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Based on document review, medical record review and staff interview, the hospital failed to ensure the nursing staff follows hospital policy when placing patients in physical restraints. This deficient practice was identified in one (1) of two (2) restraint records (Patient #9) reviewed. This has the potential to negatively impact all patient care by causing psychological or physical harm to the physically restrained patient. Findings include:

1. United Hospital Center (UHC) Patient Services Policy/Procedure Restraint or Seclusion, last revised 3/10, states in part "... Policy: United Hospital Center acknowledges that the use of restraint or seclusion poses an inherent risk to the physical safety as well as the psychological well-being of the individual and staff...While the restraint or seclusion is in use it will be frequently evaluated and will be ended at the earliest possible time... Assessment on Admission The Registered Nurse's (RN's) initial risk/safety assessment of the patient includes obtaining information about the patient that could help minimize the use of restraints or seclusion... Alternative Interventions Less restrictive interventions will be considered prior to the initiation of restraints. These alternatives will be documented in the HED Assess/Daily Interventions under "restraints," or on the OPTIO flow sheet... Patient & Family Education When restraints are used, the patient and family members, as appropriate, will receive an explanation as to why restraints are implemented and will be educated about them...Education will be documented in HED or other appropriate documentation forms... Summary of Documentation The medical record will document the following with the use of restraints: ...Justification for use...The circumstances that led to use...Non-physical interventions...Rationale for the type of physical intervention selected...Patient and family education..."

2. Review of the medical record for Patient #9 revealed the patient was admitted to the nursing unit on 6/21/10 at 1755 through the Emergency Department (ED) with a diagnosis of Alzheimer's Dementia with Altered Mental Status. The nursing admission history and assessment documented at 1850 revealed the patient's current mental status was inappropriate, agitated, anxious and angry. Documentation by the Patient Care Assistant (PCA) at 2042 revealed the patient was in physical restraints. There is no documented evidence in the medical record what circumstances led to the need for restraints or if any less restrictive interventions were attempted first. Further review of the medical record revealed a physician's telephone order for restraints timed for 2100. The order is a pre-printed order form, completed with check marks to indicate type of restraint and physician's reason for restraint. This patient's order was marked for Vest and Wrist restraints due to Confusion/Disorientation, Agitated/Hostile, Harm to Self, Wandering/Attempting to get out of bed.

Further review of nursing documentation revealed no documented evidence of whether the patient was in the Vest restraint or the Wrist restraints, leaving the surveyor to assume the patient was in 3-point restraints. The reassessment was completed every two (2) hours by either the PCA or RN until 0615, when it appears the restraints were removed. On every documented reassessment, the patient was sleeping except one (1), but still in restraints. Review of the medical record also revealed no documented evidence of patient and/or family education about the restraint use. After the restraints were discontinued, nursing documentation continued to state the patient was confused and disoriented.

3. During an interview with the Unit Manager (UM) in the morning of 8/25/10, the medical record was reviewed and the UM agreed with the above findings.

Based on document review and staff interview it was determined the hospital failed to ensure that for every patient placed in either physical or chemical restraints the multidisciplinary plan of care is modified to reflect changes in the patient's condition and status which requires the use of any type of restraint. This deficient practice occurred in two (2) of two (2) patient records reviewed which had physical/chemical restraints applied (patient #1 and #9). Failure to change the patient's plan of care can result in staff not providing consistent care and interventions which could possibly result in physical or mental harm. Findings include:

1. Review of the medical record for patient #1 revealed the patient was admitted on 10/26/09 and had a right total knee replacement performed on 10/27/09. The admission assessment recorded the patient as being alert and oriented. On 10/29/09 at 0208 hrs the nurse obtained telephone orders for Haldol 1 milligram (mg) injection now and wrist restraints. The patient's multidisciplinary plan of care was not modified to reflect the change in the patient's mental status and restraint application.

During an interview on 8/24/10 at 0745 hrs with the Nurse Practitioner who cared for patient #1 she stated when she saw the patient at the office prior to her surgery she was alert and oriented. She stated the patient had gotten very confused the morning of 10/29/09 and when she and the physician made rounds about 0730 hrs the patient was in wrist restraints and was alert but was confused. She added normally they discharge their knee surgery patients on the third day post operation but this patients discharge was held up due to her confusion.

Record #1 was reviewed with the Nurse Manager on 8/25/10 at 1300 hrs and the Nurse Manager agreed the patient's Plan of Care did not have documentation about the restraint used on this patient.



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2. Review of the medical record for Patient #9 revealed the patient was admitted to the nursing unit on 6/21/10 at 1755 through the Emergency Department (ED) with a diagnosis of Alzheimer's Dementia with Altered Mental Status. The nursing admission history and assessment documented at 1850 revealed the patient's current mental status was inappropriate, agitated, anxious and angry. Documentation by the Patient Care Assistant (PCA) at 2042 revealed the patient was in physical restraints. The restraint reassessment was completed every two (2) hours by either the PCA or RN until 0615, when it appears the restraints were removed. Further review of the medical record revealed no documented evidence of the patient's Plan of Care being modified to add restraints.

During an interview with the Unit Manager (UM) in the morning of 8/25/10, the medical record was reviewed and the UM agreed with the above findings.

Based on document review, medical record review and staff interview it was determined that the hospital nursing staff failed to ensure that ongoing evaluations and interventions are documented on all patients as required by hospital policy. This deficient practice occurred in one (1) of two (2) medical records reviewed in which a patient had restraints applied (patient #1). Failure to document patient evaluations can result in all staff not being informed of the patients current status and interventions that were made which can result in not addressing all of the patients needs. Findings include:

1. The hospital policy for nursing documentation (approved 4/2009) states in part:
"From the initial assessment and ongoing reassessment, patient specific needs will be identified by the registered nurse. Interventions and evaluations will be documented."

2. Review of the medical record for patient #1 revealed the the patient was admitted to 5 North on 10/26/09 with a diagnosis of advanced osteoarthritis of the right knee. The patient underwent a right total knee replacement on 10/27/09. The record contained a restraint application form dated 10/29/09 for the use of wrist restraints. There were also physician telephone orders dated 10/29/09 and timed 0208 hrs to give Haldol 1 mg injection now and every hour as needed for agitation and to apply wrist restraints. The medication administration record documented on 10/29/09 the administration of Haldol 1 milligram (mg) at 0230 hrs and a second dose at 0405 hrs. The nurses's notes and flow sheets lacked documentation of the patient condition requiring the application of the restraints, the need for administration of two doses of Haldol and any subsequent reassessments of the patient's condition.

3. The nurse manager of 5 North was interviewed on 8/23/10 in the afternoon and agreed that nursing should have documented what happened with patient #1 on 10/29/09 at 0200 hrs. She concurred the patient had become very agitated, confused and combative when attempting to get out of bed after having just had her right knee replaced. The Manager added this situation required the intervention of several staff members to prevent the patient from falling.
The Manager stated what mental changes that occurred with this patient on 10/29/09 and the staff interventions should have been documented in the patient's record.