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Based on interview and record review the facility failed to obtain a new physician order after four hours for renewal of four-point violent restraints for one (#11) of two patients reviewed for restraints form a total of 12, resulting in the potential for unmet needs and injury. Findings include:

On 6/22/16 a review of the closed clinical record for patient #11, a 52 year old male revealed an admission to the emergency department on 6/7/16 at 2239 for altered mental status and abnormal labs. Presenting symptoms were documented as severe combativeness, confusion, disorientation and lethargy (being drowsy, dull, listless, apatetic or sluggish). Diagnosis was documented as Hepatic Encephalopathy (occurrence of confusion, altered level of consciousness and eventually coma as a result of liver failure).

Further review of the Electronic medical record (EMR) with the facility Chief Executive Officer, Staff A revealed the following: A Nurse's note dated 6/7/16 at 2245 documented "Patient awake, alert and oriented times one. Does not follow commands, attempts to pull at wires/monitoring equipment. Patient thrashing in bed. From home, Emergency Medical Services (EMS) states patient has abnormal ammonia levels and has been confused all day with family. Restrained times four with vinyl restraints (four point) without incident. Security and EMS bedside to assist."

A restraint summary flowsheet documented the following: Restraint status, start 6/7/16 2315 (Per the Nurse's note restraints were placed at 2245). Monitoring for Psychological Status, Physical Comfort, Circulation, Continuous Observation, and Discontinuation Criteria was documented every 15 minutes from 6/7/16 at 2315 to 6/8/16 at 0300 with two omissions at 2300 and 2330.

Per Staff A the EMR did not contain documentation related to the four point violent restraints being discontinued. Staff A stated the flowsheet documented every 15 minute restraint checks until 0300.

Staff A reviewed the EMR and stated "I do not see another order for the restraints. The last documentation of every 15 minute checks was at 0300. There should have been a new order after four hours."

A review of the facility policy titled "Restraint Policy: Guidelines for the use of Restraints/Seclusion" revealed the following: "The purpose of this policy is to provide guidelines for protecting the patient and others while preserving the patient's rights, dignity and well being when employing restraint or seclusion. The goal of (name of the facility) is to create a culture that supports the right of the patient to be restraint free. . .The use of restraint or seclusion will be ordered by a physician who is responsible for the care of the patient. . .Restraint: any method of involuntarily restricting a person's freedom of movement, physical activity or normal access to his body. Limited to the following indications: Potential for self harm. Potential to injure others. Potential to interfere with medical interventions. . .Physical restraint devices may vary by site and include. . .Neoprene (leather) restraint-wrist and/or ankle. . .All orders will be entered into the medical record. . .Orders are limited to the following time frames: Four hours for adults (18 and older). . .Upon expiration of the order, the patient is re-evaluated to determine whether continued restraint or seclusion is appropriate (an order is obtained as appropriate) as follows: Four hours for adults. . .If it is necessary for the order to be continued the nurse must contact the physician for a new order and document in the EMR the need for the continued use of violent restraints. . .Before writing a new order for the use of restraints for the management of violent or self-destructive behavior, a physician must see and assess the patient. The required examination by the physician shall be conducted not more than 30 minutes (behavior Health Unit) before the expiration of the expiring order for restraint."

Based on record review, and interview the facility failed to ensure nursing staff (1) updated and/or developed a care plan for altered skin integrity and (2) developed a care plan that addressed the use of hand mitts for 1 (#1) of 10 patients reviewed for care plans from a total of 12 sampled patients, resulting in the potential for unmet care needs. Findings include:

On 6/21/16 at 1315, a review of the closed medical record for patient #1 documented the following:

According to the admission face sheet patient #1 was a 61 year old male admitted to the facility on 1/5/16 with a diagnosis of lactic acidosis.

A review of nursing progress notes dated 1/5/16 through 1/7/16 documented the patient was in the Emergency Department on 1/5/16 and was subsequently admitted to the Intensive Care Unit on 1/5/16 through 1/7/16. The patient was transferred to the Medical floor on 1/7/16 until his discharge on 1/12/16.

Nursing notes documented that bilateral hand mitts were applied on patient #1 due to his hitting his head (self injurious) and due to biting self on 1/5/16. There were no orders for hand mitts. There were no care plans for hand mitts. There were no monitoring flow sheets for hand mitts.

A review of daily nursing complex assessments records dated 1/5/16 and 1/6/16 documented the patient's skin was intact. A Braden Scale for Predicting Pressure Sore Risk scored the patient at "17" (at risk) for skin breakdown. Type of mattress Enhancement: Pressure redistribution mattress. The patient was assessed as incontinent for bowel and bladder, and listed the patient as bedfast.

A review of daily nursing complex assessments records documented the following:
On 1/7/16 at 0302, the patient had redness to both hands.
On 1/8/16 at 0800 and at 2200, the patient had redness to the groin. Barrier lotion was applied at 2200.
On 1/9/16 at 1540, the patient had redness to the groin and redness to the left wrist. Barrier lotion was documented as applied at that time.
On 1/10/16 at 0823, redness to groin. No mention of skin treatments documented.
On 1/11/16 at 1100, left wrist redness and groin reddened. No mention of skin treatments
On 1/11/16 at 2000 redness to tip of nose near left nostril. No mention of groin or wrist assessments.

A review of the patient's "Risk of Pressure Ulcer" care plan (dated 1/5/16) documented:
Goal: Patient will remain free of skin breakdown
Goal Intervention: Assess skin integrity/risk for skin breakdown and implement skin integrity plan of care and interventions per policy
Assist patient with turning and/or activity often to prevent pressure ulcers.

A review of the patient's "Hourly Rounding" flowsheets documented the patient was not turned on repositioned or checked for incontinence every hour on the following dates and times:
On 1/7/16 between 0900 and 1500 and on 1/7/16 between 1900 and 2300.
On 1/8/16 between 0700 and 1400.
On 1/9/16 between 0000 and 1530.
On 1/10/16 between 0000 and 1400.
On 1/11/16 there was no evidence that documented the patient was repositioned.
On 1/12/16 between 0800 and 1130 there was no evidence that documented the patient was turned or repositioned or checked for incontinence.

Further record review revealed there were no orders or treatment records documented in the clinical record that addressed that change in the patient's skin integrity to his groin.

A review of the nursing discharge assessment note, dated 1/12/16 (no time), documented the patient was discharged with redness to the groin. However, there were no instructions documented in the clinical record that documented the patient/caregiver were given instructions on how to care of the redness to the patient's groin.

On 6/22/16 at 1355, during an interview and record review with Chief Nursing Officer Staff A, she explained it was their policy for all patients to be checked hourly and to be checked for pain, bathroom assistance and to be turned and repositioned. Additionally, she explained staff were responsible for completing the "Hourly Rounding" flow sheets for all patients.

When asked to explain why there were no orders for Hand mitts or orders for skin treatments for changes in skin conditions documented in the medical record, Staff A said it's possible it was a nursing judgement, staff may have or may not have contacted the physician.

When asked to explain what caused the redness to the patient's wrist, or what caused the injury to the patient's left nostril, Staff A said he probably hit himself. When asked if that injury was witnessed, Staff A stated, "There's nothing documented."

When asked why there were no care plans for the change in the patient's skin integrity for his wrist and groin, she (Staff A) said there should have been care plans for those changes in the patient's skin integrity. Staff A explained she did not know how long the mitts were in place since there was no further documentation.

On 6/22/16 at 1415, a review of the facility's "Care Plan and Patient Education" policy (dated 2010) did not address when to develop a care plan. It only documented electronic instructions for accessing or adding to a "Care Plan."