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Based on record review and staff interview during the Allegation Survey, the hospital did not ensure A) the physicians' orders specified the reason for the restraint for one (1) of the five (5) records reviewed, B) alternative interventions were attempted prior to the application of the restraint for two (2) of the five (5) records reviewed and C) the physician did a complete medical evaluation of the patient's condition upon the application of restraints for four (4) of the five (5) records reviewed.

Findings:

A) Review of Medical Record #15's Restraint/Seclusion Progress Note/Order forms dated 06/19/10 at 6:30PM and 06/20/10 at 6:30PM, did not include a reason for the restraint. This section of the form was blank.

On 10/27/10 at 11:00AM this was confirmed with the Director of Nursing and the Director of Quality Management on interview.

B) Review of Medical Record #15's Restraint Flow Sheet Level I - Medical /Surgical form undated, did not include that alternative interventions were attempted prior to the application of the restraint. This section of the form was blank.

On 10/27/10 at 11:00AM this was confirmed with the Director of Nursing and the Director of Quality Management on interview.

Review of Medical Record #30's Restraint Flow Sheet Level I - Medical /Surgical form dated 08/20/10 at 9:00AM and 08/21/10 at 8:00PM, did not include that alternative interventions were attempted prior to the application of the restraint.

On 10/26/10 at 2:20PM this was confirmed with the Director of Nursing and the Director of Quality Management on interview.

C) Review of Medical Record #29's Restraint/Seclusion Progress Note/Order form dated 03/21/10 at 3:00AM and 7:00AM, documented the physician ordered four (4) point restraints which were applied to the patient. There was no documented evidence that the physician completed a medical evaluation of the patient's condition at 3:00AM and 7:00AM.

On 10/26/10 at 11:25AM this was confirmed with the Director of Nursing on interview.

Review of Medical Record #28's Restraint/Seclusion Progress Note/Order Form dated 05/21/10 at 3:30AM, documented the physician ordered bilateral wrist restraints and a soft vest restraint which was applied to the patient. There was no documented evidence that the physician completed a medical evaluation of the patient's condition when the restraints were ordered.

On 10/26/10 at 11:00AM this was confirmed with the Director of Nursing on interview.

Review of Medical Record #15's Restraint/Seclusion Progress Note/Order form dated 06/19/10 at 6:30PM and 06/20/10 at 6:30PM, documented the physician ordered a soft vest restraint which was applied to the patient. There was no documented evidence that the physician completed a medical evaluation of the patient's condition on 06/19/10 and 06/20/10.

On 10/27/10 at 11:00AM this was confirmed with the Director of Nursing and the Director of Quality Management on interview.

Review of Medical Record #30's Restraint/Seclusion Progress Note/Order form dated 08/21/10 at 9:00AM, documented the physician ordered bilateral wrist restraints and a soft vest restraint which was applied to the patient. There was no documented evidence that the physician completed a medical evaluation of the patient's condition.

On 10/26/10 at 2:30PM this was confirmed with the Director of Nursing and the Director of Quality Management on interview.
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Based on record review and staff interview during the Allegation Survey, the hospital did not ensure that a physician order was obtained immediately after the application of a restraint.

Findings:

Review of Medical Record #30's Restraint Level I - Medical/Surgical form dated 08/21/10 at 8:00PM, documented that bilateral wrist restraints were applied to the patient. However, a physician order for the restraints was not obtained until 08/22/10 at 9:00AM; thirteen (13) hours after the restraints were applied.

On 10/26/10 at 2:30PM this was confirmed with the Director of Nursing and the Director of Quality Management on interview.
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Based on record review and staff interview during the Allegation Survey, the hospital did not ensure the attending physician was notified by the House Officer that the patient required restraints.

Findings:

Review of Medical Record #28 revealed on 05/21/10 at 3:30AM the House Officer ordered bilateral wrist restraints and a soft vest restraint which were applied to the patient. There was no documented evidence that the attending physician was notified that the patient required restraints.

On 10/26/10 at 11:00AM this was confirmed with the Director of Nursing on interview.

Review of Medical Record #29 revealed on 03/21/10 at 3:00AM the House Officer ordered bilateral wrist and ankle restraints which were applied to the patient. There was no documented evidence that the attending physician was notified that the patient required restraints.

On 10/26/10 at 11:25AM this was confirmed with the Director of Nursing on interview.

Review of Medical Record #15 revealed on 06/19/10 at 6:30PM and on 06/20/10 at 6:30PM the House Officer ordered a soft vest restraint which was applied to the patient. There was no documented evidence that the attending physician was notified that the patient required a restraint.

On 10/27/10 at 11:00AM this was confirmed with the Director of Quality Management on interview.
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Based on record review and staff interview during the Allegation Survey, the hospital did not ensure the restrained patient's vital signs and behavior were consistently monitored.

Findings:

Review of Medical Record #30's Restraint/Seclusion Progress Note/Order form dated 08/20/10 at 9:00AM, documented an order for vital signs every two (2) hours.

Review of Medical Record #30's Documents Review Report dated 08/20/10, documented vital signs at 9:00AM and 12:00 noon. Review of Documents Review Report dated 08/21/10, documented vital signs at 5:00AM and 8:00AM. The vital signs were not consistently performed every two (2) hours as per the physician's order.

On 10/26/10 at 2:10PM this was confirmed with the Director of Nursing and the Director of Quality Management on interview.

Review of Medical Record #15's Restraint Flow Sheet Level I - Medical/Surgical form dated 06/19/10, documented at 6:30PM the patient was placed in a soft vest restraint. Between 06/19/10 7:00PM and 06/20/10 6:30PM there was no documented evidence that the restrained patient's behavior was evaluated every thirty (30) minutes as per hospital policy, during this twenty-three and one-half hour (23?) timeframe.

On 10/27/10 at 11:00AM this was confirmed with the Director of Nursing and the Director of Quality Management on interview.
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Based on record review and staff interview during the Allegation Survey, the hospital did not ensure the medical staff received education regarding the hospital policy entitled "Restraint and Seclusion."

Findings:

Review of Physician #1's personnel file revealed the physician orientation package did not include the hospital's policy entitled "Restraint and Seclusion."

The hospital Administrators could not provide documented evidence that Physician #1 and Physician #2 received education regarding the hospital policy entitled "Restraint and Seclusion."

On 10/22/10 this was confirmed with the Medical Director.
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Based on record review and staff interview during the Allegation Survey, the hospital did not ensure that each staff member with direct patient contact completed in depth education and training on the proper and safe use of restraints for patients who exhibit violent or self destructive behavior.

Findings:

Review of Nurse #1's and Nurse #2's personnel files revealed the nurses did not receive in depth education and training on the proper and safe use of restraints for patients who exhibit violent or self destructive behavior.

On 10/26/10 at 11:40AM an interview with the Director of Nursing revealed the Nurse Manager of the Special Care Unit received the in depth education and training on the proper and safe use of restraints for patients who exhibit violent or self destructive behavior however the nurses in the Special Care Unit did not yet receive the training.
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Based on record review and staff interview during the Allegation Survey, the hospital did not ensure that a patient death that occurred within twenty-four (24) hours after the patient was removed from restraints was reported to CMS.

Findings:

Review of Medical Record #31 revealed that on 03/10/10 at 1:00AM bilateral wrist restraints were ordered and applied to the patient. At 7:00AM the restraints were discontinued because the patient's condition no longer required the use of restraints. At 10:27AM the patient expired (the patient's death was not related to the restraints).

There was no documented evidence that the death associated with the use of restraints was reported to CMS.

On 10/27/10 this was confirmed with the Director of Quality Management on interview.