The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LAKELAND REGIONAL MEDICAL CENTER 1324 LAKELAND HILLS BLVD LAKELAND, FL 33805 March 7, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on medical record review, staff interview, and review of policy and procedures it was determined the facility failed to ensure that patients' rights were protected and promoted.

1. The facility failed to ensure each patient, or when appropriate, their representative was informed of the patient's rights in advance of providing or discontinuing patient care. Refer to A0117.

2. The facility failed to provide the standardized notice, "An Important Message from Medicare" (IM), within 2 days of admission. Refer to A0117.

3. The facility failed to ensure the patient's representative was given the right to participate in the development and implementation of the discharge plan. Refer to A0130.

4. The facility failed to ensure the patient's representative was afforded the right to make informed decisions related to discharge planning for the patient's post acute care. The facility failed to ensure the patient's representative was provided information and disclosures needed to make an informed decision regarding the patient's proposed treatment. Refer to A0131.

5. The facility failed to ensure the hospital staff and practitioners complied with the patient's advanced directives for decision making. Refer to A0132.

6. The facility failed to ensure three of thirteen patients had the right to be free from restraint and failed to ensure the restraint was discontinued at the earliest possible time. Refer to A0154.

7. The facility failed to ensure patients were assessed to determine if restraint was necessary to protect a patient. Refer to A0164.

8. The facility failed to ensure the use of restraints was in the accordance with the order of a physician for 3 of thirteen patients. Refer to A0168.

9. The facility failed to monitor the condition of a patient who was restrained according to the facility's policy. Refer to A0175.

10. On 3/06/2012 at 2:00 p.m. an interview with the Director of Quality was conducted. The interview revealed roll belts are utilized in the facility. The roll belts are used as reminders for patients to call for assistance when getting out of bed. It was determined that documentation of the patient's ability to release the roll belts was to be demonstrated daily. If the patient was unable to demonstrate the ability to release the roll belt then the roll belt was considered a restraint. The Director of Quality revealed the use of roll belts, utilized as a non restraint, are not tracked. Therefore, there was no data to review to indicate if patients are demonstrating the ability to release the roll belt or if the staff was utilizing the roll belt as a restraint. Two records of patients utilizing the roll belt, as a non restraint, revealed no evidence the patient was able to release the roll belt.

The cumulative effect of the facility's failure to ensure the patients' rights were protected and promoted has resulted in the determination that the Condition of Participation for Patients Rights 42 CFR 482.13 is out of compliance.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and staff interview it was determined the facility failed to ensure each patient, or when appropriate, the patient's representative, was informed of the patient's rights in advance of providing or discontinuing patient care for two (#2, #3) of thirteen patients sampled. The facility failed to provide the standardized notice, "An Important Message from Medicare" (IM), within 2 days of admission for four (#2, #3, #7, #12) of thirteen patients sampled. This does not ensure patients and/or their representatives have the information necessary to exercise their rights.

Findings include:

1. Review of patient #2's medical record revealed the patient was admitted to the facility on [DATE] and discharged on [DATE]. Review of the physician's H & P (History & Physical) dated 1/17/2012 revealed the patient was demented and was unable to provide a history. Review of the nursing admission assessment, dated 1/17/2012 at 12:00 p.m. revealed the patient had a history of Alzheimer's. Review of the medical record revealed no evidence the patient or the patient's representative received notice of the patient's rights.

An interview on 3/06/2012 at 3:05 p.m. with the Manager of Patient Access & Registration Services confirmed the findings.

2. Review of patient #3's medical record revealed the patient was admitted to the facility on [DATE] and discharged from the facility on 2/08/2012. Review of the nursing admission assessment, dated 2/03/2012 at 4:30 p.m. revealed the patient was confused. Review of the medical record revealed no evidence the patient or the patient's representative received notice of the patient's rights.

An interview on 3/06/2012 at 3:05 p.m. with the Manager of Patient Access & Registration Services confirmed the findings.

3. Review of patient #2's medical record revealed the patient was admitted to the facility on [DATE] and discharged on [DATE]. Review of the record revealed the patient was a Medicare beneficiary. Review of the record revealed no evidence the patient or patient's representative was provided the standardized notice, "An Important Message from Medicare" (IM), within 2 days of admission, in accordance with regulation 42 CFR 489.27(b), which cross references the regulation at 42 CFR 405.1205. Review of the physician's orders dated 1/17/2012 revealed the patient was to be admitted as an inpatient to the facility.

An interview on 3/06/2012 at 3:05 p.m. with the Manager of Patient Access & Registration Services confirmed the findings.

4. Review of patient #3's medical record revealed the patient was admitted to the facility on [DATE] and discharged from the facility on 2/08/2012. Review of the record revealed the patient was a Medicare beneficiary. Review of the record revealed no evidence the patient or patient's representative was provided the standardized notice, "An Important Message from Medicare" (IM), within 2 days of admission. Review of the physician's orders, dated 2/03/2012, revealed the patient was to be admitted as an inpatient to the facility.

An interview on 3/06/2012 at 3:05 p.m. with the Manager of Patient Access & Registration Services confirmed the findings.

5. Review of patient #7's medical record revealed the patient was admitted to the facility on [DATE] and was still currently a patient at the facility at the time of survey. Review of the record revealed the patient was a Medicare beneficiary. Review of the record revealed no evidence the patient or patient's representative was provided the standardized notice, "An Important Message from Medicare" (IM), within 2 days of admission. Review of the physician's orders dated 3/04/2012 revealed the patient was to be admitted as an inpatient to the facility.

An interview on 3/7/2012 at 11:35 a.m. with the Manager of Patient Access & Registration Services confirmed the findings.

6. Review of patient #12's medical record revealed the patient was admitted to the facility on [DATE] and was still currently a patient at the facility at the time of survey. Review of the record revealed the patient was a Medicare beneficiary. Review of the record revealed no evidence the patient or patient's representative was provided the standardized notice, "An Important Message from Medicare" (IM), within 2 days of admission. Review of the physician's orders dated 3/01/2012 revealed the patient was to be admitted as an inpatient to the facility.

An interview on 3/7/2012 at 11:35 a.m. with the Manager of Patient Access & Registration Services confirmed the findings.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the medical record, review of patient's rights and staff interview it was determined the facility failed to ensure the patient's representative was provided the right to participate in the development and implementation of the patient's plan of care and discharge plan for one (#1) of thirteen sampled patients. This does not ensure patients and/or their representatives have the information necessary to exercise their rights.

Findings include:

Review of the medical record for patient #1 revealed the patient was admitted to the facility on [DATE] and was discharged on [DATE]. The admitting diagnosis was altered mental status. Review of the H & P revealed the patient had a history of a [DIAGNOSES REDACTED] and status post craniotomy. The patient was readmitted with aggressive behavior and psychosis from the skilled nursing facility to where he had been discharged . The H & P stated the patient had been discharged earlier today, 1/14/2012, back to the skilled nursing facility but was now readmitted to the current facility.

Review of the record revealed a form for designation of health care proxy. Review of the form revealed the form designated the spouse as the patient's health care proxy. The form revealed the spouse accepted the responsibility by signature dated 12/09/2011. The form was witnessed on the same date, 12/09/2011.

Review of the record revealed a social worker completed a discharge planning assessment for the patient on 1/15/2012 at 4:45 p.m. The social worker noted the patient was admitted with altered mental status and was confused. Documentation revealed the social worker called and spoke with the spouse at the time of the assessment. The spouse informed the social worker that the patient was a long term resident at a local SNF (Skilled Nursing Facility) and that she wanted the patient transferred closer to her home. Documentation revealed the social worker informed the spouse the SNF would have to initiate the process to transfer the patient to another facility closer to home. The SW documented she called and spoke with the liaison at the SNF at the time of the assessment. The liaison stated they would accept the patient back and that they are currently waiting on a bed to transfer the patient to a facility closer to the spouse.

On 1/16/2012 the social worker documented there were no orders for discharge written in spite of consult. The physician wrote orders for a SNF. Nursing stated discharge was pending for tomorrow.

On 1/18/2012 the social worker documented she received a consult for DME (Durable Medical Equipment) and home health services. The social worker faxed the orders and spoke with the home health agency to inform them of a need for a home nebulizer and home health.

Review of the record revealed the patient was discharged on [DATE] in the care of the patient's mother. Review of the record revealed no documentation the social worker notified the designated health care surrogate of the change in orders to discharge the patient home with home health services. There was no documentation the health care surrogate approved of the discharge plan. The facility failed to ensure the patient's designated health care surrogate was afforded the right to participate in the development and implementation of a safe discharge plan.

Review of the facility's patient rights, as provided to the patient upon admission, stated the patient's advance directives will be honored by the staff, the patient was encouraged to participate in the plan of care and to receive complete information in order to make informed decisions regarding medical treatment.

Review of the record revealed the patient was incapacitated upon admission to the facility and a designated health care proxy had been determined as evidenced by the completed form.

The social worker and director of risk management were interviewed on 3/06/2012 at 2:45 p.m. and confirmed the above findings.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the medical record, review of patient's rights and staff interview it was determined the facility failed to ensure the patient's designated healthcare representative was involved with the patient's care planning and treatment for two (#1, #2) of thirteen sampled patients. The facility failed to ensure the patient's designated healthcare representative was provided information and disclosures needed to make an informed decision about whether to consent to blood transfusion for one (#2) of thirteen sampled patients. This does not ensure patients and/or their representatives have the information necessary to exercise their rights and make informed decisions for care and treatment.

Findings include:

1. Review of the medical record for patient #1 revealed the patient was admitted to the facility on [DATE] and was discharged on [DATE]. The admitting diagnosis was altered mental status. Review of the H & P revealed the patient had a history of a [DIAGNOSES REDACTED], status post craniotomy, and the patient was readmitted with aggressive behavior and psychosis from a skilled nursing facility. The H & P stated the patient had been discharged earlier today, 1/14/2012, back to the skilled nursing facility but was now readmitted to the current facility.

Review of the record revealed a form for designation of health care proxy which was previously executed. Review of the form revealed the form designated the spouse as the patient's health care proxy. The form revealed the spouse accepted the responsibility by her signature and was dated 12/09/2011. The form was witnessed on the same date, 12/09/2011.

Review of the record revealed a social worker completed a discharge planning assessment for the patient on 1/15/2012 at 4:45 p.m. The social worker noted the patient was admitted from a nursing home with altered mental status and was confused. Documentation revealed the social worker called and spoke with the spouse at the time of the assessment on 1/15/2012. The spouse informed the social worker that the patient was a long term resident at a local SNF (Skilled Nursing Facility) and that she wanted the patient transferred closer to her home. Documentation revealed the social worker informed the spouse the SNF would have to initiate the process to transfer the patient to another facility closer to home. The SW documented she called and spoke with the liaison at the SNF at the time of the assessment. The liaison stated they would accept the patient back and that they are currently waiting on a bed to transfer the patient to a facility closer to the spouse.

On 1/16/2012 the social worker documented the physician wrote direct orders for the SNF and nursing stated discharge was pending for tomorrow.

On 1/18/2012 the social worker documented she received a consult for DME and home health services. The social worker faxed the orders and spoke with the home health agency.

Review of the record revealed the patient was discharged on [DATE] in the care of the patient's mother. Review of the record revealed no documentation the social worker notified the designated health care surrogate of the change in orders to discharge the patient home with home health services. There was no documentation the health care surrogate approved of the discharge plan.

Review of the facility's patient rights, as provided to the patient upon admission, stated the patient's advance directives will be honored by the staff, the patient was encouraged to participate in the plan of care and to receive complete information in order to make informed decisions regarding medical treatment.

Review of the record revealed the patient was incapacitated upon admission to the facility and a designated health care proxy had been determined as evidenced by the completed form.

The social worker and director of risk management were interviewed on 3/06/2012 at 2:45 p.m. and confirmed the above findings.

2. Review of patient #2's medical record revealed the patient was admitted to the facility on [DATE]. Review of the physician's H & P dated 1/17/2012 revealed the patient was demented and had a history of Alzheimer's. The physician's impression included symptomatic anemia and dementia.

Review of the record revealed an order on 1/17/2012 to transfuse 2 units of Packed Red Blood Cells. Review of the record revealed an informed consent for transfusion of blood and blood products was obtained on 1/17/2012 from the patient as evidenced by the patient's signature on the document. Documentation in the medical record revealed the patient suffered from dementia, Alzheimer's and was unable to provide a medical history as documented by the physician in the H & P. Documentation revealed the patient was not able to make an informed decision.

Interview on 3/7/2012 at 3:15 p.m. confirmed the findings.

3. Review of patient #2's medical record revealed the patient was admitted to the facility on [DATE] and discharged on [DATE]. Review of the physician's H & P dated 1/17/2012 revealed the patient was demented and was unable to provide a history. Review of the nursing admission assessment dated [DATE] at 12:00 p.m. revealed the patient had a history of Alzheimer's.

Review of the record revealed the patient had executed an advanced directive. Review of the executed living will revealed the patient designated the spouse and then two sons as Power Of Attorney and healthcare surrogate.
Review of the record revealed on 1/18/2012 at 5:28 a.m. the patient sustained an unwitnessed fall. Review of the post fall assessment form and nursing notes revealed none of the patient's representatives had been notified and informed of the fall. Review of the documentation revealed the facility failed to ensure the patient's designated healthcare representative was notified and had the opportunity to be involved with the patient's care planning and treatment.

An interview on 3/7/2012 at 3:15 p.m. with the Director of Quality confirmed the findings.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the medical record, review of patient's rights and staff interview it was determined the facility failed to comply with the patient's advanced directives and designation of healthcare representative for one (#1) of thirteen sampled patients. This practice does not ensure the patient's rights are maintained.

Findings include:

Review of the record revealed patient #1 designated a healthcare representative as evidenced by a previously executed document. The facility failed to consult with the designated representative and discharged the patient to the care of his mother therefore failing to comply with the patient's advanced directive.

Review of the medical record revealed the patient was admitted to the facility on [DATE] and was discharged on [DATE]. The admitting diagnosis was altered mental status. Review of the record revealed a form for designation of health care proxy, which was previously executed. Review of the form revealed the form designated the spouse as the patient's health care proxy. The form revealed the spouse accepted the responsibility by her signature and was dated 12/09/2011. The form was witnessed on the same date, 12/09/2011.

Review of the record revealed a social worker completed a discharge planning assessment for the patient on 1/15/2012 at 4:45 p.m. The social worker noted the patient was admitted from a nursing home with altered mental status and was confused. Documentation revealed the social worker called and spoke with the spouse at the time of the assessment on 1/15/2012. The spouse informed the social worker that the patient was a long term resident at a local SNF (Skilled Nursing Facility) and that she wanted the patient transferred closer to her home. se.

On 1/18/2012 the social worker documented she received a consult for DME (Durable Medical Equipment) and home health services. The social worker spoke with the home health agency to inform them of a need for a home nebulizer and home health services.

Review of the record revealed the patient was discharged on [DATE] in the care of the patient's mother. Review of the record revealed no documentation the social worker notified the designated health care surrogate of the change in orders to discharge the patient home with home health services. There was no documentation the health care surrogate approved of the discharge plan.

Review of the facility's Patient Rights, as provided to the patient upon admission, stated the patient's advance directives will be honored by the staff, the patient was encouraged to participate in the plan of care and to receive complete information in order to make informed decisions regarding medical treatment. Review of the record revealed the patient was incapacitated upon admission to the facility and a designated health care proxy had been determined as evidenced by the completed form.

The social worker and director of risk management were interviewed on 3/06/2012 at 2:45 p.m. and confirmed the above findings.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, staff interview and review of facility policy and procedures it was determined the facility failed to ensure patients had the right to be free from restraints for three (#2, #3, #12) of thirteen patients sampled. This does not ensure patients are provided safe care in a safe environment free from the inappropriate use of restraint.

Findings include:

1. Review of the medical record for patient #2 revealed the patient was admitted from a SNF to the facility on [DATE] for fatigue, dyspnea on exertion and anemia. Review of the physician's H&P dated 1/17/2012 revealed the patient was demented and was unable to provide a history. Review of the nursing admission assessment, dated 1/17/2012 at 12:00 p.m., revealed the patient had a history of Alzheimer's.

Review of the record revealed on 1/18/2012 at 5:28 a.m. the patient sustained an unwitnessed fall. Review of the post fall assessment and nursing notes revealed the patient was assessed and was noted to be confused at 5:28 a.m., 6:00 a.m., 7:00 a.m. and 8:00 a.m. Review of the medical record revealed on 1/18/2012 at 10:00 a.m. a roll belt was applied to the patient.

Review of the facility's policy, "Restraint Usage, Implementation, and Monitoring" , last approved 8/2010, stated roll belts are utilized when the patient was able to consistently release themselves. Evaluation of a patient's ability to release the belt was performed and documented every 24 hours.

Interview on 3/06/2012 at 3:30 p.m. with the Director of Quality confirmed the roll belt use and stated if the release of the roll belt cannot be demonstrated by the patient the roll belt was considered a restraint and an order would be obtained.

Review of the record revealed no documentation the patient demonstrated the ability to release the roll belt upon application on 1/18/2012. Review of the record revealed on 1/19/2012 at 8:00 a.m. nursing documented the roll belt was intact. There was no documentation the patient demonstrated the ability to release the roll belt. Nursing documentation on 1/19/2012 at 9:00 a.m. revealed the patient was confused and the nurse re-oriented the patient to day, date and place. The patient was discharged from the facility on 1/19/2012 at 3:30 p.m.

Documentation revealed the roll belt was applied following a fall by the patient on 1/18/2012. Review of the record revealed no clinical justification for the use of the roll belt being used as a restraint. Review of the record revealed no attempted interventions prior to the application of the roll belt and no assessment for the need of the roll belt. Review of a prior admission to the facility on [DATE] revealed the patient was also noted to be confused during the admission. A sitter was provided to ensure patient safety and a safe environment for the patient.

Interview with the Director of Quality on 3/07/2012 at 3:15 p.m. confirmed the findings.

2. Review of the medical record for patient #3 revealed the patient was admitted to the facility on [DATE] for a UTI (Urinary Tract Infection), dementia and dizziness. The nursing admission assessment dated [DATE] at 4:30 p.m. revealed the patient was confused, oriented to self only, and had frequent urination. Documentation revealed the patient was admitted from an ALF (Assisted Living Facility) and was mobile with a walker prior to hospitalization .

Nursing documentation on 2/03/2012 at 7:30 p.m. stated the patient was found out of bed, was placed back in bed and a roll belt was applied. There was no documentation the patient was educated on the necessity or use of the roll belt. There was no documentation the patient demonstrated the ability to release the roll belt. Review of the nursing admission assessment revealed the patient had generalized weakness but there was no functional assessment completed. Nursing documented N/A for functional assessment. It was noted the patient was admitted form an ALF and was mobile with a walker prior to admission.

Nursing documentation on 2/03/2012 at 7:45 p.m. stated the patient was found out of bed folding up the roll belt. The patient was placed back in bed and a vest restraint was applied. A physician order was obtained for the vest restraint. Documentation revealed the patient was monitored every 2 hours at 8:00 p.m., 10:00 p.m. and 12:00 a.m. on 2/04/2012. At 1:05 a.m. on 2/04/2012 the patient was found on the floor. Documentation revealed the patient stated she was trying to get to the bathroom. Nursing documented the patient sustained a laceration to the left temple and complained of pain in the left groin, hip and upper leg. The physician was notified and orders received. Review of the test results revealed the patient sustained a fractured hip.

Review of the record revealed no evidence a bed alarm or other alternatives were attempted prior to the use of the restraint.

3. Review of the medical record for patient #12 revealed the patient was admitted to the facility on [DATE] for a stroke alert. Nursing admission documentation revealed the patient was identified at high risk for falls and strict fall precautions were initiated at 4:00 p.m. Documentation revealed on 3/02/2012 at 1:00 a.m. a vest restraint was applied to the patient. The clinical justification revealed the patient was attempting to get out of bed without assistance and was unable to safely ambulate. Review of the documentation revealed the vest restraint remained in place until 3/06/2012 at 8:00 a.m. Review of the restraint documentation revealed on 3/04/2012 there were no attempted interventions provided to the patient in order to assess if the restraint could be removed or a less restrictive restraint could be used. Review of the record revealed on 3/05 and 3/06 there was no documentation the patient required the restraint to ensure the immediate physical safety of the patient and no documentation there were any attempted interventions provided to the patient. Review of the documentation revealed no assessment to demonstrate a continued need for the restraint.

On 3/07/2012 at 11:50 a.m. an interview with the manager of the stroke unit confirmed the findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, staff interview and review of the facility's policy and procedures it was determined the facility failed to ensure patients were assessed to determine if restraint was necessary to protect the patient from harm for one (#12) of thirteen patients sampled. This does not ensure patients are provided safe care in a safe environment free from the inappropriate use of restraint.

Findings include:

Review of the medical record for patient #12 revealed the patient was admitted to the facility on [DATE] for a stroke alert. Nursing admission documentation revealed the patient was identified at high risk for falls and strict fall precautions were initiated at 4:00 p.m.

Documentation revealed on 3/02/2012 at 1:00 a.m. a vest restraint was applied to the patient. The clinical justification revealed the patient was attempting to get out of bed without assistance and was unable to safely ambulate. Review of the documentation revealed the vest restraint remained in place until 3/06/2012 at 8:00 a.m.

Review of the restraint documentation revealed on 3/04/2012 there were no attempted interventions provided to the patient in order to assess if the restraint could be removed or a less restrictive restraint could be applied. Review of the record revealed on 3/05 and 3/06 a comprehensive assessment was performed. Review of the record revealed alternatives attempted or the rationale for not using alternatives was not documented. Review of the documentation revealed no assessment to demonstrate a continued need for the restraint.

Review of the facility's policy, "Restraint Usage, Implementation, and Monitoring" , last approved 8/2010, stated restraints may only be used when less restrictive interventions have been determined to be ineffective to protect the patient. The use of restraint occurs only after alternatives to such use have been considered and/or attempted as appropriate.

On 3/07/2012 at 11:50 a.m. an interview with the manager of the stroke unit confirmed the findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, staff interview and review of the facility's policy and procedures it was determined the facility failed to ensure the use of a restraint was in accordance with the order of a physician for three (#2, #3, #12) of thirteen patients sampled. This practice does not provide for the safe and effective use of restraints.

Findings include:

1. Review of the medical record for patient #12 revealed the patient was admitted to the facility on [DATE] for a stroke alert. Documentation revealed on 3/02/2012 at 1:00 a.m. a vest restraint was applied to the patient. The clinical justification revealed the patient was attempting to get out of bed without assistance and was unable to safely ambulate. Review of the documentation revealed the vest restraint remained in place until 3/06/2012 at 8:00 a.m.

Review of the physician orders revealed there was no order for the use of the restraint on 3/05 and 3/06/12.

Review of the facility's policy, "Restraint Usage, Implementation, and Monitoring", last approved 8/2010, stated an order must be obtained from the physician immediately after applying the restraint if not obtained prior to application of the restraint.

On 3/07/2012 at 11:50 a.m. an interview with the manager of the stroke unit confirmed the findings.

2. On 3/06/2012 at 2:00 p.m. an interview with the Director of Quality was conducted. The interview revealed roll belts are utilized in the facility. The roll belts are used as reminders for patients to call for assistance when getting out of bed. It was determined that documentation of the patient's ability to release the roll belts was to be demonstrated daily. If the patient was unable to demonstrate the ability to release the roll belt then the roll belt was considered a restraint.

Two records reviewed revealed a roll belt was placed on the patient.

Review of patient #2's medical record revealed the patient was admitted on [DATE]. Documentation revealed the patient sustained an unwitnessed fall on 1/18/2012. Following the fall a roll belt was placed on the patient. Documentation revealed the patient was confused. There was no documentation the patient demonstrated the ability to release the roll belt. Review of the record revealed no order for restraint with a roll belt.

Review of patient #3's medical record revealed the patient was admitted on [DATE] at 4:30 p.m. Documentation revealed the patient was confused upon admission. At 7:30 p.m. documentation revealed the patient was found out of bed and placed in a roll belt. Review of the record revealed no indication for the necessity of the roll belt. There was no documentation the patient demonstrated the ability to release the roll belt.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, staff interview and review of the facility's policy and procedures it was determined the facility failed to ensure the condition of the patient who was restrained was monitored by trained staff every two hours as required by facility policy for one (#12) of thirteen patients sampled. This does not ensure the restraint is discontinued at the earliest possible time.

Findings include:

Review of the medical record for patient #12 revealed the patient was admitted to the facility on [DATE] for a stroke alert. Documentation revealed on 3/02/2012 at 1:00 a.m. a vest restraint was applied to the patient. The clinical justification revealed the patient was attempting to get out of bed without assistance and was unable to safely ambulate. Review of the documentation revealed the vest restraint remained in place until 3/06/2012 at 8:00 a.m.

Review of the facility's policy, "Restraint Usage, Implementation, and Monitoring", last approved 8/2010, stated a patient restrained for non violent behavior will be assessed every two hours. The assessment will include documentation for the need to continue the restraint, the patient's mental status, behavior, skin integrity, circulation, sensory and movement, restraint placement, basic needs, exercise and injuries related to the restraint.

Review of the record revealed on 3/05 and 3/06/12 the patient was not assessed every two hours as required by the facility policy.

An interview on 3/07/2012 at 11:50 a.m. with the manager of the M3 Stroke Unit confirmed the findings.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of quality assessment performance improvement indicators it was determined that the facility failed to set priorities for its performance improvement activities that focused on problem prone areas and that affect health outcomes, patient safety and quality of care related to patient's rights and use of restraints. The facility's failure to implement and set priorities places patients at risk for adverse health outcomes, patient safety and quality of care.

Findings include:

On 3/06/2012 at 2:00 p.m. an interview with the Director of Quality was conducted. The interview revealed roll belts are utilized in the facility. The roll belts are used as reminders for patients to call for assistance when getting out of bed. It was determined that documentation of the patient's ability to release the roll belts was to be demonstrated daily. If the patient was unable to demonstrate the ability to release the roll belt then the roll belt was considered a restraint. The Director of Quality revealed the use of roll belts, utilized as a non restraint, are not tracked. Therefore, there was no data to review to indicate if patients are demonstrating the ability to release the roll belt or if the staff was utilizing the roll belt as a restraint.

Two records reviewed revealed a roll belt was placed on the patient. Review of patient #2's medical record revealed the patient was admitted on [DATE]. Documentation revealed the patient sustained an unwitnessed fall on 1/18/2012. Following the fall a roll belt was placed on the patient. Documentation revealed the patient was confused. There was no documentation the patient demonstrated the ability to release the roll belt. Review of the record revealed no order for restraint with a roll belt and no documentation the patient was monitored and assessed every 2 hours as required by the facility's restraint policy.

Review of patient #3's medical record revealed the patient was admitted on [DATE] at 4:30 p.m. Documentation revealed the patient was confused upon admission. At 7:30 p.m. documentation revealed the patient was found out of bed and placed in a roll belt. Review of the record revealed no indication for the necessity of the roll belt. There was no documentation the patient demonstrated the ability to release the roll belt.

Review of the medical record for patient #12 revealed the patient was admitted to the facility on [DATE]. Documentation revealed on 3/02/2012 at 1:00 a.m. a vest restraint was applied to the patient. The clinical justification revealed the patient was attempting to get out of bed without assistance and was unable to safely ambulate. Review of the documentation revealed the vest restraint remained in place until 3/06/2012 at 8:00 a.m.

Review of the physician orders revealed there was no order for the use of the restraint on 3/05 and 3/06. Review of the record revealed on 3/05 and 3/06 a comprehensive assessment was performed. Review of the record revealed alternatives attempted or the rationale for not using alternatives was not documented. Review of the documentation revealed no assessment to demonstrate a continued need for the restraint.

Data for the use of restraints and compliance in documentation was reviewed for October 2011 through February 2012. The data that was reviewed revealed the facility had poor compliance with obtaining physician order for restraint, face to face evaluations being completed, alternative interventions being attempted, assessments completed and not documenting the reason for restraints. Interview with the Director of Quality on 3/06/2012 at 2:00 p.m. confirmed the findings.
VIOLATION: DOCUMENTATION OF EVALUATIONS Tag No: A0811
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview it was determined the facility failed to ensure the patient's discharge plan was developed and discussed with the patient's designated healthcare representative for one (#1) of thirteen patients sampled. This does not ensure the patient's discharge plan is appropriate and the patient's representative is in agreement with the discharge plan.

Findings include:

Patient #1 was admitted to the facility on [DATE] and discharged on [DATE]. The admitting diagnosis was altered mental status.

Review of the record revealed a form for designation of health care proxy. Review of the form revealed the form designated the patient's spouse as the health care proxy. The form revealed the spouse accepted the responsibility by signature dated 12/09/2011. The form was witnessed on the same date 12/09/2011.

Review of the record revealed a social worker completed a discharge planning assessment for the patient on 1/15/2012 at 4:45 p.m. The social worker noted the patient was admitted with altered mental status and was confused. Documentation revealed the social worker called and spoke with the spouse at the time of the assessment. The spouse informed the social worker that the patient was a long term resident at a local SNF (Skilled Nursing Facility) and that she wanted the patient transferred closer to her home. Documentation revealed the social worker informed the spouse the SNF would have to initiate the process to transfer the patient to another facility closer to home. The SW documented she called and spoke with the liaison at the SNF at the time of the assessment. The liaison stated they would accept the patient back and that they are currently waiting on a bed to transfer the patient to a facility closer to the spouse.

On 1/16/2012 the social worker documented there were no orders for discharge written in spite of the consult. The physician wrote direct orders for the SNF and nursing stated the discharge was pending for tomorrow.

On 1/18/2012 the social worker documented she received a consult for DME (Durable Medical Equipment) and home health services. The social worker faxed the orders and spoke with the home health agency to inform them of a need for a home nebulizer and home health services.

Review of the record revealed the patient was discharged on [DATE] in the care of the patient's mother. Review of the record revealed no documentation the social worker notified the designated health care surrogate of the change in orders to discharge the patient home with home health services. There was no documentation the health care surrogate approved of the discharge plan. The facility failed to ensure the patient's designated health care surrogate was afforded the right to participate in the development and implementation of the discharge plan.

Review of the facility's Patient Rights, as provided to the patient upon admission, stated the patient's advance directives will be honored by the staff, the patient was encouraged to participate in the plan of care and to receive complete information in order to make informed decisions regarding medical treatment. Review of the record revealed the patient was incapacitated upon admission to the facility and a designated health care proxy had been determined as evidenced by the completed form.

Review of the record revealed an addendum to the SW (Social Worker) notes on 1/20/2012. The note at 8:49 a.m. stated the SW received a telephone call from the patient's designated healthcare representative (spouse). The spouse stated she was not notified of the patient's discharge on 1/18/2012. The SW stated she left a message on the spouse's voicemail of the discharge and plan to discharge home with the mother.

Documentation on 1/20/2012 at 11:53 a.m. noted the SW stated the mother informed the SW that she had notified the patient's spouse of the plan to discharge the patient home with the mother. The mother stated the spouse was in agreement with the discharge plan. The SW stated a telephone call was received from the patient's spouse on 1/20/2012 in which the spouse stated the patient's mother did not contact her to inform her of the discharge plans.

The social worker and director of risk management were interviewed on 3/06/2012 at 2:45 p.m. and confirmed the above findings.

The social worker stated she attempted to call the patient's spouse prior to the discharge home with the mother but was unable to provide documentation of any attempts to contact the patient's spouse.