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Based on record review, interview and policy review, the facility failed to monitor 1 (#2) of 4 restrained patients per policy resulting in potential for patient harm. Findings include:

On 9/9/14 at approximately 1030, patient #2's medical record was reviewed with staff #C. It was noted that patient #2 was admitted through the Emergency Department, was intubated, and an order for soft bilateral limb restraints was obtained on 9/7/14 at 0330. The restraint was ordered because patient #2 was unable to follow safety instructions. Patient #2 was monitored until 0530 per "Restraint Flowsheet". On 9/7/14 at 0700, an order was obtained for hard limb bilateral wrist restraints (soft limb restraints failed), but there was no documentation of the patient being monitored after 0530 on 9/7/14 per "Restraint Flowsheet." Additional review of the "Nursing Assessments" and "Nursing Progress Notes" with Staff #C, on 9/9/14 at approximately 1530, revealed no additional restraint monitoring in the medical record. There was a Nursing Note on 9/7/14 at 1040 that documented "Bil (bilateral) leather wrist restraints removed immediately after extubation." Staff #C stated, "The nurse should have documented (monitoring) at 0700 and 0900, at a minimum."

On 9/9/14 at approximately 1530, a review of the facility policy/procedure titled, "Restraint Use", dated "1/14/14" documented, "Patients restrained for any reason should have....documented a minimum of every two hours..." This had not been done. Staff C stated, "It was an agency nurse that didn't document (every two hours)."

Based on file review and interview, the facility failed to document agency staff restraint training for 1 (Staff #G) of 1 agency staff. Findings include:

File review of agency staff #G, on 9/10/14 at approximately 1100, revealed that the nurse was competent for staffing the Emergency Department and Critical Care areas of the hospital. There was some behavioral restraint training documented but non-behavioral restraint training was not evident. On 9/10/14 at 1115, staff #B and #C were queried about non-behavioral (medical/surgical) restraint training and documentation requirements and staff #C stated, "It's stapled in the left side the personnel file." Inspection of that area revealed no entries for restraint training/documentation. It was not evident that the nurse was trained on the every two hour documentation requirement for restraints.

Based on interview and file review, the facility failed to maintain an internal restraint/death log for review of non-reportable deaths in restraints as required. Findings include:

Interview with the Quality Director, on 9/10/14 at approximately 1030, revealed that the facility did not maintain a restraint/death log. The Quality Director stated, "We don't have a log... We have had only one restraint reportable death in 2011." Further discussion with the Quality Director verified that she had information on a reportable death, but did not maintain information or a log for restraint/deaths that were not reportable. She stated, "I know, I looked it up, we have to maintain a log."