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.

ST JOSEPH REGIONAL MEDICAL CENTER 415 SIXTH STREET LEWISTON, ID 83501 Dec. 9, 2011
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observations, staff and patient interview, and review of hospital policies, grievance documentation, and patient records, it was determined the facility failed to ensure its policies identified Geri-chairs and four side rails raised on hospital beds as potential restraints and a comprehensive grievance process was in place which ensured grievances were identified, thoroughly investigated, and each grievant provided with a written response. The cumulative effect of these negative practices resulted in 1) a systemic failure which allowed patients throughout the hospital to be restrained at staffs' discretion, without physician authorization, and without documentation of the need for, and use of, the restraints; and 2) the failure to identify grievances, document thorough timely resolution, and provide written responses to each grievant. Findings include:

1. Refer to A 118 as it relates to the facility's failure to ensure the process for grievance identification had been thoroughly developed and implemented.

2. Refer to A 123 as it relates to the facility's failure to provide written notice of the resolution of grievances.

3. Refer to A 159 as it relates to the facility's failure to identify uses of Geri-chairs and four side rails raised on a hospital bed as potential restraints.

4. Refer to A 164 as it relates to the facility's failure to ensure restraints were only utilized after a comprehensive assessment and when less restrictive interventions were determined to be ineffective.

5. Refer to A 166 as it relates to the facility's failure to ensure the use of physical restraints was incorporated into patients' plans of care.

6. Refer to A 168 as it relates to the facility's failure to ensure physical restraints were used only as ordered by a physician or other LIP.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on review of complaint information and hospital policies, and staff interview, it was determined the facility failed to ensure the process for grievance identification had been thoroughly developed and implemented. This impacted 6 of 6 sample patients (#11 - #16) whose registered concerns were reviewed. It had the potential to impact all patients/representatives who expressed concerns. Lack of clarity related to the grievance process resulted in the failure to identify issues as grievances and the failure to provide written responses to those grievances. Findings include:

1. The facility failed to establish an adequate definition of a grievance to guide staff in making a determination between complaints and grievances as follows:

The hospital's "Patient/Visitor Complaints or Grievances" policy, last reviewed by the hospital 8/2008, defined a grievance as "a matter that was not resolved promptly by department staff with support staff contacted to assist in resolution of the matter... Grievances may either be submitted verbally or in writing to the Medical Center. (This may include concerns noted from Patient Satisfaction Surveys.)" The policy did not define the time frame intended by "resolved promptly."

The policy also indicated, "Every effort is made to address these matters [concerns, complaints or other expressions of dissatisfaction] promptly by the most appropriate staff. However, there may be times when the matter remains unresolved. At that time, the patient or his/her representative will be reminded of their option to file a grievance with the respective Department Director and/or Patient Affairs/Compliance Director, and have such grievance reviewed and responded to within a reasonable time frame." Reminding a complainant of the option to file a grievance if the matter was not resolved contradicted the policy's definition of a grievance. The policy defined a grievance as a matter that was not resolved promptly by staff, whether or not the patient/representative opted "to file a grievance."

The policy defined the procedure utilized for complaint resolution. According to the policy, "Every effort will be made at the department level to resolve the patient/family/visitor complaint/concern related to services provided by the Medical Center in a timely manner by department staff. Staff may consult Department Directors and/or Patient Affairs Director for assistance with resolving complaints/concerns...If resolution is not achieved, the matter will be referred to the Patient Affairs/Compliance Director for further follow up. The Patient Affairs Director may involve Department Directors and/or members of the Administrative Team to seek resolution, and at this point a determination should be made if the matter will be considered a grievance." Determining if an unresolved matter was to be considered a grievance contradicted the hospital's definition of a grievance.

In addition, according to the policy, the final response to a grievance included "name of the contact person and phone number; steps taken on behalf of the patient to investigate the grievance, the results of the process; and the date of completion. In lieu of a written response, a meeting or phone conversation may be held to discuss the matter if agreed upon by both parties." However, the regulation requires a written response be provided even if other measures (such as meetings) were used to resolve issues.

The definition of a grievance did not clearly guide staff in determining when an issue was to be treated as a complaint and when it would be considered a grievance and handled as such.

The policy did not specify that if a patient care complaint was not resolved by the staff present, was postponed for later resolution, referred to other staff for later resolution, required investigation, and/or required further action for resolution, the complaint would be considered a grievance. The definition of a grievance did not include the information that written complaints were always considered grievances. The policy did not indicate that when a patient or their representative requested to make a "formal complaint," it was to be considered a grievance. The policy did not address complaints regarding allegations of abuse, neglect, or patient harm.

A "Complaint Summary Report," from 1/01/11 to 11/30/11 was reviewed. The report contained basic information, including the date of the occurrence, type of complaint, and the resolution date for 107 patient concerns registered. Excluding the billing complaints, 50 of the concerns listed were documented as resolved between one and sixty days after the date of occurrence, which indicated the issue was not resolved promptly by department staff at the time the complaint was raised. Between the first concern registered on 1/03/11, and the last concern received on 11/15/11, 19 concerns did not have a resolution date listed.

During an interview on 11/30/11 at 10:15 AM, the VP of Patient Care Services stated that she could only recall one patient concern that had risen to the level of a grievance in the several years she had been employed at the facility.

On 12/01/11 at 9:40 AM, the Patient Affairs Assistant was interviewed regarding the facility's grievance process. She stated she had been hired into the position as of 8/01/11. She confirmed that no patient concern had risen to the level of a grievance since she had assumed the role of Patient Affairs Assistant and no letters of resolution had been sent to patients or patients' representatives.

During the interview, she stated patients/representatives often spoke with her (or with the previous Patient Affairs Assistant) in person. She stated the typical procedure was for any patient concern to be referred to the Patient Affairs Assistant for investigation and resolution. She confirmed that occasionally issues could have been resolved by nursing personnel in the department involved, but were routinely referred to Patient Affairs.

On 12/01/11 at 9:40 AM, the Patient Affairs Assistant reviewed documentation of six concerns, related to Patients #11 - 16, listed on the "Complaint Summary Report," from 1/01/11 to 11/30/11. The Patient Affairs Assistant confirmed the documentation for concerns related to Patients #11, #15, and #16 indicated the complaints were resolved one or more days after the date the concerns were registered and were therefore grievances by policy definition. She confirmed the documentation of investigation and resolution information related to Patients #12 - #14 was dated after the date the concern was registered and documented as resolved. She confirmed the additional documentation made it difficult to determine when the complaint was actually resolved. If the complaint was actually resolved days after it was registered it should have been considered a grievance. She confirmed that none of the concerns reviewed for Patients #11 - #16 were treated as grievances, and no one received a written response regarding the steps of the investigation and the results.

The facility failed to ensure the process for grievance identification and resolution had been thoroughly developed and implemented.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on staff interview and review of complaint information and hospital policy, it was determined the hospital failed to provide written notice of the resolution of grievances for 6 of 6 patients (#11 - #16) whose complaint/grievance information was reviewed. This had the potential to result in a lack of clarity for complainants as to the steps taken to resolve the grievances, the resolution of the grievances, and who the complainant could contact for further information or communication. Findings include:

The hospital's "Patient/Visitor Complaints or Grievances" policy, last reviewed by the hospital 8/2008, defined a grievance as "a matter that was not resolved promptly by department staff with support staff contacted to assist in resolution of the matter... Grievances may either be submitted verbally or in writing to the Medical Center. (This may include concerns noted from Patient Satisfaction Surveys.)"

According to the policy, the final response to a grievance included "name of the contact person and phone number; steps taken on behalf of the patient to investigate the grievance, the results of the process; and the date of completion. In lieu of a written response, a meeting or phone conversation may be held to discuss the matter if agreed upon by both parties." However, the regulation requires a written response be provided even if other measures (such as meetings) were used to resolve issues.

A "Complaint Summary Report," from 1/01/11 to 11/30/11 was reviewed. The report contained basic information, including the date of the occurrence, type of complaint, and the resolution date for 107 patient concerns registered. Excluding the billing complaints, 50 of the concerns listed were documented as resolved between one and sixty days after the date of occurrence. This would have indicated the issue was not resolved promptly by department staff at the time the complaint was registered and should have been considered a grievance based on the hospital policy definition. Between the first concern registered on 1/03/11, and the last concern received on 11/15/11, 19 concerns did not have a resolution date listed.

The Patient Affairs Assistant was interviewed on 12/01/11 at 9:40 AM. She stated she assumed her current position on 8/01/11. Samples of the concerns found on the "Complaint Summary Report," from 1/01/11 to 11/30/11, were reviewed with her. She confirmed that none of the complainants received a written notice of response to their concern, even though the complaint was not promptly resolved. She confirmed that in some cases the documentation did not clearly indicated whether or not the issue was resolved promptly, which made it difficult to determine if the concern should have been treated as a grievance. Examples follow:

1. On 12/01/11 at 9:40 AM, the Patient Affairs Assistant reviewed documentation from a concern she had been involved in regarding Patient #16. She stated Patient #16's husband spoke with her in person, on 8/29/11, regarding his concerns of his wife's recent falls on the medical/oncology floor. The Patient Affairs Assistant reviewed her documentation regarding the investigation. She stated she reviewed Patient #16's medical record and discussed Patient #16's course of care with nursing staff and physicians. She stated the resolution of the investigation included the Department Director reviewing all the documentation related to the falls with Patient #16's husband, and physician follow up evaluation. She stated she spoke with Patient #16's husband following the investigation and he was satisfied with the response he received. The Patient Affairs Assistant stated the issue was resolved on 8/31/11. She agreed that the issue was not promptly resolved by department staff at the time of the complaint. She confirmed no written response was provided to the complainant.

The investigation of the complaint took three days to complete and therefore met the definition of a grievance based on the hospital policy. The complainant did not receive a final response with the steps taken to investigate the concern, results of the investigation, contact person's name and number, and the date of completion.

2. Documentation regarding a concern for Patient #15 was reviewed. The first page of the documentation was composed of several items to which the author wrote in a response. It was documented the date occurrence was 1/10/11 and the resolution date was 1/11/11. The location of the occurrence was the billing office/admitting and the resolution type was an "Apology." The author documented a summary of the concern "...STAFF RUDE TO SON REGARDING IDENTIFICATION OF SELF." The author documented the resolution, "DD [Department Director] AWARE AND APOLOGY TO FAMILY IN ADDITION TO ASSIST WITH ACCOUNT." The identity of the author could not be determined in the printed information.

A second page contained a narrative written by the Patient Affairs Assistant on 1/31/11 at 12:10 PM (20 days after the documented resolution date). She documented, "STAFF ARGUED WITH MOM ADN [sic] THAT SHE REALLY WASN'T MOTHER AND WOULD NOT PROVIDE SSN [Social Security Number] INFO [Information]."

A third page contained additional information documented by the Patient Affairs Assistant on 1/31/11 at 12:10 PM. "[Department Director] AWARE WILL F/U [Follow up] WITH STAFF AND PROVIDE EDUCATION.

MOM VERY NICE, [Department Director] F/U WITH HER AS WELL. SHE GOT NEEDED INFO FROM SS [Social Security] OFFICE - UNNECESSARY [sic] EXTRA STEP." It is unclear when the Department Director was notified of, and resolved, the concerns. It was not clear whether this "MOM" referred to was the same individual mentioned on the second page who argued that "SHE REALLY WASN'T MOTHER."

The current Patient Affairs Assistant was interviewed on 12/01/11 at 9:40 AM. She reviewed the above information and stated that it appeared the Department Director was involved with the complainant at the time the event occurred and the Department Director resolved the complaint and provided resolution to the parties involved. However, she confirmed the date of resolution was not the same date as the date of occurrence, and the additional documentation from the Patient Affairs Assistant was much later than the date of resolution. She confirmed the lack of clarity in the documented information related to the timeline and details of the investigation and resolution of the concern. She confirmed this complaint was not treated as a grievance and Patient #15 did not receive a written response.

The facility failed to ensure the complainant received a written response which included the steps of investigation and the result of the grievance process.

3. Documentation regarding a concern for Patient #11 was reviewed. The first page of the documentation was composed of several items to which the author wrote in a response. It was documented the date occurrence was 4/07/11 and the resolution date was 6/15/11. The location of the occurrence was the medical/oncology floor and the resolution type was an "Apology." The author documented a summary of the concern "...ATMOSPHERE OF NOT CARING - NO BATH, DIRTY GOWN/LINES, [sic]." The author documented the resolution, "MET W/ [with] BOTH DAUGHTER&SON [sic], MATTER RESOLVED, APOLOGIZED..."

A second page contained a narrative, "...the overall feeling was that staff were too concerned with the routine that they did not exhibit compassionate care. She states that he laid in a filthy gown/bed, offered no bath.

He was transferred to ICU [Intensive Care Unit] and that is where I met them.

Upon further interview face to face - no c/ [complaint] in ICU and son had none voiced period...

Apologized and offered for her to meet with again [sic] - wanted to hear the story, etc. she has yet to contact us...

She did bring up a concern about d/c [discharge] instructions from OP [out patient] (admitted after a bronch [bronchoscopy]) as she thought it was confusing. Upon review [name] and I noted opportunity to improve and [name] took the matter up for review with her staff..."

The date the narrative was entered and the author of the information could not be determined. It was unclear when the author met with the family or if the family was interviewed more than one time. There was no evidence the concern about care had been investigated or that a resolution had been presented to the family. The concern with the OP discharge instructions was evaluated and processes changed as a result, however it did not appear the complainant received a response regarding the resolution.

The current Patient Affairs Assistant reviewed the above information on 12/01/11 at 9:40 AM. She reviewed the information on her computer and located some additional information to further explain the investigation. She stated the daughter and son spoke with the Patient Affairs Assistant in person. She stated, following that conversation the information was reviewed with the ICU Department Director who in turn spoke with her staff. However, the documentation indicated the concerns were related to the medical/oncology floor, not ICU. The current Patient Affairs Assistant stated that Patient #11's medical record was reviewed by the Department Director (unclear which Department Director) to look for opportunities to improve care. She confirmed that the timeline of conversations with the family and the process of the investigation and resolution were not clearly delineated. She explained that the previous Patient Affairs Assistant was waiting to hear back from the family after Patient #11's full stay at the hospital. She stated the family did not follow up, and therefore, the account was closed. She confirmed the family did not receive a written notice regarding the steps taken to investigate the concerns or the results of the investigation.

The facility failed to ensure the complainant received a written response which included the steps of investigation and the result of the grievance process.

4. Documentation regarding a concern filed by Patient #13 was reviewed. The first page of the documentation was composed of several items to which the author wrote in a response. It was documented the date occurrence was 2/25/11 and the resolution date was 2/24/11 (one day prior to the date of the occurrence.) The location of the occurrence was the radiology department and the resolution type was an "Apology." The author documented a summary of the concern "...STAFF WERE RUDE, ROUGH AND WE'E [sic] HURTING ME,WANTS TO LODGE FORMALCOM [sic]." It appeared as if Patient #13 wished to file a formal complaint, which would be considered a grievance. The author documented the resolution, "TALK TO [name of Department Director], HE REFERRED TO ME, APOLOGIZED, SHE WAS SATISFIED." It was unclear what the author meant by "HE REFERRED TO ME." The identity of the author could not be determined based on the printed information.

A second page of information contained a narrative of the report. It could not be determined who wrote the information, or when the information was gathered or entered into the computer. The author documented, "RUDE AND ROUGH. SHE C/ [complained] SHE WAS HURTING AND IT WAS WORSE WHEN THEY WERE GRABBING HER ARMS AND LEGS AND THE OLD GUY GRABBED HER NECK. JUST THREW ME BACK ON THE BED, GAVE ME A PILLOW AND SENT ME BACK. I ASKED THE ER [emergency room ] NURSE FOR [Radiology Department Director]'S NUMBER. I DID NOT REFUSE I TOLD THEM JUST TO TAKE THE PICTURE. THAT HURTS THAT HURTS. NEVER IN MY LIFE HAVE I HAD TO SCREAM FOR HELP LIKE THAT IN A HOSPITAL. IF THEY DON'T LIKE THEIR JOB THEY SHOULDN'T WORK THERE. I KNOW YOU TRY. I HATE [name of another facility] WON'T GO THERE. I NEEDED PAIN MED. THEY SAID THEY'D GIVE ME SOMETHING IN ER. I HAVE MORE SWELLING IN MY BRAIN NOW, NOT DOING WELL, STILL HURT - LEGS AND RIBS AND STUFF FROM FALLING.

I ASSURED HER THAT [Radiology Department Director] IS AWARE AND THAT HE WILL F/U [follow up] WITH HIS STAFF. I THANKED HER FOR SHARING HER CONCERNS AND SHE THANKED ME FOR CALLING 'SORRY I DIDN'T CALL YOU.' WHEN ASKED IF THERE WAS ANYTHING ELSE I COULD DO FOR HER SHE SAID NO. I TOLD HER THAT WE WANT TO DO WELL AND SERVE OUR PT [patient] WITH RESPECT AND COURTESY AND WE WILL USE HER FEED BACK TO IMPROVE OUR SERVICES."

The date, time, and manner in which the concern was registered was not documented clearly (i.e. did Patient #13 phone the hospital after leaving or was she referred to the Patient Affairs Assistant while still in the facility). It was unclear exactly when Patient #13 was interviewed regarding the details of her treatment by radiology staff. The narrative did not describe the events in an understandable manner, and it was unclear if Patient #13 was suffering pain from a fall that occurred during the rough treatment or if the injuries were sustained prior to receiving care at the hospital. The report did not contain sufficient information to determine a thorough investigation of the grievance had been conducted, i.e., were staff involved interviewed. The report did not contain information regarding the resolution of the investigation or a written notice sent to Patient #13. Because no dates were documented on the second page of the information provided, and the resolution date was unclear, it was difficult to determine when Patient #13's concerns were resolved.

The current Patient Affairs Assistant reviewed the information regarding Patient #13's concern, on 12/01/11 at 9:40 AM. She stated that it appeared the Radiology Department Director deferred to the Patient Affairs Assistant to complete the investigation and provide the resolution to Patient #13. She confirmed it was difficult to accurately determine when the concern was received by the facility and the timeline and details of the investigation and resolution. She confirmed the written narrative was difficult to follow and no written notice was provided to Patient #13.

The facility failed to ensure the complainant received a written response which included the steps of investigation and the result of the grievance process.

5. Documentation regarding a concern for Patient #12 was reviewed. The first page of the documentation was composed of several items to which the author wrote in a response. It was documented the date occurrence was 3/10/11 and the resolution date was 3/10/11. However, additional information was documented on 3/14/11 at 12:37 PM by the Patient Affairs Assistant, making it difficult to determine the actual timeline of the investigation. The location of the occurrence was the surgical/orthopedic floor and the resolution type was an "Apology." The author documented a summary of the concern "...NRS [nurses] WERE MEAN TO WIFE AND UNPROFESSIONAL, HOLDING PAIN MEDS." The author documented the resolution, "APOLOGIZED, ASSURED REVIEW & ACTION WHERE APPROPR [appropriate] DD [Department Director] - SOC [Standard of Care] MET." The identity of the author could not be determined in the printed information.

A second page of information contained a narrative of the report. The Patient Affairs Assistant entered a narrative dated 3/14/11 at 12:37 PM. "SO [significant other] - [name], PLEASANT BUT UPSET. OVERWHELMED WITH SICK SO [significant other] AND YOUNG CHILDREN.

SEEMS THAT NURSES ARE SWEET AS ROSES WHEN HE WAS THERE BUT SO [significant other] WOULD CALL HIM AND TELL THEY WERE MEAN WHEN HE WAS GONE.

PAIN MED ISSUES, [Department Director] WAS AWARE AND REVIEWED AT THE TIME AND MEDICATED ACCORDING TO ORDERS - NOT WITHOLDING. PT [patient] WOULD COME TO DESK OR ANOTHER PT'S ROOM TO ASK FOR MEDS. STAFF AWARE AND WERE TRYING TO ADDRESS HER CONCERNS IN COMPASSIONATE AND CARING MANNER." It was not clear when the complainant was spoken with, if Patient #12 was interviewed, when the Department Director reviewed the record, or if the complainant received a response to the concerns noted. The date of the narrative, 3/14/11, conflicted with the date of resolution of 3/10/11.

The current Patient Affairs Assistant reviewed the information regarding the above concern on 12/01/11 at 9:40 AM. She stated it did not appear that Patient #12 was interviewed and it could not be determined that the complainant actually received a response. She confirmed this was not treated as a grievance and no written response was provided to Patient #12.

The facility failed to ensure the complainant received a written response which included the steps of investigation and the result of the grievance process.

6. Documentation regarding a concern for Patient #14 was reviewed. The first page of the documentation was composed of several items to which the author wrote in a response. It was documented the date of occurrence was 2/14/11 and the resolution date was 2/14/11. However, additional information was documented on 2/18/11 at 10:43 AM by the Patient Affairs Assistant, making it difficult to determine the actual timeline of the investigation. The location of the occurrence was the medical/oncology floor and the resolution type was an "Apology." The author documented a summary of the concern "...UPSET RE: [regarding] COMMUNICATION W/ [with] NURSES - MOM'S CONDITION WORSE THAN IS." It was not clear what the miscommunication between the family and nursing staff was. The author documented the resolution, "F/U WITH STAFF, MD [Medical Doctor] SPOKE WITH FAMILY, CALL BACK, NO FURTHER CONCERN." It was not clear what was meant by "CALL BACK." It could have meant the facility contacted the family involved, but the individual who made the call was not noted. The documentation did not indicate what "F/U WITH STAFF" involved. The identity of the author could not be determined in the printed information.

A second page contained a narrative written by the Patient Affairs Assistant on 2/18/11 at 10:43 AM. "NURSE GOT CONFUSED RE PT SHE WAS TALING [sic] ABOUT - COMFORT CARE - FREAKED DAUGHTER OUT [sic]

THEN PT CONFUSED AND NR [nurse] SAID WOULD MOST LIKELY DO CT [Computerized Topography] IF NOT CLEARED AND DAUGHTER ASSUMED THAT MEANT CA [cancer] IN BRAIN...[sic]

WORKED IT OUT...[sic]"

The events surrounding the concern were not clearly documented. It was not clear when nursing staff were spoken to or exactly how the concern was investigated or resolved. The Patient Affairs Assistant documented information on 2/18/11, so it was not clear when the concern was resolved. The results of the investigation were not noted.

The current Patient Affairs Assistant reviewed the above information on 12/01/11 at 9:40 AM. She stated the previous Patient Affairs Assistant contacted Patient #14's physician and asked the physician to clarify the medical issues concerning Patient #14. She stated the Patient Affairs Assistant also spoke with nursing staff to clarify the issues related to the miscommunication. She stated it was unclear what the timeline of the investigation and resolution of the complaint was based on the documentation. She confirmed this was not treated as a grievance and no written response was provided to Patient #14.

The facility failed to provide written notice regarding the resolution of the grievance.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0159
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff and patient interviews, observation, and review of medical records and hospital policies, it was determined the hospital failed to identify uses of Geri-chairs and four side rails raised on a hospital bed as potential restraints. This directly impacted 2 of 5 current patients (#2 and #8) who were observed in Geri-chairs, and 2 of 5 current patients (#1 and #2) who were known to have four side rails raised on their beds. This resulted in a systemic failure which allowed patients throughout the hospital to be restrained at staffs' discretion, without physician authorization, and without documentation of the need for, and use of, the restraints. Findings include:

The hospital had 145 beds and 4 floors. Patient care areas were on floors 3 and 4. The use of Geri-chairs and four side rails up on beds as restraints, was identified on 2 of the 4 adult units (the Medical/Oncology Department and Surgical/Orthopedic Department) and confirmed to be used hospital-wide at staffs' discretion. The policies related to Geri-chairs, and the use of four side rails on hospital beds, were as follows:

1. The "RESTRAINTS" policy, revised 3/01/11, was reviewed. The policy defined a physical restraint as "Any manual method or physical or mechanical device that immobilized or reduces the ability to move his/her body, head, or limbs." The policy contained a section, "EXEMPTIONS FROM THE REQUIREMENTS IN THIS POLICY." Geri-chairs and top bed rails were among the devices listed as being exempt from the classification of restraints. The use of the Geri-chair and other devices were identified in the policy as "Protective devices used to support/sustain the delivery of care and/or ADL.." It additionally stated "Need for these devices will be based on an assessment of the patient."

The facility had a policy, "RESTRAINTS: Geri-chairs, Therapeutic Use," last reviewed by the hospital on [DATE]. According to this policy, "Use of geriatric chairs provides a safe method of meeting care needs for patients which may eliminate the need for restraint." The policy indicated Geri-chairs could be used for the following purposes:

- "For motor activities. Should be used in conjunction with supplies or activities for hand use.
- "For calming effect. Allows patient to be closer to other people. Provides a different environment which may help calm the patient. Provides a different interaction level, can talk while sitting rather than lying in bed."
- "For re-orientation. To place patient in a social situation with familiar surroundings."
- "For socialization. To allow more opportunities to talk with other patients, visitors, nurses, secretaries, etc."
- "For mental stimulation. To allow for more contact with other people. To encourage reading, puzzles, contact with the environment. To make patients more aware of day/night, time, etc."
- "For a change of environment from their room. To allow the patient to change environment from a single room to a group room, nearer to activity areas, etc."

In addition, the policy indicated documentation accompanying use of the Geri-chair was to identify the patient's need for the chair in conjunction with at least one of the following seven a nursing diagnosis: Fear, Diversional Activity Deficit, Anxiety, Impaired Thought Processes, Ineffective Individual Coping, Social Isolation, and Altered Thought Processes. A plan of care was to address the identified diagnosis(es). The policy did not state that Geri-chairs needed to be easy for the patient to get out of to ensure they were not restraints. The policy did not state that a physician's or LIP's order for restraints would be required if a patient was not able to easily remove the tray and exit the chair on his/her own.

The policy did not guide staff in assessing patients to determine if the Geri-chair could be appropriately used to meet the therapeutic needs of patients. The policy did not indicate what monitoring protocols, such as for toileting, repositioning, attending to personal needs, were to be put into place once a patient was seated in the Geri-chair and could not get out. In addition, the policy did not outline the documentation required in the medical record to support the use of the Geri-chair as restraint.

Geri-chairs were used by staff as follows:

a. Patient #2 was a [AGE] year old male, admitted to the Medical/Oncology department on 11/28/11, with a diagnosis of [DIAGNOSES REDACTED]#2 was alert and oriented. It also indicated he ambulated independently. An 11/29/11 Psychosocial Assessment documented Patient #2 was confused and did not want to stay in bed. A physician progress note, dated 11/30/11 at 8:00 AM, indicated Patient #2 was still very weak and unsteady on his feet.

On 12/01/11 at 10:45 AM, Patient #2 was observed sitting in a Geri-chair in the doorway to his room. Upon initiation of a conversation with Patient #2, he requested a hacksaw. When he was questioned why he needed a hacksaw, he stated "I need a hacksaw to get out of this chair; two nurses were not able to take off this table." (He indicated the tray connected to the Geri-chair).

A review of Patient #2's record with the Department Director of the Medical/Surgical Units was completed on 12/01/11 at 8:45 AM. She confirmed the record did not document an assessment for the need of a Geri-chair, there were no physician's orders, and no modifications to his plan of care to include Geri-chair use. In a subsequent interview on 12/01/11 at 10:45 AM, she stated the Geri-chair was used for patient safety, and not considered to be a restraint.

b. Patient #8 was a [AGE] year old female, admitted to the Medical/Oncology department on 11/29/11, with a diagnosis of [DIAGNOSES REDACTED]#8 had mild dementia and was very forgetful and impulsive. It also stated she had poor balance and weakness and listed a front wheeled walker and gait belt as assistive devices. The assessment further stated she could be up with the assistance of one person. Her 11/29/11 physician admission orders indicated under "Activity" that she was to be up with assistance only.

On 11/30/11 beginning at 3:10 PM, Patient #8 was observed sitting in a Geri-chair with the tray secured. Patient #8's Geri-chair was situated close to the nursing station. Patient #8 was observed for approximately 30 minutes while this surveyor reviewed her medical record with the Department Director of the Medical/Surgical Units. During that time Patient #8 called out to staff members, "Please help me, please help me get out," and reached out with her hands to try and grab staff when they walked close to her. During the observation time, there were three hospital staff members at the desk area, and two in the hallway area. No one was observed to address Patient #8 or her concerns.

A review of Patient #8's record with the Department Director of the Medical/Surgical Units was completed on 12/01/11 at 8:30 AM. She confirmed the record did not document an assessment for the need of a Geri-chair, there were no physician's orders, and no modifications to her plan of care to include Geri-chair restraint use.

c. A CNA in the Medical/Oncology department was interviewed on 12/01/11 at 2:40 PM. She stated Geri-chairs were used frequently for patients who were at risk for a fall or who were confused.

A Medical/Oncology department RN was interviewed on 12/01/11 at 2:45 PM. She stated more than 50% of patients in the department were at risk for falls. She stated Geri-chairs were used to prevent falls. The RN was asked if she would consider the Geri-chair a restraint and she stated, "I probably would, but not really, it is for patient safety."

A Surgical/Orthopedic RN was interviewed on 12/02/11 at 8:30 AM. She stated staff used Geri-chairs with the tray "a lot" for confused patients so that they do not get up on their own and get hurt. She stated some patients fall out of regular wheelchairs and therefore are placed in a Geri-chair. She also stated that after spinal surgeries patients may be placed in them to help maintain appropriate positioning.

On 12/02/11 at 9:45 AM, the Department Director of the Medical/Surgical Units confirmed that confused patients were often placed in Geri-chairs. However, she explained the patients were always placed in the direct line of sight of nursing staff. She stated that patients could not easily get out of a Geri-chair themselves but required the assistance of staff. She stated this was the reason patients in Geri-chairs were always visible to staff. The VP of Patient Care Services, present during the interview on 12/02/11 at 9:45 AM, stated for confused patients the tray was set up with tissues, water, and perhaps something to occupy the patient's attention. She stated utilizing the Geri-chairs encouraged socialization and stimulation for patients. Both individuals stated that the facility did not consider the use of Geri-chairs to be a restraint based on the manner in which they are used.

On 12/07/11 at 2:35 PM, the VP of Patient Care Services was interviewed. She explained that since the change to the electronic medical record staff were not prompted to document, and stated that she did not believe staff had been instructed to document an assessment and reason for the therapeutic use of the Geri-chair. She confirmed that staff often did not differentiate in their documentation when a patient was in a Geri-chair or other type of chair. She stated it was routine for staff to complete rounding on each patient on an hourly basis to assess for pain, positioning, personal, and toileting needs. She stated this was routinely documented in the medical record.

Geri-chairs were used for patients as restraints.

2. The "RESTRAINTS" policy, revised 3/01/11, was reviewed. The policy defined a physical restraint as "Any manual method or physical or mechanical device that immobilized or reduces the ability to move his/her body, head, or limbs." The policy did not address the use of four side rails as either a restraint, or being exempt from the requirements of the policy. When side rails prevent a patient from voluntarily getting out of bed, they are, by definition, a restraint.
Four side rails were used for patients as follows:

a. Patient #2 was a [AGE] year old male, admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]#2 was alert and oriented. It also indicated he ambulated independently. An 11/29/11 Psychosocial Assessment documented Patient #2 was confused and did not want to stay in bed. A physician progress note, dated 11/30/11 at 8:00 AM, indicated Patient #2 was still very weak and unsteady on his feet.

The Charge Nurse in the Medical/Oncology department was interviewed on 11/30/11 at 3:00 PM. She explained that Patient #2 became increasingly confused during his first night in the hospital and fall prevention measures were implemented around midnight on 11/28/11. The Charge Nurse stated measures for fall prevention included posting a sign outside of Patient #2's room, keeping the room free of clutter, activation of the bed alarm, wearing rubber-soled socks, and placing all four side rails up when Patient #2 was in bed.

Patient #2's medical record contained "Safety Precautions" documentation which indicated Patient #2 was on "Fall Precautions" with four side rails raised on his bed at the following times:

- 11/29/11 at 12:00 AM, 8:00 AM, and 5:00 PM. An RN documented that Patient #2 had a fall at 4:30 PM and the "FALL PROTICAL [sic]" was instituted. In addition, nursing notes documented Patient #2 had an unwitnessed fall on 11/29/11 at 4:30 PM. The record entry stated Patient #2 had slipped when he was getting out of bed, and was found on the floor towards the foot of the bed.
-11/30/11 at 1:00 AM, 8:00 AM, and 4:00 PM.
-12/01/11 at 12:30 AM, 8:00 AM, 4:00 PM, and 11:44 PM. At 4:00 PM, the RN documented that Patient #2 was "SOMETIMES CONFUSED AND IMPULSIVE."

In an interview on 11/30/11 at 3:30 PM, the RN in the Medical/Oncology department who cared for Patient #2 at the time of his fall, stated she had been called to the room after the fall. The RN stated all four side rails had been up on Patient #2's bed, and she did not know how he scooted to the foot of the bed.

In an interview with Patient #2 on 12/01/11 at 3:50 PM, he stated he had to go to the bathroom, and had been trying to get out of bed when he fell . Patient #2 stated he was not sure if he had requested assistance before attempting to get out of bed.

A CNA in the Medical/Oncology department was interviewed on 12/01/11 at 2:40 PM. She stated patients determined to be at risk for falls would have four side rails up.

A Medical/Oncology department RN was interviewed on 12/01/11 at 2:45 PM. She stated more than 50% of patients in the Medical/Oncology department were at risk for falls. She stated four side rails were used to prevent falls. The RN was asked if she would consider bed rails a restraint and she stated, "I probably would, but not really, it is for patient safety."






b. Patient #1 was a [AGE] year old female admitted on [DATE] for repair of an incarcerated ventral hernia. According to the website freemd.com, last updated 8/19/10, a ventral hernia is a piece of intestine that protrudes through an abnormal opening in the abdominal wall. In a person with an incarcerated hernia, the intestine has become stuck in the abnormal opening. When this happens, the blood supply to the intestine is reduced, and the intestinal tissue starts to die. Patient #1's medical record contained documentation related to "Safety Precautions." On 11/27/11 at 4:03 PM, and on 11/28/11 at 12:00 AM, 12:46 PM, and 5:11 PM, nursing staff documented Patient #1 was on fall precautions and hourly rounding, and had four side rails raised on her bed for safety. Subsequent documentation indicated Patient #1 remained on fall precautions but had only two bed rails raised. On 11/30/11 at 1:33 PM, nursing documentation indicated that Patient #1 had a steady gait and had ambulated independently multiple times. The RN documented that Patient #1 was no longer a fall risk.

An RN documented, on 12/01/11 at 5:49 AM, that Patient #1 fell out of bed and hit the right side of her head, which was tender to the touch. The RN indicated Patient #1 complained of left knee pain and sustained a scratch on the knee. The RN then documented, "ROOM LIGHTS ON, ALL FOUR BED RAILS UP POST FALL PROTOCOL SET."

The "POST FALL PROTOCOL," dated 7/2006, was reviewed. The protocol did not include direction to staff to raise four side rails for safety after a patient fall.

The "FALL GUIDELINES, High Risk" policy, last revised by the hospital 3/16/11, was reviewed. The policy contained a section related to "Post fall protocol..." According to the policy, numerous assessments would be completed immediately after the fall and in the following 48 hours. The patient's fall risk was to be re-evaluated as well as the appropriateness of interventions. The care plan was to be updated as needed. The policy did not include direction for the staff to raise all four side rails on the bed.

In an interview with the Department Director of the Medical/Surgical Units, on 11/30/11 at 4:10 PM, she stated a component of fall prevention is to have the bed's four side rails up. She stated orders to raise four side rails were not obtained, and the use of four raised rails was for "patient safety."

An RN working in the Surgical/Orthopedic department was interviewed on 12/02/11 at 8:30 AM. She stated all four side rails would be raised on a patient who was confused or after a patient had a fall. She stated she had patients attempt to climb over or through the rails. She stated it could be considered a restraint but that it was either raise all four rails or risk the patient falling out of bed.

On 12/02/11 at 9:45 AM, the VP of Patient Care Services and the Department Director of the Medical/Surgical Units were interviewed jointly. The VP of Patient Care Services stated that the specific bed chosen by the hospital was designed to allow all four rails to be up without being considered a restraint. She stated the hospital thoroughly researched this aspect of the bed before deciding to purchase.

On 12/07/11 at 2:35 PM, the VP of Patient Care Services explained when all four rails of the bed are raised, there is an exit space between the top and bottom rails. She stated because the facility did not view the use of four side rails as a restraint they were used at the staff's discretion for a variety of patient needs.

However, on 12/08/11 at 5:18 PM, the VP of Patient Care Services provided photographs of staff exiting the bed. The exit space was noted to be toward the foot of the bed, not between the top and bottom rails as previously discussed.

The facility failed to identify Geri-chairs and four side rails on a hospital bed as potential restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff and patient interviews, observation, and review of medical records and hospital policies, it was determined the facility failed to ensure restraints were only utilized after a comprehensive assessment and when less restrictive interventions were determined to be ineffective. This directly impacted 2 of 5 current patients (#2 and #8) who were observed in Geri-chairs and 2 of 5 current patients (#1 and #2) who were known to have four side rails raised on their beds. This resulted in patients being restrained without an assessment to determine if the use of the restraint outweighed the risk of not using the restraint. Findings include:

1. Patient #2 was a [AGE] year old male, admitted to the Medical/Oncology department on 11/28/11, with a diagnosis of [DIAGNOSES REDACTED]#2 was alert and oriented. It also indicated he ambulated independently. An 11/29/11 Psychosocial Assessment documented Patient #2 was confused and did not want to stay in bed. A physician progress note, dated 11/30/11 at 8:00 AM, indicated Patient #2 was still very weak and unsteady on his feet. Patient #2 was physically restrained without a comprehensive assessment to determine if less restrictive interventions would suffice. Examples include:

a. During an observation on 12/01/11 at 10:45 AM, Patient #2 was noted to be sitting in a Geri-chair in the doorway to his room. Upon initiation of a conversation with Patient #2, he requested a hacksaw. When he was questioned why he needed a hacksaw, he stated "I need a hacksaw to get out of this chair; two nurses were not able to take off this table." (He indicated the tray connected to the Geri-chair).

Patient #2's medical record was reviewed. It did not contain documentation of an assessment of Patient #2 prior to use of the Geri-chair to determine the rationale for use of the Geri-chair as opposed to the less restrictive interventions.

On 12/02/11 at 9:45 AM, the Department Director of the Medical/Surgical Units confirmed that confused patients were often placed in Geri-chairs. However, she explained the patients were always placed in the direct line of sight of nursing staff. She stated that patients could not easily get out of a Geri-chair themselves but required the assistance of staff. She stated this was the reason patients in Geri-chairs were always visible to staff.

On 12/07/11 at 2:35 PM, the VP of Patient Care Services was interviewed. She explained that since the change to the electronic medical record staff were not prompted, and she did not believe staff had been instructed, to document an assessment and reason for the use of the Geri-chair. She confirmed that staff often did not differentiate in their documentation when a patient was in a Geri-chair or other type of chair.

Patient #2's medical record did not contain documentation of a comprehensive assessment to support the use of the Geri-chair restraint.

b. Patient #2's medical record contained "Safety Precautions" documentation which indicated Patient #2 was on "Fall Precautions" with four side rails raised on his bed at the following times:

-11/29/11 at 12:00 AM, 8:00 AM, and 5:00 PM. An RN documented that Patient #2 had a fall at 4:30 PM and the "FALL PROTICAL [sic]" was instituted. The nursing notes documented the fall was unwitnessed. The record entry stated Patient #2 had slipped when he was getting out of bed and was found on the floor towards the foot of the bed.
-11/30/11 at 1:00 AM, 8:00 AM, and 4:00 PM.
-12/01/11 at 12:30 AM, 8:00 AM, 4:00 PM, and 11:44 PM. At 4:00 PM, the RN documented that Patient #2 was "SOMETIMES CONFUSED AND IMPULSIVE."

The Charge Nurse in the Medical/Oncology department was interviewed on 11/30/11 at 3:00 PM. She explained that Patient #2 became increasingly confused during his first night in the hospital and fall prevention measures were implemented around midnight on 11/28/11. The Charge Nurse stated measures for fall prevention included posting a sign outside of Patient #2's room, keeping the room free of clutter, activation of the bed alarm, wearing rubber-soled socks, and placing all four side rails up when Patient #2 was in bed.

Patient #2 was interviewed on 12/01/11 at 3:50 PM. He stated he had to go to the bathroom and had been trying to get out of bed when he fell . Patient #2 stated he was not sure if he had requested assistance before attempting to get out of bed.

The RN in the Medical/Oncology department who cared for Patient #2 at the time of the fall was interview on 11/30/11 at 3:30 PM. She stated she had been called to the room after the fall. The RN stated all four side rails had been up on Patient #2's bed and she did not know how he scooted to the foot of the bed.

Patient #2's record was reviewed. It did not contain a comprehensive assessment to determine if the use of four side rails up on his bed outweighed the risk of not having all four side rails up.

The VP of Patient Care Services was interviewed on 12/07/11 at 2:35 PM. She explained that the bed used by the hospital was specifically designed to not be considered a restraint when all four rails were in use. She stated, as a result of this, four bed rails were used for a variety of reasons, not just for patient safety. She confirmed that there was no particular assessment completed prior to implementing the use of four side rails and they were used at the staff's discretion.

A Geri-chair with a tray attached and a bed with all four side rails raised were used for Patient #2 without comprehensive assessments to determine the appropriateness of their use.

2. Patient #8 was a [AGE] year old female, admitted to the Medical/Oncology department on 11/29/11, with a diagnosis of [DIAGNOSES REDACTED]#8 had mild dementia and was very forgetful and impulsive. It also stated she had poor balance and weakness and listed a front wheeled walker and gait belt as assistive devices. The assessment further stated she could be up with the assistance of one person. Her 11/29/11 physician admission orders indicated under "Activity" that she was to be up with assistance only.

During an observation on 11/30/11 beginning at 3:10 PM, Patient #8 was observed sitting in a Geri-chair with the tray secured. Patient #8's Geri-chair was situated close to the nursing station. Patient #8 was observed for approximately 30 minutes while this surveyor reviewed medical records with the Department Director of the Medical/Surgical Units. During that time Patient #8 called out to staff members "Please help me, please help me get out," and reached out with her hands to try to grab staff when they walked close to her. During the observation time, there were three hospital staff members at the desk area, and two in the hallway area. No one was observed to address Patient #8 or her concerns.

Patient #8's medical record was reviewed. It did not contain documentation of an assessment of Patient #8 prior to use of the Geri-chair to determine the rationale for use of the Geri-chair as opposed to the less restrictive alternatives.

A review of Patient #8's record with the Department Director of the Medical/Surgical Units was completed on 12/01/11 at 8:30 AM. She confirmed the record did not document an assessment for the need of a Geri-chair.

On 12/02/11 at 9:45 AM, the Department Director of the Medical/Surgical Units confirmed that confused patients were often placed in Geri-chairs. However, she explained the patients were always placed in the direct line of sight of nursing staff. She stated that patients could not easily get out of a Geri-chair themselves but required the assistance of staff. She stated this was the reason patients in Geri-chairs were always visible to staff.

On 12/07/11 at 2:35 PM, the VP of Patient Care Services was interviewed. She explained that since the change to the electronic medical record staff were not prompted, and she did not believe staff had been instructed, to document an assessment and reason for the use of the Geri-chair. She confirmed that staff often did not differentiate in their documentation when a patient was in a Geri-chair or other type of chair.

Patient #8's medical record did not contain documentation of a comprehensive assessment to support the use of the Geri-chair restraint.

3. Patient #1 was a [AGE] year old female admitted on [DATE], for repair of an incarcerated ventral hernia. According to the website freemd.com, last updated 8/19/10, a ventral hernia is a piece of intestine that protrudes through an abnormal opening in the abdominal wall. In a person with an incarcerated hernia, the intestine has become stuck in the abnormal opening. When this happens, the blood supply to the intestine is reduced, and the intestinal tissue starts to die. Patient #1's medical record contained documentation related to "Safety Precautions." On 11/27/11 at 4:03 PM, and on 11/28/11 at 12:00 AM, 12:46 PM, and 5:11 PM, nursing staff documented Patient #1 was on fall precautions and hourly rounding, and had four side rails raised on her bed for safety. Subsequent documentation indicated Patient #1 remained on fall precautions but had only two bed rails raised. On 11/30/11 at 1:33 PM, nursing documentation indicated that Patient #1 had a steady gait and had ambulated independently multiple times. The RN documented that Patient #1 was no longer a fall risk.

An RN documented, on 12/01/11 at 5:49 AM, that Patient #1 fell out of bed and hit the right side of her head, which was tender to the touch. The RN indicated Patient #1 complained of left knee pain and sustained a scratch on the knee. The RN then documented, "ROOM LIGHTS ON, ALL FOUR BED RAILS UP POST FALL PROTOCOL SET."

The "POST FALL PROTOCOL," dated 7/2006, was reviewed. The protocol did not include direction to staff to raise four side rails for safety after a patient fall.

The "FALL GUIDELINES, High Risk" policy, revised 3/16/11, was reviewed. The policy contained a section related to "Post fall protocol..." According to the policy, numerous assessments would be completed immediately after the fall and in the following 48 hours. The patient's fall risk was to be re-evaluated as well as the appropriateness of interventions. The care plan was to be updated as needed. The policy did not include direction for the staff to raise all four side rails on the bed.

Patient #1's record was reviewed. It did not include an assessment of Patient #1 to determine the reason for the fall and the risks and benefits of having all four side rails raised versus less restrictive alternatives.

The VP of Patient Care Services was interviewed on 12/07/11 at 2:35 PM. She explained that the bed used by the hospital was specifically designed to not be considered a restraint when all four rails were in use. She stated, as a result of this, four bed rails were used for a variety of reasons, not just for patient safety. She confirmed that there was no particular assessment completed prior to implementing the use of four side rails and they were used at the staff's discretion.

Assessments of Patient #1 were not completed prior to having four side rails raised on her bed for fall prevention.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff and patient interviews, observation, and review of medical records and hospital policies, it was determined the facility failed to ensure the use of physical restraints was incorporated into patients' plans of care. This directly impacted 2 of 5 current patients (#2 and #8) who were observed in Geri-chairs and 2 of 5 current patients (#1 and #2) who were known to have four side rails raised on their beds. This resulted in patients being restrained without clear and consistent guidance to staff regarding the use of the restraints. Findings include:

1. Patient #2 was a [AGE] year old male, admitted to the Medical/Oncology department on 11/28/11, with a diagnosis of [DIAGNOSES REDACTED]#2 was alert and oriented. It also indicated he ambulated independently. An 11/29/11 Psychosocial Assessment documented Patient #2 was confused and did not want to stay in bed. A physician progress note, dated 11/30/11 at 8:00 AM, indicated Patient #2 was still very weak and unsteady on his feet. Patient #2 was physically restrained without the use of the restraints incorporated into his plan of care. Examples include:

a. During an observation on 12/01/11 at 10:45 AM, Patient #2 was noted to be sitting in a Geri-chair in the doorway to his room. Upon initiation of a conversation with Patient #2, he requested a hacksaw. When he was questioned why he needed a hacksaw, he stated "I need a hacksaw to get out of this chair; two nurses were not able to take off this table." (He indicated the tray connected to the Geri-chair).

Patient #2's plan of care was reviewed. The use of the Geri-chair was not included in his plan of care. The Department Director of the Medical and Surgical units reviewed Patient #2's medical record on 12/01/11 at 9:30 AM, and confirmed there was no modification to the POC for the use of a Geri-chair.

The facility did not modify Patient #2's POC to include the use of the Geri-chair restraint.

b. Patient #2's medical record contained "Safety Precautions" documentation which indicated Patient #2 was on "Fall Precautions" with four side rails raised on his bed at the following times:

-11/29/11 at 12:00 AM, 8:00 AM, and 5:00 PM. An RN documented that Patient #2 had a fall at 4:30 PM and the "FALL PROTICAL [sic]" was instituted. The nursing notes documented the fall was unwitnessed. The record entry stated Patient #2 had slipped when he was getting out of bed and was found on the floor towards the foot of the bed.
-11/30/11 at 1:00 AM, 8:00 AM, and 4:00 PM.
-12/01/11 at 12:30 AM, 8:00 AM, 4:00 PM, and 11:44 PM. At 4:00 PM, the RN documented that Patient #2 was "SOMETIMES CONFUSED AND IMPULSIVE."

The Charge Nurse in the Medical/Oncology department was interviewed on 11/30/11 at 3:00 PM. She explained that Patient #2 became increasingly confused during his first night in the hospital and fall prevention measures were implemented around midnight on 11/28/11. The Charge Nurse stated measures for fall prevention included posting a sign outside of Patient #2's room, keeping the room free of clutter, activation of the bed alarm, wearing rubber-soled socks, and placing all four side rails up when Patient #2 was in bed.

Patient #2 was interviewed on 12/01/11 at 3:50 PM. He stated he had to go to the bathroom and had been trying to get out of bed when he fell . Patient #2 stated he was not sure if he had requested assistance before attempting to get out of bed.

The RN in the Medical/Oncology department who cared for Patient #2 at the time of the fall was interview on 11/30/11 at 3:30 PM. She stated she had been called to the room after the fall. The RN stated all four side rails had been up on Patient #2's bed and she did not know how he scooted to the foot of the bed.

Patient #2's record was reviewed. The use of the four side rails on Patient #2's bed was not included on his plan of care.

In an interview on 11/29/11 at 3:30 PM, a Clinical Care Coordinator in the Medical/Oncology department reviewed Patient #2's record and confirmed the POC did not address the use of all four side rails.

The facility did not modify Patient #2's POC to include the use of the four side rails restraint.

2. Patient #8 was a [AGE] year old female, admitted to the Medical/Oncology department on 11/29/11, with a diagnosis of [DIAGNOSES REDACTED]#8 had mild dementia and was very forgetful and impulsive. It also stated she had poor balance and weakness and listed a front wheeled walker and gait belt as assistive devices. The assessment further stated she could be up with the assistance of one person. Her 11/29/11 physician admission orders indicated under "Activity" that she was to be up with assistance only.

During an observation on 11/30/11 beginning at 3:10 PM, Patient #8 was observed sitting in a Geri-chair with the tray secured. Patient #8's Geri-chair was situated close to the nursing station. Patient #8 was observed for approximately 30 minutes while this surveyor reviewed medical records with the Department Director of the Medical/Surgical Units. During that time Patient #8 called out to staff members "Please help me, please help me get out," and reached out with her hands to try to grab staff when they walked close to her. During the observation time, there were three hospital staff members at the desk area, and two in the hallway area. No one was observed to address Patient #8 or her concerns.

A review of Patient #8's record with the Department Director of the Medical/Surgical Units was completed on 12/01/11 at 8:30 AM. She confirmed the record did not show modifications to Patient #8's plan of care to include Geri-chair use.

The facility did not modify Patient #8's POC to include the use of the Geri-chair restraint.

3. Patient #1 was a [AGE] year old female admitted on [DATE], for repair of an incarcerated ventral hernia. According to the website freemd.com, last updated 8/19/10; a ventral hernia is a piece of intestine that protrudes through an abnormal opening in the abdominal wall. In a person with an incarcerated hernia, the intestine has become stuck in the abnormal opening. When this happens, the blood supply to the intestine is reduced, and the intestinal tissue starts to die.

Patient #1's medical record contained documentation related to "Safety Precautions." On 11/27/11 at 4:03 PM, and on 11/28/11 at 12:00 AM, 12:46 PM, and 5:11 PM, nursing staff documented Patient #1 was on fall precautions and hourly rounding, and had four side rails raised on her bed for safety. Subsequent documentation indicated Patient #1 remained on fall precautions but had only two bed rails raised. On 11/30/11 at 1:33 PM, nursing documentation indicated that Patient #1 had a steady gait and had ambulated independently multiple times. The RN documented that Patient #1 was no longer a fall risk.

An RN documented, on 12/01/11 at 5:49 AM, that Patient #1 fell out of bed and hit the right side of her head, which was tender to the touch. The RN indicated Patient #1 complained of left knee pain and sustained a scratch on the knee. The RN then documented, "ROOM LIGHTS ON, ALL FOUR BED RAILS UP POST FALL PROTOCOL SET."

The "FALL GUIDELINES, High Risk" policy, revised 3/16/11, was reviewed. The policy contained a section related to "Post fall protocol..." According to the policy, numerous assessments would be completed immediately after the fall and in the following 48 hours. The patient's fall risk was to be re-evaluated as well as the appropriateness of interventions. The care plan was to be updated as needed. The policy did not include the use of four side rails.

An RN in the Surgical/Orthopedic department reviewed Patient #1's record. She confirmed that the use of four side rails was not documented in the medical record following the fall, and was not on the POC.

The facility failed to ensure hospital staff had incorporated the use of the four side rails restraint into Patient #1's plan of care after her surgery and after her fall.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff and patient interviews, observation, and review of medical records and hospital policies, it was determined the facility failed to ensure physical restraints were used only as ordered by a physician or other LIP. This directly impacted 2 of 5 current patients (#2 and #8) who were observed in Geri-chairs and 2 of 5 current patients (#1 and #2) who were known to have four side rails raised on their beds. This resulted in patients being restrained at staffs' discretion. Findings include:

1. Patient #2 was a [AGE] year old male, admitted to the Medical/Oncology department on 11/28/11, with a diagnosis of [DIAGNOSES REDACTED]#2 was alert and oriented. It also indicated he ambulated independently. An 11/29/11 Psychosocial Assessment documented Patient #2 was confused and did not want to stay in bed. A physician progress note, dated 11/30/11 at 8:00 AM, indicated Patient #2 was still very weak and unsteady on his feet. Patient #2 was physically restrained without physician authorization. Examples include:

a. During an observation on 12/01/11 at 10:45 AM, Patient #2 was noted to be sitting in a Geri-chair in the doorway to his room. Upon initiation of a conversation with Patient #2, he requested a hacksaw. When he was questioned why he needed a hacksaw, he stated "I need a hacksaw to get out of this chair; two nurses were not able to take off this table." (He indicated the tray connected to the Geri-chair).

Patient #2's medical record was reviewed. A physician order for the use of the Geri-chair was not found in the record. In an interview on 12/01/11 at 10:45 AM, the Department Director of the Medical/Surgical Units stated Patient #2 did not have orders for a restraint or for placement in a Geri-chair, as the chairs were for patient safety and not considered a restraint.

Patient #2 was restrained in a Geri-chair without a physician order to do so.

b. Patient #2's medical record contained "Safety Precautions" documentation which indicated Patient #2 was on "Fall Precautions" with four side rails raised on his bed at the following times:

-11/29/11 at 12:00 AM, 8:00 AM, and 5:00 PM. An RN documented that Patient #2 had a fall at 4:30 PM and the "FALL PROTICAL [sic]" was instituted. The nursing notes documented the fall was unwitnessed. The record entry stated Patient #2 had slipped when he was getting out of bed and was found on the floor towards the foot of the bed. The documentation further stated Patient #2 continued to be impulsive and attempting to get out of bed and that he was confused and forgetful.
-11/30/11 at 1:00 AM, 8:00 AM, and 4:00 PM.
-12/01/11 at 12:30 AM, 8:00 AM, 4:00 PM, and 11:44 PM. At 4:00 PM, the RN documented that Patient #2 was "SOMETIMES CONFUSED AND IMPULSIVE."

The Charge Nurse in the Medical/Oncology department was interviewed on 11/30/11 at 3:00 PM. She explained that Patient #2 became increasingly confused during his first night in the hospital and fall prevention measures were implemented around midnight on 11/28/11. The Charge Nurse stated measures for fall prevention included posting a sign outside of Patient #2's room, keeping the room free of clutter, activation of the bed alarm, wearing rubber-soled socks, and placing all four side rails up when Patient #2 was in bed.

Patient #2 was interviewed on 12/01/11 at 3:50 PM. He stated he had to go to the bathroom and had been trying to get out of bed when he fell . Patient #2 stated he was not sure if he had requested assistance before attempting to get out of bed.

The RN in the Medical/Oncology department who cared for Patient #2 at the time of the fall was interview on 11/30/11 at 3:30 PM. She stated she had been called to the room after the fall. The RN stated all four side rails had been up on Patient #2's bed and she did not know how he scooted to the foot of the bed.

Patient #2's record was reviewed. Physician orders for the use of the four side rails were not found.

During an interview on 11/30/11 at 4:10 PM, the Department Director of the Medical/Surgical Units stated a component of fall prevention was to have the bed's four side rails up. She stated orders to raise four side rails were not obtained, and the use of four raised rails was for "patient safety."

The facility failed to ensure restraints were implemented with a physician's order.

2. Patient #8 was a [AGE] year old female, admitted to the Medical/Oncology department on 11/29/11, with a diagnosis of [DIAGNOSES REDACTED]#8 had mild dementia and was very forgetful and impulsive. It also stated she had poor balance and weakness and listed a front wheeled walker and gait belt as assistive devices. The assessment further stated she could be up with the assistance of one person. Her 11/29/11 physician admission orders indicated under "Activity" that she was to up with assistance only.

During an observation on 11/30/11 beginning at 3:10 PM, Patient #8 was observed sitting in a Geri-chair with the tray secured. Patient #8's Geri-chair was situated close to the nursing station. Patient #8 was observed for approximately 30 minutes while this surveyor reviewed medical records with the Department Director of the Medical/Surgical Units. During that time Patient #8 called out to staff members "Please help me, please help me get out," and reached out with her hands to try to grab staff when they walked close to her. During the observation time, there were three hospital staff members at the desk area, and two in the hallway area. No one was observed to address Patient #8 or her concerns.

The Department Director of the Medical/Surgical Units reviewed Patient #8's medical record on 12/01/11 at 9:30 AM, and confirmed there were no orders for a restraint or for placement in a Geri-chair, as the chairs were for patient safety and not considered a restraint.

The facility failed to ensure restraints were implemented with a physician's order.

3. Patient #1 was a [AGE] year old female admitted on [DATE], for repair of an incarcerated ventral hernia. According to the website freemd.com, last updated 8/19/10; a ventral hernia is a piece of intestine that protrudes through an abnormal opening in the abdominal wall. In a person with an incarcerated hernia, the intestine has become stuck in the abnormal opening. When this happens, the blood supply to the intestine is reduced, and the intestinal tissue starts to die.

Patient #1's medical record contained documentation related to "Safety Precautions." On 11/27/11 at 4:03 PM, and on 11/28/11 at 12:00 AM, 12:46 PM, and 5:11 PM, nursing staff documented Patient #1 was on fall precautions and hourly rounding, and had four side rails raised on her bed for safety. Subsequent documentation indicated Patient #1 remained on fall precautions but had only two bed rails raised. On 11/30/11 at 1:33 PM, nursing documentation indicated that Patient #1 had a steady gait and had ambulated independently multiple times. The RN documented that Patient #1 was no longer a fall risk.

An RN documented, on 12/01/11 at 5:49 AM, that Patient #1 fell out of bed and hit the right side of her head, which was tender to the touch. The RN indicated Patient #1 complained of left knee pain and sustained a scratch on the knee. The RN then documented, "ROOM LIGHTS ON, ALL FOUR BED RAILS UP POST FALL PROTOCOL SET." The "POST FALL PROTOCOL," last reviewed by the hospital 7/2006, was reviewed. There was no direction to staff to raise four side rails for safety after a patient fall.

An RN in the Surgical/Orthopedic department was interviewed on 12/02/11 at 8:30 AM. She stated all four side rails would be raised on a patient who was confused or after a patient had a fall. She stated she had patients attempt to climb over or through the rails. She stated it could be considered a restraint but that it was either raise all four rails or risk the patient falling out of bed.

On 12/02/11 at 9:45 AM, the VP of Patient Care Services and the Department Director of the Medical/Surgical Units were interviewed jointly. The VP of Patient Care Services stated that the specific bed chosen by the hospital was designed to allow all four rails to be up without being considered a restraint. She stated the hospital thoroughly researched this aspect of the bed before deciding to purchase.

After her surgery and after her fall, Patient #1 was physically restrained by the use of the four side rails without a physician order.

The facility failed to ensure restraints were implemented with a physician's order.