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.

EASTERN IDAHO REGIONAL MEDICAL CENTER 3100 CHANNING WAY IDAHO FALLS, ID 83404 Nov. 20, 2015
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff and patient interview, it was determined the hospital failed to ensure 3 of 4 current patients (#11, #12, and #13), who were interviewed, were informed of whom to contact to file a grievance. This prevented patients from exercising their rights and prevented the hospital from identifying care issues. Findings include:

1. Patients were not aware of whom to contact to file a grievance, as follows:

a. Patient #11 was interviewed on 11/18/15 between 11:30 AM and 12:15 PM. She was a current patient who was admitted on [DATE]. She stated she had not been given a copy of the patient rights, including her right to file grievances. She also stated she had not been informed of whom she could contact to file a grievance.

b. Patient #12 was interviewed on 11/18/15 between 11:30 AM and 12:15 PM. He was a current patient who was admitted on [DATE]. He stated he had not been given a copy of the patient rights, including his right to file grievances. He also stated he had not been informed of whom he could contact to file a grievance.

c. Patient #13 was interviewed on 11/18/15 between 11:30 AM and 12:15 PM. He was a current patient who was admitted on [DATE]. He stated he had not been given a copy of the patient rights, including his right to file grievances. He also stated he had not been informed of whom he could contact to file a grievance.

The Nursing Director of the Medical/Oncology Unit was interviewed on 11/18/15 beginning at 2:05 PM. He stated the hospital kept bound patient handbooks in rooms. He took the surveyor into an empty room and there was a 3 ring binder in a drawer. The binder contained approximately fifty pages of material including the rights. The Director looked at the binder but was not immediately able to find the grievance information. He eventually located it on page 12.

Patients were not informed of where to find grievance information, including who to contact to file a grievance. Additionally, the information in the patient room handbooks was not readily identifiable.

Patients were not informed of their right to file grievances, including whom to contact.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, staff interview and review of hospital policies, it was determined the hospital failed to provide a safe environment for 1 of 2 patients (#3) who were restrained for violent or self destructive behavior and whose records were reviewed. This failed practice had the potential to result in negative patient outcomes and interfere with the safety of all patients. Findings include:

1. Patient #3 was a [AGE] year old male admitted on [DATE], with diagnoses of bilateral lower extremity cellulitis and end stage Alzheimer's disease. He was discharged on [DATE].

The hospital failed to ensure policies were followed to provide for Patient #3's safety. Examples include:

a. The hospital's policy #491, Code "5" - Request for Assistance, effective 3/14/12, stated "Upon "Code 5" notification, all available personnel will report to the area. The charge nurse/clinical team leader, department director or house supervisor will act as "Code 5" leader and assume responsibility for evaluating the need for assistance. The Code 5 leader will inform those present of the situation and identify those needed to assist."

Patient #3's record included a Nurses' Note dated 10/16/15 at 9:45 PM. The note stated "Code 5 (all available male assistance/security) called in response to patient's escalating aggression and threat to self and staff." The note further stated "Officers restrained patient with bed sheets for patient's and staff's safety." There was no documentation in Patient #3's record stating how the security officers were informed or directed, or who acted as the Code 5 leader.

Patient #3's record included a Nurses' Note dated 10/16/15 at 11:35 PM. It stated security officers were in Patient #3's room, and he was released from the sheet restraints placed by the officers.

During an interview on 11/18/15 at 11:10 AM, the Assistant CNO reviewed Patient #3's record. She stated it was not the hospital's practice to restrain patients with sheets.

The Director of ICU was interviewed on 11/19/15 at 11:15 AM. He stated he was the chair of the Restraint Committee for the hospital. When asked if the hospital used sheets to restrain patients, he stated "No, never."

A hospital security office was interviewed on 11/19/15 at 8:40 AM. He stated security officers responded to Code 5 situations. He stated in most cases the nurse in charge deferred to the security officers in situations where a patient was exhibiting aggressive behavior and required restraint. He described sheet restraints as rolled sheets applied over the patient's chest and/or legs, tied to one side of the bed and held down by a security officer on the other side of the bed. He reviewed Patient #3's record and stated he did not believe the officers stayed with him for the 1 hour and 50 minutes he was in sheet restraints and stated they probably tied the sheets to both sides of the bed. It was unclear how the sheet would be quickly released in case of an emergency.

Patient #3 was restrained with sheets applied by the hospital's security officers.

b. The hospital's policy #391, Patient Restraint/Seclusion, effective 9/30/14, stated "An order for restraint or seclusion must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of restraint or seclusion. The order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release." Additionally, it stated "When a LIP/physician is not available to issue a restraint or seclusion order, an RN with demonstrated competence may initiate restraint or seclusion use based upon face-to-face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint or seclusion is initiated."

Patient #3's record included a Nurses' Note dated 10/16/15 at 9:45 PM, at the time sheet restraints were applied. The note stated "MD contacted and orders received to give IM Geodon 20 mg now and notify him of effectiveness." A Nurses' Note dated 10/16/15 at 9:53 PM, stated Patient #3's physician was notified of his behavior. The note documented the physician instructed the nurse to administer Geodon and call back it if did not work, to discuss restraints. However, sheet restraints were in place. Patient #3's record did not include a physician's order for the sheet restraints applied on 10/16/15 at 9:45 PM, and removed 1 hour and 50 minutes later.

During an interview on 11/18/15 at 11:10 AM, the Assistant CNO reviewed Patient #3's record and confirmed there was not a physician's order for the sheet restraints.

Patient #3 was placed in restraints without a physician's order.

c. The hospital's policy #391, Patient Restraint/Seclusion, effective 9/30/14, included a section titled "Second Tier of Review" which stated "A member of nursing administration/management (e.g., nursing supervisor, manager/director, CNO, etc.) will review the need for restraint or seclusion with the RN who has determined that the patient requires restraint or seclusion. The second tier of review will occur with the initial application or restraint or seclusion."

Patient #3's record did not include documentation of a Second Tier of Review during the 1 hour and 50 minutes he was restrained with sheets.

During an interview on 11/19/15 at 11:15 AM, the Director of ICU, who is the chair of the Restraint Committee, reviewed Patient #3's record and confirmed there was no Second Tier of Review after sheet restraints were applied.

Patient #3's need for restraint was not reviewed, to determine if policies were followed and restraints were appropriate.

d. The hospital's policy #391, Patient Restraint/Seclusion, effective 9/30/14, stated "A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation...to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others."

Patient #3's record did not include documentation of a face-to-face evaluation by a physician or other trained professional within 1 hour of the placement of restraints for violent/self destructive behavior, to complete a physical and behavorial evaluation, assess the safety of the patient, and determine the need to continue or terminate the restraint.

During an interview on 11/18/15 at 11:10 AM, the Assistant CNO reviewed Patient #3's record and confirmed there was no documentation of a face-to-face evaluation by a physician or other trained professional within 1 hour of the implementation of restraints.

Patient #3 did not receive a face-to-face evaluation after being restrained.

e. The Director of ICU was interviewed on 11/19/15 at 11:15 AM. He stated he was the chair of the Restraint Committee for the hospital. He stated the hospital's unit Directors were members of the Restraint Committee which met monthly. He stated at each meeting he asked the Directors if they were aware of any problems on their units related to restraints, then gave each Director the names of patients on their unit who were restrained within the last month. They returned to their units to complete audits of restraint records. He stated the hospital had an audit tool and it was the responsibility of each Director to monitor and audit restraint records on their unit.

Documentation of an audit of Patient #3's restraint record was requested. On 11/19/15 at 11:50 AM, the Director of Risk Management stated he spoke to the Unit Director who stated no audit of Patient #3's restraint record was completed. Therefore, there was no evaluation of the appropriateness of the restraint and the safety of the patient.

Minutes of the Restraint Committee monthly meetings in 2015 were requested. In a letter faxed to surveyors on 11/20/15, the Director of Risk Management stated "In response to your request for restraint committee minutes; please be advised the committee did not meet in 2015, therefore there are no minutes."

The hospital failed to review restraint records to ensure the safety of patients was not jeopardized.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review, and staff interview, it was determined the use of restraints was not implemented in accordance with current, clear, and complete orders of physicians or other LIPs for 1 of 2 patients (#3) who were restrained for violent of self destructive behavior and whose records were reviewed. This resulted in missing or incomplete orders and restraint use that was not consistent with the orders of a physician or other LIP. This had the potential to result in unsafe care of restrained patients. Findings include:

The hospital's policy #391, Patient Restraint/Seclusion, effective 9/30/14, stated "An order for restraint or seclusion must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of restraint or seclusion. The order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release." Additionally, it stated "When a LIP/physician is not available to issue a restraint or seclusion order, an RN with demonstrated competence may initiate restraint or seclusion use based upon face-to-face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint or seclusion is initiated."

Patient #3 was a [AGE] year old male admitted on [DATE], with diagnoses of bilateral lower extremity cellulitis and end stage Alzheimer's disease. He was discharged on [DATE].

Patient #3's record included a Nurses' Note dated 10/16/15 at 9:45 PM. The note stated all available male assistance/security officers were called due to Patient #3's escalating aggression. The note further stated "Officers restrained patient with bed sheets for patient's and staff's safety. MD contacted and orders received to give IM Geodon 20 mg now and notify him of effectiveness." A Nurses' Note dated 10/16/15 at 9:53 PM stated Patient #3's physician was notified of his behavior. The note documented the physician instructed the nurse to administer Geodon and call back it if did not work, to discuss restraints.

Patient #3's record included a physician's order for bilateral soft wrist restraints, dated 10/16/15 at 11:04 PM. His record included a Nurses' Note dated 10/16/15 at 11:35 PM. It stated security officers were in Patient #3's room, he was released from the sheet restraints placed by the officers and placed in bilateral upper extremity soft restraints. Patient #3's record did not include a physician's order for the sheet restraints applied on 10/16/15 at 9:45 PM, and removed 1 hour and 50 minutes later.

During an interview on 11/18/15 at 11:10 AM, the Assistant CNO reviewed Patient #3's record and confirmed there was not a physician's order for the sheet restraints.

Patient #3 was placed in restraints without a physician's order.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review, and staff interview, it was determined the hospital failed to ensure orders for restraint used to manage violent or self-destructive behavior were renewed every 4 hours for 1 of 2 patients (#3) who were restrained for more than 4 hours to manage violent or self-destructive behavior and whose records were reviewed. This resulted in lack of oversight by a physician or qualified LIP and had the potential to interfere with patient safety. Findings include:

The hospital's policy #391, Patient Restraint/Seclusion, effective 9/30/14, included guidelines for restraints for violent or self-destruction behavior. It stated physician orders for restraints must not exceed 4 hours for adults 18 and older.

Patient #3 was a [AGE] year old male admitted on [DATE], with diagnoses of bilateral lower extremity cellulitis and end stage Alzheimer's disease. He was discharged on [DATE].

Patient #3's record included a physician's order for bilateral soft wrist restraints, dated 10/16/15 at 11:04 PM.

Patient #3's record included a restraint monitor note dated 10/16/15 at 11:35 PM. The note stated bilateral soft wrist restraints were implemented due to violent/self destructive behavior.

Nurses' Notes in Patient #3's clinical record dated 10/17/15 at 2:00 AM, 3:52 AM, 5:30 AM, 7:37 AM, 8:10 AM, 8:28 AM, and 10:00 AM, documented restraints were in place due to violent/self destructive behavior. A Nurses' Note dated 10/17/15 at 11:00 AM stated Patient #3's restraints were removed.

Patient #3's record included a physician's order for bilateral soft wrist restraints, dated 10/16/15 at 11:04 PM. The order expired at 3:04 AM on 10/17/15. His record did not include physician orders for restraints used from 3:04 to 11:00 AM on 10/17/15.

During an interview on 11/18/15 at 11:10 AM, the Assistant CNO reviewed Patient #3's record and confirmed the physician's restraint order was not renewed every 4 hours.

Orders for restraints used to manage Patient #3's violent or self-destructive behavior were not renewed at a minimum of every 4 hours.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review, and staff interview, it was determined the hospital failed to ensure the condition of patients who were restrained was monitored by trained staff for 1 of 2 patient (#3) who were restrained for violent or self destructive behavior and whose records were reviewed. This resulted in a lack of oversight and had the potential to interfere with patient safety. Findings include:

The hospital's policy #391, Patient Restraint/Seclusion, effective 9/30/14, included a section on monitoring patients in restraint. It stated "An RN will assess the patient at least every 2 hours." The policy stated the assessment would include signs of injury associated with the restraint, including circulation of affected extremities, respiratory and cardiac status, psychological status, needs for range of motion, hydration and nutritional needs, hygiene and elimination needs, and consideration of less restrictive alternatives to restraint.

Patient #3 was a [AGE] year old male admitted on [DATE], with diagnoses of bilateral lower extremity cellulitis and end stage Alzheimer's disease. He was discharged on [DATE].

Patient #3's record included a Nurses' Note dated 10/16/15 at 9:45 PM. The note stated all available male assistance/security officers were called due to his escalating aggression. The note further stated "Officers restrained patient with bed sheets for patient's and staff's safety."

Patient #3's record included a physician's order for bilateral soft wrist restraints, dated 10/16/15 at 11:04 PM. His record included a Nurses' Note dated 10/16/15 at 11:35 PM. It stated security officers were in Patient #3's room, he was released from the sheet restraints placed by the officers and placed in bilateral upper extremity soft restraints due to violent/self destructive behavior. Patient #3's record did not include documentation of an RN assessment during the 1 hour and 50 minutes he was restrained by sheets.

Patient #3's record included a "Restraints Monitor" note dated 10/17/15 at 2:00 AM, 2 hours and 25 minutes after his bilateral upper extremity soft restraints were applied. However, the entry did not include an assessment of his status and needs, or consideration of alternatives to restraint.

Patient #3's record included an RN assessment related to his restraints dated 10/17/15 at 3:52 AM, 4 hours and 17 minutes after restraints were applied to his upper extremities.

Patient #3's record included an RN assessment related to his restraints dated 10/17/15 at 5:30 AM. However, the next RN assessment related to restraints was documented at 8:10 AM, 2 hours and 40 minutes after the previous assessment. An additional RN assessment related to restraints was documented at 11:00 AM, 2 hours and 50 minutes after the previous assessment. The restraints were discontinued at that time.

During an interview on 11/18/15 at 11:10 AM, the Assistant CNO reviewed Patient #3's record and confirmed his status and needs related to restraints were not assessed by an RN every 2 hours.

Patient #3's condition was not monitored frequently while he was in restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review, and staff interview, it was determined the hospital failed to ensure a face-to-face meeting by a physician or LIP was conducted within 1 hour of the application of behavioral restraints for 1 of 2 patients (#3) who were restrained to manage violent or self-destructive behavior and whose records were reviewed. This prevented the hospital from evaluating the causes and appropriateness of the need for restraint. Findings include:

The hospital's policy #391, Patient Restraint/Seclusion, effective 9/30/14, stated "A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation...to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others."

Patient #3 was a [AGE] year old male admitted on [DATE], with diagnoses of bilateral lower extremity cellulitis and end stage Alzheimer's disease. He was discharged on [DATE].

Patient #3's record included a Nurses' Note dated 10/16/15 at 9:45 PM. The note stated all available male assistance/security officers were called due to Patient #3's escalating aggression. The note further stated "Officers restrained patient with bed sheets for patient's and staff's safety."

Patient #3's record included a physician's order for bilateral soft wrist restraints dated 10/16/15 at 11:04 PM. His record included a Nurses' Note dated 10/16/15 at 11:35 PM. It stated security officers were in Patient #3's room, he was released from the sheet restraints placed by the officers and placed in bilateral upper extremity soft restraints due to violent/self destructive behavior. A Nurses' Note date 10/17/15 at 11:00 AM stated his wrist restraints were removed.

Patient #3 was in sheet restraints for 1 hour and 50 minutes. He was in soft wrist restraints for 11 hours and 25 minutes. However, Patient #3's record did not include documentation of a face-to-face evaluation by a physician or other trained professional within 1 hour of the placement of restraints for violent/self destructive behavior.

During an interview on 11/18/15 at 11:10 AM, the Assistant CNO reviewed Patient #3's record and confirmed there was no documentation of a face-to-face evaluation by a physician or other trained professional within 1 hour of the implementation of restraints.

Patient #3 did not receive a face-to-face evaluation after being restrained.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0194
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of restraint education information, medical record review, and staff interview, it was determined the hospital failed to ensure security officers had education, training, and demonstrated knowledge to manage patients exhibiting out-of-control and/or aggressive behavior. This resulted in inappropriate use of restraint to manage the aggressive behavior of 1 of 2 patients (#3) who were restrained to protect the safety of self and others. This failure placed all patients experiencing behavioral and psychiatric challenges at risk of physical and/or mental harm. Findings include:

Patient #3's record documented he was a [AGE] year old male admitted on [DATE], with diagnoses of bilateral lower extremity cellulitis and end stage Alzheimer's disease. He was discharged on [DATE].

Patient #3's record included a Nurses' Note dated 10/16/15 at 9:45 PM. The note stated all available male assistance/security officers were called due to Patient #3's escalating aggression. The note further stated "Officers restrained patient with bed sheets for patient's and staff's safety." Patient #3's record included a Nurses' Note dated 10/16/15 at 11:35 PM. It stated security officers were in Patient #3's room, and he was released from the sheet restraints placed by the officers.

During an interview on 11/18/15 at 11:10 AM, the Assistant CNO reviewed Patient #3's record. She stated it was not the hospital's practice to restrain patients with sheets.

The Director of ICU was interviewed on 11/19/15 at 11:15 AM. He stated he was the chair of the Restraint Committee for the hospital. When asked if the hospital used sheets to restrain patients, he stated "No, never."

The hospital utilized off duty Police Officers as hospital security officers. Training records for 3 Security Officers scheduled for duty on 11/19/15 were requested, including records for the Security Officer who restrained Patient #3 noted above. The hospital provided documents titled "Idaho Peace Officer Standards and Training," dated 1/01/15, for all 3 Security Officers. The documents included a record of training such as firearms training, stalking investigations, and arrest techniques. No training specific to hospital duties, including hospital restraint training, was included in training reports.

The Director of Risk Management was interviewed on 11/19/15 beginning at 12:00 noon. He stated there was no record of hospital training for Security Officers, including restraint training.

The hospital used a system for the management of behavior called "Non Violent Crisis Intervention (NVCI)."

The on duty Security Officer was interviewed on 11/19/15 beginning at 8:40 AM. He stated Security Officers participated in the placement of restraints for patients with violent or self destructive behavior. The Security Officer stated he had not received restraint training at the hospital. He stated he did not know what behavior management system the hospital used. He stated he did not know what the acronym NVCI stood for. He stated he did not use the hospital's behavior management system. He stated, if Security Officers responded to a call regarding patients' acting out, then the nurses deferred to the officers to help things calm down.

Staff members who restrained patients were not trained by the hospital.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, review of patient rights information, and staff and patient interview, it was determined the hospital failed to ensure 3 of 4 current patients (#11, #12, and #13), who were interviewed, were informed of their rights. This prevented patients from exercising their rights. Findings include:

1. Patients were not aware of their rights. Examples include:

a. Patient #11 was interviewed on 11/18/15 between 11:30 AM and 12:15 PM. She was a current patient who was admitted on [DATE]. She stated she was not given a copy of the patient rights and had not been informed of her rights by staff.

b. Patient #12 was interviewed on 11/18/15 between 11:30 AM and 12:15 PM. He was a current patient who was admitted on [DATE]. He stated he was not given a copy of the patient rights and had not been informed of his rights by staff.

c. Patient #13 was interviewed on 11/18/15 between 11:30 AM and 12:15 PM. He was a current patient who was admitted on [DATE]. He stated he was not given a copy of the patient rights and had not been informed of his rights by staff.

Patients were not informed of their rights.

2. The 3 current patients noted above each had a folder that contained information from the hospital but did not contain a copy of patient rights.

The Unit Secretary was interviewed on 11/18/15 beginning at 12:15 PM. She had folders of patient information she was preparing at the nursing station on the Medical/Oncology Unit. She stated the folders included a brochure outlining patient rights. The folders she was preparing did not include a copy of patient rights. She went into a back room and retrieved a box of patient rights brochures and placed them in the folders. The rights brochures were not in the folders in the rooms of the above patients.

The Nursing Director of the Medical/Oncology Unit was interviewed on 11/18/15 beginning at 2:05 PM. He stated the hospital did not use the patient rights brochures any more. He presented a bound patient handbook and stated the hospital kept one in each patient room. He took the surveyor into an empty room and there was a 3 ring binder in a drawer. This was different from the handbook presented earlier. The binder contained approximately fifty pages of material including the rights.

Staff members were not clear about a consistent method of informing patients of their rights. If booklets were placed in patient rooms, patients were not aware of this. The hospital failed to ensure patients were informed of their rights.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on patient record review, policy review and staff interview, it was determined the hospital failed to ensure the use of restraints was implemented in accordance with safe and appropriate techniques as determined by hospital policy for 1 of 2 patients (#3) who were restrained for violent or self destructive behavior and whose records were reviewed. This resulted in an inability of the hospital to ensure restraints were implemented in a safe and effective manner. The findings include:

1. The hospital's policy #391, Patient Restraint/Seclusion, effective 9/30/14, included a section titled "Second Tier of Review" which stated "A member of nursing administration/management (e.g., nursing supervisor, manager/director, CNO, etc.) will review the need for restraint or seclusion with the RN who has determined that the patient requires restraint or seclusion. The second tier of review will occur with the initial application of restraint or seclusion."

Patient #3's record included a Nurses' Note dated 10/16/15 at 9:45 PM. The note stated all available male assistance/security officers were called due to his escalating aggression. The note further stated "Officers restrained patient with bed sheets for patient's and staff's safety."

Patient #3's record included a Nurses' Note dated 10/16/15 at 11:35 PM. It stated security officers were in Patient #3's room, he was released from the sheet restraints placed by the officers.

Patient #3's record did not include documentation of a Second Tier of Review during the 1 hour and 50 minutes he was restrained with sheets.

During an interview on 11/19/15 at 11:15 AM, the Director of ICU, who is the chair of the Restraint Committee, reviewed Patient #3's record and confirmed there was no Second Tier of Review after sheet restraints were applied.

Patient #3's need for restraint was not reviewed per hospital policy.

2. Refer to A168 as it relates to the failure of the hospital to ensure restraints were implemented in accordance with current, clear, and complete orders of physicians or other LIPs who were authorized to order restraints.

3. Refer to A171 as it refers to the failure of the hospital to ensure orders for restraint used to manage violent or self-destructive behavior were renewed every 4 hours in accordance with hospital policy.

4. Refer to A175 as it relates to the failure of the hospital to ensure the condition of patients who were restrained was monitored by trained staff.

5. Refer to A178 as it relates to the failure of the hospital to ensure a face-to-face meeting by a physician or LIP was conducted within 1 hour of the application of restraints used to manage violent or self-destructive behavior.

The hospital failed to ensure policies related to safe and appropriate use of restraints were followed.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, review of patient rights information, review of medical records and hospital policies, and patient and staff interview, it was determined the hospital failed to ensure patients' rights were protected and promoted. This resulted in the failure of the hospital to ensure each patient received care in a safe setting, and restraints were used safely and appropriately by qualified staff to protect the patient or others from harm. Findings include:

1. Refer to A117 as it relates to the failure of the hospital to ensure all patient were informed of their rights.

2. Refer to A118 as it relates to the failure of the hospital to ensure all patient were informed of whom to contact to file a grievance.

3. Refer to A144 as it relates to the failure of the hospital to ensure care was provided to patients in a safe setting.

4. Refer to A167 as it relates to the failure of the hospital to ensure the use of restraints was implemented in accordance with safe and appropriate techniques as determined by hospital policy.

5. Refer to A168 as it relates to the failure of the hospital to ensure restraints were implemented in accordance with current, clear, and complete orders of physicians or other LIPs who were authorized to order restraints.

6. Refer to A171 as it relates to the failure of the hospital to ensure orders for restraints used to manage violent or self-destructive behavior were renewed in accordance with hospital policy.

7. Refer to A175 as it relates to the failure of the hospital to ensure the condition of patients who were restrained was monitored by trained staff.

8. Refer to A178 as it relates to the failure of the hospital to ensure a face-to-face meeting by a physician or LIP was conducted within 1 hour of the application of restraints used to manage violent or self-destructive behavior.

9. Refer to A194 as it relates to the failure of the hospital to ensure security staff had education, training, and demonstrated knowledge to manage violent or aggressive patients.

The cumulative effects of these negative systemic practices seriously impeded the ability of the hospital to protect patient rights and provide services in a safe setting.