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Based on observations, medical record review, staff and family interviews, and policy/procedure reviews, it was determined that the facility was not protecting and promoting the rights of 1 (#10) of 2 sampled patients who had orders for restraints.

The findings include:

1. Refer to standard A0166
2. Refer to standard A0169
3. Refer to standard A0171
4. Refer to standard A0172
5. Refer to standard A0174

Based on medical record review and staff interview, the facility failed to ensure that 1 (#10) of 2 sampled patients had a plan of care that included measurable goals and a system for evaluating the ordered interventions for restraints.

The findings include:

Review of the medical record for Patient #10 revealed he had an order for wrist restraints for up to 24 hours on a daily basis from 9/12/14 through 9/22/14. The order for restraint did not include any necessary goals to be reached in order for release of restraint.

Review of the medical record for Patient #10 revealed the nursing care plan included a problem identified with confusion. The family stated the goal was to have nursing home placement. Interventions included reality orientation, communication enhancement, and restraints.There were no measurable goals listed for removal of the restraints. On 9/23/14 at 2:00PM, the Health Records Navigator stated the system doesn't offer the physician choices for restraint release expectations. She stated it is just up to the nurses' discretion when she feels the patient can be released from the restraints.

Interview with the Chief Nursing Officer on 9/23/14 at 8:50AM revealed the daily order for restraint for Patient #10 was probably a result of the computer software flagging the MD to ask if the restraint order needed renewal and the MD just clicking it. She did not have an answer for why no one addressed the order when it wasn't being followed.

Patient #10 was on 1:1 observation and the every 15 minute documentation revealed on 9/13/14 from 08:00 - 08:45, the patient was sleeping. The patient was also sleeping from 10:15-12:15 and again from 14:30-15:15. The nursing restraint log revealed documentation of restraint on 9/13/14 from 08:00-22:00. There was no further documentation to indicate the patient was released from restraint during any of the episodes of sleep. On 9/14/14, Patient #10 was coded on the 15 minute observation sheet as sleeping from 12:15-14:00 and again from 22:00-22:45. The nursing restraint log revealed documentation of restraint on 9/14/14 from 06:00-23:00 without release.

Review of the psychiatric progress note dated 9/13/14 at 12:35 revealed his mental status examination: "The patient is an elderly white male. He is not aware of his location. He is not agitated at this time. He is able to generate a list of 6 animals on the space of 1 minute with no perseverative responses. Short-term memory is poor. The patient is disoriented to time. No frank paraperceptions or delusions are observed or elicited at this encounter." There was no mention of the patient being in restraints during the exam or any mention of the patient needing restraints even though the nursing restraint log indicated he was in restraint during this time.

Based on medical record review and staff interviews, the facility failed to ensure that restraint orders were only initiated when documented behaviors warranted their use and not as a standing order for 1 (#10) of 18 sampled patients.

The findings include:

Review of the medical record for Patient #10 revealed a daily order for restraints for Non-Behavioral Management from 9/12/14 through 9/22/14.

Review of the nursing restraint log revealed documentation of restraint use for Patient #10 from 9/12/14 through 9/16/14. There was no documentation for restraint use on 9/17/14 through 9/22/14 even though the physician had them ordered.

Review of the facility Restraint Policy revealed orders for restraints must be time limited and are never to be written as a standing order or on an "as needed" basis.

Interview with the Chief Nursing Officer on 9/23/14 at 8:50AM revealed the daily order for restraints for Patient #10 was probably a result of the computer software flagging the MD to ask if the restraint order needed renewal and the MD just clicking it. She did not have an answer for why no one addressed the order when it was not being followed.

Based on family interviews, medical record reviews, and policy/procedure review, the facility failed to ensure that 1 (#10) of 2 sampled patients on suicide precautions needing restraint wasn't restrained for longer than 4 hours without the order being renewed.

The findings include:

Interview with the daughters of Patient #10 on 9/22/14 at 11:50AM revealed they had several concerns regarding their father's care. They revealed their father was Baker Acted to the facility after becoming aggressive with their mother at home. They both stated the facility put restraints on their father's wrists and the staff would not let him up to go to the bathroom. They confirmed they were notified about the restraint order, but there was no mention of what it would take for the restraints to be removed. They acknowledged they understood that their father was aggressive and hitting or kicking the staff at times but the restraints were kept on for days.

Interview with the Director of Patient Care Logistics on 9/22/14 at 12:10PM revealed all patients admitted under a Baker Act or who are a suicide risk have to have a 1:1 Sitter if they are on a medical or surgical floor.

Review of the medical record for Patient #10 revealed he was admitted to the facility on 9/11/14 under a Baker Act initiated by law enforcement after being called to the home by the wife for violent behavior. He had a history of dementia and was admitted to a medical floor with encephalopathy possibly due to a urinary tract infection. His admission orders dated 9/11/14 included suicide precautions and a 1:1 observer. A free text nurse note dated 9/12/14 at 12:36PM revealed the patient became agitated, stating he wanted to go home. Patient was ambulated on the unit for approximately 20 minutes. Patient refused to return to his room and started yelling. He attempted to pull out suprapubic catheter, and grabbed charge nurse by the hand. Code Grey was called and patient was assisted back to his room and seated in the recliner. Hand restraints applied.
Review of the physician's orders revealed an order was placed on 9/12/14 at 13:02 for restraints -Non-Behavioral to be discontinued 9/13/14 at 13:30. The reason for restraint checked on the electronic medical record was attempting to dislodge tubes or dressings, attempting unsafe ambulation, and attempting unsafe wandering. There was no indication of behavior required to release restraints. There was a daily order to renew restraints through 9/22/14 when the patient was discharged.

Review of the facility's policies for Suicide Risk Assessment and Restraints revealed there are 2 types of restraint management, behavioral and non-behavioral. Non-Behavioral Management is used for patients on medical/surgical floors with secondary diagnoses of emotional or behavioral disorders. Behavioral Management is for patients admitted to the Mental Health Unit with a primary diagnosis of Emotional/Behavioral Disorder. The requirements for physician evaluation and face-to-face visits are more stringent with Behavioral Management than with Non-Behavioral Management. However, the policy for suicide risk assessment states that any patient on suicide precautions who is placed in physical restraint, use the order form and flow sheet for "Restraint for Behavior Management." Review of the policy on restraint for behavior management revealed the patient has to have a face-to-face evaluation by a physician, other licensed independent practitioner, or a registered nurse specifically trained to perform the one-hour evaluation. Restraint orders are time limited to 4 hours for adults. The documentation for the one-hour face-to-face evaluation will be documented on a paper form labeled, "Behavioral Restraint One Hour Face to Face Evaluation" Form. The Restraint Policy also revealed that the practitioner will educate and discuss with the patient and family/significant others, the behaviors necessary to bring about release from restraint.

There was no documentation of a face-to-face evaluation for Patient #10 after the initial order for restraint or a renewal order after 4 hours. The initial order for restraint on 9/12/14 was to be discontinued on 9/13/14.

During an interview with the Director of Quality, the Chief Nursing Officer, and the Chief Medical Officer on 9/23/14 at 11:45AM, they were asked to clarify the policy for behavioral restraints vs non-behavioral restraints. The Director of Quality stated Non- Behavioral Restraints would be for medical/surgical restraints if the patient is attempting unsafe ambulation, unsafe wandering, but is non-violent and cooperative. Behavioral Restraints would be used if the patient is violent to themselves or others. The Chief Nursing Officer stated Patient #10 was kind of in a 'grey area'. He was medical/surgical Non-Behavioral, but he also was combative and kicking the nurses, so he could have been classified as Behavioral as well. The Chief Medical Officer stated non behavioral would include actions caused from fever or pulling out tubes. Hallucinating would be Behavioral.


Review of the every 15 Minute Monitoring Sheet that is filled out by the 1:1 observer revealed Patient #10 was coded as having hallucinations from 9/12/14 through 9/14/14.

Based on medical record review and staff interviews, the facility failed to ensure that 1 (#10) of 2 sampled patients who had an order for restraint was examined and assessed for the continued use of restraint before renewing the order.

The findings include:

Review of the medical record for Patient #10 revealed he was admitted to the facility on 9/11/14 under a Baker Act initiated by law enforcement after being called to the home by the wife for violent behavior. He had a history of dementia and was admitted to a medical floor with encephalopathy possibly due to a urinary tract infection. His admission orders dated 9/11/14 included suicide precautions and a 1:1 observer. A free text nurse note dated 9/12/14 at 12:36PM revealed the patient became agitated, stating he wanted to go home. Patient was ambulated on the unit for approximately 20 minutes. Patient refused to return to his room and started yelling. He attempted to pull out suprapubic catheter, and grabbed charge nurse by the hand. Code Grey was called and patient was assisted back to his room and seated in the recliner. Hand restraints applied.
Review of the physician's orders revealed an order was placed on 9/12/14 at 13:02 for restraints - Non-Behavioral to be discontinued 9/13/14 at 13:30. The reason for restraints checked on the electronic medical record was attempting to dislodge tubes or dressings, attempting unsafe ambulation, and attempting unsafe wandering. There was no indication of behavior required to release restraints.

Review of the physician's progress notes revealed a physical exam was completed on 9/13/14 after Patient #10 was ordered restraints on 9/12/14. The evaluation did not include any documentation of behaviors requiring restraint or the continued need for restraint. There was documentation in the physician's progress notes that Patient #10 was seen by a physician daily, but there was never any mention of behaviors requiring restraint or the need for continued restraint. The physician note dated 9/16/14 revealed a notation that patient was out of restraints for most of yesterday, but no mention of the need to continue restraints, and yet the order was renewed.


During an interview with the Chief Nursing Officer on 9/24/14 at 9:00AM, she confirmed that she could not find any physician documentation in Patient #10's record that the behaviors for restraints were addressed.

Based on family interview, medical record review, and staff interviews, the facility failed to ensure 1 (#10) out of 2 sampled patients had restraints discontinued when the episode of behavior requiring the restraints was resolved.

The findings include:

Interview with the daughters of Patient #10 on 9/22/14 at 11:50AM revealed they had several concerns regarding their father's care. They revealed their father was Baker Acted to the facility after becoming aggressive with their mother at home. They both stated the facility put restraints on their father's wrists and the staff would not let him up to go to the bathroom. They confirmed they were notified about the restraint order, but there was no mention of what it would take for the restraints to be removed. They acknowledged they understood that their father was aggressive and hitting or kicking the staff at times, but the restraints were kept on for days.

Review of the medical record for Patient #10 revealed he had an order for wrist restraints for up to 24 hours on a daily basis from 9/12/14 through 9/22/14. The order for restraint did not include any necessary goals to be reached in order for release of restraint.

Interview with the Chief Nursing Officer on 9/23/14 at 8:50AM revealed the daily order for restraints for Patient #10 was probably a result of the computer software flagging the MD to ask if the restraint order needed renewal and the MD just clicking it. She did not have an answer for why no one addressed the order when it wasn't being followed.

Patient #10 was on 1:1 observation and the every 15 minute documentation revealed on 9/13/14 from 08:00 - 08:45, the patient was sleeping. The patient was also sleeping from 10:15-12:15 and again from 14:30-15:15. The Nursing Restraint Log revealed documentation of restraints on 9/13/14 from 08:00-22:00. There was no further documentation to indicate the patient was released from restraints during any of the episodes of sleep. On 9/14/14, Patient #10 was coded on the 15 Minute Observation Sheet as sleeping from 12:15-14:00 and again from 22:00-22:45. The nursing restraint log revealed documentation of restraints on 9/14/14 from 06:00-23:00 without release.

Review of the psychiatric progress note dated 9/13/14 at 12:35 revealed his mental status examination: "The patient is an elderly white male. He is not aware of his location. He is not agitated at this time. He is able to generate a list of 6 animals in the space of 1 minute with no perseverative responses. Short-term memory is poor. The patient is disoriented to time. No frank paraperceptions or delusions are observed or elicited at this encounter." There was no mention of the patient being in restraints during the exam or any mention of the patient needing restraint even though the nursing restraint log indicated he was in restraints during this time.

Based on observations, family interviews, medical record review, and policy/procedure review, the facility failed to ensure that nursing personnel were providing care and services that meet current standards of practice for: 1.) 2 sampled patients in the operating room (#17, #18); 2.) 2 sampled patients on suicide precautions (#10, #12);
3.) 1 sampled patient receiving care in the Emergency Department (ED) (#2), of 18 sampled patients.

The Florida Nurse Practice Act, Chapter 464.003 defines the "Practice of professional nursing" as "The performance of those acts requiring substantial specialized knowledge, judgment and nursing skill based upon applied principles of psychological, biological, physical and social sciences" which shall include, but not limited to: The administration of medications and treatments as prescribed by a duly licensed practitioner "practice of practical nursing" as the performance of selected acts, including the administration of treatments and medications in the care of the ill, injured or infirmed, and the promotion of wellness, maintenance of health and prevention of illness of others, under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician or a licensed dentist.

The findings include:

1. Review of the operating room policy for Time-Outs dated 7/18/07 revealed, "The ENTIRE SURGICAL TEAM must actively communicate and acknowledge the time-out. Silence or nodding is not acceptable."
During the surgical department tour on 9/23/14 an observation was made at 9:20AM of Patient #17 being prepped for surgery in Operating Room (OR) #4. The staff was present in the operating room and anesthesia had been initiated. At 9:24AM, a Time-Out was called for by the circulating nurse. The Consent was read aloud and he stated, "No fires, no equipment concerns." There was no verbal acknowledgement by any of the staff present to indicate they were in agreement with what was read. The procedure was then started by the general surgeon.
Upon exiting OR #4 on 9/23/14 at 9:30AM, the Director of Surgical Services stated she had some re-educating to do regarding the Time-Out procedure.
The surgical department tour continued on 9/23/14 and an observation was made at 9:55AM of Patient #18 in OR #8. The patient was already on the table and was scheduled to have a right total shoulder repair. The staff were manipulating the patient's position for the surgery and the patient was having some blood pressure issues that anesthesia was addressing. At 10:05AM, a Time-Out was called by the surgeon and the circulator read the Consent and the surgeon said 'yes'. There was no other verbal acknowledgement from the other staff present that they were in agreement with what was stated. The scrub tech was opening packages at the back table and the Certified Registered Nurse Anesthetist (CRNA) and a student in the room were talking among themselves. The patient was then prepped and draped. At 10:15AM, a second Time-Out was called prior to the incision. Again, there was no verbal acknowledgement from any of the staff present that they were in agreement or not with what was stated. The surgery was initiated at 10:18AM.
After exiting OR #8 on 9/23/14 at 10:20AM, the Director of Surgical Services confirmed the Time-Out procedure was not completed appropriately for either observation. She stated she would be fixing this problem immediately.
Review of the medical record for Patient #17 revealed RN circulator documentation of a Time-Out was for 9/23/14 at 9:24AM. The documentation revealed a notation of 'completed' for introduction of the team members; 'completed' for team members have confirmed the following: identity, procedure, incision site, and Consent, and fire safety time-out completed. These 3 items were not observed to have been completed during the Time-Out in OR #4.
2. Interview with the daughters of Patient #10 on 9/22/14 at 11:50AM revealed they had several concerns regarding their father's care. They revealed their father was Baker Acted to the facility after becoming aggressive with their mother at home. They both stated the facility put restraints on their father's wrists and the staff would not let him up to go to the bathroom. They confirmed they were notified about the restraint order but there was no mention of what it would take for the restraints to be removed. They acknowledged they understood that their father was aggressive and hitting or kicking the staff at times, but the restraints were kept on for days.
Review of the medical record for Patient #10 revealed physician orders for restraints every day starting 9/12/14 through 9/22/14. Interview with Employee I on 9/22/14 at 12:00PM revealed he was not currently restrained. She reviewed the medical record and stated the last documentation of restraint was on 9/16/14 at 7:32AM. She stated he was not restrained today, because he was being discharged. Review of the nursing restraint log revealed documentation of restraint from 9/12/14 through 9/16/14. There was no documentation of restraint for 9/17/14 through 9/22/14 even though the physician had ordered restraints.
Review of the medical record for Patient #12 revealed she was admitted to the facility on 9/21/14 under a Baker Act and was placed on a medical floor with a 1:1 Sitter. Review of the Suicide Risk Observation Checklist revealed it was dated 9/21/14 at 13:00 and signed by a nurse on the 7A-7P shift, but the checklist was not completed.

Interview with Employee M, Charge Nurse, on 9/22/14 at 1:45PM revealed Baker Act patients have to have a 1:1 sitter. He reviewed the patient's observation flow sheet and stated the nurse should be filling out the top of the observation sheet every shift. He noted that Patient #12's observation sheet was blank on top.

Interview with Employee O, RN, on 9/22/14 at 1:45PM revealed she is the nurse for Patient #12. She stated her responsibility is to make sure the sitter is always present and make sure the patient is safe and there is nothing to harm her. She stated she makes sure that the 15-minute check documentation is completed. She stated she was not sure why the observation sheet was blank at the top. She stated as soon as the Baker Act was started, the nurse should have documented on the checklist at the top of the observation sheet. She stated she signed it because she noticed the signature was blank, but she didn't fill out the checklist. Review of the 1:1 monitoring sheet for Patient #12 dated 9/22/14 revealed a lack of documentation on the 15-minute checks from 11:00-12:45. Employee O revealed she is responsible for seeing that the sitter is present and completing the documentation of the 15-minute checks. She stated she did not know why the sheet had holes in documentation. Interview with Employee N on 9/22/14 at 1:50PM revealed she has been a sitter for 3 years. She stated she is to observe the patient and their behavior and document it every 15 minutes. When asked why the observation sheet had blanks from 11:00-12:45, she stated the patient was just sleeping and she thought she would document it later. Review of the Suicide Risk Observation Check List sheet revealed the directions on 1:1 monitoring is to document behavior and initial this monitoring every 15 minutes.

3. Patient #2 filed a grievance stating she was seen in the ED on 7/16/14 complaining of pain in her side after a fall at home. The facility had x-rays performed and she was informed by the ED physician that there were no fractures. She revealed she returned to the ED on 7/27/14 with increasing pain and was informed that she had rib fractures that showed up on her previous x-rays and nobody called to notify her.
Interview with Employee D, RN, on 9/24/14 at 11:33AM revealed the ED Quality Assurance (QA) Nurse is responsible for notifying patients when there is a discrepancy in the reading of the x-rays by radiology compared to the ED physician. Employee D stated that the ED QA Nurse acknowledged that he did not call and report the fracture from the radiology report to Patient #2, based on the grievance follow-up.

Based on policy/procedure review, medical record review, and staff interviews, the facility failed to ensure that nursing care plans were developed with measurable goals and interventions and then implemented for 2 of 18 sampled patients ( #10, #12).

The findings include:


Review of the facility policy and procedure "Interdisciplinary Care Plan and Charting" revealed the data from the nursing assessment is used to develop an individualized care plan reflective of problems and goals. The patient's progress towards achieving his or her goals and resolving his or her problems shall be evaluated on a frequency identified in the goals.


Review of the medical record for Patient #10 revealed the nursing care plan included a problem identified with confusion. The family's stated goal was to have nursing home placement. Interventions included reality orientation, communication enhancement, and restraints.There were no measurable goals listed for any of the interventions.

Review of the medical record for Patient #12 with the Health Records Navigator revealed the nursing assessment included a patient goal to go home. There was no documentation of a nursing care plan in the electronic medical record.

Interview with the Chief Nursing Officer on 9/23/14 at 4:00PM revealed the policy for nursing care plans does not include a time element for completion. She stated her expectation would be that the care plan should be completed within 24 hours of admission, because the nursing assessment is to be completed in 24 hours. She stated that Patient #12 was admitted on 9/21/14 and should definitely have a care plan by now.