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A. Based on a review of Hospital policy and procedure, medical record review and staff interview, it was determined that in 5 of 6 (Pt #'s 1, 2, 3, 4 & 5) medical records reviewed in which patients were put into restraints for promotion of medical healing and/or safety, the Hospital failed to ensure that patients were monitored as indicated per Hospital policy.

Findings include:

1. The Hospital policy and procedure titled, "Utilization of Restraints & Seclusion" was reviewed on 03/07/11. It indicated under, "Orders: For patients in restraints for promotion/maintenance of medical surgical healing...Patients being restrained to promote/maintain medical surgical healing will be monitored, with documentation, every 30 minutes for the first hour and every two hours there after or more frequently as necessary to adequately reflect the patients condition and to protect safety and dignity."

2. The medical records of Pt #'s 1, 2, 3, 4 & 5 were reviewed on 03/07/11 & 03/08/11. There was no documentation to indicate that there were 30 minute checks completed during the first hour after the restraint had been applied to reflect the patient's condition for any of the above patient's.

3. During an interview conducted on 03/08/11 at 2:00 PM with the Director of Risk Management & Regulatory Preparedness, Patient Safety Officer, the above finding was confirmed.

A. Based on a review of Hospital policy and procedure, medical record review and staff interview, it was determined that in 1 of 1 (Pt #1) medical records reviewed in which the patient expired while in a restraint, the Hospital failed to notify CMS within the close of the next business day following the knowledge of the patient's death.

Findings include:

1. The policy and procedure titled, "Utilization of Restraints & Seclusion" was reviewed on 03/07/11. It indicated under, "Procedure I. G. CMS Mandated Reporting, b. Each death that occurs while a patient is in restraints or seclusion...e. Report to CMS by telephone no later than the close of the next business day following knowledge of the patient's death. Document date and time of call to CMS in patient's medical record..."

2. The medical record of Pt #1 was reviewed on 03/07/11. It indicated that Pt #1 was admitted to the Hospital on 02/03/11 with a diagnosis of Fall with multiple Rib Fractures, Dementia and/or Delirium, Hypertension, Obesity and possible Urinary Tract Infection. Documentation indicated that on 02/06/11 at 1605, an order read, "Lorazepam 0.5 mg IV now...May use safety vest if needed for protection of falling." Documentation indicated that at 2150, "Patient found with bubbles in mouth and not responding. Code Blue called." At 2213, Pt #1 was pronounced dead by the physician. There was no documentation in Pt #1's medical record of notification to CMS of the death in restraints, as of this survey date.

3. During an interview conducted on 03/07/11 at 11:00 AM with the Vice President of Patient Care Services, the above finding was confirmed, and it was determined that CMS was notified on 03/03/11. It was also determined that a root cause analysis was currently being conducted by the Hospital for this death in restraints on this survey date.