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Based on interview and record review, the facility failed to follow policy and procedure for restraints for 1 (#9) of 2 patients reviewed for restraints out of a total sample of 12, resulting in the potential for unsatisfactory outcomes for any patient placed in restraints. Findings include:

See specific Tags:
A-0168: Based on interview and record review the facility failed to obtain an order for hard (behavioral) restraints.

A-0187: Based on interview and record review the facility failed to document the patient condition or symptoms that required behavioral restraints.

Based on interview and record review, the facility staff failed to obtain an order for hard restraints for 1 (#9) of 2 patients reviewed for restraints, resulting in the potential for unsatisfactory outcomes for any patient placed in restraints. Findings include:

On 3/16/22 at approximately 1145, interview with Charge Nurse H revealed that patient #9 had recently been in "medical soft restraints," but they were currently discontinued. Patient #9 was a 67-year-old male admitted to the medical unit. Per Charge Nurse H, the patient required a constant observer for potential elopement. He was homeless, he required medication adjustments, he required Social Service interventions, and an Adult Protective Services referral was in progress.

On 3/16/22 at 1150, record review with Clinical Coordinator J revealed that night Staff Nurse R had obtained a "Restraint-Non-Violent. Soft Limb x 2. Unable to follow safety instructions..." The Plan of Care was updated by Nurse R on 3/16/22 at 0416. Nurse R documented, "Type of Restraint: Soft limb x 2; restraints; Location of Restraint: Right upper extremity, left lower extremity." On 3/16/22 at 0600, Nurse R documented on the "Restraint Non-Violent Plan of Care, Type of Restraint: Hard Key x 2--right upper extremity, left lower extremity." Further record review with Clinical Coordinator J, on 3/16/22 at approximately 1200, revealed no order was documented for the hard key restraints as required or documented behaviors which would require hard restraints.

On 3/16/22 at approximately 1200, interview with Charge Nurse H revealed that the patient was put in hard restraints because he was swinging and trying to punch the night nurse. Interview with Nurse Manager K, on 3/16/22 at approximately 1200, revealed that she was not aware that the patient had been placed in hard restraints. There was no documentation of this behavior in the patient's medical record. There was no incident or variance report documented regarding the patient punching or attempting to punch the nurse.

On 3/16/22 at approximately 1205, interview with day Staff Nurse L revealed that she removed the hard keyed restraints "after talking to the patient this morning around 7:30." She stated that the patient agreed on acceptable behaviors.

On 3/17/22 at 1400, review of the facility policy titled "Restraint in the Non-Psychiatric Healthcare Setting, #CLN-CO-4.004, dated 2/28/20" documented "Initial Order (for aggressive behaviors) Physician/APP designee must be contacted prior to application or within 30 minutes of emergency application; Face-to face assessment...required within one hour of applying restraints even if the restraints are removed within that hour." This had not been done.

Based on interview and record review, the facility nursing staff failed to document the patient symptoms which required restraints for 1 (#9) of 2 patients reviewed for restraints, resulting the the potential for unsatisfactory outcomes for any patient placed in restraints. Findings include:

On 3/16/22 at approximately 1145, interview with Charge Nurse H revealed that patient #9 had recently been in "medical soft restraints," but they were currently discontinued. Patient #9 was a 67-year-old male admitted to the medical unit. Per Charge Nurse H, the patient required a constant observer for potential elopement. He was homeless, he required medication adjustments, he required Social Service interventions, and an Adult Protective Services referral was in progress.

On 3/16/22 at approximately 1200, interview with Charge Nurse H revealed that the patient was put in hard restraints because he was swinging and trying to punch the night nurse. Interview with Nurse Manager K, on 3/16/22 at approximately 1200, revealed that she was not aware that the patient had been placed in hard restraints. There was no documentation of this behavior in the patient's medical record. There was no incident or variance report documented regarding the patient punching or attempting to punch the nurse.

On 3/16/22 at approximately 1205, interview with day Staff Nurse L revealed that she removed the hard keyed restraints "after talking to the patient this morning around 7:30." She stated that the patient agreed on acceptable behaviors.

On 3/17/22 at 1400, review of the facility policy titled "Restraint in the Non-Psychiatric Healthcare Setting, #CLN-CO-4.004, dated 2/28/20" documented "Reason for Use: Use is driven by unanticipated outburst of severely aggressive or destructive behavior that poses an imminent danger to self/others and non-physical interventions would not be effective." Also, "Nursing Assessment and Documentation Required: On-going throughout the episode of restraint--minimally continuously first 15 minutes then every 15 minutes as documented by the RN..." This had not been done.