HospitalInspections.org

Based on clinical record review, staff interview and facility policy/procedure review, it was determined the facility staff failed to determine if less restrictive interventions were ineffective prior to applying a restraint for one (1) of four (4) patients.

The findings included:

The surveyor reviewed Patient #8's clinical record with Staff Member (SM) #2. Patient #8 had a physician's order for the use of "soft, wrist bilateral" on 3/9/2022. There was no documentation of what least restrictive alternatives were used, and proven to be ineffective, prior to the application of restraints at 10:45 p.m.

During the clinical record reviews with SM #2 on 4/26/2022, the surveyor discussed the findings. SM #2 confirmed there was no documentation indicating what least restrictive interventions were used prior to the application of restraints for Patient #8. SM #2 explained that restraints are a "focus" for the facility. A patient safety huddle, that includes the leadership team, occurs each weekday morning at 9:00 a.m. The huddle includes a discussion of the patients in restraints at that time of the huddle. A member of the team will select a random number of patient charts (with restraints) to review for documentation accuracy and to ensure staff is adhering to restraint policy and procedures. Immediate feedback is provided if an issue is identified.

At the exit conference on 4/26/2022, the findings were discussed with SMs #1, #2 (again), #11, #12, #13, #14, and #15. SM #12 reiterated the facility's focus on restraints and ensuring the staff are adhering to restraint policy and procedures.

The facility policy and procedure "Use of Restraints for Nonviolent, Non-Self-Destructive Patient Situations-Medical Use of Restraints" was reviewed and evidenced, in part: "...III. ALTERNATIVES - Least Restrictive A... The use of restraint occurs when other less-restrictive interventions have been attempted but found ineffective for providing a safe and therapeutic environment for the patient, staff and others...".

Based on clinical record review, staff interview and facility policy/procedure review, it was determined the facility staff failed to obtain a new physician's order prior to applying restraints for one (1) of four (4) patients.

The findings included:

The surveyor reviewed Patient #6's clinical record with Staff Member (SM) #2. A physician's order for non-violent, soft, bilateral wrist restraints was entered on 2/26/2022 at 6:04 p.m.; however, restraints were not applied at that time. The non-violent, soft, bilateral wrist restraints were applied on 2/27/2022 at 8:29 a.m. The next physician's restraint order was entered on 2/27/2022 at 6:48 p.m.

During the clinical record reviews with SM #2 on 4/26/2022, the surveyor discussed the findings. SM #2 confirmed that a new order should have been obtained prior to the application of restraints on 2/27/2022 at 8:29 a.m. and acknowledged the staff are not permitted to apply restraints "PRN".

At the exit conference on 4/26/2022, the findings were discussed with SMs #1, #2 (again), #11, #12, #13, #14, and #15.

The facility policy and procedure titled, "Use of Restraints for Nonviolent, Non-Self-Destructive Patient Situations-Medical Use of Restraints" was reviewed and evidenced, in part: "...IV. RESTRAINT ORDER (to manage non-violent or non-self-destructive behavior) A. An order from a physician or authorized practitioner is required for all instances of restraint... 2. Each episode of restraint use must be initiated with a new order from the MD/provider or other LIP [Licensed Independent Practitioner]... 3. PRN [as needed] orders ARE NOT permissible... V. INITIATION A. In emergency situations, if a physician is not available to issue an order, physical restraint can be initiated by a registered nurse based on an appropriate assessment of the patient. 1. If the registered nurse initiates the restraint, an order must be obtained from the physician/provider or LIP as soon as possible...".

Based on clinical record review, staff interview and facility policy/procedure review, it was determined the facility staff failed to conduct a face-to-face evaluation within one (1) hour of applying violent or self-destructive behavior restraints for one (1) of four (4) patients.

The findings included:

The surveyor reviewed Patient #5's clinical record with Staff Member (SM) #2. A hard, four (4) point violent restraint was applied to Patient #5 on 2/15/2022 5:35 a.m. There was no documentation that a face-to-face evaluation was conducted within one (1) hour of the restraint application.

During the clinical record reviews with SM #2 on 4/26/2022, the surveyor discussed the findings. SM #2 confirmed there was no documentation present in the clinical record indicating a face-to-face evaluation had been conducted. SM #14 explained that a "qualified nurse" can perform the face-to-face assessment; per SM #14, "a nursing supervisor" would be considered a "qualified nurse". The surveyor and SM #2 reviewed the clinical record again and found no documentation from the nursing supervisor, on duty at the time of restraint application, indicating a face-to-face evaluation was conducted.

At the exit conference on 4/26/2022, the findings were discussed with SMs #1, #2 (again), #11, #12, #13, #14, and #15.

The facility policy and procedure titled, "Physical Restraint or Seclusion - Use of Restraints or Seclusion for Violent, Self-Destructive Patient Situations, was reviewed and evidenced, in part: "...V. INITIATION A. When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1 hour after initiation of the intervention by a: 1. Physician or other LIP [Licensed Independent Practitioner] 2. Registered nurse or physician assistant who has been trained in accordance with the requirements specified by CMS and has documented evidence of that training in his/her HR [Human Resources] file...".

Based on staff interview and facility document review, it was determined that the facility failed to ensure that all staff were either vaccinated for COVID-19 or had an approved exemption or delay (Vaccination or exemption rate 98.63%).

The findings included:

The surveyor reviewed the tracking log and documentation of the facility's staff. One thousand four hundred and thirty-seven (1437) out of one thousand four hundred and fifty-seven (1457) staff members (98.63%) were fully or partially vaccinated or exempt. Twenty (20) or 1.37% of staff members are either unvaccinated or do not have an approved exemption or delay.

On 4/25/2022, the surveyor reviewed the COVID-19 staff vaccination numbers and policy with Staff Members (SMs) #2, #3, #4, and #5 and on 4/26/2022 with SM #2 and #3. SMs #3 and #5 explained the facility had experienced "crisis" staffing challenges which contributed to the facility implementing a COVID-19 staff vaccination deadline of 4/23/2022. Both, SM #3 and #5, acknowledged the deadline was not in line with the Centers for Medicare and Medicaid Services' (CMS) deadline.

On 4/26/2022 at the exit conference, the findings were reviewed with SMs #1, #2, #11, #12, #13, #14, and #15.