only good for 4 hours. She said the orders for restraints would need to be renewed thereafter.

On 8/27/19 at 1427 an interview was conducted with the Chief Nursing Officer (Staff D) and the restraint policy was reviewed. Staff D explained all patient restraints were reviewed every shift and everyday of the week to monitor the appropriateness of restraints on the non-behavioral health units and the behavioral health units. She said Nurse Managers were responsible during the week and the House Managers were responsible for the off hours and weekends.

At that time, Staff D reiterated that patient #1 was restrained for "Safety" due to his cognitive impairment and for his attempts and sucess with pulling at his Intravenous therapy lines and trying to get out of bed. However, when further queried regarding the lack of consistency with obtaining a physician's order for each episode of restraint Staff D said, "We can do that as well."

A review of the facilty's "Restraint of Patient on Non-Behavioral Health Units" policy dated last revised on 12/2018 documented on page 4 of 8:
B. Non-violent restraints
3. Orders for restraint for non-violent behavior remain in effect as long as the patient continues to exhibit the behaviors that warranted the application of restraint or until the patients behavior's or situation no longer requires restraint.