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Based on interviews, record review, and review of the facility's policy for Physical Restraints, it was determined the facility failed to ensure one (1) of four (4) sampled patients restrained, out of total sample of thirteen (13) patients, received an assessment of the patient's condition that would warrant the use of a physical restraint prior to application of the device. Patient #1 was placed in bilateral soft wrist restraints; however, there was no documented evidence an assessment was completed prior to the application of the restraints. In addition, there was no documentation to validate if or when the wrist restraints were removed.

The findings include:

Review of the facility's Physical Restraint policy, released August 2014, revealed the policy delineated responsibilities and procedural steps for clinical/nursing staff regarding physical restraints and/or seclusion of a patient. Non-Violent, non-self-destructive behavior guidelines are followed when, after a comprehensive, individualized assessment, they are required to prevent disturbing essential medical devices/equipment or to prevent interference with necessary care/treatment in which the patient consented to receive. A Registered Nurse (RN) will perform assessment/reassessment at established intervals, obtain physician orders, facilitate communication and document assessments in the patient's medical record according to policy.

Review of the clinical record revealed the facility admitted Patient #1 as a direct admit to the Intensive Care Unit (ICU) on 06/10/14 at 9:50 PM with a diagnosis of End-Stage Liver Failure related to Alcoholic Cirrhosis of the liver with Ascites. Review of the History and Physical documentation, transcribed on 06/11/14, revealed the patient had been treated for Hypotension, Hypovolemic Shock, Atrial Fibrillation with Rapid Ventricular Response, Hepatic Encephalopathy, and Gastrointestinal (GI) bleed at the transferring hospital. A nursing assessment was completed, on 06/10/14 at 10:58 PM, that revealed the patient was conscious and talking. Review of the physician orders, dated 06/10/14 at 11:18 PM, revealed the physician had been contacted via telephone with admitting orders for Patient #1. Record review revealed a telephone order was received on 06/11/14 at 5:30 AM to put Patient #1 in bilateral soft wrist restraints and give Ativan (1 mg) IV every six (6) hours. The record revealed RN #1 documented giving the Ativan on 06/11/14 at 6:02 AM. Review of the restraint monitoring form for non-violent, non-self-destructive behavior, dated 06/11/14, revealed RN #1 had documented the restraints were applied at 5:30 AM. She further checked, "no change", indicating the physical restraint was still needed when the form asked if the restraint was resolved. The nurse had initialed the form at 7:00 AM, but crossed through the time and put error. Review of the entire medical record revealed no assessment conducted prior to the use of the wrist restraints could be located.

A telephone interview with RN #1, on 09/11/14 at 5:16 PM, revealed she was the nurse who admitted Patient #1 on 06/10/14 and cared for the patient throughout the night until the patient coded and expired on 06/11/14. She stated she didn't recall the admission except the patient arrived late. She worked the 7 PM - 7 AM shift. She stated she remembered calling the physician about a physical restraint (wrist restraint) because the patient was restless, pulling things, and attempting to get out of bed without assistance. She could not recall if she initiated the restraint or not. She said she could not recall if the patient had the wrist restraints on during the code and could not recall if she had removed them. She revealed it was protocol to conduct an assessment prior to using restraints but she couldn't recall if she had conducted one. She then stated she would have to look at the record before she could really answer any questions.

Another telephone interview with RN #1, on 09/11/14 at 9:40 PM, revealed she had reviewed the clinical record regarding her documentation for Patient #1 on 06/10/14 and 06/11/14. She said she called the physician and obtained an order for bilateral wrist restraints and Ativan around 5:30 AM. She saw documentation where she had given the Ativan 1 mg IV and had documented she applied the wrist restraints at 5:30 AM on the monitoring sheet. She indicated she did not know if the wrist restraints were discontinued prior to the code at 7:20 AM that morning and did not see any documentation in the record that they had been. She said it would have been impractical to have the restraints applied during the code.

Interview with the ICU Nurse Manager, on 09/11/14 at 10:09 AM, revealed she was not present when the patient was admitted or the start of the code. She arrived at work while the code was in process. She stated she could not recall if Patient #1 was restrained during the code. She stated if a physical restraint was applied, an assessment should have been conducted prior to the application. She stated she had searched the medical record and could not find where an assessment had been conducted.