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Based on surveyor observations, staff interviews and review of hospital documents and medical records, the hospital failed to ensure the patient's rights were protected. Concerning the use of restraints, the hospital failed to ensure:

a. The restraints were applied according to a physician's order. Refer to Tag A-0168.

b. The least restrictive restraints were used. Refer to Tag A-0165.

c. The restraints were discontinued at the earliest possible time. Refer to Tag A-0154.

d. Restraint orders for patients who were a danger to self or others or violent were time limited and a one-hour face-to-face evaluation was conducted by qualified individuals.

e. Staff applied restraints in a safe manner. Refer to Tag A-0194.

f. Only hospital approved restraints were used. Refer to Tag A-0167.

Based on revies of hospital documents and medical records and interviews with hospital staff, the hospital failed to ensure:

a. Restraints were only applied as necessary and not as a means of convenience;

b. The restraints were discontinued at the earliest possible time; and

c. Restraint use was monitored, reviewed and analyzed through the hospital's quality assesssment and performance improvement (QAPI) program.

Findings:

1. Review of restraint logs listed patients with multiple types of restraints at the same time, such as 4-point (bilateral soft wrist and ankle) restraints, bilateral mittens, and waist belts. The log documented restraints were continued for several days. Example: Patient #2 was listed as being in restraints over 200 hours. Review of the chart confirmed the patient was continually in restraints, of one type or more, from 1107/14 at 1608 until 11/18/14 at 0600.

2. During an interview with staff on the afternoon of 12/03/14, Staff J and K told the surveyors that their 5th Floor unit currently had two patients in multiple types of restraints - bilateral soft wrist and ankle and lap/waist belts. They stated that on their neurological patient floor that this was common. Staff J stated her patient currently also had all four side rails up.

3. Review of patient records did not show restraint use was reviewed to ensure patient restraints were discontinued as soon as possible. For example, but not limited to:

a. Record #1 - The patient was restrained from 11/10/14 at 1800 until 11/12/14 at approximately 1700 (no definite time of release was recorded). The patient was initially put in bilateral soft wrist restraints. Bilateral ankle, bilateral mittens and waist restraints were added on 11/10/14 at 2300. The nursing notes on 11/11/14 at 0725 recorded the patient was confused, but cooperative, but the restraints continued.

b. Record #2 - The patient was in restraints from 11/07/14 at 0700 until 11/18/14 at 0600 (last recorded restraint documentation - no notation documented). The types of restraints varied from soft upper extremity (wrist) restraints to restraints times four with a waist/lap belt. Notes did not reflect a bed alarm or "sitter" were considered. The patient was discharged back to the nursing home on 11/20/14.

c. Record #3 - The patient was in restraints from 01/02/14 at1315 until 01/04/14 at 0700. The patient arrived on the unit on the ventilator. Nursing notes for 1900 on 01/12/14 recorded the patient "does not open eyes, does not follow commands, withdrawal from pain." On 01/03/14 at 0700, the nurse recorded the patient was "stuporous" with decorticate posturing. The restraints were continued.

d. Record #4 - The record indicated restraints were applied at 0200 on 07/15/14 for a procedure (airway intubation) and not removed until 07/15/14 at 1100. The patient was also sedated during this entire time. The patient died on 07/16/14.


4. QAPI meeting minutes for 2014 did not reflect restraint use was monitored, reviewed and analyzed. This was reviewed and confirmed with Staff A and B. Refer to Tag A-0273 for details.

Based on review of hospital documents and medical records and interviews with hospital staff, the hospital failed to ensure the least restrictive intervention have been used. This occurred in eight of eight (Records #1, 2, 3, 4, 5, 9, 10, and 11) patient records reviewed where restraints were used.

Findings:

1. Review of restraint logs listed patients with multiple types of restraints at the same time, such as 4-point (bilateral soft wrist and ankle) restraints, bilateral mittens, and waist belts.

2. During an interview with staff on the afternoon of 12/03/14, Staff J and K told the surveyors that their 5 th Floor unit currently had two patients in multiple types of restraints - bilateral soft wrist and ankle and lap/waist belts. They stated that on their neurological patient floor that this was common. Staff J stated her patient currently also had all four side rails up.

When asked, the surveyors were told that the unit/hospital did not use less restrictive means to ensure patient safety such as padded rails or enclosure beds. When asked about the use of "sitters", the surveyors were told they were used sometime, but not on the "step-down" unit. When asked, Staff J and K stated they already had a one-staff to three-patient ratio and it was not usually done.

3. Although the list of nursing staff provided, listed "sitters", records reviewed )Records #1, 2, 3, 4, 5, 9, 10, and 11) did not contain evidence "sitters" had been considered as an alternative to restraints. For example, but not limited to:
a. Record #1 - The patient was restrained from 11/10/14 at 1800 until 11/12/14 at approximately 1700 (no definite time of release was recorded). The patient was initially put in bilateral soft wrist restraints. Bilateral ankle, bilateral mittens and waist restraints were added on 11/10/14 at 2300. The nursing notes on 11/11/14 at 0725 recorded the patient was confused, but cooperative, but the restraints continued.

b. Record #2 - The patient was restrained from 1107/14 at 0700 until 11/18/14 at approximately 0600 (this was the last documentation on restraint). No discontinuation of the restraints was recorded, until the physician order discontinuation at 1400 on 11/18/14. The record did not contain any indication that "sitters" were tried or considered. This was confirmed during review with Staff G.

c. Record #10 - The patient was in restraints at the time of transfer to rehabilitation on 06/09/14. The record contained no documentation that using "sitter" had been considered.

Based on review of hospital documents and medical records and interviews with hospital staff, the hospital failed to ensure restraints were applied with safe application and devices used were specified in the policy.

Findings:

1. The hospital's policy does not specify what types of restraints are approved by the hospital.

2. On 12/03/14, Staff A, C, and K told the surveyors that Posey vest restraints were not used in the hospital.
a. Education/training modules provided to the surveyors did not list Posey vest restraint as restraints to be used in the hospital.
b. Record #2 - Nursing staff documented a "Posey Transport jacket" (in addition to softy bilateral wrist and ankle restraints ) was use on the patient from 11/13 at 1900 through 11/14/14 at 0300.
c. Record #5 - Nursing staff documented a Posey vest was used on the patient on 11/17/14.
d. Staff X told the surveyors on the afternoon of 12/04/14 that Posey vests were used in the Childrens hospital units.

3. On the afternoon of 12/03/14, Staff J described using the waist/lab belt restraint on Patient #5 around the chest area over the patient's sternum and diaphragm. This is not the intended or safe application of the restraint.

Based on review of hospital documents and medical records and interviews with hospital staff, the hospital failed to ensure restraints were applied according to physicians orders and if initiated by nursing staff, an order was immediately obtained. This occurred in seven of eight (Records #1, 2, 3, 4, 9, 10 and 11 or Records#1, 2, 3, 4, 5, 9, 10, and 11) patient records reviewed where restraints were used.

Findings:

The hospital's policy required restraints to be renewed at least every 24 hours.

1. Patients were placed in restraints without orders and continued without renewal at the required time. For example, but not limited to:

a. Record #1 - The patient was restrained from 11/10/14 at 1800 until 11/12/14 at 1039 without physician orders.

b. Record #2 - The patient was in restraints (verified by nursing documentation) from 11/07/14 at 0700 through 11/18/14 at 0600.
i. There were no orders for restraints on 11/08/14, 11/09/14, 11/12/14, and 11/14/14.
ii. The orders obtained indicated the restraints to be utilized were soft bilateral upper extremity (wrist - BUE) restraints. Nursing staff documented during the restraint period that the type of restraints were changed to include, at times soft bilateral wrist and ankle restraints (soft restraints times four - soft x's 4), waist restraints and/or bilateral mitten restraints.

Example, but not limited to: On 11/07/14 at 2100, the patient went from BUE to soft x's 4. Then at 0900 on 11/08/14, the patient restraints were changed also include bilateral mittens. On 11/13/14 at 1900, restraints were changed to soft x/s 4 and Posey transport jacket.

No authorizing practitioner orders were obtained for these restraint changes.

c. Record #9 - The patient was in restraints from 06/11/14 at 2000 until 06/116/14 after 0400 (last documentation of restraints - no documentation of discontinuation is documented) and from 06/17/14 at 1125 until 06/20/14 after 1756 (last documentation of restraints -no notation of discontinuation is documented). The only order found was for restraints on 07/25/14 at 0928.

d. Record #10 - The patient was in restraints (verified by nursing documentation) from 06/01/14 at 1300 until 06/09/14 after 1000 (last documentation of restraints - no notation of discontinuation is documented).
i. The patient was restrained on 06/01/14 at 1300 through 06/05 without physician orders. No orders were obtained until 06/05/14 at 1825.
ii. There were no orders for restraints on 06/07/14.

e. Record #11 - The patient was in restraints (verified by nursing documentation) from 05/03/14 at 2300 until 05/20/14 after 1212 (last documentation of restraints). There was no order for restraints until 05/06/14 at 0928.


2. Nursing staff initiated restraints, but did not immediately obtain a physician's order. For example, but not limited to:
a. Record #2 - The nurse applied bilateral soft wrist restraints on 11/07/14 at 0700. An order for the restraints was not obtained until 11/07/14 at 1608.
b. Record #3 - The nurse applied bilateral soft wrist restraints on 01/02/14 at 1315. An order was not obtained until 01/02/14 at 1812.
c. Record #4 - The nurse applied bilateral soft wrist restraints on 07/15/14 at 0200. An order for the restraints was not obtained until 07/15/14 at 1142.

Based on review of hospital documents and medical records and interviews with staff, the hospital failed to ensure for patients, that were restrained for reasons of danger to self/others or violent behavior, the orders contained the appropriate time limit for the restraint and were evaluated for appropriateness before renewal.

1. Patient #1 - The order for restraints (soft times 4 and waist) on 11/19/14 at 2010 recorded the reason for restraints was for "Danger to self/others". The order recorded the restraint was for twenty-four (24) hours and no evaluation was performed to ensure the restraints were appropriate, a lesser restraint could be utilized or if they were still needed.

2. Patient #2 - The order for restraints (bilateral upper soft) on 11/07/14 at 1608 recorded the reason for restraints was for "Danger to self/others". The order recorded the restraint was for twenty-four (24) hours and no evaluation was performed to ensure the restraints were appropriate, a lesser restraint could be utilized or if they were still needed.

3. Patient #5 - The order for restraints on 11/20/14 recorded the reason for restraints was for "Danger to self/others". The order recorded the restraint was for twenty-four (24) hours and no evaluation was performed to ensure the restraints were appropriate, a lesser restraint could be utilized or if they were still needed.

4. Restraint order are completed electronically, with options chosen. At the time of review, Staff A and F stated that they felt that the practitioner just chose the wrong order element.

5. Review of four practitioner files did not contain evidence the practitioners had been provided training on restraint orders. This was reviewed at the time of review on the afternoon or 11/04/14.

Based on review of hospital documents and medical records and staff interview, the hospital failed to ensure patients, that were restrained for reasons of danger to self/others or violent behavior, were provided a face-to-face evaluation by a qualified staff within one (1) hour after the initiation of the intervention. In three of three (Patients #1, 2, and 5) medical records reviewed of patients restrained due to "danger to self/others", a one hour face-to face evaluation was not performed.

Findings:

1. Patient #1 - The order for restraints (soft times 4 and waist) on 11/19/14 at 2010 recorded the reason for restraints was for "Danger to self/others". No one hour evaluation was performed to ensure the restraints were appropriate, a lesser restraint could be utilized or if they were still needed.

2. Patient #2 - The order for restraints (bilateral upper soft) on 11/07/14 at 1608 recorded the reason for restraints was for "Danger to self/others". No one hour evaluation was performed to ensure the restraints were appropriate, a lesser restraint could be utilized or if they were still needed.

3. Patient #5 - The order for restraints on 11/20/14 recorded the reason for restraints was for "Danger to self/others". No one hour evaluation was performed to ensure the restraints were appropriate, a lesser restraint could be utilized or if they were still needed.

4. These findings were reviewed with staff at the time of review and again at the exit conference with administrative staff on the afternoon of 12/04/14. No further documentation was provided.

Based on review of hospital documents, personnel files and medical records and interviews with hospital staff, the hospital failed to ensure staff were trained and monitored to safely apply all the types of restraints used in the hospital.

Findings:

Training files for Staff J, K, M, N, O, P, Q, and R were reviewed for competency and training, including restraint demonstration. The files documented competency validations for restraint applications.

During an interview with staff on the afternoon of 12/03/14, Staff J and K told the surveyors that their 5 th Floor unit currently had two patients in multiple types of restraints - bilateral soft wrist and ankle and lap/waist belts. They stated that on their neurological patient floor that this was common. Staff J stated her patient currently also had all four side rails up. Staff J stated that all the restraints were required because the patient had a head wound that they were protecting. She stated the patient had demonstrated rising up in bed and then fall back and without the restraints, he could be at risk for further injury. When asked how a lap/waist belt restraint would prevent this. She stated the lap/waist belt was not actually around the patient's waist. She then demonstrated where the restraint was placed. Staff J indicated the restraint was placed around the chest area over the patient's sternum and diaphragm. This is not the intended or safe application of the restraint.

Based on review of hospital documents and meeting minutes and interviews with staff, the hospital failed to ensure restraints were monitored, reviewed and analyzed as part of the quality assessment and performance improvement (QAPI) program to ensure:

a. The restraints were applied according to a physician's order;
b. The least restrictive restraints were used;
c. The restraints were discontinued at the earliest possible time; and
d. Injuries and skin disruptions resulting from the use of restraints were diminished.

Findings:

1. QAPI meeting minutes for 2014 did not reflect restraint use was monitored, reviewed and analyzed.

2. Staff B told the surveyors on 12/04/14 that the last time restraints were reviewed was 08/22/13 and that occurred only during a nursing services meeting, but no minutes were taken.

3. On 12/04/14, Staff A told the surveyors that the only monitoring and review of restraints she remembered was the monitoring for compliance with notification to CMS (Center for Medicare and Medicaid Services) of a death in restraints. Staff A stated those meetings had not occurred this year.

4. Review of nursing units' restraint logs showed patients being restrained for multiple days. Although time in restraints was recorded, the logs showed no analysis to determine if a least restrictive application had occurred or could be used. Example: One log recorded Patient #2 was in restraints over 200 hours. This patient developed skin interruptions while in restraints.

5. Nursing applied restraints and did not immediately obtain an order for the restraint; applied restraints without physician orders; and/or did not apply restraints according to physician orders. This occurred in Records #1, 2, 3, 4, 9, 10, 11. QAPI meeting minutes did not demonstrate this had been reviewed.

Based on review of hospital documents, staffing matrix, and medical record, the hospital failed to ensure nursing units were staffed to meet the specialized needs of the patients to minimize the use of restraints.

Findings:

Restraint logs indicated patients were restrained with multiple types of restraints - such as bilateral soft wrist and ankle restraints, bilateral mittens, and waist restraints.

During an interview with staff on the afternoon of 12/03/14, Staff J and K told the surveyors that their 5th Floor unit currently had two patients in multiple types of restraints - bilateral soft wrist and ankle and lap/waist belts. They stated that on their neurological patient floor that this multi-type restraint use was common. Staff J stated her patient currently also had all four side rails up.

When asked about the use of "sitters", the surveyors were told they were used sometimes, but not on the "step-down" unit. When asked, Staff J and K stated they already had a one staff to three patient ratio and it was not usually done.

Review of patient records #1, 2, 3, 4, 5, 9, 10, and 11 did not contain evidence "sitters" or one to one staff ratios were considered to meet the needs of the patients and to reduce the use of restraints, especially multi-types of restraints.

Record #2 - The patient was restraint from 1107/14 at 0700 until 11/17/14 at 0600 (last documentation of restraint). The patient was initially placed in bilateral soft upper extremity (wrist) restraints, but other types of restraints were also used during this time. The record did not record the option of using a "sitter" (someone at bedside to remind patient to not pull at devices and/or to not get out of bed) being considered. During the time the patient was in restraints, the patient developed skin interruptions on upper and lower extremities and was seen by the wound care nurse on 11/14/14 at 1731 for skin tear on upper right forearm (oval in shape measuring 2 centimeters by 0.6 centimeters wide) and redness noted on the left forearm. No other intervention was documented and no changes in restraints occurred. There is no documentation that the physician was notified and restraint orders changed.