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Based on obeservation, record review, and staff interview, the hospital failed to ensure less restrictive interventions have been determined to be ineffective to protect the patient prior to using a restraint (A0164).

Based on observation, record review and staff interview, the hospital failed to ensure less restrictive interventions have been determined to be ineffective to protect the patient prior to using a restraint for five of five sampled patients where reclining chairs were used (Patient #1, #2, #3, #4 and #5). The census was 99.

Findings include:

Review of the policy and procedure titled, Use of Restraints for Nonviolent, Non-Self Destructive Patient Situations: Medical Use of Restraints, Approval Date 01/09/18, revealed restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or other and must be discontinued at the earliest possible time. Restraints may be used in response to limit mobility or, temporarily immobilize a patient related to a medical, post-surgical or dental procedure. Any use of restraints is based on the assessed needs of the patient by a physician or registered nurse and assures that the patient and his or her rights, dignity, and well-being are preserved. A geri chair or side rails are devices that may serve multiple purposes. When they have the effect of restricting a patient's movement and cannot be easily removed by the patient, these devices constitute a restraint. Evaluation of whether devices should be used as restraints must include how they benefit the patient, and whether a less restrictive device/intervention could offer the same benefit at less risk. In any case, a thorough evaluation of the patient and his/her needs is essential. The policy defined a physical restraint as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Under this definition, commonly used hospital devices and other practices could meet the definition of a restraint, such as: geri chairs or recliners, only of the patient cannot easily remove the restraint appliance and get out of the chair on his or her own.

Tour of the geriatric psychiatric unit on 12/19/19 at 11:30 AM revealed three patients using reclining chairs (Patients #2, #3, and #4). Tour of the Progressive Care Unit (PCU) on 12/19/19 at 1:43 PM revealed one patient (Patient #5) reclined in a chair at the bedside.

1. Review of a physician note for Patient #2 revealed he/she had diagnoses including Alzheimer's dementia with behavioral disturbance, atrial fibrillation, bradycardia, cellulitis right foot, congestive heart failure, chronic kidney disease and high blood pressure. Patient #2 was admitted on 12/17/19 to the geriatric psychiatric unit after behaviors created safety issues at a long term care facility. The patient's behaviors included poor sleep, yelling out at night, throwing objects off the bedside table, visual hallucinations, fluctuating sensorium, irritability and lability. Review of the initial psychiatric evaluation dated 12/18/19 in a section titled motor/gait revealed Patient #2 was not ambulatory. Review of nursing shift assessments for Patient #2 dated 12/17/19 to 12/19/19 revealed his/her right and left upper extremities had "full movement" and the right lower extremity had "full movement." Observations were made on 12/19/19 at 12:50 of Patient #2 reclined in a recliner in the common area of the geriatric psych unit.

There was no documentation for the chair in the patient record depicting the person's ability/inability to operate the chair.

Interview with Staff AA on 12/19/19 at 12:41 PM revealed the facility did not assess the reclining chairs for the potential of restraint status. Staff AA said the reclining chairs were not considered restraints because the chairs had right side handles or push action by the seated individual that could return the reclined chair to upright seated position. Staff AA further stated the facility assessed the individual's ability to ambulate and if the person was not ambulatory then the chair would not be a restraint.

This finding was shared with the administrative staff prior to the exit conference on 12/19/19.

2. Review of an occupational therapy (OT) note dated 12/19/19 for Patient #3 revealed he/she had diagnoses including mixed dementia, hypertension, seizure disorder, Parkinson's disease, and was admitted from a nursing facility after suicidal ideations. Review of the OT assessment revealed Patient #3 had significant contractures of the right extremity that limited strength, displayed poor gross motor and fine motor coordination, requiring maximum assistance for bed mobility and assist of two and a Hoyer lift for transfers. Review of daily nursing assessments dated 12/18/19 to 12/19/19 revealed Patient #3 had "limited movement" in his/her right upper extremity and bilateral lower extremities but had "full movement" in his/her left upper extremity.

Observations were made on 12/19/19 at 11:30 AM of Patient #3 reclined in a reclining chair in the common/gathering area of the geriatric psych unit. There was no documentation on Patient #3's record about his/her ability/inability to operate the reclining chair.

3. Review of an occupational therapy note dated 12/16/19 for Patient #4 revealed he she had diagnoses including anxiety, depression, dementia and schizophrenia, admitted after increased depression with suicidal ideation. Review of the subjective data in the assessment revealed Patient #4 had "not walked or stood for at least 5-6 years," and while he/she "reported numbness and tingling in bilateral upper extremities for several months," OT evaluation revealed he she had upper extremity range of joint motion without limitation. Further review of the OT assessment revealed Patient #4 required assistance of two staff for bed mobility, transfers, self-care, and while alert and oriented had decreased safety awareness, decreased cognition and decreased activity tolerance. Review of a daily nursing assessment dated 12/14/19 to 12/18/19 revealed Patient #4 had limited movement in all upper and lower extremities and was alert and oriented to person, place and time.

Observations were made on 12/19/19 at 11:30 AM of Patient #4 in a recliner (reclined) in the common area of the geriatric psych unit. There was no documentation on Patient #4's record about his/her ability/inability to operate the reclining chair.

This finding was shared with the administrative staff prior to the exit conference on 12/19/19.

4. Review of a physical therapy (PT) evaluation for Patient #5 dated 12/17/19 revealed Patient #5 had an admitting diagnosis of shortness of breath and worsening lower extremity edema and had a history cor pulmonale, chronic hypoxemic and hypercapnic respiratory failure. Review of the PT evaluation revealed Patient #5 was "fully independent for transfers and gait" prior to admission, ambulated with a rolling walker, and demonstrated decreased activity tolerance, balance, safety and strength as well as decreased independence with ambulation and transfers.

Observations were made on 12/19/19 at 1:43 PM of Patient #5 reclined in a recliner at the bedside in room 319 of the PCU area of the hospital. There was no documentation on Patient #5's record about his/her ability/inability to operate the reclining chair.

This finding was shared with the administrative staff prior to the exit conference on 12/19/19.

5. Review of the medical record for Patient #1 revealed he/she came to the emergency department (ED) from a skilled nursing facility (SNF) on 07/10/19 with increased agitation. The chief complaint was major neuro cognitive disorder due to multiple etiologies with behavioral disturbances. Patient #1 was admitted to the geriatric behavioral unit on 07/10/19. The skin assessment on admission was documented as within normal limits (WNL). The fall risk assessment on admission revealed Patient #1 was a moderate fall risk for medical according to the Morse Fall Risk assessment and for the Edmonson Psych Fall Risk assessment the patient was identified as a fall risk.

Review of the nurses' notes revealed on 07/12/19 at 9:50 AM the patient was restless, experiencing insomnia, resistant during personal care this morning, received meds, good appetite, pacing about the unit, currently in bed resting with eyes closed, no signs or symptoms of distress; on 07/13/19 at 9:27 PM the patient continues to pace about the unit checking doors and going into other patients' rooms. Also moving furniture wround and talking gibberish; 07/14/19 at 2:58 AM the patient was cooperative after staff played music and danced with patient; 07/15/19 at 12:56 AM the patient was visible and walking around the unit. Requires redirection from going into other patients' rooms; 07/15/19 at 9:48 PM the patient was moving furniture about the unit. Exit seeking. Confused and wandering. Sitting in a recliner watching TV at the moment; 07/18/19 at 11:06 AM the patient has remained free of falls and injury so far this shift. Ambulates ad lib with slow steady gait. Nonskid footwear on; 07/19/19 12:46 AM up ad lib and wandering on the unit. He/she is confused and frequently wanders into patients' rooms. He/she was showered this evening per two staff members. The patient was somewhat cooperative, but started yelling before shower was finished. The patient then wandered around the unit becoming slower and leaning forward. The patient appeared tired but refused to go to bed. The patient was placed in a recliner with a pillow and blanket where he/she fell asleep in a few minutes; 07/21/19 at 2:47 PM while patient is up he/she is confused and requires eyes on and close supervision due to his/her high falls risk and poor judgement with is/her own safety while up and ambulating. He/she has generalized weakness and very unsteady gait while up. He/she has been very impulsive with attempts to get up or climb out of chair or bed; 07/21/19 at 4:16 PM patient attempting to get out of bed several times. Writer offered two times to get patient up and place in a recliner and bring out to day room but patient refuses to get out of bed.

Review of the nursing progress notes revealed on 07/22/19 at 2:28 PM revealed the patient was up in a geri chair (reclining chair with wheels) and Patient #1's foot was found stuck in-between the cloth and the metal of the footrest of the chair. Patient #1's foot was assessed and appeared red but skin was intact. The physician was notified on 07/22/19 at 2:28 PM. The nurse progress note dated 07/22/19 at 6:18 PM revealed the patient was restless most of the day, up in gerichair, constantly moving around. The patient's right foot was still red but appears to have no further injury. A nursing note at 8:42 PM revealed the nurse came to evaluate the patient's right foot. Significant redness and bruising, the patient unable to answer questions. Extremity has good color and pulse. X-ray ordered and physician aware.

Review of an X-ray report dated 07/22/19 at 9:48 PM revealed there were two X-ray views of the right ankle; and two X-ray views of the right foot. The findings were negative with no evidence of fractures or dislocations.

There was no evidence in the patient's record that an assessment had been completed that showed less restrictive interventions had been determined to be ineffective prior to placing the ambulatory patient in a geri chair or recliner.

This finding was shared with the administrative staff prior to the exit conference on 12/19/19.

On 12/19/19 at 1:40 PM Staff AA stated in an interview that the hospital did not have geri chairs, but the hospital did have recliners. Further interview at this time with Staff BB revealed at one time the hospital had geri chairs and the hospital got rid of them in 2005 because they were considered restraints. The recliners were not considered restraints and no assessment was needed for a patient to be put in a recliner.