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Based on observations, interviews and document review it was determined the nursing staff failed to obtain a physician's order to reapply non-violent restraints on one (1) of seven (7) restrained patients included in the survey sample (Patient # 16).

The findings included:

The surveyors requested a list of all current patients in restraints during the entrance conference on 09/12/2016 at approximately 11:11 a.m., with Staff Member #1. At 11:46 a.m. on 09/12/2016 Staff Member #1 presented the list and stated, "We only have one patient in restraints at this time [Patient #16's name]."

On 09/12/2016 at approximately 12:38 p.m. an observation was conducted with Staff Member #2 on the unit that cared for Patient #16. The observation revealed Patient #16 was intubated, had multiple medical treatment lines and a chest tube. The observation also revealed Patient #16 had bilateral soft wrist restraints in place. Staff Member #2 reported whenever a trial had been made to remove Patient #16's bilateral wrist restraints the patient attempted to extubate his/her endotracheal tube.

Review of Patient #16's electronic medical record (EMR) was conducted on 09/12/2016 at 12:08 with Staff Member #2, while unit staff completed care for Patient #16. Review of Patient #16's EMR documented the patient was directly admitted to the facility on 09/05/2016 from his/her physician's office. Patient #16's admitting diagnoses were sepsis and right urethral stone with surgery scheduled for 09/06/2016. Patient #16 was admitted to the critical care area post-surgery. An anesthesia note indicated Patient #16 was intubated during surgery and remained intubated post-surgery related to not being able to tolerate weaning off mechanical ventilation.

Review of Patient #16's EMR included nursing flowsheets for non-violent restraints. The nursing restraint flowsheets documented on 09/08/2016 at 10:57 a.m. a trial removal of Patient #16's bilateral soft wrist restraints. The nursing restraint flowsheet for 09/08/2016 documented at 12:58 p.m. Patient #16's bilaterally soft wrist restraints were back in place. The nursing restraint flowsheets for Patient #16 at 1:45 p.m. and 2:18 p.m. on 09/08/2016 documented continued assessments of the patient's wrist restraints. The EMR flowsheet documentation for Patient #16's bilateral wrist restraints contained a three (3) hour and forty-six (46) minutes gap from 2:18 p.m. until the next assessment at 6:04 p.m. on 09/08/2016. Staff Member #2 stated, "They [nursing staff] had been charting just about every hour to every two hours. I'm not sure if this was another trial attempt to remove [Patient #16's name]'s restraints." Staff Member #2 requested Staff Member #6 assist the surveyor for the remaining review of Patient #16's EMR. Staff Member #6 navigated Patient #16's EMR for other entries to explain the three hour and forty-six minute gap in assessing the patient's restraints. Staff Member #6 reported he/she was unable to find an explanation for the gap. Staff Member #6 stated, "Either the nurse had a delay in charting or it was another failed attempt to remove [his/her] restraints. We like to get our patients out of restraints as soon as possible. Sometimes it is just not possible." The review revealed nursing staff documented continued assessment of Patient #16's bilateral wrist restraints at 7:21 p.m., 8:28 p.m., 8:36 p.m., 9:00 p.m., 10:00 p.m., 11:00 p.m., and 11:50 p.m. on 09/08/2016. Patient #16's EMR documented continued restraint assessments by nursing staff at 1:00 a.m., 2:00 a.m., 3:00 a.m. 4:00 a.m., 5:00 a.m., and 6:00 a.m. on 09/09/2016.

Staff Member #6 and the surveyor reviewed the physician's restraint orders for Patient #16. Staff Member #6 stated, "Our restraint orders are for a literal twenty-four (24) hours." Review of the restraint orders revealed a physician's order electronically created at 11:27 a.m. on 09/07/2016 documented the restraint start time as "09/07/16 [at] 11:30 AM" and ending on "09/08/16 [at] 11:29 AM." The next electronic physician's order in Patient #16's EMR for restraints was electronically created on "09/09/16 [at] 0621 (6:21 a.m.)" documenting the start time as "09/09/16 [at] 06:30 AM" and the ending time as "09/10/16 [at] 06:29 AM."

The surveyor inquired if there were other physician orders for Patient #16's bilateral soft wrist restraints after the 09/07/2016 restraint order that ended "09/08/16 [at] 11:29 AM." Staff Member #6 navigated Patient #16's EMR and stated, "I cannot find any other orders for the 8th [of September]." The surveyor inquired if there were downtime orders in Patient #16's physical/paper medical record to cover application of restraints on 09/08/2016 until 6:30 a.m. on 09/09/2016. Staff Member #2 stated, "I don't think we had any downtime during the time." Staff Member #2 and Staff Member #6 reviewed Patient #16's physical/paper medical record and reported the record did not contain paper physician orders to restrain Patient #16. Staff #2 and Staff #6 verified nursing staff restrained Patient #16 from 12:58 p.m. on 09/08/2016 through 6:29 a.m. on 09/09/2016 (seventeen hours and thirty-two minutes) without a physician's order for restraints.

The above findings were conveyed to Staff Member #1 at approximately 1:01 p.m. on 09/12/2016. Staff Member #1 acknowledged nursing staff should have obtained a physician's order to reapply restraints at 12:58 p.m. on 09/08/2016. Staff Member #1 acknowledged nursing staff continued Patient #16's bilateral soft-wrist restraints on 09/08/2016 and into 09/09/2016 without a physician's order.

Based on staff interview and document reviews during the course of a complaint investigation, it was determined the facility staff failed to monitor patients placed in restraint in accordance with the facility's policy for one (1) of seven (7) restrained patients included in the survey sample (Patients #5).

The findings included:

Review of Patient #17's electronic medical record (EMR) indicated the patient was admitted to the facility on 08/30/16 for altered mental status. Patient #17's EMR documented the patient was placed in secured mitts in the progressive care unit at "2145 (9:45 p.m.)" on 08/30/16 and had restraint orders in his/her record which were signed and dated by the physician for 08/30/16. Review of Patient #17's EMR revealed every two (2) hours restraint assessment and monitoring until "2000 (8:00 p.m.)" on 08/31/16. Patient #17's EMR did not have every two (2) hour assessment and monitoring from the last entry at 8:00 p.m., until the physician's order to discontinue. Facility staff failed to perform assessment and monitoring at least four (4) separate two (2) hour intervals prior to the order to discontinue the secured mitts on 09/04/16 at "2013 (8:13 p.m.)."

Staff Member #14, an RN, assisted the surveyor with the EMR (electronic medical record) when looking for documentation of the every two (2) hour restraint monitoring and assessment for Patient #17, and at 11:45 a.m. 09/14/16, he/she stated, "I think it's (the assessment) is just not there."

An interview was conducted on 09/14/16 at 12:15 p.m., with Staff Member #1. Staff Member #1 reviewed Patient #17's EMR. Staff Member #1 reported there was no other documentation related to Patient #17's every two (2) hour assessments and monitoring between "2000 (8:00 p.m.)" on 08/31/16 and "2013 (8:13 p.m.)" on 09/04/16. Staff Member #1 verified staff had not performed as required every two (2) hour assessments and monitoring of Patient #17.

The facility's Patient Restraint and Seclusion policy states the following under the heading reassessment and monitoring guidelines: for non-violent behavior, monitor VS (vital signs) every four (4) hours and conduct an assessment every two (2) hours and PRN (as needed) by a Registered Nurse (RN) that include the following: proper position of restraint/signs of injury, circulation check, least restrictive measure tried, mental status and emotional well being, rights, dignity, and safety, level of distress or agitation, evaluation for removal, nutrition/hydration, loosen and perform range of motion (ROM), hygiene, elimination/I&O, turn/reposition/ambulate, and skin integrity under restraint.

The findings were discussed with Staff Member #1 on 09/14/16 at 12:15 p.m. and again with the administrative team during the exit conference at 4:15 p.m.

Based on interviews and document review it was determined the facility staff failed to:
1. Document a completed discharge assessment and needs evaluation for one (1) of five (5) patients included as discharge planning tracers. (Patient #8) and

2. Ensure the documentation on the discharge assessment and needs evaluation was correct for one (1) of five (5) patients included as discharge planning tracers (Patient #11).

The finding included:

1. Review of Patient #8's electronic medical record (EMR) was conducted on 09/13/2016 starting at 1:07 p.m., with Staff Member #11. Patient #8's EMR documented his/her admission on 03/02/2016 was a readmission to the facility within 30-days. Patient #8's initial readmission risk and functional assessment performed by the registered nurse (RN) on 03/02/2016 was incomplete. The RN assessment only documented the patient's home as "LTC (long term care)." The RN assessment did not include anticipated discharge needs, the patient's prior level of functioning, or patient perceived decline in ability to perform activities of daily living (ADL). Staff Member #11 verified the readmission risk and functional assessment were incomplete. Staff Member #11 reported if a patient has difficulty expressing answers to the readmission risk and functional assessment questions staff members are instructed to make reasonable efforts to contact the patient's responsible party. Staff Member #11 reported the RN should have contacted the long term care case management staff or the nursing staff. Staff Member #11 stated, "We will contact the nursing home in order to obtain a baseline level of functioning. The assessments should not have been left blank."

An end of the day meeting was conducted on 09/13/2016 from 5:15 p.m. to 5:30 p.m., with Staff Member #1. The surveyor informed the Staff Member #1 of the findings.

2. A review of Patient #11's Electronic medical record was conducted on 09/13/2016 from approximately 11:01 a.m. to 11:30 a.m. with Staff Member #11. Staff Member #1 was present in the room as the surveyors reviewed records. Patient #11's EMR indicated his/her admission on 09/09/2016 was a readmission within 30-days. Patient #11's EMR documented the patient was admitted after involvement in a slow speed motor vehicle accident. Patient #11's initial readmission risk and functional assessment was performed by the RN on 09/09/2016. The RN documented on the readmission risk assessment that Patient #11 had sustained a fall within the "past three months." The same RN documented in Patient #11's functional assessment that the patient had "No" falls within the past twelve month. The surveyor asked Staff Member #1 and Staff Member #11 if the questions related to falls were presented differently in the assessment screens, e.g., falls versus falls with injury. Staff Member #1 stated, "The screens read as you see them in the medical record. There are no other implied circumstances." Staff Member #11 reported the nurse's documentation was inconsistent. Staff Member #11 stated, "If the patient had a fall in three months then the documentation on the functional assessment should have been 'Yes" instead of 'No' (related to falls)."

An end of the day meeting was conducted on 09/13/2016 from 5:15 p.m. to 5:30 p.m., with Staff Member #1. The surveyor informed the Staff Member #1 of the findings. Staff Member #1 acknowledged awareness of the findings.

Based on interviews and document review it was determined the facility staff failed to ensure the discharge instructions/after visit summary provided clear directions regarding the patient's next dose of scheduled medications for two (2) of five (5) patients requiring discharge instructions included in the survey sample (Patients #2 and #11).

The findings included:

A review of Patient #11's Electronic medical record was conducted on 09/13/2016 from approximately 11:01 a.m. to 11:30 a.m. with Staff Member #11. Patient #11's EMR indicated his/her admission on 09/09/2016 was a readmission within 30-days. Patient #11's EMR documented the patient was admitted after involvement in a "slow speed MVA (motor vehicle accident)." Patient #11's diagnoses included "intermittent confusion, acute encephalopathy, and urinary tract infection." The case management assessment documented Patient #11 lived with a family member, but was "alone" the majority of the day. Review of Patient #11's "After Visit Summary (AVS)" included new medications (acetaminophen, delayed release aspirin and levofloxacin-an antibiotic), previous medications, "which have changed" (Lantus insulin) and medications, "which have not changed" (amiodarone, carvedilol, furosemide, aspart insulin, simvastatin, and tamsulosin). The AVS form listed each medication with its common name. Under the Common name the form included the statement "Your next dose is: Today, Tomorrow [sic] Other:_____." The statement on Patient #11's AVS for each medication was blank. The facility staff member had failed to indicate when the patient should take the next dose of his/her scheduled medications. Staff Member #11 reported he/she was not familiar with the form. Staff Member #1 requested Staff Member #6 review the AVS form with the surveyor. Staff Member #6 stated, "We have a new electronic charting system. The AVS form has changed. This statement ["Your next dose is: Today, Tomorrow Other:_____"] is new." Staff Member #6 verified the instructions related to when the patient should take his/her next dose had not been provided. Staff Member #6 verified the purpose of the statement "Your next dose is: Today, Tomorrow Other:_____", was to assist patients/caregivers to not miss or double a dose of medication, which had been administered at the facility.

Patient #11's EMR documented a case management entry related to the patient's need for skilled nursing care or home health care. The documentation by case management on 09/11/2016 indicated the patient refused placement at a skilled nursing facility. The documentation indicated the patient would return home with home health and a call should be placed to "APS (Adult Protective Service)" related to the patient's confusion and possible inability to perform self-care. Review of Patient #11's EMR documented the patient accepted the instructions regarding returning home with home health. A discharge entry by the physician on 09/12/2016 at 8:22 a.m. documented the family had considered and accepted Patient #11's placement in a skilled nursing facility. The case manager's documentation for 09/12/2016 at 10:28 a.m. indicated Patient #11 had "declined all" home health and skilled nursing facility placement. The surveyor inquired whether APS had been called according to the documentation on 09/11/2016. Staff Member #11 reviewed the case management notes and stated, "It's not documented that APS was notified."

[According to www.eMedicineHealth.com "Encephalopathy describes abnormal brain function due to problems with the brain tissue. Symptoms of encephalopathy can be generalized causing decreased level of consciousness from minimal lethargy to coma. Encephalopathy can cause abnormal thought processes including confusion, poor memory, hallucinations, and even psychotic thinking."]

A review of Patient #2's EMR was conducted on 09/14/2016 from 9:08 a.m. to 9:28 a.m., with Staff Member #17. Patient #17's EMR indicated his/her admission on 09/07/2016 was a readmission within 30-days. Patient #17's diagnoses included history of lung cancer with bone and liver metastases. Patient #2 was discharged home via ambulance service on 09/13/2016. Patient #2's discharge plans included home hospice care. Review of Patient #2's AVS listed his/her medications "which had changed" and the medications that "had not changed." Under the Common name the form included the statement "Your next dose is: Today, Tomorrow Other:_____." The statement on Patient #2's AVS was blank for each medication. The facility staff member had failed to indicate when the patient should take the next dose of his/her scheduled medications. Staff Member #17 verified staff had failed to provide instructions related to when the patient should take his/her next medication doses.
Review of the facility's policy titled "Discharge Planning and Process" read in part "D. Documentation and EMR [Electronic Medical Record] ... 4. Work through electronic medical record Discharge Navigator: ... i. MAR [Medication Administration Record]: Make sure all meds are addressed and administered before discharge ... m. Discharge Instructions: Complete discharge instructions.. Provide education on medications and prescriptions. Review with patient, family and/or discharge caregiver and include an e-signature ..."
An end of the day meeting was conducted on 09/13/2016 from 5:15 p.m. to 5:30 p.m., with Staff Member #1. The surveyor informed the Staff Member #1 of the findings. Staff Member #1 acknowledged awareness of the findings.