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.

SAINT ALPHONSUS REGIONAL MEDICAL CENTER 1055 NORTH CURTIS ROAD BOISE, ID 83706 May 1, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on staff interviews and review of medical records and hospital policies and review of grievances, it was determined the hospital failed to protect and promote patients' rights. This compromised the hospital's ability to keep patients safe and prevented staff from utilizing restraints in a consistent manner. Findings include:


1. Refer to A164 as it relates to the facility's failure to ensure restraints were used only when less restrictive interventions were determined to be ineffective to protect the patient, staff or others from harm.

2. Refer to A166 as it relates to the facility's failure to ensure patients' plans of care were modified in writing to reflect the use of restraints.

3. Refer to A168 as it relates to the facility's failure to ensure restraints were used only in accordance with the order of a physician or LIP and LIPs ordering restraints were authorized to do so by hospital policy in accordance with State law.

4. Refer to A174 as it relates to the facility's failure to ensure restraints were discontinued at the earliest possible time.

5. Refer to A185 as it relates to the facility's failure to ensure documentation in patients' medical records contained a detailed description of the patient's behavior during the time of restraints and patients' response to interventions used.

6. Refer to A187 as it relates to the facility's failure to ensure documentation of patients' conditions or symptoms that warranted the use of restraints.

7. Refer to A188 as it relates to the facility's failure to ensure patients' response to the intervention used, including the rationale for continued use of the intervention (restraints) was documented.

The cumulative effect of these negative systemic practices resulted in the inability of the hospital to promote and protect the rights of patients.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure 4 of 6 patients (# 1, #2, #3, and #4), who were physically restrained, were restrained only after a comprehensive assessment was performed and less restrictive interventions were determined to be ineffective. This resulted in the potential for unnecessary use of restraints. Findings include:

1. Patient #1's medical record documented a [AGE] year old female admitted to the facility on [DATE] for altered mental status and alcohol detoxification. Patient #1 (MDS) dated [DATE] at 9:49 AM. She was transferred to an inpatient unit some time after 1:59 PM as an "emergency room Progress Note" documented she was in the ED at that time. The medical record contained conflicting information as to whether Patient #1 was discharged on [DATE] or 2/10/12. Patient #1 was restrained without clear evidence less restrictive alternatives had been attempted and found to be ineffective. Examples include:

1/30/12:
An "emergency room Progress Note," written by an RN at 12:44 PM on 1/30/12, stated Patient #1 was "...placed in posey due to multiple attempts to get out of bed and pulling on lines." (Posey is a company that makes numerous types of soft and hard restraints.) The types of restraint(s) used were not specified. The use of less restrictive interventions prior to the application of restraints was not documented. No other nursing notes related to restraints were documented in the ED.

The "Direct Charting Flowsheet," dated 1/30/12 at 3:35 PM, called for a nursing "Adult Admission Assessment" to be completed. This was likely the time Patient #1 arrived on the inpatient unit. The time of arrival was not documented. Restraints were not mentioned in the assessment.

The first physician order for restraints was dated 1/30/12 at 5:12 PM. The order was for 4 side rails up on Patient #1's bed and bilateral wrist restraints. The order stated "Alternatives tried: Increased observation." The documentation did not state what "Increased observation" meant or indicate other interventions attempted prior to the use of restraints.

Following the "emergency room Progress Note," noted above, the first nursing documentation that mentioned Patient #1's restraints was a nursing "Restraint Non-Violent Form" dated 1/30/12 at 6:00 PM (entered at 6:55 PM). The note stated Patient #1 had bilateral wrist restraints applied and all side rails were up. The note documented "Alternatives to restraints attempted: Bed alarm, Covered exposed lines/tubes, Decreased environmental stimuli, Increased observation." The note did not state if the bed alarm was applied in the ED or on the inpatient unit. It did not describe Patient #1's response to the alarm and why it was ineffective (e.g. Patient #1 ignored the alarm, the alarm was not consistently activated and/or heard by staff). The note did not describe what the terms "Covered exposed lines/tubes, Decreased environmental stimuli, Increased observation" meant. Additionally, Patient #1's response to the interventions and whether they were used alone or if one or more were used simultaneously was not documented.

An assessment which demonstrated less restrictive alternatives were tried and were ineffective prior to the use of the side rails, wrist, and posey restraints was not documented.

2/07/12:
A physician order for a vest restraint for Patient #1 was dated 2/07/12 at 2:42 AM. It stated "Alternatives tried: Bed Alarm." It did not state the response to the bed alarm or how it was ineffective.

A subsequent nursing "Restraint Non-Violent Form," completed at 4:00 AM on 2/07/12, stated a vest restraint was applied to Patient #1. The nursing note stated Patient #1 was restrained for "Unable to follow instructions and attempts to discontinue equipment." It also indicated Patient #1 was "Unable to maintain balance/ambulate unassisted and refuses/is unable to ask for assistance." The note stated "Alternatives to Restraints Attempted: Bed alarm, Decreased environmental stimuli, Increased observation, Re-oriented." The "Restraint Non-Violent Form" did not state what specific behaviors the restraint was attempting to prevent. The terms "Decreased environmental stimuli" and "Increased observation" were not defined. The documentation did not indicate if the interventions had been used simultaneously, in combination, or alone. The corresponding 2/07/12 at 2:42 AM physician's order indicated "Alternatives tried: Bed Alarm." It could not be determined when the additional interventions had been used, as the bed alarm was the only alternative documented in the order.

The RAC, interviewed on 4/24/12 beginning at 12:30 PM, confirmed the documentation for Patient #1. She stated the use of less restrictive measures and their results were not clearly documented.

The hospital did not determine that the use of less restrictive measures were ineffective prior to utilizing restraints for Patient #1.

2. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was currently a patient as of 4/30/12. The "ED Physician Notes," dated 3/12/12 at 10:12 PM, stated Patient #3 had a history of schizophrenia and dementia. He was admitted for combative behavior.

A physician order, dated 3/30/12 at 5:26 PM, called for "Restraint: Soft Limb X4 [wrists and ankles]." The order stated "Alternatives Tried: 1:1 intervention." The order did not state how the 1:1 intervention had been ineffective. Other less restrictive interventions attempted were not documented.

A nursing "Restraint Non-Violent Form," dated 3/30/12 at 6:00 PM (34 minutes after the order was received), indicated Patient #3 was not restrained at that time. A nursing "Restraint Non-Violent Form," dated 3/30/12 at 8:00 PM, stated Patient #3 was "Resisting restraints." The note did not state what time restraints were applied or the type of restraints in use. The note stated "Alternatives to Restraints Attempted: Bed Alarm." Additionally, the note did not indicate other less restrictive measures attempted prior to the use of restraints.

The RAC, interviewed on 4/25/12 beginning at 11:10 AM, confirmed the documentation for Patient #3. She stated the use of less restrictive measures and their results were not clearly documented.

The hospital did not determine that the use of less restrictive measures were ineffective prior to utilizing restraints for Patient #3.

3. Patient #2's medical record documented a [AGE] year old male who was admitted on [DATE] with primary diagnoses of alcoholism with alcohol withdrawal. He was discharged on [DATE]. A physician's "Critical Care Progress" note, dated 2/06/12 at 1:58 PM, documented Patient #2 was transferred from the ED to ICU for continued treatment of symptoms related to alcohol withdrawal. A physician's "Critical Care Progress" note, dated 2/11/12 at 7:11 AM, indicated Patient #2 was transferred to the medical floor for continued treatment.

The initial nursing "Restraint Non-Violent Form", dated 2/06/12 at 4:00 AM documented "Alternatives to Restraints Attempted - Covered exposed lines/tubes". The documentation did not include Patient #2's response to the covering of the exposed lines/tubes. No other less restrictive alternatives were documented as being attempted.

A physician's order, dated 2/06/12 at 5:19 AM, initiated soft restraints to Patient #2's wrists and ankles. The order documented "Alternatives tried: Covered exposed lines/tubes" as an alternative to restraints. The documentation did not state what "covered exposed lines/tubes" meant or state why the intervention had been unsuccessful. No other less restrictive alternatives were documented as having been attempted.

A physician's order, dated 2/14/12 at 1:34 PM, called for a restraint vest and soft restraints to Patient #2's wrists and ankles. The order documented "Alternatives Tried: 1:1 Intervention" as an alternative to restraints. The response to 1:1 intervention as an alternative was not documented.

The nursing "Restraint Non-Violent Form," dated 2/14/12 at 12:00 PM, documented "Chair alarm" as an alternative to Patient #2's restraints. It did not document Patient #2's response to the chair alarm or other less restrictive interventions attempted.

The RAC, interviewed on 4/26/12 beginning at 8:00 AM, confirmed the documentation for Patient #2. She stated the use of less restrictive measures and their results were not clearly documented.

The hospital did not ensure less restrictive alternatives to restraints were attempted and found to be ineffective for Patient #2.

4. Patient #4's medical record documented she was an [AGE] year old female who was admitted to the facility on [DATE] and discharged on [DATE]. According to a "History and Physical" dated 2/04/12 at 5:30 PM, Patient #4 was admitted for care related to increased confusion and agitation. There was also a documented history of dementia and psychosis.

A physician's order, dated 2/04/12 at 2:38 PM, called for 4 soft limb restraints to wrists and ankles. The order documented "Alternatives tried: 1:1 intervention." The order did not document Patient #4's response to 1:1 intervention. Additionally, other less restrictive interventions were not documented as attempted.

A subsequent nursing "Restraint Non-Violent Form", dated 2/04/12 at 3:45 PM, did not include 1:1 intervention as an alternative to restraints. A second nursing "Restraint Non-Violent Form", dated 2/04/12 at 6:00 AM, did not document 1:1 intervention as an alternative to restraints. It documented "Bed alarm, Decreased environmental stimuli, Limited distractions" as the alternatives to restraints. The form did not explain what these terms meant. The form did not document Patient #4's response to these measures. The documentation did not indicate if the interventions had been used simultaneously, in combination, or alone. It could not be determined when these interventions had been attempted, as the preceding physician order (2/04/12 at 2:38 PM) called for restraints. The use of alternative interventions would indicate the patient had been released from restraints. In which case, another physician order would be required; none was present.

The RAC, interviewed on 4/26/12 beginning at 12:50 PM, confirmed the documentation for Patient #4. She stated the use of less restrictive measures and their results were not clearly documented.

The hospital did not ensure less restrictive alternatives to restraints were consistently attempted and ineffective for Patient #4.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of clinical records and hospital policies, it was determined the hospital failed to ensure the use of physical restraints was incorporated into patients' plans of care for 6 of 6 patients (#1, #2, #3, #4, #5, and #6), who were physically restrained. This resulted in patients being restrained without clear and consistent direction to staff regarding the care of patients in restraints. Findings include:

1. The policy "Restraint and Seclusion," dated 12/06/11, stated at section III.E. "Plan of care updated in accordance with the needs of the patient following assessment and evaluation." The policy did not direct staff as to how this should occur.

The RAC, interviewed on 4/26/12 beginning at 10:15 AM, stated interventions related to restraints, such as releasing the patient at least every 2 hours and providing care, were not listed in the POC. She stated staff interventions were listed in the restraint policy and staff was expected to follow them. She stated POCs related to restraints were not individualized.

2. Patient #2's medical record documented a [AGE] year old male who was admitted on [DATE] with primary diagnoses of [DIAGNOSES REDACTED]"Critical Care Progress" note, dated 2/06/12 at 1:58 PM, documented Patient #2 was transferred from the ED to ICU for continued treatment of symptoms related to alcohol withdrawal. A physician's "Critical Care Progress" note, dated 2/11/12 at 7:11 AM, indicated Patient #2 was transferred to the medical floor for continued treatment.

A physician's order, dated 2/06/12 at 5:19 AM, initiated soft restraints to both ankles and wrists. Another physician's order, dated 2/07/12 at 6:42 PM, called for the use of a restraint vest in addition to the wrist and ankle restraints. Hand mitts were also ordered on [DATE] at 10:07 AM. The nursing "Restraint Non-Violent Form", completed on 2/11/12 at 8:00 AM, stated Patient #2 remained in 4 point soft ankle and wrist restraints and had mitts applied to both hands. All non-violent restraints were discontinued on 2/16/12 at 4:00 PM according to the "Restraint Non-Violent Form."

The "Care Plan" for Patient #2 was initiated on 2/06/12 and maintained through discharge on 2/20/12. Patient #2's plan of care did not reflect the use of restraints.

The RAC was interviewed on 4/26/12 beginning at 12:50 PM. She confirmed the plan of care did not document the changing needs of the patient related to the on-going use of non-violent medical restraints.

The hospital did not ensure Patient #2's POC was modified to include restraints.

3. Patient #4's medical record documented an [AGE] year old female admitted to the facility on [DATE] for care related to increased confusion and agitation and a related history of dementia and psychosis. She was discharged on [DATE].

A physician's order, dated 2/04/12 at 2:38 PM, called for the use of soft restraints to both wrists and ankles. According to a nursing "Restraint Non-Violent Forms," Patient #4 remained in non-violent medical restraints until 2/07/12 at 8:00 AM, when restraints were discontinued.

The "Care Plan" for Patient #4 was initiated on 2/04/12 and maintained through discharge on 2/08/12. The plan of care did not reflect the use of restraints.

The RAC was interviewed on 4/26/12 beginning at 12:50 PM. She reviewed the record and confirmed the care plan did not document the on-going use of non-violent medical restraints.

Patient #4 was physically restrained without an update being made to her POC to reflect restraints.

4. Patient #5's medical record documented a [AGE] year old male who was admitted to the facility on [DATE] for care related to sub-acute delirium or increased confusion, hallucinations and disordered thinking. He was discharged on [DATE].

A physician's order, dated 4/08/12 at 4:41 PM, initiated the use of soft restraints to Patient #5's wrists and ankles. Another order, dated 4/08/12 at 4:57 PM, and immediately following the order for soft ankle and wrist restraints, documented the same restraints with the addition of "Restraint: Vest." The nursing "Restraint Non-Violent Form," dated 4/10/12 at 1:00 PM, stated Patient #5's restraints were discontinued.

The "Care Plan" for Patient #5 was initiated on 4/06/12 at 5:58 PM and maintained through discharge on 4/13/12. However, the care plan did not reflect the use of restraints.

The RAC was interviewed on 4/26/12 beginning at 12:50 PM. She confirmed the care plan did not document the changing needs of the patient related to the on-going use of non-violent medical restraints.

Patient #5's POC was not modified to include the use of physical restraints.

5. Patient #6's medical record documented a [AGE] year old woman who was admitted on [DATE] and remained a patient on the orthopedic/joint unit at the time of the survey. Patient #6 was admitted for care related to mild [DIAGNOSES REDACTED] (brain dysfunctio[DIAGNOSES REDACTED]) attributed to low-grade sepsis (whole body inflammatory state) and/or electrolyte imbalance.

A physician ordered soft bilateral wrist restraints for Patient #6 on 4/19/12 at 2:48 AM. The nursing "Restraint Non-Violent Form," dated 4/22/12 at 12:00 AM, indicated she was in restraints until this time.

The POC for Patient #6 was initiated on 4/17/12 at 9:32 PM. The care plan was not updated to reflect the use of restraints.

The RAC was interviewed on 4/30/12 beginning at 9:50 AM. She confirmed the care plan did not document the changing needs of the patient related to the on-going use of non-violent medical restraints.

The hospital did not ensure Patient #6's POC was modified to include the use of restraints.

6. Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE] for altered mental status and alcohol detoxification. The medical record contained conflicting information as to whether Patient #1 was discharged on [DATE] or 2/10/12.

The nursing "Restraint Non-Violent Forms" documented Patient #1 was restrained with wrist restraints from 1/30/12 at 6:00 PM to 2/05/12 at 2:00 PM.

Patient #1's "Care Plans," initiated on 1/30/12 and completed on 2/09/12, listed "Restraint Orders" and stated they were "Completed." The plan did not include the type of restraints used, reason and goal for the use of the restraints, or how/when monitoring was to occur to ensure Patient #1's care, comfort, and medical needs were met. Under the section labeled "Environmental Safety Measures," the plan listed "Side rails up X4 of 4" but this was not listed as a restraint. The plan did not reflect an assessment, reason, goal, or monitoring related to the use of all four side rails up on Patient #1's bed.

The RAC, interviewed on 4/24/12 beginning at 12:30 PM, confirmed the documentation for Patient #1. The RAC stated the POC did not address restraints.

Patient #1's POC was not modified to include the use of restraints.

7. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was currently a patient as of 4/30/12. The "ED Physician Notes," dated 3/12/12 at 10:12 PM, stated Patient #3 had a history of schizophrenia and dementia.

Nursing "Restraint Non-Violent Forms" documented Patient #3 was restrained from 3/30/12 at 8:00 PM until 4/06/12 at 8:00 AM.

Patient #3's "Care Plans," initiated on 3/12/12 and continued through 4/24/12 did not mention restraints or provide direction to staff in relation to restraints.

The RAC, interviewed on 4/25/12 beginning at 11:10 AM, confirmed the documentation for Patient #3. The RAC stated the POC did not include restraints.

The hospital did not ensure nursing staff modified Patient #3's POC to include restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records and staff interview, it was determined the facility failed to ensure physician orders were consistently obtained and followed for the use restraints for 6 of 6 patients (#1, #2, #3, #4, #5, and #6) for whom restraints were used. This resulted in patients being subjected to physical restraint without an appropriate order. Findings include:

1. Patient #1's medical record documented a [AGE] year old female admitted to the facility on [DATE]. According to the "History and Physical" dated 1/30/12 at 6:20 PM, Patient #1 was admitted through the ED for care related to alcohol detoxification secondary to substance abuse. The medical record contained conflicting information as to whether Patient #1 was discharged on [DATE] or 2/10/12.

An "emergency room Progress Note," written by an RN at 12:44 PM on 1/30/12, stated Patient #1 was "...placed in posey due to multiple attempts to get out of bed and pulling on lines." (Posey is a company that makes numerous types of soft and hard restraints.) The type of restraint(s) used was not specified. No other nursing notes related to restraints were documented until a "Restraint Non-Violent Form," which was dated 1/30/12 at 6:00 PM. The form indicated it was a "Restraint Initiation Assessment." It stated the type of restraints were "All side rails up, soft limb X 2, Wrists, bilateral."

A physician order for the restraints applied at 12:44 PM on 1/30/12 was not documented. The first order for restraints was dated 1/30/12 at 5:11 PM.

The RAC, interviewed on 4/24/12 beginning at 12:30 PM, confirmed the documentation for Patient #1. The RAC confirmed restraints were applied to Patient #1 at 12:44 PM on 1/30/12. She stated an order to apply the restraints was not documented.

Restraints for Patient #1 were not used in accordance with a physician order.

2. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was currently a patient as of 4/30/12. The "ED Physician Notes," dated 3/12/12 at 10:12 PM, stated Patient #3 had a history of schizophrenia and dementia. The note stated he had come from a nursing home after increased aggression and striking a nurse in the abdomen. The note stated Patient #3 was calm at first but "...became aggressive with the staff, was trying to leave, and actually required restraint and chemical sedation." "emergency room Progress Notes" by an RN at 6:41 PM, stated Patient #3 was walking in hallways and other patients' rooms. He became verbally aggressive and was placed in wrist restraints from 6:42 PM - 9:15 PM. An order for the wrist restraints was not present in the medical record.

The RAC was interviewed on 4/26/12 beginning at 10:00 AM. She confirmed the order for restraint was not documented.

Restraints for Patient #3 were not used in accordance with a physician order.

3. Patient #2's medical record documented a [AGE] year old male who was admitted on [DATE] and was discharged on [DATE]. According to the "History and Physical," Patient #2's primary diagnosis was alcoholism with alcohol withdrawal.

A physician's order, dated 2/06/12 at 5:19 AM, initiated non-violent, medical restraints for Patient #2, and stated "Soft Limb X 4 " . Nursing "Restraint Non-Violent Forms" documented Patient #2 was in restraints until 2/16/12 at 4:00 PM. No orders to continue soft 4 point restraints for Patient #2 were documented for the dates of 2/11/12 or 2/15/12.

The RAC was interviewed on 4/26/12 at 8:00 AM. She reviewed the record and confirmed the documentation in Patient #2's medical record did not explain the order discrepancies.

The facility failed to consistently obtain orders for restraints applied to Patient #2.

4. Patient #4's medical record documented an [AGE] year old female admitted to the facility on [DATE] for care related to increased confusion and agitation and a related history of dementia and psychosis. She was discharged on [DATE].

A physician's order, dated 2/04/12 at 2:38 PM, called for the use of soft restraints to both wrists and ankles "To Ensure Patient Safety." The order indicated Patient #4 could be released when she was no longer attempting to harm others. A "Restraint Non-Violent Form," was completed by the RN on 2/04/12 at 3:45 PM. The RN indicated Patient #4 was in soft limb restraints X2 and a "Vest (modified)." The medical record did not contain a physician's order for the use of a vest restraint on 2/04/12 at 3:45 PM.

The RAC reviewed Patient #4's medical record on 4/26/12 at 12:50 PM. She confirmed that a physician's order for the vest restraint was not documented.

Restraints for Patient #4 were not used in accordance with a physician order.

5. Patient #5's medical record documented a [AGE] year old male admitted to the facility on [DATE] for care related to subacute delirium, or increased confusion, hallucinations and disordered thinking. He was discharged on [DATE].

A physician's order, dated 4/10/12 at 8:12 AM, initiated soft restraints to bilateral wrists and ankles. The order indicated the reason for the restraints was "Harmful to Self." A "Restraint Non-Violent Form" was completed by the RN on 4/10/12 at 8:00 AM. The RN indicated Patient #5's wrists and ankles were restrained and he was placed in a "Vest." The medical record did not contain a physician's order for the vest restraint.

The RAC reviewed Patient #5's record on 4/26/12 beginning at 12:50 PM. She confirmed that an order for the vest restraint documented on 4/10/12 at 8:00 AM was not found in the record.

Restraints for Patient #5 were not used in accordance with a physician order.

6. Patient #6's medical record documented a [AGE] year old woman admitted on [DATE] and remained a patient on the orthopedic/joint unit at the time of the survey. Patient #6 was admitted for care related to mild [DIAGNOSES REDACTED] (brain dysfunctio[DIAGNOSES REDACTED]) attributed to low-grade sepsis (whole body inflammatory state) and/or electrolyte imbalance.

A physician's order, dated 4/19/12 at 2:48 PM, stated "Restraint: Soft limb X 2." No documentation was present in the medical record that this order was carried out.

The initial "Restraint Non-Violent Form," completed by the RN on 4/19/12 at 11:00 PM, stated 1 soft limb restraint was placed on Patient #6's right arm. The medical record did not contain a physician's order for this restraint.

The RAC was interviewed on 4/30/12 at 9:30 AM. She reviewed Patient #6's medical record and confirmed the order for initiation of restraint on 4/19/12 at 11:00 PM was not present.

Restraints for Patient #6 were not used in accordance with a physician's orders.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records, it was determined the hospital failed to ensure restraints were discontinued at the earliest possible time for 5 of 6 sample patients (#1, #2, #3, #4, and #6) who were physically restrained. This resulted in the potential for patients being restrained longer than necessary. Findings include:

1. Patient #1's medical record documented a [AGE] year old female admitted to the facility on [DATE]. According to the "History and Physical", dated 1/30/12 at 6:20 PM, Patient #1 was admitted through the ED for care related to alcohol detoxification secondary to substance abuse. The medical record contained conflicting information as to whether Patient #1 was discharged on [DATE] or 2/10/12.

"Restraint Non-Violent Forms" documented restraint usage every 2 hours between 1/30/12 at 6:00 PM and 2/05/12 at 2:00 PM when they were discontinued. The initial note, dated 1/30/12 at 6:00 PM, stated Patient #1 was placed in bilateral wrist restraints with all 4 side rails up on her bed.

After the initial note, the type of restraint used was not documented again, even though the restraint orders changed. The order on 1/31/12 at 4:45 PM, stated "Restraint: Soft Limb X 4." The order on 2/01/12 at 5:25 PM, stated "Restraint: Soft Limb X 2." The order on 2/02/12 at 11:55 AM, stated "Restraint: Soft Limb X 4." The order on 2/04/12 at 10:16 AM, stated "Restraint: Soft Limb X 2."

Between 1/30/12 at 6:00 PM to 2/05/12 at 2:00 PM, "Restraint Non-Violent Forms" documented every 2 hours that "RN Eval for Discontinuing Restraint: Behavior for restraining continues." The only exception to this occurred on 2/04/12 at 4:00 AM when the nurse documented "Sleeping and unable to evaluate cooperation" and on 2/04/12 at 6:00 AM when the nurse documented "Meeting criteria for discontinuing restraint." (The restraints were not discontinued at this time.) During the time Patient #1 was restrained, "Restraint Non-Violent Forms" did not include documentation of specific behaviors that indicated a need for continued restraint.

"Direct Charting Flowsheets" were used to document a variety of nursing assessment items such as vital signs, skin assessments, neurological assessments, IV assessments, behavior assessments, and other items. "Direct Charting Flowsheets" documented Patient #1 was either calm or sleeping 17 times between 1/30/12 at 6:00 PM to 2/05/12 at 2:00 PM. During this time, "Direct Charting Flowsheets" documented Patient #1 was agitated 5 times. The last documented time Patient #1 was agitated was on 2/03/12 at 8:00 PM. No "Direct Charting Flowsheet" described specific behavior that indicated Patient #1 required continued restraint.

The RAC, interviewed on 4/24/12 beginning at 12:30 PM, confirmed the documentation for Patient #1. She stated she could not find documentation of specific behavior that indicated Patient #1 required continued restraint.

The hospital did not discontinue restraint to Patient #1 at the earliest time.

2. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was currently a patient as of 4/30/12. diagnoses included [DIAGNOSES REDACTED]

Nursing "Restraint Non-Violent Forms" documented Patient #1 was restrained from 3/30/12 at 8:00 PM through 4/06/12 at 8:00 AM. During that time, "Restraint Non-Violent Forms" documented every 2 hours that "RN Eval for Discontinuing Restraint: Behavior for restraining continues." The only exception to this occurred on 3/30/12 at 10:00 PM and 3/31/12 at 12:00 AM and 2:00 AM when Restraint Non-Violent Forms" documented "RN Eval for Discontinuing Restraint: Sleeping and unable to evaluate cooperation." No specific behaviors indicating that Patient #3 required restraint during this time were documented in the "Restraint Non-Violent Forms."

"Direct Charting Flowsheets" documented Patient #3 was either calm or sleeping 31 times between 3/30/12 at 8:00 PM through 4/06/12 at 8:00 AM. During this time, "Direct Charting Flowsheets" documented Patient #3 was agitated only 1 time. During this time, Patient #3 did not have any tubes or lines that needed protection. Also, during this time, no "Direct Charting Flowsheet" documented Patient #1 exhibited specific behaviors that required restraint.

The RAC was interviewed on 4/26/12 beginning at 10:00 AM. She confirmed specific documentation indicating the need for restraint was not present in Patient #3's medical record.

The hospital did not discontinue restraint to Patient #3 at the earliest time.

3. Patient #2's medical record documented a [AGE] year old male who was admitted on [DATE] with primary diagnoses of [DIAGNOSES REDACTED]"History and Physicial," dated 2/06/12 at 4:15 AM, stated Patient #2 was intubated in the ED. A physician's "Critical Care Progress" note, dated 2/06/12 at 1:58 PM, documented Patient #2 was transferred from the ED to ICU for continued treatment. A physician "Critical Care Progress" note, dated 2/11/12 at 7:11 AM, indicated Patient #2 was transferred to the medical floor.

A physician's order, dated 2/06/12 at 5:19 AM, initiated soft restraints to both ankles and wrists. A "Critical Care Progress Note," dated 2/11/12 at 7:11 AM, documented Patient #2 was extubated on 2/07/12. A physician "Progress Note," dated 2/13/12 at 10:27 AM, documented Patient #2 removed his NG tube and Foley catheter. These were not replaced. A physician's order, dated 2/13/12 at 4:03 PM, called for ankle and wrist restraints and a vest restraint. The order stated "Justification: To Ensure Patient Safety." An assessment of the need for continued restraint was not documented by the physician. The nursing Restraint Non-Violent Form," dated 2/14/12 at 4:00 PM did not document the reason for restraint. An assessment of Patient #2's need for continued restraint was not documented.

The "Restraint Non-Violent Form" documented restraint usage every 2 hours between 2/06/12 at 4:00 AM and 2/16/12 at 4:00 PM when they were discontinued. The initial note, dated 2/06/12 at 4:00 AM, stated Patient #2 was placed in bilateral ankle and wrist restraints.

Between 2/06/12 at 4:00 AM and 2/16/12 at 4:00 PM, "Restraint Non-Violent Form" assessments were completed by nursing staff every 2 hours (except for a 6 hour period of time on 2/12/12 between 12:00 AM and 6:00 AM when nothing was charted) and contained documentation indicating "Behavior for restraining continues." During this time that Patient #2 was restrained, the "Restraint Non-Violent Form" did not include specific documentation as to why he needed continued restraint.

The RAC, interviewed on 4/26/12 beginning at 8:00 AM, confirmed the documentation lacked the specific behaviors that indicated Patient #2 required continued restraint.

The facility failed to ensure Patient #2's restraints were discontinued at the earliest possible time.

4. Patient #4's medical record documented an [AGE] year old female admitted to the facility on [DATE] for care related to increased confusion and agitation and a related history of dementia and psychosis. She was discharged on [DATE].

A physician's order, dated 2/04/12 at 2:38 PM, called for the use of soft restraints to both wrists and ankles. The order indicated Patient #4 could be released when she was no longer attempting to harm others.

The initial note, dated 2/04/12 at 3:45 PM, stated Patient #4 was placed in bilateral wrist restraints and a vest restraint. Between 2/04/12 at 3:45 PM and 2/07/12 at 8:00 AM, "Restraint Non-Violent Form" assessments were completed by nursing staff every 2 hours and contained documentation indicating "Behavior for restraining continues." The only exception to this occurred on 2/05/12 at 10:00 AM when the nurse documented "Sleeping and unable to evaluate cooperation." During this time that Patient #4 was restrained, the "Restraint Non-Violent Form" did not include specific documentation as to why she needed continued restraint.

Patient #4's medical record contained a "Direct Charting Flowsheet" to document a variety of nursing assessment items such as vital signs, skin assessments, neurological assessments, IV assessments, behavior assessments, and other items. Documentation on the "Direct Charting Flowsheet" indicated Patient #4 was agitated on 2 occasions, on 2/05/12 at 4:00 PM and 8:00 PM. Otherwise, nursing documentation, between 2/04/12 at 3:45 PM and 2/07/12 at 8:00 AM, indicated Patient #4 was calm, cooperative, and occasionally confused or restless. No "Direct Charting Flowsheet" documented Patient #4 exhibited specific behavior that required restraint.

The RAC, interviewed on 4/26/12 beginning at 12:50 PM, confirmed the documentation lacked the specific behaviors that indicated Patient #4 required continued restraint.

The facility failed to ensure Patient #4's restraints were discontinued at the earliest possible time.

5. Patient #6's medical record documented a [AGE] year old woman admitted on [DATE] and remained a patient on the orthopedic/joint unit at the time of the survey. Patient #6 was admitted for care related to mild [DIAGNOSES REDACTED] (brain dysfunctio[DIAGNOSES REDACTED]) attributed to low-grade sepsis (whole body inflammatory state) and/or electrolyte imbalance.

The initial "Restraint Non-Violent Form," dated 4/19/12 at 11:00 PM, indicated soft restraints were applied to Patient #6's right arm. Between 4/19/12 at 12:00 AM and 4/22/12 at 12:00 AM, "Restraint Non-Violent Form" assessments were completed by nursing staff every 2 hours with the exception of an assessment on 4/20/12 at 4:00 AM, 4:00 PM, and 6:00 PM. The documentation indicated "Behavior for restraining continues," or "continue restraint." In addition, on 4/20/12 at 8:00 AM, 10:00 AM, 12:00 PM, and 2:00 PM the RN documented a sitter was present with Patient #6. On 4/21/12 at 2:00 AM, 4:00 AM, 6:00 AM, and 8:00 AM the nurse documented "Sleeping and unable to evaluate cooperation" when documenting the evaluation to discontinue restraints. The RN documented that each of Patient #6's wrists were restrained on 4/21/12 at 10:00 AM. During the time Patient #6 remained restrained, from 4/19/12 at 11:00 PM to 4/22/12 at 12:00 AM the "Restraint Non-Violent Form" did not include specific documentation as to why she needed continued restraint.

The RAC, interviewed on 4/30/12 beginning at 9:30 AM, confirmed the documentation lacked the specific behaviors that indicated Patient #6 required continued restraint.

The facility failed to ensure Patient #6's restraints were discontinued at the earliest possible time.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0185
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records, it was determined the hospital failed to ensure a description of the patient's behavior was documented for 5 of 6 sample patients (#1, #2, #3, #4, and #6) who were physically restrained. This resulted in the potential for patients to be restrained unnecessarily. The findings include:

1. Patient #2's medical record documented a [AGE] year old male who was admitted on [DATE] with primary diagnoses of [DIAGNOSES REDACTED]"Critical Care Progress" note, dated 2/06/12 at 1:58 PM, documented Patient #2 was transferred from the ED to ICU for continued treatment. The physician "Critical Care Progress" note, dated 2/11/12 at 7:11 AM, indicated Patient #2 was transferred to the medical floor.

A physician's order, dated 2/06/12 at 5:19 AM, initiated soft restraints to both ankles and wrists to "To Ensure Patient Safety". The order stated the restraints could be released when Patient #2 was "...no longer Attempting to Harm Self." A "Restraint Non-Violent Form" was completed by an RN on 2/06/12 at 6:08 AM. It stated "Observed Behaviors for Restraint" were "Unable to follow instructions and attempts to discontinue equipment, Unable to follow instructions and pulling at tubes and lines, Unable to maintain balance/ambulate unassisted and refuses/is unable to ask for assistance."

Subsequent "Restraint Non-Violent Forms" did not provide consistent documentation of behaviors that warranted the on-going use of restraints. A physician's order, dated 2/07/12 at 7:41 AM, called for soft restraints to wrists and ankles. The nursing "Restraint Non-Violent Forms" documented 2/07/12 at 6:00 AM and 8:00 AM stated "Behavior for restraining continues." There was no clear description of Patient #2's behavior that warranted the use of restraints.

A physician order, dated 2/11/12 at 7:26 AM, called for hand mitts to both hands and soft restraints to wrists and ankles. Patient #2 was also ordered to have 1:1 supervision, a staff with him at all times. Though 1:1 supervision was ordered, the "Restraint Non-Violent Form," completed by an RN on 2/11/12 at 8:00 AM, stated Patient #2 remained in 4 point soft ankle and wrist restraints and had mitts applied to both hands. At the time a 1:1 staff was ordered, documentation could not be found that clearly identified Patient #2's behavior that necessitated the on-going use of the soft restraints to his wrists and ankles and hand mitts.

Another physician's order, dated 2/13/12 at 4:03 PM, initiated a vest and soft restraints to both ankles and wrists. The nursing "Restraint Non-Violent Forms," documented on 2/13/12 at 4:00 PM and 6:00 PM, stated "Behavior for restraining continues." A clear description of Patient #2's behavior that warranted the ongoing use of restraints could not be found.

The RAC was interviewed on 4/26/12 beginning at 8:00 AM. She reviewed the record and confirmed consistent and specific documentation of Patient #2's behavior that warranted the use of restraints could not be found.

The hospital failed to ensure a description of the behaviors that warranted the use of restraints was clearly and consistently documented for Patient #2.

2. Patient #4's medical record documented an [AGE] year old female admitted to the facility on [DATE] for care related to increased confusion and agitation and a related history dementia and psychosis. She was discharged on [DATE].

A physician's order, dated 2/04/12 at 2:38 PM, called for the use of soft restraints to both wrists and ankles. According to "Restraint Non-Violent Form," Patient #4 remained in non-violent medical restraints until 2/07/12 at 8:00 AM, when restraints were discontinued. A consistent description of Patient #4's behavior that warranted the on-going use of restraints could not be found.

A physician's order, dated 2/05/12 at 7:35 AM, called for the use of soft bilateral restraints to Patient #4's wrists and ankles. The order stated Patient #4 could be released from restraints when she was no longer "Attempting to Harm Others." The nursing "Restraint Non-Violent Forms", dated 2/05/12 at 4:00 AM, 6:00 AM and 7:45 AM did not document specific behavior indicating a need for continued restraints. The form also failed to assess mood and affect. The only terms documented for "Cognitive/Emotional Response" were "Resisting Restraints or Not Resisting Restraints." The only phrase documented for "RN Eval for Discontinuing Restraints" was "Behavior for restraining continues." There was no consistent and clear description of Patient #2's behavior that warranted the on-going use of restraints.

The nursing "Direct Charting Flowsheet" in Patient #4's record documented her behavior, mood and affect as calm and/or cooperative on 2/04/12, 2/05/12 and 2/06/12. Documentation of behavior that warranted the continued use of restraints could not be found.

The RAC was interviewed on 4/26/12 beginning at 12:50 PM. She reviewed the record and confirmed consistent and specific documentation of Patient #4's behavior that warranted the use of restraints could not be found.

The hospital failed to ensure a description of the behaviors that warranted the use of restraints was clearly and consistently documented for Patient #4.

3. Patient #6's medical record documented a [AGE] year old woman who was admitted on [DATE] and remained a patient on the orthopedic/joint unit at the time of the survey. Patient #6 was admitted for care related to mild [DIAGNOSES REDACTED] (brain dysfunctio[DIAGNOSES REDACTED]) attributed to low-grade sepsis (whole body inflammatory state) and/or electrolyte imbalance.

A physician ordered soft wrist restraints for Patient #6 on 4/19/12 at 2:48 AM. The nursing "Restraint Non-Violent Forms" contained a limited description of Patient #6's behavior that warranted the on-going use of restraints. For example, "Resisting Restraints or Not Resisting Restraints" and/or "Behavior for restraining continues" were documented on 4/20/12 from 12:00 AM through 4/21/12 at 8:00 PM. Descriptions of Patient #6's behavior for which the restraints were used could not be found during this time span.

The RAC was interviewed on 4/30/12 beginning at 9:50 AM. She reviewed the record and confirmed it was the hospital's policy that an accurate description of the patient's behavior be documented and these could not be found.

The hospital failed to ensure a description of the behaviors that warranted the use of restraints was clearly and consistently documented for Patient #6.

4. Patient #1's medical record documented a [AGE] year old female admitted to the facility on [DATE]. According to the "History and Physical" dated 1/30/12 at 6:20 PM, Patient #1 was admitted through the ED for care related to alcohol detoxification secondary to substance abuse. The medical record contained conflicting information as to whether Patient #1 was discharged on [DATE] or 2/10/12.

On 2/06/12 at 12:13 AM, a physician order for "Restraint: Soft Limb X2" was written. The order stated the reason for the restraint was "To ensure patient safety." No specific behavior was described.

A nursing "Restraint Non-Violent Form," dated 2/06/12 at 12:13 AM, documented Patient #1 was "Unable to maintain balance/ambulate unassisted and refuses/is unable to ask for assistance." The note stated wrist restraints were applied. Documentation of specific behavior that required restraining Patient #1 was not included in the note. "Restraint Non-Violent Forms" documented Patient #1 continued in restraints until 2/06/12 at 4:00 PM. A specific description of Patient #1's behavior was not documented at that time either. The "Restraint Non-Violent Form," dated 2/06/12 at 4:00 PM stated "MD wants trial of no restraints and pt [patient] can get out of wrist restraints."

On 2/07/12 at 2:41 AM, a physician order for "Restraint: Vest" was written. The order stated the reason for the restraint was "To ensure patient safety." Again, no specific behavior was mentioned.

Patient #1's first nursing "Restraint Non-Violent Form," on 2/07/12 was written at 4:00 AM. The note stated a vest restraint was applied at that time. The note stated Patient #1 was "Unable to follow instructions and attempts to discontinue equipment" and was "Unable to maintain balance/ambulate unassisted and refuses/is unable to ask for assistance." The note stated a vest restraint was applied. Documentation of specific behavior that required restraining Patient #1 was not documented. "Restraint Non-Violent Forms" documented Patient #1 continued in restraints until 2/07/12 at 6:55 PM. A specific description of Patient #1's behavior was not documented at that time. The "Restraint Non-Violent Form," dated 2/06/12 at 6:55 PM stated "MD would like to attempt pt [patient] without restraints."

The RAC, interviewed on 4/24/12 beginning at 12:30 PM, confirmed the documentation for Patient #1. She stated she could not find documentation of specific behavior that indicated Patient #1 required restraint. She stated the phrases "Unable to follow instructions and attempts to discontinue equipment" and "Unable to maintain balance/ambulate unassisted and refuses/is unable to ask for assistance" were part of the electronic medical record's programming. She stated nurses would click those items from a list of phrases on a screen and the text would be inserted into the medical record.

Staff did not document a specific description of Patient #1's behavior that indicated a need for restraint.

5. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and who was currently a patient as of 4/30/12. diagnoses included [DIAGNOSES REDACTED]

On 3/18/12 at 1:35 AM, a physician order for "Restraint: Vest, Soft Limb X2" was written. The order stated the reason written for the restraint was "To ensure patient safety." No specific behavior was mentioned.

Nursing "Restraint Non-Violent Forms" documented Patient #3 was restrained on 3/18/12 at 2:00 AM. The note stated a vest and wrist restraints were applied. The note stated "Observed Behaviors for Restraints: Unable to follow instructions and attempts to discontinue equipment." A specific description of Patient #3's behavior was not documented. The type of equipment he was reportedly attempting to discontinue was not documented. "Restraint Non-Violent Forms" documented Patient #3 was kept in restraints until 10:00 AM on 3/18/12.

On 3/30/12 at 5:26 PM, Patient #3's medical record documented a physician order for "Restraint: Soft Limb X4." The order stated the reason written for the restraint was "Protect from injury." No specific behavior was mentioned.

A nursing "Restraint Non-Violent Form" documented Patient #3 was restrained on 3/30/12 at 6:00 PM. The note stated it was a "Restraint Assessment." The note did not state the type of restraints applied to Patient #3. The note stated Patient #3 was not resisting the restraints and stated "Discontinue restraint." However, the restraints were not discontinued and no further documentation was found to explain the phrase.

The next "Restraint Non-Violent Form" was dated 3/30/12 at 8:00 PM. It did not state what type of restraint was used for Patient #3 but stated he was resisting the restraints. The note also stated "Behavior for restraining continues." The specific behavior that required placing Patient #3 in restraints was not documented. Nursing "Restraint Non-Violent Forms" documented Patient #3 remained in restraints until 4/06/12 at 8:00 AM.

The RAC was interviewed on 4/26/12 beginning at 10:00 AM. She confirmed documentation of specific behavior was not documented.

Staff did not document a description of Patient #3's behavior that indicated a need for restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0187
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review clinical records, it was determined the hospital failed to ensure the symptoms that warranted the use of the restraints was documented for 6 of 6 sample patients (#1, #2, #3, #4, #5, and #6) who were physically restrained. This lack of documentation had the potential to interfere with patients being restrained only when necessary to ensure their safety or the safety of others. Findings include:

Patient #1's medical record documented a [AGE] year old female admitted to the facility on [DATE]. According to the "History and Physical" dated 1/30/12 at 6:20 PM, Patient #1 was admitted through the ED for care related to alcohol detoxification secondary to substance abuse. The medical record contained conflicting information as to whether Patient #1 was discharged on [DATE] or 2/10/12.

On 2/06/12 at 12:13 AM, a physician order for "Restraint: Soft Limb X2" was written. The order stated the reason for the restraint was "To ensure patient safety." An individualized assessment which identified the condition or symptoms that warranted the use of restraint was not documented by the physician.

A nursing "Restraint Non-Violent Form," dated 2/06/12 at 12:13 AM, documented Patient #1 was "Unable to maintain balance/ambulate unassisted and refuses/is unable to ask for assistance." The note stated wrist restraints were applied. An individualized assessment which identified the specific symptoms that warranted the use of restraint was not documented by a nurse. "Restraint Non-Violent Forms" documented Patient #1 continued in restraints until 2/06/12 at 4:00 PM.

On 2/07/12 at 2:41 AM, a physician order was written for "Restraint: Vest." The order stated the reason for the restraint was "To ensure patient safety." A physician progress note dated 2/07/12 at 8:54 AM, stated Patient #1 was agitated last night but it did not include an assessment which identified the condition or symptoms that warranted the use of restraint.

The first nursing "Restraint Non-Violent Form," was documented in Patient #1's record on 2/07/12 at 4:00 AM. The note stated a vest restraint was applied at that time. The note stated Patient #1 was "Unable to follow instructions and attempts to discontinue equipment" and was "Unable to maintain balance/ambulate unassisted and refuses/is unable to ask for assistance." The specific symptoms that warranted the use of restraint were not documented by the nurse.

The RAC, interviewed on 4/24/12 beginning at 12:30 PM, confirmed the documentation for Patient #1. She stated she could not find documentation of symptoms that indicated Patient #1 required restraint.

Staff did not document Patient #1's condition or symptoms that warranted the use of restraints.

2. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was currently a patient as of 4/30/12. diagnoses included [DIAGNOSES REDACTED]

On 3/18/12 at 1:35 AM, a physician order for "Restraint: Vest, Soft Limb X2" was written. The order stated the reason for the restraint was "To ensure patient safety." An assessment which identified the condition or symptoms that warranted the use of restraint was not documented by the physician.

Nursing "Restraint Non-Violent Forms" documented Patient #3 was restrained on 3/18/12 at 2:00 AM. The note stated a vest and wrist restraints were applied. The note stated "Observed Behaviors for Restraints: Unable to follow instructions and attempts to discontinue equipment." An assessment which identified the specific conditions or symptoms that warranted the use of restraint was not documented.

On 3/30/12 at 5:26 PM, a physician order for "Restraint: Soft Limb X4" was written. The order stated the reason for the restraint was "Protect from injury." An assessment which identified the conditions or symptoms that warranted the use of restraint was not documented by the physician.

A nursing "Restraint Non-Violent Forms" documented Patient #3 was restrained on 3/30/12 at 6:00 PM. The note stated it was a "Restraint Assessment." The note stated Patient #3 was not resisting the restraints and it stated "Discontinue restraint." However, the restraints were not discontinued and no further documentation regarding the intent of this phrase was found. The next nursing "Restraint Non-Violent Form" was dated 3/30/12 at 8:00 PM. It did not state what type of restraint was used for Patient #3 but stated he was resisting the restraints. The note also stated "Behavior for restraining continues." An assessment which identified Patient #3's specific conditions or symptoms that warranted the use of restraint was not documented.

The RAC was interviewed on 4/26/12 beginning at 10:00 AM. She was not able to explain the note on 3/30/12 at 6:00 PM stating the restraint was discontinued. She did confirm assessments of Patient #3 showing the use of restraints was warranted, were not present in the record.

Staff did not document Patient #3's condition or symptoms that warranted the use of restraints.

3. Patient #2's medical record documented a [AGE] year old male who was admitted on [DATE] with primary diagnoses of [DIAGNOSES REDACTED]"Critical Care Progress" note, dated 2/06/12 at 1:58 PM, documented Patient #2 was transferred from the ED to ICU for continued treatment. The physician "Critical Care Progress" note, dated 2/11/12 at 7:11 AM, indicated Patient #2 was transferred to the medical floor.

A physician's order, dated 2/06/12 at 5:19 AM, initiated soft restraints bilaterally to Patient #2's ankles and wrists to "To Ensure Patient Safety". The order stated the restraints could be released when Patient #2 was "no longer Attempting to Harm Self." An individualized assessment which included the conditions or symptoms Patient #2 exhibited, was not documented.

The "Restraint Non-Violent Form" was completed by an RN on 2/06/12 at 6:08 AM. It stated the justification for the restraints were to "Maintain equipment/tube to support MED MGMT, Protect from injury." Further documentation included "Unable to follow instructions and attempts to discontinue equipment, Unable to follow instructions and pulling at tubes and lines, Unable to maintain balance/ambulate unassisted and refuses/is unable to ask for assistance." An assessment of Patient #2 which included the specific symptoms or conditions which warranted the use of the restraints was not found in Patient #2's record.

A physician order, dated 2/11/12 at 7:26 AM, indicated Patient #2 was to have 1:1 supervision, a staff with him at all times. Though 1:1 supervision was ordered, the "Restraint Non-Violent Form", completed by an RN on 2/11/12 at 8:00 AM, stated Patient #2 remained in 4 point soft ankle and wrist restraints and had mitts applied to both hands. At the time a 1:1 staff was ordered, documentation could not be found that identified Patient #2's condition and/or symptoms that necessitated the on-going use of the soft restraints to his wrists and ankles and hand mitts.

The RAC was interviewed on 4/26/12 beginning at 8:00 AM. She confirmed it was the policy of the hospital that the use of restraints was based on an individualized assessment of the patient and should include a description of the patient's condition and/or symptoms that warranted the use of restraints. She confirmed the information was missing in Patient #2's record, but was unable to explain the discrepancy.

The hospital failed to ensure the symptoms and/or conditions that warranted the use of restraints were documented in Patient #2's medical record.

4. Patient #4's medical record documented an [AGE] year old female admitted to the facility on [DATE] for care related to increased confusion and agitation and a related history dementia and psychosis. She was discharged on [DATE].

A physician's order, dated 2/04/12 at 2:38 PM, called for the use of soft restraints to both wrists and ankles "To Ensure Patient Safety". The order indicated Patient #4 could be released from restraints when she was no longer attempting to harm others. An individualized assessment of Patient #4's conditions or symptoms that warranted the use of the restraints was not documented.

A physician's order, dated 2/05/12 at 7:35 AM, called for the use of soft bilateral restraints to Patient #4's wrists and ankles "To Ensure Patient Safety". The order stated Patient #4 could be released from restraints when she was no longer "Attempting to Harm Others." Evidence of a comprehensive restraint assessment that clearly outlined Patient #4's condition and/or symptoms that warranted the initiation of the restraints could not be found.

The RAC was interviewed on 4/26/12 beginning at 12:50 PM. She confirmed it was the policy of the hospital that the use of restraints was based on an individualized assessment of the patient and should include a description of the patient's condition and/or symptoms that warranted the use of restraints. She confirmed the information was missing in Patient #4's record, but was unable to explain the discrepancy.

Patient #4 was physically restrained without an assessment of his symptoms or conditions that warranted the use of restraint.

5. Patient #5's medical record documented he was a [AGE] year old male who was admitted to the facility on [DATE] for care related to sub-acute delirium or increased confusion, hallucinations and disordered thinking. He was discharged on [DATE].

A physician's order, dated 4/08/12 at 4:41 PM, initiated the use of soft bilateral restraints to Patient #5's wrists and ankles. The order indicated the reason for the restraints was "Harmful to Self." Another order dated, 4/08/12 at 4:57 PM, and immediately following the order for soft ankle and wrist restraints, documented the same information with the addition of "Restraint: Vest." An individualized assessment which included the conditions or symptoms which warranted the use of the wrist, ankle, and vest restraint, was not documented.

The RAC was interviewed on 4/26/12 beginning at 12:50 PM. She confirmed the information was missing in Patient #5's record, but was unable to explain the discrepancy.

Restraints were applied to Patient #5 without an assessment of his symptoms or conditions to verify the need for restraint.

6. Patient #6's medical record documented a [AGE] year old woman who was admitted on [DATE] and remained a patient on the orthopedic/joint unit at the time of the survey. Patient #6 was admitted for care related to mild [DIAGNOSES REDACTED] (brain dysfunctio[DIAGNOSES REDACTED]) attributed to low-grade sepsis (whole body inflammatory state) and/or electrolyte imbalance.

A physician ordered soft bilateral wrist restraints for Patient #6 on 4/19/12 at 2:48 AM. The order indicated the justification for the restraints was to "Maintain Equip/Tube to Support Med Mgmt. Release when no longer Attempting to Harm Self." An individualized assessment of Patient #6's conditions or symptoms that warranted the restraint was not documented.

The RAC was interviewed on 4/30/12 beginning at 9:30 AM. She confirmed it was the policy of the hospital that the use of restraints was based on an individualized assessment of the patient and should include a description of the patient's condition and/or symptoms that warranted the use of restraints. She confirmed the information was missing in Patient #6's record, but was unable to explain the discrepancy.

Patient #6's conditions and symptoms were not assessed prior to the use of restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of clinical records and hospital policies and staff interviews, it was determined the hospital failed to ensure the medical records of 6 of 6 sample patients (#1, #2, #3, #4, #5 and #6) who were physically restrained, included documentation of the patient's response to the restraints and rationale for continued use. The lack of documentation impeded the ability of hospital staff to effectively assess the need for and effectiveness of the restraints. Findings include:

1. Patient #1's medical record documented a [AGE] year old female admitted to the facility on [DATE] for altered mental status and alcohol detoxification. The medical record contained conflicting information as to whether Patient #1 was discharged on [DATE] or 2/10/12.

A physician order for Patient #1 for restraints was dated 1/30/12 at 5:12 PM. The order was for 4 side rails up on her bed and bilateral wrist restraints.

Nursing "Restraint Non-Violent Forms" documented Patient #1 continued in restraints until 2/05/12 at 2:00 PM. The "Restraint Non-Violent Forms" were documented every 2 hours while Patient #1 was restrained. Except for 4:00 AM and 6:00 AM on 2/04/12, all of Patient #1's "Restraint Non-Violent Forms" documented "Behavior for restraining continues." All of the "Restraint Non-Violent Forms" stated either "Resisting restraints" or "Not resisting restraint." No specific behaviors were described. Patient #1's response to the restraints, including a specific rationale for their continued use, was not documented.

The RAC, interviewed on 4/24/12 beginning at 12:30 PM, confirmed the documentation for Patient #1. She confirmed Patient #1's response to the restraints was not clearly documented.

Hospital staff did not document Patient #1's response to the restraints.

2. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was currently a patient as of 4/30/12. The "ED Physician Notes," dated 3/12/12 at 10:12 PM, stated Patient #3 had a history of schizophrenia and dementia. He was admitted for combative behavior.

A physician order, dated 3/30/12 at 5:26 PM, called for "Restraint: Soft Limb X4 [wrists and ankles]."

"Restraint Non-Violent Forms" documented Patient #3 was restrained from 3/30/12 at 8:00 PM until 4/06/12 at 8:00 AM. The "Restraint Non-Violent Forms" were documented every 2 hours while Patient #3 was restrained. All of Patient #3's "Restraint Non-Violent Forms" documented "Behavior for restraining continues." All of the "Restraint Non-Violent Forms" stated either "Resisting restraints" or "Not resisting restraint." No specific behaviors were described. Patient #3's response to the restraints, including a specific rationale for their continued use, was not documented.

The RAC, interviewed on 4/25/12 beginning at 11:10 AM, confirmed the documentation for Patient #3. She confirmed Patient #3's response to the restraints was not clearly documented.

Hospital staff did not document Patient #3's response to the restraints and rationale for continued use.

3. Patient #2's medical record documented a [AGE] year old male who was admitted on [DATE] with primary diagnoses of [DIAGNOSES REDACTED]

A physician's order, dated 2/06/12 at 5:19 AM, initiated soft restraints to both ankles and wrists. The "Restraint Non-Violent Form" was completed by an RN on 2/06/12 at 6:08 AM. The form documented Patient #2's cognitive and emotional response as "Resisting restraints." Patient #2's response to the restraints was not clearly documented. Nursing "Restraint Non-Violent Forms" documented Patient #2 remained in restraints until 2/16/12 at 4:00 PM.

A physician's order, dated 2/07/12 at 7:41 AM, called for soft restraints to Patient #2's wrists and ankles. The order did not document Patient #2's response to restraints. The nursing "Restraint Non-Violent Forms" documented on 2/07/12 at 6:00 AM and 8:00 AM stated "Behavior for restraining continues." Patient #2's cognitive, emotional, and behavioral response to restraints was not documented at 6:00 AM. The documented response at 8:00 AM was "Resisting restraints." A clear description of Patient #2's behavior and his response to restraints was not documented.

A physician's order, dated 2/13/12 at 4:03 PM, called for a restraint vest and soft restraints to Patient #2's ankles and wrists. The order did not document Patient #2's response to restraints. The nursing "Restraint Non-Violent Form," documented on 2/13/12 at 4:00 PM and 6:00 PM, stated "Behavior for restraining continues." Patient #2's response was documented as "Not resisting restraints." There was no clear description of Patient #2's behavior or his response to restraints.

The RAC was interviewed on 4/26/12 beginning at 8:00 AM. She reviewed the record and confirmed Patient #2's response to restraints was not clearly documented.

Hospital staff did not clearly document Patient #2's response to restraints.

4. Patient #4's medical record documented an [AGE] year old female admitted to the facility on [DATE] for care related to increased confusion and agitation and a related history of dementia and psychosis. She was discharged on [DATE].

A physician's order, dated 2/04/12 at 2:38 PM, called for the use of soft restraints to both wrists and ankles. The "Restraint Non-Violent Form," dated 2/04/12 at 3:45 PM, did not document Patient #4's response to restraints.

A physician's order, dated 2/05/12 at 7:35 AM, called for the use of soft bilateral restraints to Patient #4's wrists and ankles. The nursing "Restraint Non-Violent Form", dated 2/05/12 at 4:00 AM, 6:00 AM and 7:45 AM documented Patient #4's cognitive and emotional response to restraints as "Resisting Restraints or Not Resisting Restraints." Patient #4's specific behaviors were not clearly described on the form. There was no clear description of Patient #4's behavior or his response to restraints, including a specific rationale for continued use of restraints.

The RAC was interviewed on 4/26/12 beginning at 12:50 PM. She reviewed the record and confirmed Patient #4's response to restraints was not clearly documented.

Hospital staff did not document Patient #4's response to restraints.

5. Patient #5's medical record documented a [AGE] year old male who was admitted to the facility on [DATE] for care related to sub-acute delirium or increased confusion, hallucinations and disordered thinking. He was discharged on [DATE].

A physician's order, dated 4/08/12 at 4:41 PM, called for the use of soft bilateral restraints to Patient #5's wrists and ankles. Another order dated, 4/08/12 at 4:57 PM, and immediately following the order for soft ankle and wrist restraints, documented the same information with the addition of a restraint vest. The nursing "Restraint Non-Violent Form," dated 4/08/12 at 6:00 PM, and 4/09/12 at 4:00 AM to 10:00 AM, documented Patient #5's cognitive and emotional response during this time was "Resisting Restraints" or "Sleeping." There was no clear description of Patient #5's behavior or his response to restraints, including a specific rationale for continued use of restraints.

The RAC was interviewed on 4/25/12 beginning at 11:10 AM. She reviewed the record and confirmed Patient #5's response to restraints was not clearly documented.

Hospital staff did not document Patient #5's response to restraints.

6. Patient #6's medical record documented a [AGE] year old woman who was admitted on [DATE] and remained a patient on the orthopedic/joint unit at the time of the survey. Patient #6 was admitted for care related to mild [DIAGNOSES REDACTED] (brain dysfunctio[DIAGNOSES REDACTED]) attributed to low-grade sepsis (whole body inflammatory state) and/or electrolyte imbalance.

A physician ordered soft wrist restraints for Patient #6 on 4/19/12 at 2:48 AM. On 4/20/12 from midnight through 4/21/12 at 8:00 PM, the nursing "Restraint Non-Violent Form" documented Patient #6's cognitive and emotional response as "Resisting restraints or "Not resisting restraints," with one exception on 4/20/12 at 8:00 PM when "Other: is resistant only at times to restraints" was documented. There was no clear description of Patient #6's behavior or his response to restraints.

The RAC was interviewed on 4/25/12 beginning at 11:10 PM. She reviewed the record and confirmed Patient #6's response to restraints was not clearly documented.

Hospital staff did not document Patient #6's response to restraints.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on staff interview and review of medical records, policies, and incident reports, it was determined the hospital failed to ensure the medical records service maintained responsibility for medical records at the hospital. In addition, it was determined the hospital failed to ensure a complete medical record was maintained for 6 of 6 patients (#1, #2, #3, #4, #5, and #6) whose medical records were reviewed. This resulted in a lack of evidence that the care provided to patients was responsive to their needs and compliant with physician orders. Findings include:

1. The Director of Health Information Management was interviewed on 5/01/12 beginning at 1:35 PM. She stated the Health Information Management Department was responsible for the coding, storage, back-up, and security of medical records. She stated the department was responsible for the accuracy and completeness of physician records as well as laboratory records, radiology records, and ancillary services.

The Director of Health Information Management stated the Health Information Management Department had not assumed responsibility for the completeness of nursing documentation. She stated all nursing documentation was was the responsibility of the nursing department and the Clinical Informatics Department which managed the software nurses used to document. She stated the Health Information Management Department monitored and conducted quality reviews of physician documentation and ancillary services. However, She stated the Health Information Management Department did not monitor or include nursing documentation in their quality reviews.

The DPSRC was interviewed on 5/01/12 at 3:55 PM. She stated the hospital had not implemented a policy defining who was responsible for oversight of the entire medical record including the completeness and accuracy of nursing documentation.

The medical records department of the hospital did not assume responsibility for the entire medical record.

2. The hospital failed to ensure the medical record clearly described patients progress and response to services. Refer to A449 as it relates to the lack of documentation describing patients' response to services.

3. The hospital failed to ensure the medical record entries were complete. Refer to A450 as it relates to incomplete medical records.

The cumulative effect of these systemic omissions resulted in the inability of the hospital to document the care patients received.
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of clinical records, incident reports, and hospital policies, it was determined the hospital failed to ensure the medical record clearly described patients' progress and response to services for 6 or 6 patients (#1, #2, #3 #4, #5, and #6) whose records were reviewed. This resulted in a lack of clarity regarding the care and services planned and provided to patients and patients' progress and response to those services. Findings include:

1. Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE] for altered mental status and alcohol detoxification. The medical record contained conflicting information as to whether Patient #1 was discharged on [DATE] or 2/10/12. The body of the "Discharge Summary," dictated at 10:21 PM on 2/10/12, stated Patient #1 was discharged on [DATE] while the identifying information on the discharge summary stated she was discharged on [DATE].

a. A note in Patient #1's medical record, labeled "Case Management Assessment," was dated 2/01/12 at 4:03 PM. It stated:

"Living Arrangements...House
Level of Functioning...Ambulatory
Physical Care Provider...Independent
Financial Situation...No insurance coverage, No prescription coverage
Community Resources...Arranged
Initial Plan...Home."

A "Direct Charting Flowsheet," dated 2/01/12 at 12:00 PM stated Patient #1 was only oriented to person and was only able to follow 1 step commands. The "Case Management Assessment" did not mention Patient #1's poor mental status or her need for supervision. The assessment did not state who she lived with or if supervision and assistance were available upon discharge. The assessment did not state what community resources were arranged. The assessment did not identify Patient #1's discharge planning needs.

At the time of the assessment, Patient #1's was restrained. This also was not mentioned in the assessment.

The next and final documented Case Management progress note was dated 2/08/12 at 3:48 PM. It stated Patient #1 was not appropriate for treatment at an alcohol rehabilitation facility. Patient #1's medical record did not state where she was discharged to.

The Case Manager was interviewed on 4/24/12 beginning at 11:07 AM. She stated Case Managers were responsible for discharge planning at the hospital. She stated case managers reviewed patients for discharge planning on a daily basis. She stated she did not know why there was no Case management documentation for 7 days for Patient #1. She also confirmed the medical record did not state where Patient #1 was discharged .

b. Patient #1's medical record documented a nursing "Restraint Non-Violent Form," at 4:00 AM on 2/07/12. The note stated a vest restraint was applied to Patient #1 at that time. Even though it was timed at 4:00 AM, the note stated it was actually written at 5:39 AM.

The physician order for the vest restraint was dated 2/07/12 at 2:42 AM. The time of the order did not correspond to the "Restraint Non-Violent Form." It was not clear if the restraint was actually applied at the time of the order or when it was documented. Neither the order nor the "Restraint Non-Violent Form" explained the time difference.

The RAC was interviewed on 4/24/12 beginning at 12:30 PM. She confirmed the time Patient #1 was restrained was not clear. She stated sometimes nurses were busy and did not document events until later in their shifts.

c. Patient #1's nursing "Restraint Non-Violent Form," dated 1/30/12 at 6:00 PM, stated "Type of Restraint-All side rails up, Soft limb X2." Nursing "Restraint Non-Violent Forms" documented restraint usage every 2 hours between 1/30/12 at 6:00 PM and 2/05/12 at 2:00 PM when restraints were discontinued. After the initial note on 1/30/12 at 6:00 PM, the type of restraint used was not documented again by nursing staff, even though the type of restraints ordered changed over time as follows:

A physician's order, dated 1/30/12 at 5:12 PM, stated "Restraint: Soft Limb X 2...rails X 4."

A physician's order, dated 1/31/12 at 4:45 PM, stated "Restraint: Soft Limb X 4"

A physician's order, dated 2/01/12 at 5:25 PM, stated "Restraint: Soft Limb X 2."

A physician's order, dated 2/02/12 at 11:55 AM, stated "Restraint: Soft Limb X 4."

A physician's order, dated 2/03/12 at 1:38 PM, stated "Restraint: Soft Limb X 4."

A physician's order, dated 2/04/12 at 10:16 AM, stated "Restraint: Soft Limb X 2."

A physician's order, dated 2/05/12 at 9:12 AM, stated "Restraint: Soft Limb X 2."

A physician's order, dated 2/06/12 at 12:12 AM, stated "Restraint: Soft Limb X 2."

A physician's order, dated 2/07/12 at 2:41 AM, stated "Restraint: Vest."

A physician progress note, dated 1/31/12 at 1:20 PM, stated Patient #1 was in "2 point soft restraints on upper extremity." No documentation was present explaining why 4 point restraints were ordered on [DATE] for Patient #1 or why side rails were not ordered to be continued, as they had been in the previous order on 1/30/12. A physician progress note, dated 2/04/12 at 12:26 PM, did not mention the type of restraints in use for Patient #1. No documentation was present explaining why 2 point restraints were ordered on [DATE] for Patient #1 when she had been in 4 point restraints on 2/03/12 and 2/04/12. An assessment of the changing restraint needs for Patient #1 was not documented.

A nursing "Restraint Non-Violent Form," dated 2/06/12 at 12:13 AM, stated "Unable to maintain balance/ambulate unassisted and refuses/is unable to ask for assistance." The note stated Patient #1 was placed in bilateral wrist restraints. "Restraint Non-Violent Forms" documented Patient #1 remained in restraints until 4:00 PM on 2/06/12, when they were discontinued. The note did not state why the restraint was not applied until 4:00 AM, 1 hour and 19 minutes after the order was written. No nursing note indicating a problem requiring restraint was documented at the time the order was written.

A nursing "Restraint Non-Violent Form," at 4:00 AM on 2/07/12, stated a vest restraint was applied. The nursing note stated Patient #1 was "Unable to follow instructions and attempts to discontinue equipment" and was "Unable to maintain balance/ambulate unassisted and refuses/is unable to ask for assistance." The note did not state what type of equipment Patient #1 was trying to discontinue or how placing her in a vest would prevent that.

The nursing "Direct Charting Flowsheet," dated 2/06/12 at 4:00 PM, 8:00 PM, and 2/07/12 at 12:00 AM, stated Patient #1 was calm, oriented to person, and able to follow 1 step commands. The nursing "Direct Charting Flowsheet," dated 2/07/12 at 4:00 AM, stated Patient #1 was agitated and restless. The note did not describe specifically what this meant. There was no documentation describing patient behavior that would indicate the need for restraint.

The RAC, interviewed on 4/24/12 beginning at 12:30 PM, confirmed the documentation for Patient #1. She stated she could not tell what type of restraint was used for Patient #1 at what time. She confirmed the reasons for the use of restraint were not clearly documented. She stated items documented on the "Restraint Non-Violent Forms" and the "Direct Charting Flowsheets" were chosen from a list on a computer screen. The nurse would pick the item that approximated behavior associated with the patient and click on it. That item, such as "Unable to follow instructions and attempts to discontinue equipment" was then included in the medical record. The RAC stated it was difficult for staff to document items specific to the behavior of patients.

In addition, the RAC was interviewed on 4/24/12 beginning at 10:45 AM. She stated she reviewed medical records for restraint usage. She stated she did not review medical records to determine the reason for restraint usage because it was too difficult to find information in the medical records.

d. A social work note in Patient #1's medical record, dated 2/03/12 at 11:06 AM, stated "MSW [spoke with] pt sister [name], requested she bring in his shoes when she comes to visit next. Met with pt. He is friendly and happy as finishing his PT. Will follow." This note was obviously written for another patient as Patient #1 was a confused female who did not receive PT services. It was not misfiled because the author, who was Patient #1's social worker, had to log in to Patient #1's medical record in order to enter the information.

The Social Worker was interviewed on 4/24/12 beginning at 11:20 AM. She confirmed the documentation and stated she did not know who it referred to.

Information on Patient #1's medical record did not accurately describe he care, progress, and discharge information.

2. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was currently a patient as of 4/30/12. He had diagnoses of [DIAGNOSES REDACTED]

a. Patient #3's "Care Plans," initiated on 3/14/12, included "IPOC Adult Core-Deficient Knowledge...IPOC Adult Core-Difficulty Coping R/T Hospital Stay...IPOC Adult Core-Falls-Risk of...IPOC Comprehension of Social/Discharge Services-Deficient Knowledge Re: Health Resources [initiated 3/13/12]...IPOC Adult Core-Deficient Knowledge [initiated 3/18/12]..."

No direction to staff as to how they should care for Patient #3 was documented as part of the POC. For example, the Deficient Knowledge POC did not specify what knowledge Patient #3 was deficient in or how staff should approach the problem. Instead, the POC listed "Adequate knowledge of Disease Process-Achieved or Progressing" and staff documented on an intermittent basis "Progressing, Unchanged, or Achieved." No explanation was documented.

The "ED Physician Notes," dated 3/12/12 at 10:12 PM, stated Patient #3 had a history of schizophrenia and dementia. Given Patient #3's psychiatric and mental status, it could not be determined what the POC goal and subsequent documentation meant in relation to his care. For example, five consecutive notes by the RN were documented for the problem of "Deficiant Knowledge." These included:

4/08/12 at 1:34 PM-Progressing
4/08/12 at 11:35 AM-Achieved
4/08/12 at 11:20 PM-Progressing
4/09/12 at 7:50 AM-Achieved
4/13/12 at 6/28 PM-Unchanged

The POC labeled "Difficulty Coping R/T Hospital Stay" also did not include direction to staff. The documentation stated "Effective Coping Behavior-Achieved or Progressing." RN staff documented.

4/08/12 at 1:34 PM-Progressing
4/08/12 at 11:35 AM-Achieved
4/08/12 at 11:20 PM-Progressing
4/09/12 at 7:50 AM-Achieved
4/13/12 at 6/28 PM-Unchanged
4/14/12 at 4:20 PM-Unchanged
4/16/12 at 5:24 AM-Unchanged

Other items that were not addressed in Patient #3's POC included restraints which were described above, problems voiding which were documented from 3/30/12 through 4/08/12, his psychiatric diagnoses, a urinary tract infection which was diagnosed on [DATE], the use of sitters, and contact isolation which was initiated on 4/18/12.

A nursing "Handoff Form," dated 3/16/12 at 7:58 AM, stated "Pt. had one episode of being verbally aggressive tonight. Pt. stated aggression was towards male sitter. Pt. is more calm with female sitters." Patient #3's POC did not mention the use of female sitters.

The POC was reviewed with the RAC on 4/26/12 beginning at 10:30 AM. She confirmed specific direction to staff was not included in the POC. She stated for items such as restraints, interventions were not listed on a plan because they were listed in policy. She was not able to explain what progressing, unchanged, and achieved meant in relation to the documentation. She stated the EMR limited nurses' ability to document specific plans for patient care.

The Manager of the Medical Floor was interviewed on 4/26/12 beginning at 10:45 AM. She reviewed the POC. She stated staff knew Patient #3 very well and had specific ways of interacting with him. She stated staff did not give him direct commands like "Sit down here." Instead, they approached him softly asking him if he would like to sit down. She stated this had greatly improved his episodes of aggression. She confirmed that his POC did not include specific direction to staff as to how to approach Patient #3. She also stated staff used a gait belt to ambulate Patient #3. She confirmed the POC did not direct staff to use a gait belt when ambulating him.

b. Restraint documentation in Patient #3's medical record was not clear.

Patient #3's "ED Physician Notes" were dated 3/12/12 at 10:12 PM. The note stated Patient #3 had a history of schizophrenia and dementia. The note stated he had come from a nursing home after increased aggression and striking a nurse in the abdomen. The note stated Patient #3 was calm at first but "...became aggressive with the staff, was trying to leave, and actually required restraint and chemical sedation." "emergency room Progress Notes" by an RN, at 6:41 PM on 3/12/12, stated Patient #3 was walking in hallways and other patients' rooms. He became verbally aggressive and was placed in wrist restraints at 6:42 PM. The restraints were removed at 9:15 PM that evening. An order for the wrist restraints was not present in the medical record.

The RAC was interviewed on 4/26/12 beginning at 10:00 AM. She confirmed the order for restraint was not documented.

A physician's order at 1:36 AM on 3/26/12, called for "Restraint: Soft Limb X4." No nursing documentation was present stating restraints were applied at this time. A nursing "Restraint/Seclusion-Violent Form," dated 3/26/12 at 7:55 AM, stated Patient #3 attempted to leave the floor and wandered into other patients' rooms. The form stated he was "swinging out at security." The form stated "Security held pt at four points while nursing staff applied soft restraints to legs and chest." The form stated "Type of Restraint...Soft limb X2. Vest...Restraints Applied to-Ankle, bilateral." A nursing note that explained why restraints were applied to Patient #3's ankles and not to his wrists, or how this would keep Patient #1 from swinging at staff, was not documented. A physician order for restraints corresponding to this nursing note was not documented. The next order for restraint following their application was written at 7:57 PM on 3/26/12.

A nursing "Restraint Non-Violent Form," dated 3/26/12 at 8:04 AM, stated Patient #3's restraints were discontinued at 8:00 AM. The next "Restraint Non-Violent Form," dated 3/26/12 at 8:05 AM, stated "Post Surgical Restraint Applied" at 8:00 AM including "Soft limb X2, vest,Ankles Bilateral." The competing notes were not explained in the medical record. Also, Patient #1 did not have surgery so it was not clear what "Post Surgical Restraint" meant.

The first physician "Progress Note" following the initiation of restraints was dated 3/26/12 at 4:58 PM. The note stated Patient #3 had become "...quite aggravated, agitated, screaming, spitting, etc. at about 9:00 this morning." The note did not document that restraints had been applied or whether they needed to be continued.

The RAC was interviewed on 4/25/12 beginning at 11:10 AM. She confirmed the restraint documentation for 3/26/12 and stated she could not explain the discrepancies.

c. A nursing "Restraint Non-Violent Form," dated 3/18/12 at 1:37 AM, stated Patient #3 was "Unable to follow instructions and attempts to discontinue equipment." The form did not state what equipment Patient #3 was trying to discontinue. In fact, nursing notes did not doucment any equipment or tubes in use for Patient #3 on 3/18/12. The "Restraint Non-Violent Form" also did not explain what behavior the patient exhibited that caused him to be a danger to himself or others and required restraints to protect him. The "Restraint Non-Violent Form" stated restraints were applied including "All side rails up, soft limb X2 [wrist restraints], and vest." The next restraint form was dated 3/18/12 at 4:59 AM. It stated Patient #3 was not resisting the restraints but said "Behavior for restraining continues." This same language was documented on the "Restraint Non-Violent Form" at 6:13 AM and 10:17 AM. The restraint form at 11:21 AM on 3/18/12 stated Patient #3 was able to ambulate safely and there was an "Absence of behavior requiring restraint."

The corresponding physician order, dated 3/18/12 at 1:35 AM, called for vest and wrist restraints to be applied. An order to raise all side rails, which constituted a separate restraint, was not documented.

The RAC was interviewed on 4/25/12 beginning at 11:10 AM. She confirmed the documentation and was not able to explain the discrepancies.

d. A physician order for Patient #3, dated 3/25/12 at 4:54 PM, stated "Restraint: soft limb X4...Release when no longer Attempting to Harm Self." An order for a vest restraint was not documented. A physician order, dated 3/25/12 at 4:56 PM, stated "Restraint: Therapeutic Hold. Release when no longer Attempting to Harm Self. Hands on restraint to assist patient back to room."

A corresponding nursing "Restraint Non-Violent Form," dated 3/25/12 at 4:05 PM, stated Patient #3 was "...kicking and elbowing at staff." The form did not describe the events leading up to Patient #3's outburst. The form stated "Type of Restraint...Soft limb X2. Vest, Other: Security physically hands on to escort pt to room, and keep in his bed until restraints can be applied. Restraints Applied to-Ankle, bilateral, Chest." The form indicated ankle restraints had been applied but did not state he was placed in wrist restraints as called for in the order. The form stated the restraints were discontinued at 4:45 PM on 3/25/12.

A nursing "Restraint Non-Violent Form" for Patient #3, dated 3/25/12 at 4:45 PM, stated restraints were applied including "Type of Restraint...Soft limb X2. Vest Restraint Applied to-Ankle, bilateral, Chest." A nursing "Restraint Non-Violent Form" for Patient #3, dated 3/25/12 at 6:10 PM, stated restraints were discontinued at that time.

The medical record for Patient #3 was not clear as to when the patient was restrained and why 2 point restraints were applied when 4 point restraints were ordered and why a vest restraint was applied without an order.

The RAC was interviewed on 4/25/12 beginning at 11:10 AM. She confirmed Patient #3's documentation and was not able to explain the discrepancies.

e. A nursing "Restraint Non-Violent Form," dated 3/26/12 at 7:55 AM, stated Patient #3 attempted to leave the floor and wandered into other patients' rooms. The form stated security was called and Patient #3 became aggressive, swinging at them. The form stated "Security held pt at four points while nursing staff applied soft restraints to legs and chest." The form stated "Type of Restraint...Soft limb X2. Vest...Restraints Applied to-Ankle, bilateral."

No physician order was present in the record for the restraints that were applied on 3/26/12 at 7:55 AM.

Patient #3's nursing "Restraint Non-Violent Form," dated 3/26/12 at 8:04 AM, stated restraints were discontinued at 8:00 AM. The next "Restraint Non-Violent Form," dated 3/26/12 at 8:05 AM, stated restraints were initiated at 8:00 AM. The discrepancy was not explained in the medical record.

The RAC was interviewed on 4/25/12 beginning at 11:10 AM. She confirmed the documentation and was not able to explain the discrepancy.

f. Patient #3's "Restraint Non-Violent Forms" were documented every 2 hours between 3/26/12 at 8:00 AM and 4/06/12 at 8:00 AM with the following exception: On 3/29/12, a form was not completed between 4:00 PM and 10:00 PM. No documentation was present to indicate Patient #3 was restrained during that time.

The RAC was interviewed on 4/25/12 beginning at 11:10 AM. She confirmed the documentation and was not able to explain the lack of documentation.

g. Patient #3's "Restraint Non-Violent Forms" stated they were a restraint assessment. However, they did not document specific behavior which indicated a continuing need for restraints. For example, Patient #3's "Restraint Non-Violent Forms" were documented every 2 hours between 3/26/12 at 8:00 AM and 4/06/12 at 8:00 AM. The forms did not describe Patient #3's emotional or behavioral status. Unless the restraint was being initiated or discontinued, the only items documented for "Cognitive/Emotional response" were "Resisting restraints" and "Not Resisting restraints." The only items documented for "RN Eval for Discontinuing restraints" were "Behavior for restraining continues" and "Sleeping and unable to evaluate cooperation."

The RAC was interviewed on 4/25/12 beginning at 11:10 AM. She confirmed there was not descriptive language in the medical record which explained the need for restraint.

h. A physician's order for Patient #3, dated 3/30/12 at 5:26 PM, called for "Restraint: Soft Limb X4." The order stated "Alternatives Tried: 1:1 intervention." A corresponding progress note by the physician, indicating an assessment of the need for restraint, was not present in the medical record.

A nursing "Restraint Non-Violent Form," dated 3/30/12 at 6:00 PM, indicated Patient #3 was not restrained at that time. A nursing "Restraint Non-Violent Form," dated 3/30/12 at 8:00 PM, stated Patient #3 was "Resisting restraints" although it did not indicate what type of restraints were in use. The note stated "Alternatives to Restraints Attempted: Bed Alarm." Aside from the bed alarm, the note did not indicate what less restrictive measures had been attempted prior to utilizing restraints and did not describe how they were not successful.

The RAC, interviewed on 4/25/12 beginning at 11:10 AM, confirmed the documentation for Patient #3. She stated the use of less restrictive measures and their results were not documented.

i. The type of restraint utilized for Patient #3 was not documented.

A physician order for Patient #3, dated 3/26/12 at 1:36 AM, stated "Restraint: Soft Limb X4." The corresponding nursing "Restraint Non-Violent Form" on 3/26/12 at 8:00 AM documented "Type of Restraint...Soft limb X2. Vest...Restraints Applied to-Ankle, bilateral."

A physician order for Patient #3, dated 3/27/12 at 4:20 PM and 3/28/12 at 11:12 AM, stated "Restraint: Vest." The corresponding nursing "Restraint Non-Violent Form" on 3/27/12 at 4:00 PM documented Type of Restraint...Geri Chair...Restraints Applied to-Chest." The nursing note did not state why a Geri Chair was used as a restraint without an order.

Orders from 3/29/12 at 10:12 AM through 4/01/12 at 5:06 PM stated "Restraint: Soft Limb X4." The nursing "Restraint Non-Violent Forms" from 3/29/12 at 12:00 AM through 4/01/12 at 10:00 PM did not document what type of restraints were used for Patient #3.

The order, dated 4/02/12 at 12:26 PM, stated "Restraint: Vest." None of the "Restraint Non-Violent Forms," completed every 2 hours from 4/02/12 at 2:00 AM through 10:00 PM, documented what type of restraints were used for Patient #3.

The RAC was interviewed on 4/25/12 beginning at 11:10 AM. She confirmed the type of restraints used was not documented.

j. Patient #3's medical record did not include documentation of significant events that affected his care.

A "Post Fall Assessment Form," dated 3/26/12, stated Patient #3 had an un-observed fall on that date at 7:50 AM. The form stated there were no apparent injuries or complaints related to the fall. A "Post Fall Assessment Form," dated 3/29/12 at 9:20 PM, stated Patient #3 also had an observed fall on that date. Again, the form stated there were no apparent injuries or complaints related to the fall. The falls were not documented in Patient #3's medical record.

The Medical Unit Manager reviewed Patient #3's medical record on 4/27/12 beginning at 2:45 PM. She stated the "Post Fall Assessment Form" was an internal event reporting form and was not part of the medical record. She confirmed nursing documentation describing the falls and action taken by staff was not present in the record.

"Post Fall Assessment Forms" were internal incident reports and were not part of the medical record.

3. Patient #2's medical record documented a [AGE] year old male who was admitted on [DATE] with primary diagnoses of [DIAGNOSES REDACTED]"Critical Care Progress" note, dated 2/06/12 at 1:58 PM, documented Patient #2 was transferred from the ED to ICU for continued treatment. A physician's "Critical Care Progress" note, dated 2/11/12 at 7:11 AM, indicated Patient #2 was transferred to the medical floor. Patient #2's medical record did not clearly document his goals, progress and response to the care and services provided as follows:

a. A "Case Management Progress Note" was dated 2/14/12 at 2:47 PM. It stated Patient #2 lived with his wife in [a town 270 miles from Boise]. On 2/15/12 at 10:51 AM, a "Case Management Progress Note" stated "Anticipate pt will [discharge] to inlaws home in [a town 106 miles from Boise]. I scheduled new pt appt at [clinic name] in [a town 270 miles from Boise]." Patient #2 was discharged on [DATE]. No other "Case Management Progress Note" or other documentation stated Patient #2's discharge destination.

The medical record did not document clear discharge planning interventions or discharge plans.

A Case Manager was interviewed on 4/26/12 beginning at 8:00 AM. She stated case managers reviewed patients for discharge planning. She reviewed the medical record and was unable to state where Patient #2 was discharged to.

b. A nursing "Restraint Non-Violent Form," dated 2/04/12 at 4:00 AM, documented bilateral wrist and ankle restraints were applied to Patient #2. A "History and Physical," dated 2/06/12 at 8:06 AM, documented Patient #2 was admitted to ICU on 2/06/12 at 4:15 AM. The note did not document he was agitated or required restraints. Patient #2's record included a physician's order, dated 2/06/12 at 5:19 AM, for soft restraints to both of his ankles and wrists. The physician did not document an assessment of need for restraints.

Another physician's order, dated 2/07/12 at 6:42 PM, called for the use of a restraint vest, in addition to, the wrist and ankle restraints. Nursing
"Restraint Non-Violent Forms," dated 2/07/12, did not document the restraint vest was applied.

Hand mitts were also ordered on [DATE] at 10:07 AM. The "Restraint Non-Violent Forms," dated 2/08/12 did not document the application of mitts.

The RAC was interviewed on 4/26/12 beginning at 8:00 AM. She reviewed the record and confirmed Patient #2's restraints was not clearly documented.

Hospital staff did not clearly document Patient #2's discharge planning and restraint information.

4. Patient #4's medical record documented an [AGE] year old female admitted to the facility on [DATE], for care related to increased confusion and agitation and a related history of dementia and psychosis. She was discharged on [DATE].

A physician's order, dated 2/04/12 at 2:38 PM, called for the use of soft restraints to both wrists and ankles. The "Restraint Non-Violent Form," dated 2/04/12 at 3:45 PM, documented bilateral wrist restraints and a vest restraint were applied. The medical record did not state why the restraints applied did not match the order. The "History and Physical," dated 2/04/12 at 5:30 PM, documented Patient #4 was agitated, paranoid and hallucinating. It did not mention the need for restraints. An assessment of the need for restraints was not documented.

The RAC was interviewed on 4/26/12 beginning at 12:50 PM. She reviewed the record and confirmed the medical record did not clearly document the use of restraints.

Hospital staff did not document evaluations and care provided in relation to restraints.

5. Patient #5's medical record documented a [AGE] year old male who was admitted to the facility on [DATE] for care related to sub-acute delirium or increased confusion, hallucinations and disordered thinking. He was discharged on [DATE].

A physician's order, dated 4/08/12 at 7:35 PM, documented "Discontinue after: Therapeutic Hold Complete for IM Injection." The "Restraint Non-Violent Form," dated 4/08/12 at 4:35 PM, documented "Other: pt received Therapeutic hold and IM medication administered." The medical record did not document the reason the physical hold occurred prior to the time the order was entered. There was no physician's progress note on 4/08/12 that documented the event.

A physician's order for "Restraint/Seclusion Violent," dated 4/08/12 at 4:41 PM, called for the use of soft restraints to Patient #5's wrists and ankles. Immediately following was a physician's order "Restraint Order Non-Violent," dated 4/08/12 at 4:57 PM, called for use of a restraint vest. No documentation was present explaining why one order was for violent behavior and the other was for non-violent behavior. No assessment of the need for restraint was documented by the physician on 4/08/12.

The timing of the nursing documentation was unclear. The nursing "Restraint Non-Violent Form," dated 4/08/12 at 4:30 PM, documented "Therapeutic Hold." This nursing note was not written until 8:00 PM. The nursing "Restraint Non-Violent Form," dated 4/08/12 at 4:35 PM, was written at 8:04 PM and stated Patient #5 received a therapeutic hold and IM medication. The next "Restraint Non-Violent Form" was dated 4/08/12 at 4:35 PM. It stated restraints were discontinued. It was written at 11:42 PM. The next "Restraint Non-Violent Form" was dated 4/08/12 at 6:00 PM. It stated bilateral wrist and ankle and vest restraints were applied at 4:30 PM. It was written at 5:41 PM. The final "Restraint Non-Violent Form" was dated 4/08/12 at 8:00 PM. It was written on 4/09/12 at 2:02 AM. It stated Patient #5 was resisting restraints and the behavior for restraining continued. The medical record did not clearly document when Patient #5 was restrained.

The RAC was interviewed on 4/26/12 beginning at 12:50 PM. She reviewed the record and confirmed the medical record did not clearly document the use of restraints.

Patient #5's medical record did not clearly document the use of restraints.

6. Patient #6's medical record documented a [AGE] year old woman who was admitted on [DATE] and remained a patient on the orthopedic/joint unit at the time of the survey. Patient #6 was admitted for care related to mild [DIAGNOSES REDACTED] (brain dysfunctio[DIAGNOSES REDACTED]) attributed to low-grade sepsis (whole body inflammatory state) and/or electrolyte imbalance.

A physician ordered soft bilateral wrist restraints for Patient #6 on 4/19/12 at 2:48 AM. No documentation was present that a restraint was applied at that time. The first documented use of restraint was a nursing "Restraint Non-Violent Form," dated 4/19/12 at 11:00 PM. The note documented the use of 1 soft restraint to the right arm. The next restraint order was on 4/20/12 at 4:40 AM. The order called for bilateral wrist restraints. "Restraint Non-Violent Forms," dated 4/20/12, documented Patient #6 remained in restraints for the entire day. The type of restraints used was not documented.

The RAC was interviewed on 4/26/12 beginning at 12:50 PM. She reviewed the record and confirmed the medical record did not clearly document the use of restraints.

Hospital staff did not clearly document the use of restraints.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interviews and review of medical records, policies, and incident reports, it was determined medical record entries were incomplete for 6 of 6 patients (#1, #2, #3, #4, #5, and #6) whose medical records were reviewed. This resulted in a lack of clarity related to patient care and the inability of the hospital to determine whether care had been provided. Findings include:

1. Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE] for altered mental status and alcohol detoxification. Patient #1's medical record was not complete. Examples include:

a. The date and time of discharge were not documented.

The identifying information on Patient #1's History and Physical, Discharge Summary, and physician Progress Notes all stated she was discharged on [DATE]. The body of the "Discharge Summary," dictated at 10:21 PM on 2/10/12, stated Patient #1 "...was discharged on [DATE] to her parents' home, and with plan for outpatient detox." The medical record stopped on 2/09/12. The last physician order, dated 2/09/12 at 2:52 PM, stated to discharge Patient #1. It did not say where to. The last documented medication given was dated 2/09/12 at 2:30 PM. The last nursing note was a "Direct Charting Flowsheet, dated 2/09/12 at 3:32 PM. It stated Patient #1"s IV was discontinued. No progress note by nursing, social services, or the Case Manager was present in the record stating the date and time Patient #1 was discharged or where she was discharged to.

Patient #1's Discharge Summary contained other inaccuracies. The summary stated "I appreciate the involvement of [name of social worker], who helped coordinate meeting with her family." This was in relation to facilitation of discharge planning.

The social worker noted in the discharge summary above, was interviewed on 4/24/12 beginning at 11:43 PM. She stated she did not know Patient #1 and had not been involved in her care. The RAC was present during the interview with the social worker. She stated documentation of Patient #1's discharge date and time or where she was discharged to was not present in the medical record.

b. The medical record did not document Patient #1's movement through the hospital.

Patient #1's medical record documented she (MDS) dated [DATE] at 9:49 AM. The time Patient #1 was transferred to an inpatient unit from the ED was not documented. A "emergency room Progress Note" documented she was in the ED at 1:59 PM on 1/30/12. The nursing "Direct Charting Flowsheet," dated 1/30/12 at 3:35 PM, stated an "Adult Admission Assessment" had been ordered. Patient #1 was probably on the unit at this time. The time of arrival on the inpatient unit was not documented.

The RAC, interviewed on 4/24/12 beginning at 12:30 PM, was not able to state when Patient #1 was transferred to the inpatient unit.

c. Restraint documentation was not clear.

An "emergency room Progress Note," written by an RN at 12:44 PM on 1/30/12, stated Patient #1 was "...placed in posey due to multiple attempts to get out of bed and pulling on lines." The type of restraint(s) used were not specified. No other nursing notes related to restraints were documented in the ED. After the initial note, restraints were not documented until mentioned on a nursing "Restraint Non-Violent Form," dated 1/30/12 at 6:00 PM . The form stated Patient #1 had bilateral wrist restraints applied and all side rails up. The form stated it was a "Restraint Initiation Assessment" but the medical record did not state the restraints had been removed after being applied at 12:44 PM.

The first physician order for restraints was dated 1/30/12 at 5:12 PM. The order was for 4 side rails and bilateral wrist restraints. The order's time frame did not correspond to the time of the "emergency room Progress Note" or the "Restraint Non-Violent Form" dated 1/30/12 at 6:00 PM.

The RAC, interviewed on 4/24/12 beginning at 12:30 PM, was not able to explain the time discrepancy between Patient #1's order and the "Restraint Non-Violent Form."

d. The medical record did not include the type of restraints used for Patient #1.

Nursing "Restraint Non-Violent Forms" documented restraint usage every 2 hours between 1/30/12 at 6:00 PM and 2/05/12 at 2:00 PM, when they were discontinued. After the initial note on 1/30/12 at 6:00 PM, the type of restraint used was not documented again.

A physician's order, dated 1/30/12 at 5:12 PM, stated "Restraint: Soft Limb X 2...rails X 4."

A physician's order, dated 1/31/12 at 4:45 PM, stated "Restraint: Soft Limb X 4"

A physician's order, dated 2/01/12 at 5:25 PM, stated "Restraint: Soft Limb X 2."

A physician's order, dated 2/02/12 at 11:55 AM, stated "Restraint: Soft Limb X 4."

A physician's order, dated 2/03/12 at 1:38 PM, stated "Restraint: Soft Limb X 4."

A physician's order, dated 2/04/12 at 10:16 AM, stated "Restraint: Soft Limb X 2."

A physician's order, dated 2/05/12 at 9:12 AM, stated "Restraint: Soft Limb X 2."

A physician's order, dated 2/06/12 at 12:12 AM, stated "Restraint: Soft Limb X 2."

A physician's order, dated 2/07/12 at 2:41 AM, stated "Restraint: Vest."

Because of the lack of documentation by nursing staff regarding the type of restraint utilized for Patient #1, it was not possible to determine whether restraint orders were followed or not.

A physician progress note, dated 1/31/12 at 1:20 PM, stated Patient #1 was in "2 point soft restraints on upper extremity." No documentation was present explaining why 4 point restraints were ordered on [DATE] for Patient #1 or why side rails were not ordered to be continued, as they had been in the previous order on 1/30/12. A physician progress note, dated 2/04/12 at 12:26 PM, did not mention the type of restraints in use for Patient #1. No documentation was present explaining why 2 point restraints were ordered on [DATE] for Patient #1 when she had been in 4 point restraints on 2/03/12 and 2/04/12. An assessment of the changing restraint needs for Patient #1 was not documented.

The RAC, interviewed on 4/24/12 beginning at 12:30 PM, stated she was not able to tell what restraints were in use at what time for Patient #1. She stated the documentation did not explain the rationale for the decisions to change restraint orders.

e. Patient #1's POC was not complete. It did not direct staff in the care of patient #1.

Patient #1's "Care Plans" form stated it was initiated on 1/30/12 and completed on 2/09/12. The form listed "ED Stroke Panel, Alcohol Withdrawal-IV infusions, Alcohol Withdrawal, Alcohol Withdrawal-Heparin Subcut Medical Medical VTE Prophylaxis, Alcohol Withdrawal-Nausea and Vomiting, Restraint Orders." No documentation explaining what these terms meant or providing direction to staff was present on the "Care Plans" form.

Patient #1's "Care Plans" form continued stating "IPOC Adult Core-Deficient Knowledge, IPOC Adult Core-Difficulty coping R/T Hospital Stay, IPOC Adult Core-Falls-Risk of, IPOC Risk of Injury to Self/Others & Suicide Prevention, IPOC Comprehension of Social/Discharge Services-Deficient Knowledge Re: Health Resources" None of the items listed under "Care Plans" contained direction to staff.

Patient #1's "Care Plans" form did not make sense. For example, under "IPOC Risk of Injury to Self/Others & Suicide Prevention," was listed "Type of restraint-All side rails up or Elbow immobilizers or Enclosure bed/net bed or Geri chair, or Hard X2 or Hard X3 or Hard X4 or Lap Belt, or Merry walker, or Mitt X2 or Roll belt, or Side rail wedge or Soft limb X1 or Soft limb X2." No explanation of this list meant was included. No direction to staff was included in the documentation. The only restraints listed that were used for Patient #1 were side rails and soft limb X2. Soft limb X4 restraints were ordered on [DATE], 2/02/12, and 2/03/12 but were not listed on the form. A vest restraint was used on 2/07/12 but was also not listed.

The RAC, interviewed on 4/24/12 beginning at 12:30 PM, confirmed Patient #1's care plans were confusing and did not provide direction to staff.

2. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was currently a patient as of 4/30/12. The "ED Physician Notes," dated 3/12/12 at 10:12 PM, stated Patient #3 had a history of schizophrenia and dementia. He was admitted for combative behavior.

a. Two incident reports labeled "Current Summary" documented Patient #3 fell twice, once on 3/26/12 at 7:50 AM, and once on 3/28/12 at 9:20 PM. The falls were not documented in Patient #3's medical record.

The Manager of the Medical Unit was interviewed on 4/27/12 beginning at 2:45 PM. She reviewed the medical record. She stated documentation of the falls was not present in the record.

b. Restraint documentation was not complete.

The "ED Physician Notes," dated 3/12/12 at 10:12 PM, stated Patient #3 had a history of schizophrenia and dementia. The note stated he came from a nursing home after increased aggression and striking a nurse in the abdomen. The note stated Patient #3 was calm at first but "...became aggressive with the staff, was trying to leave, and actually required restraint and chemical sedation." On 3/12/12, "emergency room Progress Notes" by an RN at 6:42 PM, stated Patient #3 was walking in hallways and other patients' rooms. The note stated he became verbally aggressive and was placed in wrist restraints at that time. The restraints were removed at 9:06 that evening. An order for the wrist restraints was not present in the medical record.

The RAC was interviewed on 4/26/12 beginning at 10:00 AM. She confirmed the order for restraint was not documented.

In another incident, a nursing "Restraint Non-Violent Form" for Patient #3, dated 3/25/12 at 4:05 PM, stated restraints were applied including "Type of Restraint...Soft limb X2. Vest... Restraints Applied to-Ankle, bilateral, Chest." A corresponding physician order for a vest restraint was not found in Patient #3's record. A nursing "Restraint Non-Violent Form" for Patient #3, dated 3/25/12 at 4:45 PM, stated restraints were discontinued at that time. Another "Restraint Non-Violent Form" for Patient #3, dated 3/25/12 at 4:45 PM, stated "Post Surgical Restraints" were applied at the same time. Patient #3 appeared to remain restrained until 8:51 PM on 3/25/12. No documentation was present to explain the conflicting nursing notes.

The RAC was interviewed on 4/25/12 beginning at 11:10 AM. She confirmed Patient #3's documentation and was not able to explain the discrepancies on 3/25/12.

b. Patient #3's POC was not complete. It did not direct staff in the care of Patient #3.

Patient #3's "Care Plans" form stated it was initiated on 3/12/12 and the plan was ongoing as of 4/25/12. The form listed "IPOC Comprehension of Social/Discharge Services-Deficient Knowledge Re: Health Resources, IPOC Risk of Injury to Self/Others: With/without Restraints-Risk for Inj: Restraint Non-Violent Beh, IPOC Adult Core-Falls-Risk of, IPOC Adult Core-Difficulty coping R/T Hospital Stay. None of the items listed under "Care Plans" contained direction to staff.

The "Care Plans" form was not clear and not complete. For example, under "IPOC Comprehension of Social/Discharge Services-Deficient Knowledge Re: Health Resources," the plan stated "Education Given-Amputee or Asthma or Bone graft/joint or Cancer or Cardiac or Chemical dependency issue, or CHF program or Community resources or Diabetes or Discharge planning/Other or Renal or Skilled Nursing Facili [sic]"

Patient #3 was not an amputee. He did not have asthma or "Bone graft/joint or Cancer" or the other diagnoses listed in this section. A reason for educating Patient #3 on these issues was not documented. In addition, Patient #3 was disoriented and education was of limited value.

Patient #3's POC stated "IPOC Risk of Injury to Self/Others: With/without Restraints-Risk for Inj: Restraint Non-Violent Beh [sic]." No direction to staff was documented. An outcome category, "Absence of Inadvertent Self-Injury-Achieved or Progressing," was listed next. Nursing "Restraint Non-Violent Forms" documented Patient #1 was restrained from 3/30/12 at 8:00 PM through 4/06/12 at 8:00 AM. Beneath the outcome heading, "Progressing" was charted on 3/30/12, 4/01/12, 4/03/12, and 4/05/12. Achieved was charted on 4/06/12. "Unchanged" was charted on 3/27/12 when Patient #3 was also restrained. The meaning of these terms was not clear. No criteria was listed explaining what these terms meant.

"IPOC Risk of Injury to Self/Others & Suicide Prevention," was listed "Type of restraint-All side rails up or Elbow immobilizers or Enclosure bed/net bed or Geri chair, or Hard X2 or Hard X3 or Hard X4 or Lap Belt, or Merry walker, or Mitt X2 or Roll belt, or Side rail wedge or Soft limb X1 or Soft limb X2." No explanation of what this list meant was included. No direction to staff was included in the documentation. No documentation in the record indicated any of these restraints were used for Patient #1 except side rails and soft limb X2. The restraints that were used on Patient #1 were not listed in the plan.

The RAC, interviewed on 4/24/12 beginning at 12:30 PM, confirmed Patient #1's care plans were confusing and did not provide direction to staff.

Dementia and schizophrenia were not listed as problems on Patient #3's plan of care.

The Manager of the Medical Unit was interviewed on 4/26/12 beginning at 10:45 AM. She stated staff had specific ways of approaching Patient #3 in order to decrease the likelihood that he would become agitated. For example, she stated staff needed to not give him direct commands such as stand up or sit down. Rather, she stated staff needed to coax him into doing things and give him choices, such as asking him if he would like to sit down. She confirmed instructions to staff regarding how to approach Patient #3 were not included in his plan of care.

Patient #3's documentation was not complete.





3. Patient #2's medical record documented a [AGE] year old male who was admitted on [DATE] and was discharged on [DATE]. According to his "History and Physical," dated 2/06/12 at 8:06 AM, Patient #2's primary diagnosis was alcoholism with alcohol withdrawal.

a. During Patient #2's hospitalization and according to the "Discharge Summary," dated 2/20/12 at 4:23 PM, he was reported to have "...required significant doses of benzodiazepines to control his tremulousness and DTs. This resulted in sedation and he had to be intubated to protect his airways." The "Discharge Summary" also stated Patient #2 "...went through significant delirium tremens and was resuscitated." He was reportedly confused and disoriented much of his hospitalization . The "Discharge Summary" also stated "...mental status improved, but he still had problems with some calculation and orientation to day, date and some timing of life events."

A physician's progress note, dated 2/17/12 at 2:21 PM, stated "This morning he was noted to be confused and possibly hallucinating." The note later stated "If the patient's mental status does not clear, will consult neuropsychiatry for more thorough evaluation for possible cognitive defects. I do not feel comfortable discharging him home as he still remains disoriented."

A "Case Management" note, dated 2/06/12 at 2:33 PM, stated Patient #2 was single and his home city was [town 9 miles from Boise]. A "Case Management," note dated 2/14/12 at 2:47 PM, stated Patient #2 lived with his wife in [town 270 miles from Boise]. A "Social Work" note, entered on 2/14/12 at 3:03 PM, stated Patient #2 lived in [town 9 miles from Boise].

A "Case Management" note dated 2/15/12 at 10:51 AM stated "Anticipated pt will dc to inlaws home in [town 106 miles from Boise] area. I scheduled new pt appt at the [clinic name] in [town 270 miles from Boise]...."

A physician's "Progress Note" dated 2/18/12 at 11:53 AM stated " ...He has no primary care physician established in [town 270 miles from Boise]. I do not feel the patient is yet safe to send home."

The medical record did not positively identify Patient #2's place of residence.

The Assistant Director of Case Management was interviewed on 4/26/12 at 9:15 AM. She reviewed Patient #2's record and was unable to confirm where Patient #2 went after discharge; to his in-law's home or with his wife. The Assistant Director was unable to identify Patient #2's primary place of residence. She could not identify a discharge plan.

Patient #2's primary residence at the time of discharge was not documented.

b. A physician's order, dated 2/06/12 at 5:19 AM, initiated non-violent, medical restraints for Patient #2, and stated "Soft Limb X 4." A nursing "Restraint Non-Violent Form," dated 2/16/12 at 4:00 PM, documented restraints were discontinued. No orders to continue soft 4 point restraints were documented for the dates of 2/11/12 or 2/15/12. According to the "Restraint Non-Violent Forms," dated 2/11/12 and 2/15/12, Patient #2 remained in soft 4 point restraints.

The RAC was interviewed on 4/26/12 at 8:00 AM. She reviewed the record and confirmed the documentation in Patient #2's medical record did not explain the order discrepancies.

4. Patient #4's medical record documented an [AGE] year old female admitted to the facility on [DATE] for care related to increased confusion and agitation and a related history of dementia and psychosis. She was discharged on [DATE].

A physician's order, dated 2/04/12 at 2:38 PM, called for the use of soft restraints to both wrists and ankles "To Ensure Patient Safety." The order indicated Patient #4 could be released when she was no longer attempting to harm others. A nursing "Restraint Non-Violent Form," was completed by the RN on 2/04/12 at 3:45 PM. The RN indicated Patient #4 was in soft limb restraints X2 and a "Vest (modified)" restraint. Patient #5's medical record did not contain a physician's order for the use of a vest restraint on 2/04/12 at 3:45 PM.

The RAC reviewed Patient #4's medical record on 4/26/12 at 8:00 AM. She confirmed that a physician's order for the vest restraint was not documented.

5. Patient #5's medical record documented a [AGE] year old male admitted to the facility on [DATE] for care related to subacute delirium, or increased confusion, hallucinations and disordered thinking. He was discharged on [DATE].

A physician's order, dated 4/10/12 at 8:12 AM, initiated soft restraints to bilateral wrists and ankles. The order indicated the reason for the restraints was "Harmful to Self." A nursing "Restraint Non-Violent Form" was completed by the RN on 4/10/12 at 8:00 AM. The RN indicated Patient #5's wrists and ankles were restrained and he was placed in a "Vest" restraint. The medical record did not contain a physician's order for the vest restraint.

The RAC reviewed Patient #5's record on 4/26/12 at 8:00 AM. She confirmed that an order for the vest restraint documented on 4/10/12 at 8:00 AM was not found in the record.

6. Patient #6's medical record documented a [AGE] year old woman admitted on [DATE] and remained a patient on the orthopedic/joint unit at the time of the survey. Patient #6 was admitted for care related to mild [DIAGNOSES REDACTED] (brain dysfunctio[DIAGNOSES REDACTED]) attributed to low-grade sepsis (whole body inflammatory state) and/or electrolyte imbalance.

A physician's order, dated 4/19/12 at 2:48 PM, stated "Restraint: Soft limb X 2." No documentation was present in the medical record that this order was carried out.

The initial nursing "Restraint Non-Violent Form," completed by the RN on 4/19/12 at 11:00 PM, stated 1 soft limb restraint was placed on Patient #6's right arm. The medical record did not contain a physician's order for this restraint.

The RAC was interviewed on 4/30/12 at 9:30 AM. She reviewed Patient #6's medical record and confirmed the order for initiation of restraint on 4/19/12 at 11:00 PM was not present.
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure an effective discharge planning process had been developed and implemented. This prevented staff from consistently assessing discharge planning needs and developing discharge plans. Findings include:

1. Refer to A806 as it relates to the failure of the hospital to conduct discharge planning evaluations.

2. Refer to A808 as it relates to the failure of the hospital to conduct discharge planning evaluations that included an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services.

3. Refer to A809 as it relates to the failure of the hospital to conduct discharge planning evaluations including an evaluation of the patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital.

4. Refer to A817 as it relates to the failure of the hospital to develop discharge plans.

5. Refer to A821 as it relates to the failure of the hospital to reassess discharge planning options as patient needs changed.

The cumulative effect of these negative facility practices impeded the hospital's ability to provide discharge planning services to patients.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, record review, and review of hospital policies, it was determined the hospital failed to provide discharge planning evaluations for 3 of 6 patients (#1, #2, and #3) whose records were reviewed for discharge planning needs. The lack of an appropriate discharge evaluation had the potential to affect all patients and prevent patients' post-hospitalization needs from being met. Findings include:

1. Patient #2's medical record documented a [AGE] year old male who was admitted on [DATE] and was discharged on [DATE]. According to the "History and Physical," dated 2/06/12 at 8:06 AM, Patient #2's primary diagnosis was alcoholism with alcohol withdrawal. A physician's "Critical Care Progress" note, dated 2/06/12 at 1:58 PM, documented Patient #2 was transferred from the ED to ICU for continued treatment of symptoms related to alcohol withdrawal. A physician "Critical Care Progress" note, dated 2/11/12 at 7:11 AM, indicated Patient #2 was transferred to the medical floor for continued treatment. According to the "Discharge Summary," dated 2/20/12, Patient #2 remained on the medical floor until discharge on 2/20/12 at 3:53 PM.

The "Discharge Summary," dated 2/20/12 at 4:23 PM, documented Patient #2 was reported to have "...required significant doses of benzodiazepines to control his tremulousness and DTs. This resulted in sedation and he had to be intubated to protect his airways." The "Discharge Summary" also stated Patient #2 "...went through significant delirium tremens and was resuscitated."

Patient #2 was reportedly confused and disoriented much of his hospitalization . A physician's progress note in Patient #2's record, dated 2/13/12 at 10:27 AM, documented "neuro: oriented x 1, but doesn't know the date. Does know he is in Boise after he says he is in [a town 303 miles from Boise]." Another physician's progress note, dated 2/17/12 at 2:21 PM, stated "This morning he was noted to be confused and possibly hallucinating." The note later stated "If the patient's mental status does not clear, will consult neuropsychiatry for more thorough evaluation for possible cognitive defects. I do not feel comfortable discharging him home as he still remains disoriented."

A "Case Management" note, dated 2/06/12 at 2:33 PM, stated Patient #2 was single and he lived in [town 9 miles from Boise]. On 2/07/12 at 11:56 AM, the "Case Management" note stated "Pt is apparently married." The name of his wife was listed, along with her phone number. A "Case Management" note, dated 2/13/12 at 2:49 PM, stated Patient #2 required assisstance with mobility and ADLs'. The next "Case Management" note that mentioned his living situation was dated 2/14/12 at 2:47 PM. The note stated Patient #2 lived in [town 270 miles from Boise]. A "Social Work" note, entered on 2/14/12 at 3:03 PM, again stated Patient #2 lived in [town 9 miles from Boise].

A "Case Management" note, dated 2/15/12 at 10:51 AM, stated "Anticipated pt will dc to inlaws home in [town 106 miles from Boise]. I scheduled new pt appt at the [clinic name] in [town 270 miles from Boise]...."

A physician's "Progress Note" dated 2/18/12 at 11:53 AM stated "The patient's social situation is tenuous as his wife is young and working fulltime and they have a 1-year old son at home, not a lot of social support. He has no primary care physician established in [town 270 miles from Boise]. I do not feel the patient is yet safe to send home."

There was no documented discharge planning evaluation that described the amount and type of supervision Patient #2 would require after discharge and who would be available to provide supervision. Where Patient #2 went after discharge was not documented in his record.

The Assistant Director of Case Management was interviewed on 4/26/12 at 9:15 AM. She reviewed Patient #2's record and was unable to confirm where Patient #2 went after discharge; to his in-law's home or with his wife. She was unable to identify a discharge planning evaluation in the medical record.

The facility failed to provide a thorough discharge planning evaluation that clearly assessed Patient #2's condition at time of discharge and how his condition would impact his post-hospitalization needs.





2. Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE]. The "History and Physical," dated 1/30/12 at 6:20 PM, stated Patient #1 came from a residential alcohol treatment center where she "...became increasingly agitated with an altered level of consciousness." The note stated she was obtunded (mentally dulled).

The identifying information on Patient #1's "Discharge Summary," dated 2/10/12 at 10:21 PM, stated she was discharged on [DATE]. The body of the "Discharge Summary" stated Patient #1 was discharged on [DATE] to her parents' home. However, the medical record stopped on 2/09/12. The last physician order, dated 2/09/12 at 2:52 PM, stated to discharge Patient #1. It did not say where to. The last documented medication given was dated 2/09/12 at 2:30 PM. The last nursing note was a "Direct Charting Flowsheet, dated 2/09/12 at 3:32 PM. It stated Patient #1's IV was discontinued. No progress note by nursing, by social services, or by the Case Manager was present in the record stating the date and time Patient #1 was discharged or where she was discharged to.

A physician progress note, dated 1/31/12 at 1:20 PM, stated Patient #1 was in 2 point restraints and was "oriented X 0 [zero]." The note stated if Patient #1's mentation did not improve the physician would consider other causes than alcohol withdrawal. Physician and nursing progress notes documented Patient #1 stayed confused throughout her stay. She also remained in restraints from 1/30/12 to 2/07/12.

A note in Patient #1's medical record was labeled "Case Management Assessment" and was dated 2/01/12 at 4:03 PM. It stated:

"Living Arrangements...House
Level of Functioning...Ambulatory
Physical Care Provider...Independent
Financial Situation...No insurance coverage, No prescription coverage
Community Resources...Arranged
Initial Plan...Home."

The "Case Management Assessment" did not mention Patient #1's poor mental status or her need for supervision. The assessment did not state who she lived with or if supervision and assistance were available upon discharge. The assessment did not state what community resources were arranged. The assessment did not identify Patient #1's discharge planning needs.

At the time of the assessment, Patient #1 was restrained. This also was not addressed in the assessment.

The next and final documented Case Management progress note was dated 2/08/12 at 3:48 PM. It stated Patient #1 had been receiving intermittent doses of antipsychotic medication and antianxiety medication. It stated Patient #1 was not appropriate for treatment at an alcohol rehabilitation facility. It stated the physician had requested a meeting with Patient #1's parents to discuss discharge. A complete discharge planning evaluation was not documented in Case Management notes.

Social work notes were documented on 1/31/12, 2/01/12, 2/02/12, 2/03/12, 2/06/12, and 2/07/12. The first social work note identified Patient #1 had no insurance. Subsequent notes discussed the possibility of Patient #1 going to an inpatient alcohol rehabilitation facility. The final social work note, on 2/07/12 at 11:35 AM, stated Patient #1 was still in restraints and was disoriented.

A complete discharge planning evaluation was not documented in social work notes.

The Case Manger for Patient #1 was interviewed on 4/24/12 beginning at 11:07 AM. She was not able to find a complete discharge planning evaluation documented in the medical record.

A discharge planning evaluation was not conducted for Patient #1.

3. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was currently a patient as of 4/30/12. The "ED Physician Notes," dated 3/12/12 at 10:12 PM, stated Patient #3 had a history of schizophrenia and dementia. He was admitted for combative behavior.

A "Case Management Assessment," dated 3/13/12 at 9:00 AM, stated Patient #3 lived in a long term care facility and was "Assisted by staff at extended care facility." It stated he had Medicare and Medicaid. It stated Patient #3 was placed on a mental hold. It also stated the long term care facility he came from refused to take him back. There were 33 Case Management notes documented in the medical record. However, a complete discharge planning evaluation, including identification of discharge planning needs, was not documented.

The Case Manager and Social Worker were interviewed together on 4/25/12 beginning at 1:55 PM. They stated Patient #3 was still an inpatient because of discharge planning problems. They were not able to identify a complete discharge planning evaluation in the medical record.

A complete discharge planning evaluation was not conducted for Patient #3.

4. The hospital policy, "DISCHARGE PLANNING," revised 11/10, stated the screening process for discharge planning needs was initiated on all patients by the RN using the "admission assessment tool." The policy stated referrals were made to the Case Manager for discharge planning based on the nursing assessment. The policy stated, "The [Case Manager] will complete a further review utilizing the assessment of the admitting nurse as well as his or her own evaluation of patient/family needs as they coordinate a plan for patients who are identified as having a need for more complex discharge planning." The policy listed "Clinical Indicators which may identify a potential need for transition/discharge planning..." The policy did not identify a consistent approach to evaluating patients' discharge planning needs or how this would be documented.

The Assistant Director for Case Management was interviewed on 4/26/12 beginning at 8:55 AM. She stated a discharge planning evaluation tool, or other process to provide consistency, had not been developed. She stated staff had to "glean" discharge planning needs from reading case management notes.

The hospital had not developed a consistent discharge planning evaluation process to ensure patients' post-discharge needs were met.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, and review of medical records and hospital policies, it was determined the hospital failed to evaluate the likelihood of patients needing post-hospital services and/or the availability of those services. This affected 3 of 6 patients (#1, #2, and #3) whose records were reviewed for discharge planning and had the potential to affect all inpatients. The lack of a system to evaluate the likelihood of patients needing post-hospital services had the potential to result in unmet patient needs after discharge. Findings include:

1. Patient #2's medical record documented a [AGE] year old male who was admitted on [DATE] and was discharged on [DATE]. According to the "History and Physical," dated 2/06/12 at 8:06 AM, Patient #2's primary diagnosis was alcoholism with alcohol withdrawal. A physician's "Critical Care Progress" note, dated 2/06/12 at 1:58 PM, documented Patient #2 was transferred from the ED to ICU for continued treatment of symptoms related to alcohol withdrawal. A physician's "Critical Care Progress" note, dated 2/11/12 at 7:11 AM, indicated Patient #2 was transferred to the medical floor for continued treatment. According to the "Discharge Summary," dated 2/20/12, Patient #2 remained on the medical floor until discharged from the facility on 2/20/12 at 3:53 PM.

According to Patient #2's "Discharge Summary," dated 2/20/12 at 4:23 PM, he was reported to have "...required significant doses of benzodiazepines to control his tremulousness and DTs. He was reportedly confused and disoriented much of his hospitalization . Patient #2's mental status was documented in a physician's progress note, dated 2/17/12 at 2:21 PM. The note stated, "This morning he was noted to be confused and possibly hallucinating." The note later stated "If the patient's mental status does not clear, will consult neuropsychiatry for more thorough evaluation for possible cognitive defects. I do not feel comfortable discharging him home as he still remains disoriented."

A physician's "Progress Note," dated 2/18/12 at 11:53 AM, stated "The patient's social situation is tenuous as his wife is young and working fulltime and they have a 1-year old son at home, not a lot of social support. He has no primary care physician established in [town 270 miles from hospital]. I do not feel the patient is yet safe to send home."

A discharge planning evaluation was not present in Patient #2's record.

A "Case Management" note, dated 2/13/12 at 2:49 PM, stated, "requires assist with mobility and ADLs." A "Case Management" note, dated 2/15/12 at 10:51 AM, stated "Anticipated pt will dc to inlaws home in [town 106 miles from Boise]. I scheduled new pt appt at the [Clinic name] in [town 270 miles from Boise]...." No other "Case Management" notes documented an assessment of Patient #2's needs.

Seven "Social Work" notes were documented between 2/07/12 and 2/20/12. None of the notes documented an assessment of Patient #2's post-discharge needs and services available to meet those needs.

The Assistant Director of Case Management was interviewed on 4/26/12 at 9:15 AM. She reviewed Patient #2's record and was unable to confirm where Patient #2 went after discharge; to his in-law's home in [town 270 miles from Boise] or with Patient #2's wife in [town 9 miles from Boise]. She confirmed there was no discharge planning evaluation.





2. Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE]. The "History and Physical," dated 1/30/12 at 6:20 PM, stated Patient #1 came from a residential alcohol treatment center where she "...became increasingly agitated with an altered level of consciousness." The note stated she was obtunded (mentally dulled).

Patient #1 was discharged on either 2/09/12 or 2/10/12. The "Discharge Summary," dated 2/10/12 at 10:21 PM, contained conflicting information about the dates. No progress note by nursing services, by social services, or by the Case Manager was present in the record stating the date and time Patient #1 was discharged or where she was discharged to.

A "Case Management Assessment," dated 2/01/12 at 4:03 PM, stated Patient #1 lived in a house, was ambulatory, and was independent. The assessment stated Patient #1 had no insurance coverage and no prescription coverage. It stated substance abuse treatment was arranged and said Patient #1's initial plan was "home." The "Case Management Assessment" did not mention Patient #1's poor mental status or the need for supervision. The assessment did not include the likelihood of Patient #1 needing post-hospital services.

The Case Manager for Patient #1 was interviewed on 4/24/12 beginning at 11:07 AM. She stated the plan for Patient #1 was always to discharge her back to the residential alcohol treatment center rather than home. She reviewed Patient #1's record and was not able to find a discharge planning evaluation that included the likelihood of Patient #1 needing post-hospital services. The Case Manager stated a specific discharge planning evaluation which included items that should be assessed for all patients needing a discharge planning evaluation had not been developed.

A discharge planning evaluation, including the likelihood of the need for post-hospital services, was not conducted for Patient #1.

3. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was currently a patient as of 4/30/12. The "ED Physician Notes," dated 3/12/12 at 10:12 PM, stated Patient #3 had a history of schizophrenia and dementia. He was admitted for combative behavior.

A "Case Management Assessment," dated 3/13/12 at 9:00 AM, stated Patient #3 lived in a long term care facility and was "Assisted by staff at extended care facility." It stated he had Medicare and Medicaid. It stated Patient #3 was placed on a mental hold. It also stated the long term care facility he came from refused to take him back. The assessment did not include the likelihood of Patient #3 needing post-hospital services.

Case Management notes and Social Work notes discussed the possibily of Patient #3 being discharged to a SNF, to an Assisted Livng Facility, to a niece's home, and to a 2 person Certified Family Home. Case Management notes and Social Work notes did not include an assessment of the need for specific post-hospital services Patient #3 required in order to develop a workable discharge plan.

The Case Manager and Social Worker were interviewed together on 4/25/12 beginning at 1:55 PM. They stated Patient #3 was still an inpatient because of discharge planning problems. They were not able to identify a complete discharge planning evaluation in the medical record including the likelihood of Patient #3 needing post-hospital services.

A discharge planning evaluation, including the likelihood of the need for post-hospital services, was not conducted for Patient #3.

4. The hospital policy, "DISCHARGE PLANNING", revised 11/10, stated "The [Case Manager] will complete a further review utilizing the assessment of the admitting nurse as well as his or her own evaluation of patient/family needs as they coordinate a plan for patients who are identified as having a need for more complex discharge planning." The policy did not direct staff to evaluate patients for the likelihood of needing post-hospital services.

The Assistant Director for Case Management was interviewed on 4/26/12 beginning at 8:55 AM. She confirmed the policy did not direct staff to evaluate patients for the likelihood of needing post-hospital services.

The hospital had not developed a discharge planning evaluation process that included an evaluation of the likelihood of patients needing post-hospital services.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, and review of medical records and hospital policies, it was determined the hospital failed to evaluate patients' capacity for self-care and the possibility of patients being cared for in their home environment after discharge. This affected 3 of 6 patients (#1, #2, and #3) whose records were reviewed for discharge planning, and had the potential to affect all patients. This had the potential to result in unmet patient needs after discharge. Findings include:

1. Patient #2's medical record documented a [AGE] year old male who was admitted on [DATE] and was discharged on [DATE]. According to the "History and Physical," dated 2/06/12 at 8:06 AM, Patient #2's primary diagnosis was alcoholism with alcohol withdrawal. A physician's "Critical Care Progress" note, dated 2/06/12 at 1:58 PM, documented Patient #2 was transferred from the ED to ICU for continued treatment of symptoms related to alcohol withdrawal. A physician "Critical Care Progress" note, dated 2/11/12 at 7:11 AM, indicated Patient #2 was transferred to the medical floor for continued treatment. According to the "Discharge Summary," dated 2/20/12, Patient #2 remained on the medical floor until discharged from the facility on 2/20/12 at 3:53 PM.

According to Patient #2's "Discharge Summary," dated 2/20/12 at 4:23 PM, he was reported to have "...required significant doses of benzodiazepines to control his tremulousness and DTs. This resulted in sedation and he had to be intubated to protect his airways." The "Discharge Summary" also stated Patient #2 "...went through significant delirium tremens and was resuscitated."

A physician's progress note, dated 2/13/12 at 10:27 AM, documented "neuro: oriented x 1, but doesn't know the date. Does know he is in Boise after he says he is in [town 303 miles from Boise]." Another physician's progress note, dated 2/17/12 at 2:21 PM, documented Patient #2's mental status. The note stated "This morning he was noted to be confused and possibly hallucinating." The note later stated "If the patient's mental status does not clear, will consult neuropsychiatry for more thorough evaluation for possible cognitive defects. The patient may have had an anoxic episode during his presentation. ...I do not feel comfortable discharging him home as he still remains disoriented."

A physician's "Progress Note," dated 2/18/12 at 11:53 AM, stated, "The patient's social situation is tenuous as his wife is young and working fulltime and they have a 1-year old son at home, not a lot of social support.... I do not feel the patient is yet safe to send home."

A "Case Management" note, dated 2/15/12 at 10:51 AM, stated "Anticipated pt will dc to inlaws home in [town 106 miles from Boise] area. I scheduled new pt appt at the [clinic name] in [town 270 miles from Boise]...."

A "Social Work" note, dated 2/20/12 at 4:27 PM, stated "...he will be referred to Brain Injury Rehab program. He has been instructed that he is not to drive, return to work, operate power tools and abstain from all alcohol. Discharge to home. [Physician's name] will interview pt's wife for additional history."

The Assistant Director of Case Management was interviewed on 4/26/12 at 9:15 AM. She reviewed Patient #2's record and was unable to confirm where Patient #2 went after discharge; to his in-law's home in [town 270 miles from the hospital] or with his wife in [town 9 miles from Boise]. Supporting documentation could not be found that explained whether the facility verified Patient #2's ability to care for himself in the home. Additionally, there was no mention of the availability of family to supervise Patient #2 in the home if need be.

The facility failed to evaluate Patient #2's capacity for self-care and ability to function in the home environment with or without supervision.





2. Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE]. The "History and Physical," dated 1/30/12 at 6:20 PM, stated Patient #1 came from a residential alcohol treatment center where she "...became increasingly agitated with an altered level of consciousness." The note stated she was obtunded (mentally dulled).

Patient #1 was discharged on either 2/09/12 or 2/10/12. No progress note by nursing, by social services, or by the Case Manager was present in the record stating the date and time Patient #1 was discharged or where she was discharged to.

Patient #1 was confused and presented with discharge planning needs. A physician's progress note, dated 1/31/12 at 1:20 PM, stated Patient #1 was in 2 point restraints and was "oriented X 0 [zero]."

A "Case Management Assessment," dated 2/01/12 at 4:03 PM, stated Patient #1 lived in a house, was ambulatory, and was independent. The assessment stated Patient #1 had no insurance coverage and no prescription coverage. It stated substance abuse treatment was arranged and said Patient #1's initial plan was "home." The "Case Management Assessment" did not mention Patient #1's impaired mental status or the need for supervision. The assessment did not include an assessment of the likelihood of Patient #1's capacity for self-care.

The Case Manager for Patient #1 was interviewed on 4/24/12 beginning at 11:07 AM. She confirmed a discharge planning evaluation that included the likelihood of Patient #1's capacity for self-care could not be found in Patient #1's record.

A discharge planning evaluation, including the likelihood of Patient #1's capacity for self-care, was not conducted.

3. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was currently a patient as of 4/30/12. The "ED Physician Notes," dated 3/12/12 at 10:12 PM, stated Patient #3 had a history of schizophrenia and dementia. He was admitted for combative behavior.

A "Case Management Assessment," dated 3/13/12 at 9:00 AM, stated Patient #3 lived in a long term care facility prior to admission and was "Assisted by staff at extended care facility." It stated Patient #3 was placed on a mental hold. It also stated the long term care facility he came from refused to take him back.

The assessment did not include the likelihood of Patient #3's capacity for self-care. It did not evaluate Patient #3's ability to perform his own activities of daily living. It did not evaluate how much supervision he might need such as whether he needed to be discharged to a locked facility or not. Subsequent Case Management notes as well as Social Service notes did not evaluate these items.

The Case Manager and Social Worker were interviewed together on 4/25/12 beginning at 1:55 PM. They stated Patient #3 was still an inpatient because of discharge planning problems. They were not able to identify a discharge planning evaluation in the medical record which included the likelihood of Patient #3's capacity for self-care.

A discharge planning evaluation for Patient #3, including his ability to care for himself, was not conducted.

4. The hospital policy, "DISCHARGE PLANNING", revised 11/10, stated, "The [Case Manager] will complete a further review utilizing the assessment of the admitting nurse and as well as his or her own evaluation of patient/family needs as they coordinate a plan for patients who are identified as having a need for more complex discharge planning." The policy did not direct staff to evaluate patients for self care ability and the likelihood of returning to the environment they came from.

The Assistant Director for Case Management was interviewed on 4/26/12 beginning at 8:55 AM. She confirmed the policy did not direct staff to evaluate patients for the likelihood of patients' capacity for self-care or the possibility they could return to the environment from where they came.

The hospital had not developed a discharge planning evaluation process that included an evaluation of patients self care abilities and the likelihood of returning to the environment they came from.
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure the discharge plan was reassessed as the patient's discharge planning needs changed for 1 of 4 discharged patients (Patient #1) whose medical records were reviewed. This prevented the hospital from developing new plans in response to changing discharge planning needs. Findings include:

Patient #1's medical record documented a [AGE] year old female who was admitted on [DATE]. The "History and Physical," dated 1/30/12 at 6:20 PM, stated Patient #1 came from a residential alcohol treatment center where she "...became increasingly agitated with an altered level of consciousness." The note stated she was obtunded (mentally dulled).

Patient #1's date and time of discharge were not documented. The identifying information on Patient #1's "Discharge Summary," dated 2/10/12 at 10:21 PM, stated she was discharged on [DATE]. The body of the "Discharge Summary" stated Patient #1 was discharged on [DATE] to her parents' home. However, the medical record stopped on 2/09/12. No progress note by nursing, by social services, or by the Case Manager was present in the record stating the date and time Patient #1 was discharged or where she was discharged to.

Patient #1's "Direct Charting Flowsheet," dated 2/09/12 at 12:00 noon, stated she had short term memory loss, garbled speech, and was only able to follow 1 step commands. "Restraint Non-violent Forms" documented Patient #1 was restrained from 1/30/12 to 2/07/12.

A "Case Management Assessment," dated 2/01/12 at 4:03 PM, stated Patient #1 lived in a house, was ambulatory, and was independent. The assessment stated Patient #1 had no insurance coverage and no prescription coverage. It stated "Community Resources" were arranged but it did not identify those resources. It said Patient #1's initial plan was "home." It did not include the possibility of Patient #1 returning to the residential treatment center she came from. The "Case Management Assessment" did not include a specific discharge plan.

The next and final documented "Case Management" progress note was dated 2/08/12 at 3:48 PM. It stated Patient #1 had been receiving intermittent doses of antipsychotic medication and anti-anxiety medication. It stated Patient #1 was not appropriate for treatment at a residential alcohol treatment facility. It stated the physician had requested a meeting with Patient #1's parents to discuss discharge. A discharge plan was not documented in Case Management notes.

Social work notes were documented on 1/31/12, 2/01/12, 2/02/12, 2/03/12, 2/06/12, and 2/07/12. A social work note, dated 2/02/12 at 3:17 PM, stated Patient #1 could go to a residential alcohol treatment center when she was medically cleared. The note stated she was "...not medically cleared yet. Attempted to meet with pt. she is disoriented, in restraints. Will follow when mentally clear to discuss plan." A complete discharge plan, including an alternative based on Patient #1's medical condition, was not developed. The final note, on 2/07/12 at 11:35 AM, stated Patient #1 was still in restraints and her mental status was "not clearing." The note stated Patient #1 was not a candidate to return to the alcohol treatment center she came from. A discharge plan was not developed to locate other services and residential options for Patient #1, when it became known she was not a candidate for a residential alcohol treatment program.

The Case Manger for Patient #1 reviewed the medical record and was interviewed on 4/24/12 beginning at 11:07 AM. She confirmed a discharge plan was not documented for Patient #1. However, she stated the initial plan was to send Patient #1 to a residential alcohol treatment program. She stated it was eventually determined Patient #1 was not medically appropriate for that program due to her confusion and her inability to care for herself. She confirmed further assessment of discharge planning needs and another discharge plan were not documented.

The Case Manger stated she thought Patient #1 was discharged with her parents but she said she was not certain of this. She could not say whether Patient #1 was discharged to her own home or to her parents' home. She could not say whether supervision was available for Patient #1 after discharge. The Social Worker joined the interview with the Case Manager at 11:20 PM. They stated they initially thought Patient #1 was going to the residential alcohol treatment program. They stated all of a sudden Patient #1 was gone and they were "out of the loop" regarding what happened to her.

Patient #1's discharge plan was not reassessed after placement in a residential alcohol treatment program fell through.