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Based on interviews and document review, the facility failed to ensure an order was obtained from a physician, or other Licensed Independent Practitioner (LIP), for a patient prior to the patient being placed in physical restraints (Patient #10). The facility failed to obtain a renewal restraint order for a patient that remained in restraints after the initial restraint episode ended (Patient #11).

These failures created the potential for an unsafe patient care environment in which the responsible attending physicians or practitioners were not aware of patients' medical needs and current health status.

FINDINGS:

POLICY

According to the policy, Patient Restraints, an order for restraint must be obtained from an LIP/Physician who was responsible for the care of the patient prior to the application of restraint. The duration of an order for restraint with non-violent and non-self destructive behavior must not exceed 24 hours for the initial order. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint and behavior-based criteria for release.

To continue restraint use beyond the initial order duration, the LIP/physician must see the patient, perform a clinical assessment and determine if continuation of restraint was necessary. If reassessment indicates an ongoing need for restraint, a new order must be written each calendar day by the LIP/Physician. Documentation requirements for restraint use include order for restraint and any renewal orders for restraint. The Chief Nursing Officer (CNO) provides leadership and organizational accountability for monitoring the safety, appropriateness, and necessity of restraint use.

1. The facility failed to obtain a restraint order for a patient prior to placing the patient in physical restraints.

a) On 01/10/16 Patient #10 was admitted for altered mental status and placed in restraints for his/her safety because s/he was disoriented and confused.

Review of the Clinical Documentation Record, 24 Hour Restraint Care Record for Patient Safety, and Rights and Dignity Check sheet each dated 01/10/16 at 7:00 a.m. revealed bilateral soft wrist restraints were placed on Patient #10 on 01/10/16 at 7:00 a.m. by Registered Nurse (RN) #11.

The facility obtained a Medical Doctor (MD) order at 11:25 a.m. on 01/11/16, more than 28 hours after the restraints were applied to Patient #10's bilateral upper extremities (BUE).

b) On 02/03/16 at 11:40 a.m., an interview was conducted with RN #14. S/he stated nursing staff needed a physician's order before restraints were applied. Further, s/he stated physicians were readily available to write a restraint order in emergency situations, and physicians went directly into the patient's room and assessed the patient before writing an order for restraints.

c) On 02/04/16 at 2:40 p.m., an interview was conducted with Clinical Nurse Coordinator (CNC) #1. S/he stated nursing staff needed to get a physician's order before placing a patient in restraints.

d) On 02/04/16 at 3:21 p.m., an interview was conducted with Director #2. The Director stated the expectation was for nursing staff to always get a physician's order before placing restraints on a patient, and in emergency situations, the physician should be notified as soon as possible to obtain a restraint order. S/he stated there were always physicians in the Intensive Care Unit (ICU), which made it easy to obtain a restraint order within minutes.

e) On 02/09/16 at 8:45 a.m., an interview was conducted with the Chief Nursing Officer (CNO #5). The CNO stated the physician had to complete a face-to-face assessment of the patient prior to writing a restraint order. Further, s/he stated in an emergency situation an order had to be received within minutes of applying the restraints, and all restrained patients should have a current restraint order in the medical record.

2. The facility failed to obtain a renewal restraint order for a patient that continued to be in restraints after the initial restraint episode ended.

a) Patient #11 was admitted on 01/24/16 with altered mental status.

Review of Patient #11's IDEV - Discharge Report, dated 01/28/16, revealed an initial order for a non-violent, BUE, soft restraint was received on 01/24/16 at 8:22 p.m. by MD #13. The order expiration time was 01/25/16 at 8:22 p.m., 24 hours later.

b) During an interview conducted with the CNO on 02/09/16 at 8:45 a.m., the CNO stated all restrained patients needed to have a current MD order in their medical record. S/he stated "standing" or "as needed" orders could not be used, and physicians had to do a face-to-face assessment of the patient. In the event of an emergency, restraints could be applied to a patient, but a MD order had to be obtained and placed in the patient's medical record within minutes of the patient being restrained.

c) Review of the Clinical Documentation Record, dated 01/25/16, showed Patient #11's condition changed, and the patient required additional restraints due to combative behavior. A new physician's restraint order was obtained, which expired four hours later.

Record review revealed restraints were applied to Patient #11's four extremities on 01/25/16 at 2:20 p.m., and the patient's response to the restraint was "Combative." The Restraints Monitor also revealed a restraint notification to a physician was made. The order expiration time was 01/25/16 at 6:38 p.m., 4 hours later.

d) During an interview conducted on 02/04/16 at 2:40 p.m. with CNC #1, the CNC stated the expectation of nursing staff related to behavioral restraint orders was to keep the patient safe, apply restraints, and have a MD come see the patient immediately and provide a written order for the restraint. The CNC stated behavioral restraint orders were only valid for 4 hours. Further, s/he stated if the patient was ready to transition from 4 point restraints (a behavioral restraint order) to 2 point restraints (a non-violent, medical restraint order), a separate discussion would have needed to take place with the MD. A new physician's order for restraints would need to be obtained because patients could not be transitioned from a behavioral restraint order to a medical 24-hour restraint order without the MD writing a new order.

There was no documentation a new restraint order for Patient #11 was obtained as the CNC specified.

e) Review of Patient #11's Restraints Monitor, dated 01/25/16, revealed the patient was in soft wrist restraints to all extremities (4 point restraints) at 3:00 p.m., 4:00 p.m., and 5:00 p.m. At 6:00 p.m., a change occurred and Patient #11 was restrained using BUE soft restraints only.

No new restraint orders were located within the medical record for Patient #11, despite the patient being restrained from 6:00 p.m. on 01/25/16 until 01/26/16 at 4:00 a.m., which resulted in an additional 10 hours without a restraint order from a LIP or physician.

f) During an interview conducted on 02/04/16 at 3:21 p.m. with the Director, s/he stated the expectation of nursing staff was that MD orders were obtained and documented when restraints were used. Specifically, s/he stated behavioral restraint orders needed to be renewed every 4 hours.
The Director stated if a patient was ready to transition from behavioral restraints (4 point restraints) to medical restraints (2 point restraints), the expectation of nursing staff was to have a conversation with a MD.

Further, the Director stated s/he would expect the RN to notify the MD that the patient had transitioned from behavioral to medical restraint use, and the expectation was both the MD notification and the new MD order should occur within minutes of the restraint being changed. The Director stated the ICU was fortunate that they always had access to a MD within the ICU setting to obtain such orders.

The facility failed to obtain a physician's order to transition Patient #11 from behavioral to medical restraints which resulted in the patient being restrained after the initial order expired.

Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23, NURSING SERVICES, was out of compliance.

A-0395: A registered nurse must supervise and evaluate the nursing care for each patient. The facility failed to ensure nursing staff reassessed the patient after a change in condition that warranted additional nursing assessments and prior to administering a medication. Additionally, the facility failed to ensure nursing staff obtained a physician's order for a patient prior to the patient being placed in physical restraints and failed to obtain a renewal restraint order for a patient that remained in restraints after the initial restraint episode ended (Patients #10 and #11). These failures resulted in the patient receiving a medication without a nursing assessment to ensure the medication was warranted when administered. Further these failures created the potential for an unsafe patient care environment in which the responsible attending physicians or practitioners were not aware of patients' medical needs and current health status.

A-0398: Non-employee licensed nurses who are working in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of the clinical activities of non-employee nursing personnel which occur within the responsibility of the nursing services. The facility failed to ensure contracted personnel (Registered Nurses #8 and #9) adhered to the facility's policies. Specifically, the facility failed to ensure contracted nursing staff obtained a renewal restraint order for a patient that remained in restraints for 10 hours after the initial restraint episode ended. This failure resulted in patients not having a physician's order for restraints while being restrained and created the potential for negative outcomes.

Based on interviews and document review, the facility failed to ensure nursing staff reassessed a patient after the patient experienced a change in condition that warranted additional nursing assessments and prior to administering a medication that was ordered before the change of condition in 1 of 1 records reviewed where a change in condition occurred without a reassessment (Patient #11)

Additionally, the facility failed to ensure nursing staff obtained a physician's order for a patient prior to the patient being placed in physical restraints and failed to obtain a renewal restraint order for a patient that remained in restraints after the initial restraint episode ended (Patients #10 and #11).

This failure resulted in a patient receiving a medication after experiencing a change in condition without a nursing assessment to ensure the medication was warranted when administered. Further these failures created the potential for an unsafe patient care environment in which the responsible attending physicians or practitioners were not aware of patients' medical needs and current health status.

FINDINGS:

POLICY

According to the policy, Adult Fall Prevention Guidelines, if a patient falls, the following is initiated: assess immediately for evidence of injury before moving the patient.

According to the policy, Patient Restraints, an order for restraint must be obtained from an LIP/Physician who was responsible for the care of the patient prior to the application of restraint. The duration of an order for restraint with non-violent and non-self destructive behavior must not exceed 24 hours for the initial order. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint and behavior-based criteria for release.

To continue restraint use beyond the initial order duration, the LIP/physician must see the patient, perform a clinical assessment and determine if continuation of restraint was necessary. If reassessment indicates an ongoing need for restraint, a new order must be written each calendar day by the LIP/Physician. Documentation requirements for restraint use include order for restraint and any renewal orders for restraint. The Chief Nursing Officer (CNO) provides leadership and organizational accountability for monitoring the safety, appropriateness, and necessity of restraint use.

REFERENCE

According to the Lippincott Manual of Nursing Practice 10th Edition, (pp. 1210), subsequent assessment for patients with a head injury includes assessing level of consciousness. Change in mental status is the most sensitive indicator of a change in the patient's condition. Subsequent assessments for patient with a head injury also include vital sign collection. Patients who have sustained a head injury may have associated irregular heartbeat, noted by an irregular or rapid pulse.

According to the Mosby's 2013 Nursing Drug Reference 26th Edition, (pp. 605), Cardiovascular Side Effects for Haloperidol Lactate include: orthostatic hypotension, hypertension, heart rhythm changes, rapid heart rate and sudden death.

1. Patient #11's medical record lacked evidence the patient was reassessed after a change of condition that warranted additional nursing assessments and before administering a medication that was ordered prior to the change of condition.

a) Record review of Patient #11's Clinical Documentation Record, dated, 01/26/16 at 6:38 a.m. showed Registered Nurse #9 (RN) documented the patient woke up agitated, at approximately 4:00 a.m., tore his/her restraints off and jumped out of bed, which led to the patient removing his/her peripheral IV, monitoring equipment, and Foley catheter. S/he documented the patient left his/her room and stumbled into the Intensive Care Unit (ICU), the patient was agitated, not following commands, and non-verbal.

RN #9 documented a MD (Physician) was notified at 4:05 a.m. of Patient #11's agitation and a verbal order for Haldol 10 MG (an antipsychotic medication used in the treatment of schizophrenia, delirium, agitation, acute psychosis and hallucinations in alcohol withdrawal) was received to be given intramuscularly (IM) due to the loss of the patient's intravenous (IV) access.

RN #9 documented Patient #11 hit his/her head twice on a nursing station desk which left two lacerations to the patient's forehead. RN #9 noted Patient #11 was placed back in his/her bed about 4:10 a.m. and leather restraints were applied. S/he documented Patient #11 was breathing but lethargic and Haldol was given.

There was no documentation a nursing assessment was completed after the patient hit his/her head and experienced a change in condition and prior to the administration of Haldol.

b) Review of a Condensed Activity Report, dated 01/26/16, showed Security Officer (SO) #17 documented Patient #11 was placed in 4 point restraints (all four extremities were restrained), right arm up, left arm down, and both legs when s/he was returned to bed after the fall.

c) Review of a Medication Discharge Summary, revealed Haldol 10 mg IM was given on 01/26/16 at 4:12 a.m. The Medication Summary revealed the injection site was Patient #11's right thigh, and the most common medication side effects were reviewed with the patient, including decreased blood pressure.

However, given the facility documented the patient was lethargic and recently sustained a head injury it was not evident if Patient #11 understood what was reviewed with him/her regarding medication side effects.

d) On 02/03/16 at 11:40 a.m. an interview with RN #15 was conducted. S/he stated Haldol should not be given to a patient who was lethargic due to its additional sedative effect. RN #15 stated Haldol could compromise a patient's airway and the nurse should continue to monitor and reassess the patient after a baseline assessment and vital signs were collected.

e) During an interview, on 02/04/16 at 2:00 p.m., Charge RN #3 stated nursing assessments and vital signs should have been completed before administering Haldol to a patient. S/he stated his/her expectation was that Haldol would be held if a patient was too sedated, and s/he would expect nursing staff to hold Haldol if a patient was lethargic and reassess the patient at a later time.

Charge RN #3 acknowledged RN #21 administered Haldol for RN #9, who was the primary RN taking care of Patient #11 the morning of 01/26/16. S/he also stated a blood pressure and pulse were not collected prior to RN #21 administering Haldol to Patient #11, after s/he sustained a fall and change in condition, nor was the patient hooked up to cardiac monitoring equipment prior to the administration of Haldol.

f) On 02/04/16 at 2:40 p.m., an interview was conducted with the ICU Clinical Nurse Coordinator (CNC #1). S/he stated nurses were required to perform a patient assessment before administering Haldol and s/he expected nurses to assess if the patient was alert and oriented and could follow commands. The CNC stated a patient should be placed on a cardiac monitor before administering Haldol to assess for cardiac rhythm changes, and s/he expected nurses to not administer Haldol if a patient was lethargic. S/he stated nurses should not administer Haldol to a patient who had just sustained a head injury.

g) An interview with the Director of the Adult ICU (Director #2) was conducted on 02/04/16 at 3:21 p.m. S/he stated his/her expectation was for nursing staff to assess the patient's level of consciousness, agitation level, and cardiac monitoring prior to Haldol being administered.

h) An interview was conducted on 02/09/16 at 8:45 a.m. with the Chief Nursing Officer (CNO #5). S/he stated the expectation when administering Haldol IM was for nurses to collect, assess, and document vital signs. S/he stated Haldol IM would be held if the patient were not responsive, or if the patient's blood pressure or heart rate were low. The CNO stated s/he expected nursing staff to call the physician if there was a change in patient condition. The CNO stated RN #21 did not meet facility expectations for collecting vital signs, and did not meet facility expectations for a nursing reassessment before s/he administered Haldol IM to Patient #11.

There was no documentation the facility reassessed the patient after s/he experienced a fall and change in condition and prior to administering Haldol.

According to the Patient Notes, dated 01/26/16 at 6:36 a.m., RN #9 documented a code (an emergency situation in which a patient is in cardiopulmonary arrest) was called at approximately 4:11 a.m. on 01/26/16 and Patient #11 was declared deceased at 4:34 a.m.

2) Nursing staff failed to assess Patient #11 for injuries after s/he suffered a fall.

a) Record review of the Risk Management Report, dated 01/26/16, revealed RN #9 documented Patient #11 slipped in his/her blood, fell to the floor and sustained two lacerations to his/her forehead. RN# 9 documented the patient was lethargic; however, no further assessment was done including vital signs.

b) An interview with Charge RN #3 was conducted on 02/04/16 at 2:00 p.m. Charge RN #3 stated if a patient sustained a fall in the ICU, the expectation of nursing staff was to initially check the patient for any injuries prior to moving the patient, which included an assessment to check if the patient was alert and oriented, and if the patient had a change in condition.

c) On 02/04/16 at 2:40 p.m., an interview was conducted with CNC #1 . S/he stated if a patient fell in the ICU the expectation of nursing staff was to assess the patient before moving him/her back to the bed. The CNC stated the assessment should include vital signs, if the patient was alert and orientated, whether or not the patient could follow commands, and a visual assessment.

d) An interview with Director #2 was conducted on 02/04/16 at 3:21 p.m. The Director stated if a patient sustained a fall, the expectation of nursing staff would have been to collect and document the patient's vital signs in his/her medical record.

There was no documentation in the clinical record to show Patient #11 was assessed after his/her fall.

3. Nursing staff failed to obtain a restraint order for a patient prior to placing the patient in physical restraints.

a) On 01/10/16 Patient #10 was admitted for altered mental status and placed in restraints for his/her safety because s/he was disoriented and confused.

Review of the Clinical Documentation Record, 24 Hour Restraint Care Record for Patient Safety, and Rights and Dignity Check sheet each dated 01/10/16 at 7:00 a.m. revealed bilateral soft wrist restraints were placed on Patient #10 on 01/10/16 at 7:00 a.m. by Registered Nurse (RN) #11.

The facility obtained a Medical Doctor (MD) order for restraints at 11:25 a.m. on 01/11/16, more than 28 hours after the restraints were applied to Patient #10's bilateral upper extremities (BUE).

b) On 02/03/16 at 11:40 a.m., an interview was conducted with RN #14. S/he stated nursing staff needed a physician's order before restraints were applied. Further, s/he stated physicians were readily available to write a restraint order in emergency situations, and physicians went directly into the patient's room and assessed the patient before writing an order for restraints.

c) On 02/04/16 at 2:40 p.m., an interview was conducted with Clinical Nurse Coordinator (CNC) #1. S/he stated nursing staff needed to get a physician's order before placing a patient in restraints.

d) On 02/04/16 at 3:21 p.m., an interview was conducted with Director #2. The Director stated the expectation was for nursing staff to always get a physician's order before placing restraints on a patient, and in emergency situations, the physician should be notified as soon as possible to obtain a restraint order. S/he stated there were always physicians in the Intensive Care Unit (ICU), which made it easy to obtain a restraint order within minutes.

e) On 02/09/16 at 8:45 a.m., an interview was conducted with the Chief Nursing Officer (CNO #5). The CNO stated the physician had to complete a face-to-face assessment of the patient prior to writing a restraint order. Further, s/he stated in an emergency situation an order had to be received within minutes of applying the restraints, and all restrained patients should have a current restraint order in the medical record.

4. Nursing staff failed to obtain a renewal restraint order for a patient that continued to be in restraints after the initial restraint episode ended.

a) Patient #11 was admitted on 01/24/16 with altered mental status.

Review of Patient #11's IDEV - Discharge Report, dated 01/28/16, revealed an initial order for a non-violent, BUE, soft restraint was received on 01/24/16 at 8:22 p.m. by MD #13. The order expiration time was 01/25/16 at 8:22 p.m., 24 hours later.

b) During an interview conducted with the CNO on 02/09/16 at 8:45 a.m., the CNO stated all restrained patients needed to have a current MD order in their medical record. S/he stated "standing" or "as needed" orders could not be used, and physicians had to do a face-to-face assessment of the patient. In the event of an emergency, restraints could be applied to a patient, but a MD order had to be obtained and placed in the patient's medical record within minutes of the patient being restrained.

c) Review of the Clinical Documentation Record, dated 01/25/16, showed Patient #11's condition changed, and the patient required additional restraints due to combative behavior. A new physician's restraint order was obtained, which expired 4 hours later, on 01/25/16 at 6:38 p.m.

Record review revealed restraints were applied to Patient #11's four extremities on 01/25/16 at 2:20 p.m., and the patient's response to the restraint was "Combative." The Restraints Monitor form also revealed a restraint notification to a physician was made. The order expiration time was 01/25/16 at 6:38 p.m., 4 hours later.

d) During an interview conducted on 02/04/16 at 2:40 p.m. with CNC #1, the CNC stated the expectation of nursing staff related to behavioral restraint orders was to keep the patient safe, apply restraints, and have a MD come see the patient immediately and provide a written order for the restraint. The CNC stated behavioral restraint orders were only valid for 4 hours.

Further, s/he stated if the patient was ready to transition from 4 point restraints (a behavioral restraint order) to 2 point restraints (a non-violent, medical restraint order), a separate discussion would have needed to take place with the MD. A new physician's order for restraints would need to be obtained because patients could not be transitioned from a behavioral restraint order to a medical 24-hour restraint order without the MD writing a new order.

There was no documentation a new restraint order for Patient #11 was obtained as the CNC specified.

e) Review of Patient #11's Restraints Monitor, dated 01/25/16, revealed the patient was in soft wrist restraints to all extremities at 3:00 p.m., 4:00 p.m., and 5:00 p.m. At 6:00 p.m., a change occurred and Patient #11 was restrained using BUE soft restraints only.

No new restraint orders were located within the medical record for Patient #11, despite the patient being restrained from 01/25/16 at 6:00 p.m. until 01/26/16 at 4:00 a.m., which resulted in an additional 10 hours without a restraint order from a LIP or physician.

f) During an interview conducted on 02/04/16 at 3:21 p.m. with the Director, s/he stated the expectation of nursing staff was that MD orders were obtained and documented when restraints were used. Specifically, s/he stated behavioral restraint orders needed to be renewed every 4 hours. The Director stated if a patient was ready to transition from behavioral restraints (4 point restraints) to medical restraints (2 point restraints), the expectation of nursing staff was to have a conversation with a MD.

Further, the Director stated s/he would expect the RN to notify the MD that the patient had transitioned from behavioral to medical restraint use, and the expectation was both the MD notification and the new MD order should occur within minutes of the type of restraint being changed. The Director stated the ICU was fortunate that they always had access to a MD within the ICU setting to obtain such orders.

The facility failed to obtain a physician's order to transition Patient #11 from behavioral to medical restraints which resulted in the patient being restrained after the initial order expired.

Based on interviews and document reviews, the facility failed to ensure contracted personnel (Registered Nurses #8 and #9) adhered to the facility's policies. Specifically, the facility failed to ensure contracted nursing staff obtained a renewal restraint order for a patient that remained in restraints for 10 hours after the initial restraint episode ended.

This failure resulted in patients not having a physician's order for restraints while being restrained and created the potential for negative outcomes. Further, the failure created the potential for an unsafe patient care environment in which the responsible attending physicians were not aware of patients' medical needs and current restraint status.

FINDINGS:

POLICY

According to the policy, Patient Restraints, an order for restraint must be obtained from an LIP/Physician who was responsible for the care of the patient prior to the application of restraint. The duration of an order for restraint with non-violent and non-self destructive behavior must not exceed 24 hours for the initial order. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint and behavior-based criteria for release.

To continue restraint use beyond the initial order duration, the LIP/physician must see the patient, perform a clinical assessment and determine if continuation of restraint was necessary. If reassessment indicates an ongoing need for restraint, a new order must be written each calendar day by the LIP/Physician. Documentation requirements for restraint use include order for restraint and any renewal orders for restraint.

The Chief Nursing Officer (CNO) provides leadership and organizational accountability for monitoring the safety, appropriateness, and necessity of restraint use.

1. The facility failed to ensure non-employee (contracted) nursing personnel adhered to facility policies and protocols by neglecting to obtain a renewal restraint order for a patient.

a) Patient #11 was admitted on 01/24/16 with altered mental status. Review of the Restraints Monitor Form, dated 01/25/16, revealed contracted personnel (Registered Nurses #8 and #9, RN) provided services for Patient #11 on 01/25/16.

Review of Patient #11's IDEV - Discharge Report, dated 01/28/16, revealed an initial order for a non-violent, BUE, soft restraint was received on 01/24/16 at 8:22 p.m. by MD #13 (Medical Doctor). The order expiration time was 01/25/16 at 8:22 p.m., 24 hours later.

b) During an interview conducted with the Chief Nursing Officer (CNO #5) on 02/09/16 at 8:45 a.m., the CNO stated all restrained patients needed to have a current physician's order in their medical record. S/he stated "standing" or "as needed" orders could not be used, and physicians had to do a face-to-face assessment of the patient. In the event of an emergency, restraints could be applied to a patient, but a MD order had to be obtained and placed in the patient's medical record within minutes of the patient being restrained.

c) Review of the Clinical Documentation Record, dated 01/25/16, showed Patient #11's condition changed, and the patient required additional restraints due to combative behavior. A new physician's restraint order was obtained, which expired 4 hours later.

Record review revealed restraints were applied to Patient #11's four extremities on 01/25/16 at 2:20 p.m., and the patient's response to the restraint was "Combative." The Restraints Monitor also revealed a restraint notification to a physician was made. The order expiration time was 01/25/16 at 6:38 p.m., 4 hours later.

d) During an interview conducted on 02/04/16 at 2:40 p.m. with the Clinical Nurse Coordinator (CNC #1), the CNC stated the expectation of nursing staff related to behavioral restraint orders was to keep the patient safe, apply restraints, and have a MD come see the patient immediately and provide a written order for the restraint. The CNC stated behavioral restraint orders were only valid for 4 hours. Further, s/he stated if the patient was ready to transition from 4 point restraints (a behavioral restraint order) to 2 point restraints (a non-violent, medical restraint order), a separate discussion would have needed to take place with the MD. A new physician's order for restraints would need to be obtained because patients could not be transitioned from a behavioral restraint order to a medical 24-hour restraint order without the MD writing a new order.

There was no documentation a new restraint order for Patient #11 was obtained by RN #8 or RN #9 as the CNC specified.

e) Review of Patient #11's Restraints Monitor, dated 01/25/16, revealed the patient was in soft wrist restraints to all extremities at 3:00 p.m., 4:00 p.m., and 5:00 p.m. At 6:00 p.m., a change occurred and Patient #11 was restrained using BUE soft restraints only.

No new restraint orders were located within the medical record for Patient #11, despite the patient being restrained from 01/25/16 at 6:00 p.m. until 01/26/16 at 4:00 a.m., which resulted in an additional 10 hours without a restraint order from a LIP or physician.

f) During an interview conducted on 02/04/16 at 3:21 p.m. with the Director (Director #2), s/he stated the expectation of nursing staff was that MD orders were obtained and documented when restraints were used. Specifically, s/he stated behavioral restraint orders needed to be renewed every 4 hours.

The Director stated if a patient was ready to transition from behavioral restraints (4 point restraints) to medical restraints (2 point restraints), the expectation of nursing staff was to have a conversation with a MD.

Further, the Director stated s/he would expect the RN to notify the MD that the patient had transitioned from behavioral to medical restraint use, and the expectation was both the MD notification and the new MD order should occur within minutes of the type of restraint being changed. The Director stated the ICU was fortunate that they always had access to a MD within the ICU setting to obtain such orders.

The facility failed to ensure contracted staff obtained a physician's order to transition Patient #11 from behavioral to medical restraints which resulted in the patient being restrained after the initial order expired.

Based on interviews and document review, the facility failed to ensure an order was obtained from a physician, or other Licensed Independent Practitioner (LIP), for a patient prior to the patient being placed in physical restraints (Patient #10). The facility failed to obtain a renewal restraint order for a patient that remained in restraints after the initial restraint episode ended (Patient #11).

These failures created the potential for an unsafe patient care environment in which the responsible attending physicians or practitioners were not aware of patients' medical needs and current health status.

FINDINGS:

POLICY

According to the policy, Patient Restraints, an order for restraint must be obtained from an LIP/Physician who was responsible for the care of the patient prior to the application of restraint. The duration of an order for restraint with non-violent and non-self destructive behavior must not exceed 24 hours for the initial order. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint and behavior-based criteria for release.

To continue restraint use beyond the initial order duration, the LIP/physician must see the patient, perform a clinical assessment and determine if continuation of restraint was necessary. If reassessment indicates an ongoing need for restraint, a new order must be written each calendar day by the LIP/Physician. Documentation requirements for restraint use include order for restraint and any renewal orders for restraint. The Chief Nursing Officer (CNO) provides leadership and organizational accountability for monitoring the safety, appropriateness, and necessity of restraint use.

1. The facility failed to obtain a restraint order for a patient prior to placing the patient in physical restraints.

a) On 01/10/16 Patient #10 was admitted for altered mental status and placed in restraints for his/her safety because s/he was disoriented and confused.

Review of the Clinical Documentation Record, 24 Hour Restraint Care Record for Patient Safety, and Rights and Dignity Check sheet each dated 01/10/16 at 7:00 a.m. revealed bilateral soft wrist restraints were placed on Patient #10 on 01/10/16 at 7:00 a.m. by Registered Nurse (RN) #11.

The facility obtained a Medical Doctor (MD) order at 11:25 a.m. on 01/11/16, more than 28 hours after the restraints were applied to Patient #10's bilateral upper extremities (BUE).

b) On 02/03/16 at 11:40 a.m., an interview was conducted with RN #14. S/he stated nursing staff needed a physician's order before restraints were applied. Further, s/he stated physicians were readily available to write a restraint order in emergency situations, and physicians went directly into the patient's room and assessed the patient before writing an order for restraints.

c) On 02/04/16 at 2:40 p.m., an interview was conducted with Clinical Nurse Coordinator (CNC) #1. S/he stated nursing staff needed to get a physician's order before placing a patient in restraints.

d) On 02/04/16 at 3:21 p.m., an interview was conducted with Director #2. The Director stated the expectation was for nursing staff to always get a physician's order before placing restraints on a patient, and in emergency situations, the physician should be notified as soon as possible to obtain a restraint order. S/he stated there were always physicians in the Intensive Care Unit (ICU), which made it easy to obtain a restraint order within minutes.

e) On 02/09/16 at 8:45 a.m., an interview was conducted with the Chief Nursing Officer (CNO #5). The CNO stated the physician had to complete a face-to-face assessment of the patient prior to writing a restraint order. Further, s/he stated in an emergency situation an order had to be received within minutes of applying the restraints, and all restrained patients should have a current restraint order in the medical record.

2. The facility failed to obtain a renewal restraint order for a patient that continued to be in restraints after the initial restraint episode ended.

a) Patient #11 was admitted on 01/24/16 with altered mental status.

Review of Patient #11's IDEV - Discharge Report, dated 01/28/16, revealed an initial order for a non-violent, BUE, soft restraint was received on 01/24/16 at 8:22 p.m. by MD #13. The order expiration time was 01/25/16 at 8:22 p.m., 24 hours later.

b) During an interview conducted with the CNO on 02/09/16 at 8:45 a.m., the CNO stated all restrained patients needed to have a current MD order in their medical record. S/he stated "standing" or "as needed" orders could not be used, and physicians had to do a face-to-face assessment of the patient. In the event of an emergency, restraints could be applied to a patient, but a MD order had to be obtained and placed in the patient's medical record within minutes of the patient being restrained.

c) Review of the Clinical Documentation Record, dated 01/25/16, showed Patient #11's condition changed, and the patient required additional restraints due to combative behavior. A new physician's restraint order was obtained, which expired four hours later.

Record review revealed restraints were applied to Patient #11's four extremities on 01/25/16 at 2:20 p.m., and the patient's response to the restraint was "Combative." The Restraints Monitor also revealed a restraint notification to a physician was made. The order expiration time was 01/25/16 at 6:38 p.m., 4 hours later.

d) During an interview conducted on 02/04/16 at 2:40 p.m. with CNC #1, the CNC stated the expectation of nursing staff related to behavioral restraint orders was to keep the patient safe, apply restraints, and have a MD come see the patient immediately and provide a written order for the restraint. The CNC stated behavioral restraint orders were only valid for 4 hours. Further, s/he stated if the patient was ready to transition from 4 point restraints (a behavioral restraint order) to 2 point restraints (a non-violent, medical restraint order), a separate discussion would have needed to take place with the MD. A new physician's order for restraints would need to be obtained because patients could not be transitioned from a behavioral restraint order to a medical 24-hour restraint order without the MD writing a new order.

There was no documentation a new restraint order for Patient #11 was obtained as the CNC specified.

e) Review of Patient #11's Restraints Monitor, dated 01/25/16, revealed the patient was in soft wrist restraints to all extremities (4 point restraints) at 3:00 p.m., 4:00 p.m., and 5:00 p.m. At 6:00 p.m., a change occurred and Patient #11 was restrained using BUE soft restraints only.

No new restraint orders were located within the medical record for Patient #11, despite the patient being restrained from 6:00 p.m. on 01/25/16 until 01/26/16 at 4:00 a.m., which resulted in an additional 10 hours without a restraint order from a LIP or physician.

f) During an interview conducted on 02/04/16 at 3:21 p.m. with the Director, s/he stated the expectation of nursing staff was that MD orders were obtained and documented when restraints were used. Specifically, s/he stated behavioral restraint orders needed to be renewed every 4 hours.
The Director stated if a patient was ready to transition from behavioral restraints (4 point restraints) to medical restraints (2 point restraints), the expectation of nursing staff was to have a conversation with a MD.

Further, the Director stated s/he would expect the RN to notify the MD that the patient had transitioned from behavioral to medical restraint use, and the expectation was both the MD notification and the new MD order should occur within minutes of the restraint being changed. The Director stated the ICU was fortunate that they always had access to a MD within the ICU setting to obtain such orders.

The facility failed to obtain a physician's order to transition Patient #11 from behavioral to medical restraints which resulted in the patient being restrained after the initial order expired.

Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23, NURSING SERVICES, was out of compliance.

A-0395: A registered nurse must supervise and evaluate the nursing care for each patient. The facility failed to ensure nursing staff reassessed the patient after a change in condition that warranted additional nursing assessments and prior to administering a medication. Additionally, the facility failed to ensure nursing staff obtained a physician's order for a patient prior to the patient being placed in physical restraints and failed to obtain a renewal restraint order for a patient that remained in restraints after the initial restraint episode ended (Patients #10 and #11). These failures resulted in the patient receiving a medication without a nursing assessment to ensure the medication was warranted when administered. Further these failures created the potential for an unsafe patient care environment in which the responsible attending physicians or practitioners were not aware of patients' medical needs and current health status.

A-0398: Non-employee licensed nurses who are working in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of the clinical activities of non-employee nursing personnel which occur within the responsibility of the nursing services. The facility failed to ensure contracted personnel (Registered Nurses #8 and #9) adhered to the facility's policies. Specifically, the facility failed to ensure contracted nursing staff obtained a renewal restraint order for a patient that remained in restraints for 10 hours after the initial restraint episode ended. This failure resulted in patients not having a physician's order for restraints while being restrained and created the potential for negative outcomes.

Based on interviews and document review, the facility failed to ensure nursing staff reassessed a patient after the patient experienced a change in condition that warranted additional nursing assessments and prior to administering a medication that was ordered before the change of condition in 1 of 1 records reviewed where a change in condition occurred without a reassessment (Patient #11)

Additionally, the facility failed to ensure nursing staff obtained a physician's order for a patient prior to the patient being placed in physical restraints and failed to obtain a renewal restraint order for a patient that remained in restraints after the initial restraint episode ended (Patients #10 and #11).

This failure resulted in a patient receiving a medication after experiencing a change in condition without a nursing assessment to ensure the medication was warranted when administered. Further these failures created the potential for an unsafe patient care environment in which the responsible attending physicians or practitioners were not aware of patients' medical needs and current health status.

FINDINGS:

POLICY

According to the policy, Adult Fall Prevention Guidelines, if a patient falls, the following is initiated: assess immediately for evidence of injury before moving the patient.

According to the policy, Patient Restraints, an order for restraint must be obtained from an LIP/Physician who was responsible for the care of the patient prior to the application of restraint. The duration of an order for restraint with non-violent and non-self destructive behavior must not exceed 24 hours for the initial order. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint and behavior-based criteria for release.

To continue restraint use beyond the initial order duration, the LIP/physician must see the patient, perform a clinical assessment and determine if continuation of restraint was necessary. If reassessment indicates an ongoing need for restraint, a new order must be written each calendar day by the LIP/Physician. Documentation requirements for restraint use include order for restraint and any renewal orders for restraint. The Chief Nursing Officer (CNO) provides leadership and organizational accountability for monitoring the safety, appropriateness, and necessity of restraint use.

REFERENCE

According to the Lippincott Manual of Nursing Practice 10th Edition, (pp. 1210), subsequent assessment for patients with a head injury includes assessing level of consciousness. Change in mental status is the most sensitive indicator of a change in the patient's condition. Subsequent assessments for patient with a head injury also include vital sign collection. Patients who have sustained a head injury may have associated irregular heartbeat, noted by an irregular or rapid pulse.

According to the Mosby's 2013 Nursing Drug Reference 26th Edition, (pp. 605), Cardiovascular Side Effects for Haloperidol Lactate include: orthostatic hypotension, hypertension, heart rhythm changes, rapid heart rate and sudden death.

1. Patient #11's medical record lacked evidence the patient was reassessed after a change of condition that warranted additional nursing assessments and before administering a medication that was ordered prior to the change of condition.

a) Record review of Patient #11's Clinical Documentation Record, dated, 01/26/16 at 6:38 a.m. showed Registered Nurse #9 (RN) documented the patient woke up agitated, at approximately 4:00 a.m., tore his/her restraints off and jumped out of bed, which led to the patient removing his/her peripheral IV, monitoring equipment, and Foley catheter. S/he documented the patient left his/her room and stumbled into the Intensive Care Unit (ICU), the patient was agitated, not following commands, and non-verbal.

RN #9 documented a MD (Physician) was notified at 4:05 a.m. of Patient #11's agitation and a verbal order for Haldol 10 MG (an antipsychotic medication used in the treatment of schizophrenia, delirium, agitation, acute psychosis and hallucinations in alcohol withdrawal) was received to be given intramuscularly (IM) due to the loss of the patient's intravenous (IV) access.

RN #9 documented Patient #11 hit his/her head twice on a nursing station desk which left two lacerations to the patient's forehead. RN #9 noted Patient #11 was placed back in his/her bed about 4:10 a.m. and leather restraints were applied. S/he documented Patient #11 was breathing but lethargic and Haldol was given.

There was no documentation a nursing assessment was completed after the patient hit his/her head and experienced a change in condition and prior to the administration of Haldol.

b) Review of a Condensed Activity Report, dated 01/26/16, showed Security Officer (SO) #17 documented Patient #11 was placed in 4 point restraints (all four extremities were restrained), right arm up, left arm down, and both legs when s/he was returned to bed after the fall.

c) Review of a Medication Discharge Summary, revealed Haldol 10 mg IM was given on 01/26/16 at 4:12 a.m. The Medication Summary revealed the injection site was Patient #11's right thigh, and the most common medication side effects were reviewed with the patient, including decreased blood pressure.

However, given the facility documented the patient was lethargic and recently sustained a head injury it was not evident if Patient #11 understood what was reviewed with him/her regarding medication side effects.

d) On 02/03/16 at 11:40 a.m. an interview with RN #15 was conducted. S/he stated Haldol should not be given to a patient who was lethargic due to its additional sedative effect. RN #15 stated Haldol could compromise a patient's airway and the nurse should continue to monitor and reassess the patient after a baseline assessment and vital signs were collected.

e) During an interview, on 02/04/16 at 2:00 p.m., Charge RN #3 stated nursing assessments and vital signs should have been completed before administering Haldol to a patient. S/he stated his/her expectation was that Haldol would be held if a patient was too sedated, and s/he would expect nursing staff to hold Haldol if a patient was lethargic and reassess the patient at a later time.

Charge RN #3 acknowledged RN #21 administered Haldol for RN #9, who was the primary RN taking care of Patient #11 the morning of 01/26/16. S/he also stated a blood pressure and pulse were not collected prior to RN #21 administering Haldol to Patient #11, after s/he sustained a fall and change in condition, nor was the patient hooked up to cardiac monitoring equipment prior to the administration of Haldol.

f) On 02/04/16 at 2:40 p.m., an interview was conducted with the ICU Clinical Nurse Coordinator (CNC #1). S/he stated nurses were required to perform a patient assessment before administering Haldol and s/he expected nurses to assess if the patient was alert and oriented and could follow commands. The CNC stated a patient should be placed on a cardiac monitor before administering Haldol to assess for cardiac rhythm changes, and s/he expected nurses to not administer Haldol if a patient was lethargic. S/he stated nurses should not administer Haldol to a patient who had just sustained a head injury.

g) An interview with the Director of the Adult ICU (Director #2) was conducted on 02/04/16 at 3:21 p.m. S/he stated his/her expectation was for nursing staff to assess the patient's level of consciousness, agitation level, and cardiac monitoring prior to Haldol being administered.

h) An interview was conducted on 02/09/16 at 8:45 a.m. with the Chief Nursing Officer (CNO #5). S/he stated the expectation when administering Haldol IM was for nurses to collect, assess, and document vital signs. S/he stated Haldol IM would be held if the patient were not responsive, or if the patient's blood pressure or heart rate were low. The CNO stated s/he expected nursing staff to call the physician if there was a change in patient condition. The CNO stated RN #21 did not meet facility expectations for collecting vital signs, and did not meet facility expectations for a nursing reassessment before s/he administered Haldol IM to Patient #11.

There was no documentation the facility reassessed the patient after s/he experienced a fall and change in condition and prior to administering Haldol.

According to the Patient Notes, dated 01/26/16 at 6:36 a.m., RN #9 documented a code (an emergency situation in which a patient is in cardiopulmonary arrest) was called at approximately 4:11 a.m. on 01/26/16 and Patient #11 was declared deceased at 4:34 a.m.

2) Nursing staff failed to assess Patient #11 for injuries after s/he suffered a fall.

a) Record review of the Risk Management Report, dated 01/26/16, revealed RN #9 documented Patient #11 slipped in his/her blood, fell to the floor and sustained two lacerations to his/her forehead. RN# 9 documented the patient was lethargic; however, no further assessment was done including vital signs.

b) An interview with Charge RN #3 was conducted on 02/04/16 at 2:00 p.m. Charge RN #3 stated if a patient sustained a fall in the ICU, the expectation of nursing staff was to initially check the patient for any injuries prior to moving the patient, which included an assessment to check if the patient was alert and oriented, and if the patient had a change in condition.

c) On 02/04/16 at 2:40 p.m., an interview was conducted with CNC #1 . S/he stated if a patient fell in the ICU the expectation of nursing staff was to assess the patient before moving him/her back to the bed. The CNC stated the assessment should include vital signs, if the patient was alert and orientated, whether or not the patient could follow commands, and a visual assessment.

d) An interview with Director #2 was conducted on 02/04/16 at 3:21 p.m. The Director stated if a patient sustained a fall, the expectation of nursing staff would have been to collect and document the patient's vital signs in his/her medical record.

There was no documentation in the clinical record to show Patient #11 was assessed after his/her fall.

3. Nursing staff failed to obtain a restraint order for a patient prior to placing the patient in physical restraints.

a) On 01/10/16 Patient #10 was admitted for altered mental status and placed in restraints for his/her safety because s/he was disoriented and confused.

Review of the Clinical Documentation Record, 24 Hour Restraint Care Record for Patient Safety, and Rights and Dignity Check sheet each dated 01/10/16 at 7:00 a.m. revealed bilateral soft wrist restraints were placed on Patient #10 on 01/10/16 at 7:00 a.m. by Registered Nurse (RN) #11.

The facility obtained a Medical Doctor (MD) order for restraints at 11:25 a.m. on 01/11/16, more than 28 hours after the restraints were applied to Patient #10's bilateral upper extremities (BUE).

b) On 02/03/16 at 11:40 a.m., an interview was conducted with RN #14. S/he stated nursing staff needed a physician's order before restraints were applied. Further, s/he stated physicians were readily available to write a restraint order in emergency situations, and physicians went directly into the patient's room and assessed the patient before writing an order for restraints.

c) On 02/04/16 at 2:40 p.m., an interview was conducted with Clinical Nurse Coordinator (CNC) #1. S/he stated nursing staff needed to get a physician's order before placing a patient in restraints.

d) On 02/04/16 at 3:21 p.m., an interview was conducted with Director #2. The Director stated the expectation was for nursing staff to always get a physician's order before placing restraints on a patient, and in emergency situations, the physician should be notified as soon as possible to obtain a restraint order. S/he stated there were always physicians in the Intensive Care Unit (ICU), which made it easy to obtain a restraint order within minutes.

e) On 02/09/16 at 8:45 a.m., an interview was conducted with the Chief Nursing Officer (CNO #5). The CNO stated the physician had to complete a face-to-face assessment of the patient prior to writing a restraint order. Further, s/he stated in an emergency situation an order had to be received within minutes of applying the restraints, and all restrained patients should have a current restraint order in the medical record.

4. Nursing staff failed to obtain a renewal restraint order for a patient that continued to be in restraints after the initial restraint episode ended.

a) Patient #11 was admitted on 01/24/16 with altered mental status.

Review of Patient #11's IDEV - Discharge Report, dated 01/28/16, revealed an initial order for a non-violent, BUE, soft restraint was received on 01/24/16 at 8:22 p.m. by MD #13. The order expiration time was 01/25/16 at 8:22 p.m., 24 hours later.

b) During an interview conducted with the CNO on 02/09/16 at 8:45 a.m., the CNO stated all restrained patients needed to have a current MD order in their medical record. S/he stated "standing" or "as needed" orders could not be used, and physicians had to do a face-to-face assessment of the patient. In the event of an emergency, restraints could be applied to a patient, but a MD order had to be obtained and placed in the patient's medical record within minutes of the patient being restrained.

c) Review of the Clinical Documentation Record, dated 01/25/16, showed Patient #11's condition changed, and the patient required additional restraints due to combative behavior. A new physician's restraint order was obtained, which expired 4 hours later, on 01/25/16 at 6:38 p.m.

Record review revealed restraints were applied to Patient #11's four extremities on 01/25/16 at 2:20 p.m., and the patient's response to the restraint was "Combative." The Restraints Monitor form also revealed a restraint notification to a physician was made. The order expiration time was 01/25/16 at 6:38 p.m., 4 hours later.

d) During an interview conducted on 02/04/16 at 2:40 p.m. with CNC #1, the CNC stated the expectation of nursing staff related to behavioral restraint orders was to keep the patient safe, apply restraints, and have a MD come see the patient immediately and provide a written order for the restraint. The CNC stated behavioral restraint orders were only valid for 4 hours.

Further, s/he stated if the patient was ready to transition from 4 point restraints (a behavioral restraint order) to 2 point restraints (a non-violent, medical restraint order), a separate discussion would have needed to take place with the MD. A new physician's order for restraints would need to be obtained because patients could not be transitioned from a behavioral restraint order to a medical 24-hour restraint order without the MD writing a new order.

There was no documentation a new restraint order for Patient #11 was obtained as the CNC specified.

e) Review of Patient #11's Restraints Monitor, dated 01/25/16, revealed the patient was in soft wrist restraints to all extremities at 3:00 p.m., 4:00 p.m., and 5:00 p.m. At 6:00 p.m., a change occurred and Patient #11 was restrained using BUE soft restraints only.

No new restraint orders were located within the medical record for Patient #11, despite the patient being restrained from 01/25/16 at 6:00 p.m. until 01/26/16 at 4:00 a.m., which resulted in an additional 10 hours without a restraint order from a LIP or physician.

f) During an interview conducted on 02/04/16 at 3:21 p.m. with the Director, s/he stated the expectation of nursing staff was that MD orders were obtained and documented when restraints were used. Specifically, s/he stated behavioral restraint orders needed to be renewed every 4 hours. The Director stated if a patient was ready to transition from behavioral restraints (4 point restraints) to medical restraints (2 point restraints), the expectation of nursing staff was to have a conversation with a MD.

Further, the Director stated s/he would expect the RN to notify the MD that the patient had transitioned from behavioral to medical restraint use, and the expectation was both the MD notification and the new MD order should occur within minutes of the type of restraint being changed. The Director stated the ICU was fortunate that they always had access to a MD within the ICU setting to obtain such orders.

The facility failed to obtain a physician's order to transition Patient #11 from behavioral to medical restraints which resulted in the patient being restrained after the initial order expired.

Based on interviews and document reviews, the facility failed to ensure contracted personnel (Registered Nurses #8 and #9) adhered to the facility's policies. Specifically, the facility failed to ensure contracted nursing staff obtained a renewal restraint order for a patient that remained in restraints for 10 hours after the initial restraint episode ended.

This failure resulted in patients not having a physician's order for restraints while being restrained and created the potential for negative outcomes. Further, the failure created the potential for an unsafe patient care environment in which the responsible attending physicians were not aware of patients' medical needs and current restraint status.

FINDINGS:

POLICY

According to the policy, Patient Restraints, an order for restraint must be obtained from an LIP/Physician who was responsible for the care of the patient prior to the application of restraint. The duration of an order for restraint with non-violent and non-self destructive behavior must not exceed 24 hours for the initial order. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint and behavior-based criteria for release.

To continue restraint use beyond the initial order duration, the LIP/physician must see the patient, perform a clinical assessment and determine if continuation of restraint was necessary. If reassessment indicates an ongoing need for restraint, a new order must be written each calendar day by the LIP/Physician. Documentation requirements for restraint use include order for restraint and any renewal orders for restraint.

The Chief Nursing Officer (CNO) provides leadership and organizational accountability for monitoring the safety, appropriateness, and necessity of restraint use.

1. The facility failed to ensure non-employee (contracted) nursing personnel adhered to facility policies and protocols by neglecting to obtain a renewal restraint order for a patient.

a) Patient #11 was admitted on 01/24/16 with altered mental status. Review of the Restraints Monitor Form, dated 01/25/16, revealed contracted personnel (Registered Nurses #8 and #9, RN) provided services for Patient #11 on 01/25/16.

Review of Patient #11's IDEV - Discharge Report, dated 01/28/16, revealed an initial order for a non-violent, BUE, soft restraint was received on 01/24/16 at 8:22 p.m. by MD #13 (Medical Doctor). The order expiration time was 01/25/16 at 8:22 p.m., 24 hours later.

b) During an interview conducted with the Chief Nursing Officer (CNO #5) on 02/09/16 at 8:45 a.m., the CNO stated all restrained patients needed to have a current physician's order in their medical record. S/he stated "standing" or "as needed" orders could not be used, and physicians had to do a face-to-face assessment of the patient. In the event of an emergency, restraints could be applied to a patient, but a MD order had to be obtained and placed in the patient's medical record within minutes of the patient being restrained.

c) Review of the Clinical Documentation Record, dated 01/25/16, showed Patient #11's condition changed, and the patient required additional restraints due to combative behavior. A new physician's restraint order was obtained, which expired 4 hours later.

Record review revealed restraints were applied to Patient #11's four extremities on 01/25/16 at 2:20 p.m., and the patient's response to the restraint was "Combative." The Restraints Monitor also revealed a restraint notification to a physician was made. The order expiration time was 01/25/16 at 6:38 p.m., 4 hours later.

d) During an interview conducted on 02/04/16 at 2:40 p.m. with the Clinical Nurse Coordinator (CNC #1), the CNC stated the expectation of nursing staff related to behavioral restraint orders was to keep the patient safe, apply restraints, and have a MD come see the patient immediately and provide a written order for the restraint. The CNC stated behavioral restraint orders were only valid for 4 hours. Further, s/he stated if the patient was ready to transition from 4 point restraints (a behavioral restraint order) to 2 point restraints (a non-violent, medical restraint order), a separate discussion would have needed to take place with the MD. A new physician's order for restraints would need to be obtained because patients could not be transitioned from a behavioral restraint order to a medical 24-hour restraint order without the MD writing a new order.

There was no documentation a new restraint order for Patient #11 was obtained by RN #8 or RN #9 as the CNC specified.

e) Review of Patient #11's Restraints Monitor, dated 01/25/16, revealed the patient was in soft wrist restraints to all extremities at 3:00 p.m., 4:00 p.m., and 5:00 p.m. At 6:00 p.m., a change occurred and Patient #11 was restrained using BUE soft restraints only.

No new restraint orders were located within the medical record for Patient #11, despite the patient being restrained from 01/25/16 at 6:00 p.m. until 01/26/16 at 4:00 a.m., which resulted in an additional 10 hours without a restraint order from a LIP or physician.

f) During an interview conducted on 02/04/16 at 3:21 p.m. with the Director (Director #2), s/he stated the expectation of nursing staff was that MD orders were obtained and documented when restraints were used. Specifically, s/he stated behavioral restraint orders needed to be renewed every 4 hours.

The Director stated if a patient was ready to transition from behavioral restraints (4 point restraints) to medical restraints (2 point restraints), the expectation of nursing staff was to have a conversation with a MD.

Further, the Director stated s/he would expect the RN to notify the MD that the patient had transitioned from behavioral to medical restraint use, and the expectation was both the MD notification and the new MD order should occur within minutes of the type of restraint being changed. The Director stated the ICU was fortunate that they always had access to a MD within the ICU setting to obtain such orders.

The facility failed to ensure contracted staff obtained a physician's order to transition Patient #11 from behavioral to medical restraints which resulted in the patient being restrained after the initial order expired.