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Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure the type of restraints used were the least restrictive intervention available to maintain the patient's safety.

Findings:

1. Records #4 and 5 did not contain documentation less restrictive interventions had been tried or determined to be ineffective.

2. On the afternoon of 11/14/2012, Staff A, H and I told the surveyor that restraint reassessment and documentation of continued need for medical-use restraints would be documented at least every shift.

3. At 1500 on 11/14/2012, Staff A, H and I told the surveyor that the hospital had recently replaced preprinted restraint forms with all documentation being computerized. The computerized version had listed reasons for restraints, but no area for individualized text. Staff A and D told the surveyor that the " protocol " the hospital used for developing the computerized version was reviewed by CMS for input. According to the form, in addition to " Pulls at tubes, lines, dressing, etc. " , the approved reasons for restraints included: " Decreased level on consciousness, Can be aroused but unable to maintain wakefulness; exhibits confusion and/or disorientation; unable to remember instructions; (and) no understanding of therapies, equipment, risks. "

4. Staff A, H and I agreed that just because a patient had decreased level of consciousness, confusion, disorientation or was unable to remember instructions, it did not necessarily mean the patient needed restrained.

5. Restraint justification documented for Patient #4 did not contain evidence every shift that wrist restraints were the least restrictive intervention that could be utilized to protect the patient. Although the computerized entry checked at least once a day that the patient "pulls at tubes, lines, dressings, etc.", the checked documentation in the restraint portion the other times listed "decreased level of consciousness" and/or "no understanding of equipment, therapies and risks." Nursing narrative did not describe actions that would necessitate restraints. These findings were reviewed with Staff H at the time of review. She stated she remembered the patient and that although he would sleep, they were "constantly titrating" his sedation and he would immediately try to pull at his tubes/lines when he became slightly conscious.

6. Patient #5 - At the time of initiation of restraints on 11/01/2012 at 1900, the nurse documented,"decreased level of consciousness, arousable but unable to maintain wakefulness" as the reason for the restraint. The documentation did not support the need for restraint. The findings were reviewed with Staff H at the time of review of the afternoon of 11/14/2012.

Based on review of hospital documents and medical records and interviews with hospital staff, the hospital failed to ensure restraints were used in accordance with physician's orders. This occurred for three of five patient records (Records #3, 4 and 5) reviewed.

Findings:

1. State Hospital Licensure Standards, Chapter 667, Subchapter 15-8, requires that a patient may be restrained only upon the order of a physician or licensed independent practitioner. "Orders for physical restraint shall include a statement of reason for the restraint and specify which approved facility methods and devices shall be used."

2. Record #3 - On 10/16/2012 at 1540, the nurse changed the patient's restraint from soft right arm restraint to a waist restraint without a physician's order.

3. The hospital's "Restraint and Seclusion" policy, approval 10/20/2012, required renewal or new order to be "issued no less often than once each calendar day." Patient #3 was restrained on 12/21/2012 without a physician's order.

Staff A and I told the surveyor that once an order was written, depending where the patient was located, the computer program generated an automatic prompt in the way of a nursing "order/flag" to the physician to write a continuation or discontinue of the restraint order.

4. The hospital's "Restraint and Seclusion" policy, approval 10/20/2012, documented for critical care units, "Continues use of restraint will require a renewal order every 7 days based on physicians (sic) evaluation."

a. Patient #4 - The patient was placed in soft wrist restraints on 09/24/2012 at 0330, at the time of oral intubation, and, according to documentation in the medical record, remained in restraints until 10/08/2012 at 1524, when they were removed. The chart did not contain an initial order or any order for renewal of the restraints.

Staff H told the surveyor on 11/14/2012 at 1350, that she remembered this patient and the physician ordered restraint at the time of the intubation.

b. Patient #5 - The patient was placed in soft wrist restraints on 11/01/2012 at 1900. and continued until 11/02/2012 after 0300 (last time restraint documentation occurred). The chart did not contain an order for restraints.

c. She stated I and J told the surveyor on the afternoon of 11/14/2012 that although the nurse may check the box notifying the physician of the need for an order for restraint, the computer did not register the order until the physician "hits the button" to generate an order and therefor none of the prompts for continued restraint orders are generated.

5. The above findings were reviewed and confirmed with staff during the chart reviews.

Based on review of patient medical records and hospital documents, the hospital failed to ensure the clinical record contained documentation of the date and time CMS (Centers for Medicare and Medicaid Services) was notified of the death of a patient during the use of restraints. This occurred for one of two deaths in restraints that should have been reported to CMS (Record #3 of Records #1 and 3).

Findings:

1. A hospital policy titled, "In Case of Death, Notification and Responsibility", documented staff were required to "Document the date and the time the death was reported to CMS in the patient's medical record.

2. Although hospital reports and the death in restrain log recorded CMS was notified of Patient #3's death, the medical record did not contain this information. This was confirmed with Staff D at the time of review on the afternoon of 11/14/2012.