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.

COMANCHE COUNTY MEMORIAL HOSPITAL 3401 WEST GORE BLVD LAWTON, OK 73505 Oct. 30, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on clinical record review, hospital document and policy/procedure review and staff interview, it was determined the hospital does not meet the Condition of Participation for 42 CFR 482.13 - Patient's Rights. Findings:

1. The hospital failed to establish a time frame for review and response to patient grievances and failed to ensure this time frame was explained to patients in the patient's rights information provided at the time of admission. See Tag A 0122.

2. The hospital failed to ensure a written notice of the hospital's determination of the grievance investigation was provided to the complainant. See Tag A 0123.

3. The hospital failed to ensure restraints were used only to ensure the immediate safety of patients and staff and were discontinued at the earliest possible time. The hospital does not review and analyze restraint use, other than in the geriatric psychiatric unit, through the quality assessment and performance improvement (QAPI) program to ensure restraints are discontinued as soon as possible and are not used for staff convenience. See Tag A 0154.

4. The hospital failed to ensure the use of less restrictive interventions before the use of physical restraint. See Tag A 0164.

5. The hospital failed to ensure the type of restraints used were the least restrictive intervention available to maintain the patient's safety. See Tag A 0165.

6. The hospital failed to document the use of restraints in the plan of care. See Tag A 0166.

7. The hospital failed to ensure restrained patients were assessed immediately to verify restraints were safely and properly applied. See Tag A 0167.

8. The hospital failed to ensure restraints were used in accordance with physician's orders and failed to ensure hospital policies for restraints conformed to federal guidelines. See Tag A 0168.

9. The hospital failed to ensure restraints used to manage violent behavior were ordered according to appropriate time frames. See Tag A 0171.

10. The hospital failed to develop policies and procedures to discontinue restraints at the earliest possible time. See Tag A 0174.

11. The hospital failed to ensure a one hour face to face evaluation was done for patients restrained for violent or self-destructive behaviors. See Tag A 0178.

12. The hospital failed to ensure documentation in the clinical record gave a clear description of the patient's behavior that warranted the use of restraint. See Tag A 0185.

13. The hospital failed to ensure the staff documented the patient's response to restraints. See Tag A 0188.

14. The hospital failed to ensure staff were adequately trained to safely implement the use of restraints. See Tag A 0194.

15. The hospital failed to ensure all staff were trained and demonstrated skills competency related to the use of restraints. See Tag A 0208.

16. The hospital failed to document in the clinical record the date and time CMS (Centers for Medicare and Medicaid Services) was notified of the death of a patient during the use of restraints. See Tag A 0214.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of hospital documents and medical records and interviews with hospital staff, the hospital failed to ensure restraints were used in accordance with physician's orders and failed to ensure hospital policies for restraints conformed to federal guidelines.

Findings:

1. State Hospital Licensure Standards, Chapter 667, Subchapter 15-8, requires that a patient may be restrained only upon the order of a physician or licensed independent practitioner. "Orders for physical restraint shall include a statement of reason for the restraint and specify which approved facility methods and devices shall be used."

2. A hospital policy titled, "Restraints and Seclusion Behavioral Standards," documented, "... Use of restraints requires an order from a licensed independent practitioner... Order is time limited to 24 hours and must include reason for restraints, type of restraints... Renewal order must be done within 24 hours... RN may implement restraint and notify the physician within 8 hours..." The hospital policy stipulated that orders for restraints would comply with the regulations.

3. Patient #1 - The physician order, written by the emergency department physician, for restraint for agitation on 10/22/2012 did not specify the number and where "soft restraints" were to be applied or the duration. Wrist restraints were applied at 2045. At 2100, the nurse put the patient in four-point restraints (added bilateral lower restraints) without a physician's order to do so. Staff G, when interview on the afternoon of 10/30/2012 stated that at about 2215 she added a vest restraint because the patient broke the left wrist restraint. She stated the vest restraint did not replace the four-point restraint, but was in addition to it. She did not obtain an order for the restraint. These findings were confirmed by interview with Staff G.

4. Patient #4 - The clinical record documented the patient was restrained every day from 10/17/12 until his death on 10/23/12. There was no documentation of a physician's order to restrain the patient on 10/20/12, 10/22/12 and 10/23/12.

5. Patient #6 - The clinical record documented the patient was restrained every day from 07/23/12 until 07/31/12. There was no documentation of a physician's order to restrain the patient on 07/26/12, 07/27/12 and 07/3012.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on policy and procedure review, document review and staff interview, it was determined the hospital failed to establish a time frame for review and response to patient grievances and failed to ensure this time frame was explained to patients in the patient's rights information provided at the time of admission. Findings:

The hospital grievance policy and the hospital's patients' rights information was reviewed. Neither had documentation of time frames established for the hospital to respond to patient grievances.

Six patient grievances were reviewed. There was no evidence of a consistent written response time by the hospital. One grievance was reported on 02/24/12. No written response had yet been given to the complainant at the time of the survey.

Staff C confirmed the hospital had no time frame established for responding to patient grievances.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on policy and procedure review, document review and staff interview, it was determined the hospital failed to ensure a written notice of the hospital's determination of the grievance investigation was provided to the complainant. Findings:

The hospital grievance policy was reviewed. The policy did not document how a patient grievance should be addressed in writing.

Six patient grievances were reviewed. None of the responses by the hospital included documentation of investigation specific to each allegation in the grievances. Five of the written responses had no documentation of the hospital's findings or conclusions related to the grievances.

Staff C reviewed the grievances and confirmed this finding in an interview.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of hospital documents, policies and procedures and medical records and interviews with hospital staff, the hospital failed to ensure restraints were used only to ensure the immediate safety of patients and staff and were discontinued at the earliest possible time. The hospital does not review and analyze restraint use, other than in the geriatric psychiatric unit, through the quality assessment and performance improvement (QAPI) program to ensure restraints are discontinued as soon as possible and are not used for staff convenience.

Findings:

1. The surveyors requested QAPI and Patient Safety Committee meeting minutes that showed review and analysis of seclusion and restraints with plans of action when indicated to reduce the use of restraints. The information provided for medical-surgical units restraint use was only statistical information. It contained no information that showed restraints had been reviewed to ensure restraint uses were appropriate; removed as soon as possible; renewed as per policy; orders were complete and accurate; documentation showed specific patient behavior that warranted use/continued use. Meeting minutes did not reflect restraint use had been analyzed with action plans to reduce use.

2. Patient #2 - On 05/05/2012 at 0011, the patient pulled out his drain. The patient had exploratory surgery on 05/08/2012. The patient returned to the unit at 1745. Nursing notes did not document the patient had any demonstrated need for restraints. The nurse obtained a verbal order for bilateral soft wrist restraints at 1945. The order documented a duration of 24 hours or until family or one-to-one sitter was available. The top of the restraint flow sheet recorded the need for restraints as patient was "pulling at tubes/invasive lines". This was not evidenced in the nursing notes. The nursing note for 1945 documented the patient was sleeping. The note at 1945 documented the nurse could not provide instructions to the patient "due to falling asleep." Again at 2100, the nursing narrative documented the patient was sleeping. The restraint flow sheet 2000 and 2200 on 05/08/2012 and 05/09/2012 at 0200, 0400, 0600, and 0730 documented the patient was sleeping. Although the flow sheet contains a check mark that restraints needed to be continued, the nursing documentation does not support this. This finding was reviewed with Staff C at the time of review on the afternoon of 10/29/2012. No additional information was provided.

3. Patient #3 was admitted on [DATE] with Stage IV Hodgkin's [DIAGNOSES REDACTED] and respiratory failure. Upon admission, the nurses' notes documented the patient was confused, disoriented and "impulsively removes [oxygen] and replacement frequently..." There was no documentation the patient was uncooperative or was attempting to remove other lines such as the Foley catheter and a central IV line.

At 4:15 p.m., the nurse's notes documented the patient was found to have removed the BiPAP mask, but allowed replacement of it and then allowed oxygen to be applied by nasal cannula.

At 6:00 p.m., the nurses documented the patient was confused, but the "color was better". There was no other documentation of the patient's physical status or behavior or of any other nursing assessments or interventions.

At 7:10 p.m., the nurses documented a telephone order from the physician for the application of soft wrist restraints. Vital signs were documented at 7:15 p.m. At 7:44 p.m., the nurse's notes documented the patient had removed his oxygen but allowed the nursing staff to replace it. He cooperated with instructions to take deep breaths.

At 8:10 p.m., the nursing staff again found the patient without his oxygen and documented he was combative when the oxygen was reapplied. There was no documentation of a nursing assessment of the patient's condition, including an assessment for physical changes and assessment of pain and anxiety.

At 8:20 p.m., the nurse's notes documented soft wrist restraints were applied to both upper extremities. There was no documentation in the nursing notes or on the restraint form that indicated what less restrictive measures were used prior to the application of wrist restraints. There was no documentation of the patient's response to the application of the restraints.

Neither the nurse's notes, nor the restraint form documented other interventions attempted before the application of restraints.

The next vital signs were documented at 10:33 p.m. The nurse's notes documented the wrist restraints were taken off. At 12:15 a.m., the patient requested water and "verbalized he will not take O2 off if restraints taken off.." There was no documentation of the patient's behavior after this time.

At 1:21 a.m., nurse's notes documented, "... Wife and daughter called and set up password... Request for [no] wrist restraints to be reapplied and BiPAP set up. Also request for physician to be notified for pain and anxiety management..." There was no documentation the physician was notified and no new orders for pain or anxiety medications were documented. The restraint form indicated the wrist restraints were reapplied at this time.

At 3:00 a.m., the restraint form documented the wrist restraints were released, the patient given sips of water, and the restraints reapplied at 3:18 a.m. There was no documentation of an assessment of the patient, including vital signs and assessment for pain/ anxiety at this time. There was no documentation of the patient's behavior.

At 4:20 a.m., the patient was found without respirations and without pulse. The patient was pronounced dead at 4:33 a.m..

4. A review of hospital documentation of patients restrained in 2012 indicated 356 patients had been restrained so far in 2012. The document indicated there were multiple incidents were patients were restrained for multiple days during the hospitalization . Staff C stated the average length of stay at the hospital was 4-5 days. According to a hospital 2012 restraint data sheet:

~ one patient was restrained for 222 hours during a 9 day period
~ one patient was restrained for 236 hours during a 24 day period
~ one patient was restrained for 308 hours during a 23 day period
~ one patient was restrained for 382 hours during a 27 day period.

There were multiple instances of patients restrained for more than 72 hours, often more than 100 hours.

Staff C was asked if any of these cases of restraint had been reviewed in any administrative patient care or executive meeting. She stated they had not. She stated she thought some of this data was incorrect.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of medical record and policy and procedure review and staff interview, it was determined the hospital failed to ensure the use of less restrictive interventions before the use of physical restraint.

Findings:

1. Patient #2 - Nursing notes did not document if or what less restrictive measures, other that a sitter, had been attempted prior the patient being placed in restraints. The nurse obtained a verbal order for bilateral soft wrist restraints at 1945. The order documented a duration of 24 hours or until family or one-to-one sitter was available. The top of the restraint flow sheet recorded the need for restraints as patient was "pulling at tubes/invasive lines". This was not evidenced in the nursing notes. The nursing note for 1945 documented the patient was sleeping. The note at 1945 documented the nurse could not provide instructions to the patient "due to falling asleep." Again at 2100, the nursing narrative documented the patient was sleeping. The restraint flow sheet 2000 and 2200 on 05/08/2012 and 05/09/2012 at 0200, 0400, 0600, and 0730 documented the patient was sleeping. Although the flow sheet contains a check mark that restraints needed to be continued, the nursing documentation does not support this. This finding was review with Staff C at the time of review on the afternoon of 10/29/2012. No additional information was provided.

2. Patient #3 was admitted on [DATE] with Stage IV Hodgkin's [DIAGNOSES REDACTED] and respiratory failure. Upon admission, the nurses' notes documented the patient was confused, disoriented and "impulsively removes [oxygen] and replacement frequently..." There was no documentation the patient was uncooperative or was attempting to remove other lines such as the Foley catheter and a central IV line.

At 4:15 p.m., the nurse's notes documented the patient was found to have removed the BiPAP mask, but allowed replacement of it and then allowed oxygen to be applied by nasal cannula.

At 6:00 p.m., the nurses documented the patient was confused, but the "color was better". There was no other documentation of the patient's physical status or behavior or of any other nursing assessments or interventions.

At 7:10 p.m., the nurses documented a telephone order from the physician for the application of soft wrist restraints. Vital signs were documented at 7:15 p.m. At 7:44 p.m., the nurse's notes documented the patient had removed his oxygen but allowed the nursing staff to replace it. He cooperated with instructions to take deep breaths.

At 8:10 p.m., the nursing staff again found the patient without his oxygen and documented he was combative when the oxygen was reapplied. There was no documentation of a nursing assessment of the patient's condition, including an assessment for physical changes and assessment of pain and anxiety.

At 8:20 p.m., the nurse's notes documented soft wrist restraints were applied to both upper extremities. There was no documentation in the nursing notes or on the restraint form that indicated what less restrictive measures were used prior to the application of wrist restraints. There was no documentation of the patient's response to the application of the restraints.

Neither the nurse's notes, nor the restraint form documented other interventions attempted before the application of restraints.

The next vital signs were documented at 10:33 p.m. The nurse's notes documented the wrist restraints were taken off. At 12:15 a.m., the patient requested water and "verbalized he will not take O2 off if restraints taken off.." There was no documentation of the patient's behavior after this time.

At 1:21 a.m., nurse's notes documented, "... Wife and daughter called and set up password... Request for [no] wrist restraints to be reapplied and BiPAP set up. Also request for physician to be notified for pain and anxiety management..." There was no documentation the physician was notified and no new orders for pain or anxiety medications were documented. The restraint form indicated the wrist restraints were reapplied at this time.

At 3:00 a.m., the restraint form documented the wrist restraints were released, the patient given sips of water, and the restraints reapplied at 3:18 a.m. There was no documentation of an assessment of the patient, including vital signs and assessment for pain/ anxiety at this time. There was no documentation of the patient's behavior. There was no documentation found in the clinical record that indicated any other interventions (other than increased staff observation and placement closer to the nurse's station) was attempted prior to the use of restraints.

At 4:20 a.m., the patient was found without respirations and without pulse. The patient was pronounced dead at 4:33 a.m..

3. Patient #6 was admitted to a room and placed in soft wrist restraints. The nurse's notes stated the wrist restraints were "applied for pt safety and to prevent pulling of Foley & IV..."
Prior to the application of the restraints, there was no documentation the patient had been unsafe or had tried to pull the Foley catheter or the IV. There was no later documentation of any behaviors or symptoms that warranted the use of wrist restraints. Further review of the patient's record indicated he remained restrained for the entire 8 days of admission. Other than confusion and trying to touch the Foley catheter, there was no documentation of behaviors that warranted restraints. There was no documentation found in the clinical record that indicated any other interventions (other than increased staff observation and placement closer to the nurse's station) was attempted prior to the use of restraints. The patient was restrained even while visitors were at the bedside. He was restrained until two hours before his discharge to a nursing home.

4. A review of three other clinical records had documentation of the same three less restrictive interventions: increased staff observation, placement closer to the nurse's station and emotional comfort. None of the clinical records documented any different interventions attempted before restraints were used. Staff B was asked if staff should document all interventions attempted before restraints are used. She stated staff documented less restrictive interventions on the restraint flow sheet by using the "check" boxes. She was asked if other interventions might be appropriate for different patients. No response was made.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure the type of restraints used were the least restrictive intervention available to maintain the patient's safety. Findings:

A hospital policy, titled "Restraints and Seclusion Behavioral Standards," documented, "... All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff... Restraint... must be discontinued at the earliest possible time... Restraint... may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm... The type or technique of restraint... used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm...


1. Patient #2 - On going nursing notes did not document continues assessment and trial of less restrictive alternative to restraints were identified or tried. The nurse obtained a verbal order for bilateral soft wrist restraints at 1945. The order documented a duration of 24 hours or until family or one-to-one sitter was available. The top of the restraint flow sheet recorded the need for restraints as patient was "pulling at tubes/invasive lines". This was not evidenced in the nursing notes. The nursing note for 1945 documented the patient was sleeping. The note at 1945 documented the nurse could not provide instructions to the patient "due to falling asleep." Again at 2100, the nursing narrative documented the patient was sleeping. The restraint flow sheet 2000 and 2200 on 05/08/2012 and 05/09/2012 at 0200, 0400, 0600, and 0730 documented the patient was sleeping. Although the flow sheet contains a check mark that restraints needed to be continued, the nursing documentation does not support this. The nursing narrative note for 05/09/2012 at 0030 documented the patient had wrist restraints bilaterally to prevent pulling out lines, but the documentation does not record that the patient attempted to pull at the tubes/lines whenever he was reassessed or released or if any other less restrictive measure were tried. This finding was review with Staff C at the time of review on the afternoon of 10/29/2012. No additional information was provided.

2. Patient #3 was admitted on [DATE] with Stage IV Hodgkin's [DIAGNOSES REDACTED] and respiratory failure. Upon admission, the nurses' notes documented the patient was confused, disoriented and "impulsively removes [oxygen] and replacement frequently..." There was no documentation the patient was uncooperative, combative or was attempting to remove other lines such as the foley catheter and a central IV line.

At 4:15 p.m., the nurse's notes documented the patient was found to have removed the BiPAP mask, but allowed replacement of it and then allowed oxygen to be applied by nasal cannula.

At 6:00 p.m., the nurses documented the patient was confused, but the "color was better". There was no other documentation of the patient's physical status or behavior or of any other nursing assessments or interventions.

At 7:10 p.m., the nurses documented a telephone order from the physician for the application of soft wrist restraints. Vital signs were documented at 7:15 p.m. At 7:44 p.m., the nurse's notes documented the patient had removed his oxygen but allowed the nursing staff to replace it. He cooperated with instructions to take deep breaths.

At 8:10 p.m., the nursing staff again found the patient without his oxygen and documented he was combative when the oxygen was reapplied. There was no documentation of a nursing assessment of the patient's condition, including an assessment for physical changes and assessment of pain and anxiety.

At 8:20 p.m., the nurse's notes documented soft wrist restraints were applied to both upper extremities. There was no documentation in the nursing notes or on the restraint form that indicated what less restrictive measures were used prior to the application of wrist restraints. There was no documentation of the patient's response to the application of the restraints.

Neither the nurse's notes, nor the restraint form documented other interventions attempted before the application of restraints.

The next vital signs were documented at 10:33 p.m. The nurse's notes documented the wrist restraints were taken off. At 12:15 a.m., the patient requested water and "verbalized he will not take O2 off if restraints taken off.." There was no documentation of the patient's behavior after this time.

At 1:21 a.m., nurse's notes documented, "... Wife and daughter called and set up password... Request for [no] wrist restraints to be reapplied and BiPAP set up. Also request for physician to be notified for pain and anxiety management..." There was no documentation the physician was notified and no new orders for pain or anxiety medications were documented. The restraint form indicated the wrist restraints were reapplied at this time.

At 3:00 a.m., the restraint form documented the wrist restraints were released, the patient given sips of water, and the restraints reapplied at 3:18 a.m. There was no documentation of an assessment of the patient, including vital signs, and assessment for pain/ anxiety at this time. There was no documentation of the patient's behavior.

At 4:20 a.m., the patient was found without respirations and without pulse. The patient was pronounced dead at 4:33 a.m..

3. Patient #6 was maintained in soft wrist restraints for the entire eight days of admission. There was no documentation of other interventions that were attempted prior to the use of restraints. There was no evidence of periodic trials at other interventions during the useof restraints. Even when family members were at the bedside, the wrist restraints remained in place. Except on one occassion when the patient complained directly of being in pain, there was no documentation pain and/or anxiety medications were attempted at any other time during the use of restraints.

4. Patient #4 was first restrained on 10/17/12. The patient was administered propofol and then placed on a mechanical ventilator. Although the patient was remained on propofol and was completely sedated and non-responsive, the clinical record documented the patient remained restrained until 10/23/12. Staff D was asked if there was an ICU protocol that stated a ventilator patient should remained restrained. He stated he was not aware of any policy like that.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to document the use of restraints in the plan of care for six of six patients who were reviewed for the use of restraints. Findings:

1. A hospital policy titled, "Restraints and Seclusion Behavioral Standards," documented, "... The nurse will develop goals for the patient to determine if the less restrictive manner is being applied, and the use of restraints is meeting the intended goals. These goals are documented on the restraint flow sheet...." The policy had no other instruction for care planning for a patient who required restraints.

2. Six clinical records for patients who were restrained were reviewed for evidence the nursing staff identified problems, goals and individualized less restrictive interventions for the use of restraints.

Three restraint forms had no documentation of less restrictive measures taken before restraints were applied. None of the six had documentation of daily progress goals.

3. None of the comprehensive care plans documented the use of restraints and/or had updates to the use of restraints as needed.

Staff C was informed of this finding. No response was made.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on clinical record, policy and procedure review and staff interview, it was determined the hospital failed to ensure restrained patients were assessed immediately to verify restraints were safely and properly applied. Findings:

A hospital policy titled, "Restraints and Seclusion," documented, "... Application of Physical Restraints: Follow manufacturer's guidelines..." The policy did not include what type of physical restraints were used by the hospital. No manufacturers' instructions were attached to the policy.

The policy did not direct staff to assess restrained patients for safe and proper application, including at the time of the first application, and when restraints were reapplied after care was provided.

Staff D stated the hospital used soft limb restraints, soft vest restraints, mittens and vinyl restraints. He stated staff were trained to apply restraints during new employee orientation.

A review of staff training materials had no reference to the type of restraints were used in the hospital and how each should be applied and assessed for safe application.

Six clinical records for restrained patients were reviewed. None of the records had documentation restraints were immediately assessed for safe and proper application at any time.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure the staff documented the patient's response to restraints. Findings:

A hospital policy for restraint and seclusion did not direct staff to document the patient's response to the application of restraints.

Clinical records for six patients who were restrained contained no documentation of the patients' response to the restraints.

Staff D stated documentation was a problem. He stated he was not aware a response to restraints should be documented.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure restraints used to manage violent behavior were ordered according to appropriate time frames. Findings:

A hospital policy titled, "Restraints and Seclusion," documented, "... Behavioral Health Standards For Physical/Mechanical Restraint:.. Renewal order must be done within 8 hours..."

DOCUMENTATION:... All orders for... behavioral restraints shall contain time limitation not to exceed 4 hours for adults..."

Hospital documents indicated patient #5 was restrained for 124 hours during a seven day hospitalization . Nurse's notes on the second day of admission (07/03/12) indicated the patient was "aggressive and dangerous to self and others."

Bilateral wrist restraints were ordered for "pt's non-compliance with Dr. orders x 24 hours..." Two hours later, bilateral lower extremity restraints were ordered for "potential harm to self and others x 24 hours..." There was no order for a vest restraint.

The restraint flowsheet documented the patient was restrained with bilateral upper and lower restraints and a vest restraint for 10 hours on that day.

On the next day, 07/04/12, the physician renewed the order for bilateral upper and lower restraints and a chest restraint for a period of 24 hours. Nurses' notes documented the patient was "agitated... screaming... non-compliant with care... obnoxious..."

The patient was restrained, in varying degrees, over the remainder of the hospitalization for behavioral problems including verbal/physical aggression and attempts to leave the hospital.

None of the physician's orders for restraints due to behavioral problems were time limited less than 24 hours.

Staff C was asked if there were different ordering guidelines for patients restrained due to behavioral problems. She reviewed the policy and stated it was not clear.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to develop policies and procedures to discontinue restraints at the earliest possible time. Findings:

A review of the hospital's policy and procedure on restraints indicated the following guidance for removal of a restraint:

"... Criteria for removal from a restraint shall be that the patient no longer meets the criteria for the restraint and/or is no longer a danger to themselves or others..." No other guidance was found in the policy for discontinuing restraints.

The policy did not address assessment of the patient at the time restraints are removed, the patient's response to removal of restraints and the required documentation of this in the clinical record. The policy did not address who was qualified to make a decision to discontinue restraints.

A review of clinical records for six patients who were restrained during hospitalization had no documentation the patients were assessed to no longer be a danger to themselves or others at the time restraints were removed.

According to the clinical record for patient #5, it appeared the patient was restrained until the time of discharge. The patient was discharged home in a cab.

A review of patient restraints for 2012 documented patients had been restrained for extended periods of time, including one patient who had been restrained 308 hours during a 23 day stay in the hospital.

Staff D was asked if staff were trained on policies and procedures on earliest removal of restraints. He stated they were.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on clinical record review and staff interview, it was determined the hospital failed to ensure a one hour face to face evaluation was done for patients restrained for violent or self-destructive behaviors. Findings:

A hospital policy, titled "Restraints and Seclusion Behavioral Standards," documented, "... A Registered Nurse trained in seclusion/behavioral restraints may perform the 'face to face' evaluation, but the licensed independent practitioner treating the patient must be consulted as soon as possible... The charge nurse (RN) will conduct a clinical assessment of the patient's physical and psychological condition, write the order and record the assessment in the clinical record within 60 minutes of implementing the seclusion or behavioral restraint..."

The clinical record for patient #5 documented the patient was placed in soft wrist restraints "due to dangerous behavior." There was no documentation that described the "dangerous behavior." No comprehensive assessment of the patient's physical and psychological condition was found in the record.

An hour and forty-five minutes later, the nursing staff documented, "...advised MD of pt's aggressive and dangerous behavior... [doctor name deleted] advised he would be to unit to see pt after surgery is completed..."

Fifteen minutes later the nursing staff documented, "...Pt's behavior continues to be harmful to self and others. Call to [doctor] to advise that pt's behavior continues to be violent and dangerous to self and others. Orders for 4 [point] restraints..."

An hour later, the nursing staff documented, "... Pt sitting up pulling at restraints and IV lines. Aggressive to staff. MD requested no further calls until after surgery..."

An hour later, the nursing staff documented, "... Pt sitting up in bed yelling and aggressive..."

Four and a half hours after the patient was placed in restraints for violent behavior, the MD evaluated the patient face to face.

Staff D was asked if all nurses were trained to evaluate a patient in need of physical restraints. He stated they were. He was asked if the documentation reflected accurately what was happening with the patient and a thorough physical and psychological assessment. He stated documentation was a problem.

He was asked if the one hour face to face evaluation applied to all areas of the hospital. He stated it applied to the behavioral health areas of the hospital.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0185
Based on clinical record review and staff interview, it was determined the hospital failed to ensure documentation in the clinical record gave a clear description of the patient's behavior that warranted the use of restraint. Findings:

The clinical record for patient #5 documented the patient was placed in soft wrist restraints "due to dangerous behavior." There was no documentation that described the behavior. No documentation of a comprehensive assessment of the patient's physical and psychological condition at the time of the restraint was found in the record.

An hour and forty-five minutes later, the nursing staff documented, "...advised MD of pt's aggressive and dangerous behavior..." No description was given of the patient's aggressive, dangerous behavior.

Fifteen minutes later the nursing staff documented, "...Pt's behavior continues to be harmful to self and others. Call to [doctor] to advise that pt's behavior continues to be violent and dangerous to self and others. Orders for 4 [point] restraints..." No clear description of what the patient was doing that was harmful to self and others was found in the clinical record.

An hour later, the nursing staff documented, "... Pt sitting up pulling at restraints and IV lines. Aggressive to staff. MD requested no further calls until after surgery..." There was no description of what "aggressive to staff" meant.

An hour later, the nursing staff documented, "... Pt sitting up in bed yelling and aggressive..." No other description of the patient's behavior was found in the clinical record.

There was no documentation of the patient's response when the wrist restraints were first applied. There was no documentation of the patient's response when the ankle restraints were added.

The restraint flow sheet documented the patient also was placed in a vest restraint. There was no documentation of this application in the nurses' notes and no documentation of the patient's response.

Staff D was asked if all nurses were trained to evaluate a patient in need of physical restraints. He stated they were. He was asked if the documentation reflected accurately what was happening with the patient and a thorough physical and psychological assessment. He stated documentation was a problem.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0194
Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure staff were adequately trained to safely implement the use of restraints. Findings:

A hospital policy, titled "Restraints and Seclusion Behavioral Standards," documented, "... All staff involved in restraining a patient will have annual training in restraints... Training educated staff about minimizing the use of restraints. Training will include identification of underlying causes, how staff can affect the behaviors of patients, de-escalation, and mediation, self-protection, and behavior modification techniques. Direct care staff will also receive on-going training in safe use of restraints and the application and removal of mechanical restraints..."

Staff D stated new employees were trained on the restraint policy on "day two" of orientation and were required to demonstrate competency with the use of restraints.

The new employee orientation agenda had no documentation of restraint training for any day of the orientation process.

The restraint training materials given to employees were reviewed. The new employee orientation packet had a four slide presentation on the use of restraints. One slide described a patient scenario for the use of restraints, the next two slides had broad general information about the use of restraints. The last slide was a copy of the restraint flow sheet.

There was no evidence any other printed materials on restraints (such as a copy of the policy and procedure) were given to the new employees. There was no evidence the staff were trained on all elements as described in the hospital policy and procedure.

Other than training on the use of the restraint flow sheet, there was no evidence of training in the comprehensive documentation requirements for the use of restraints.

Staff B stated all nursing employees were re-trained annually "on-line" for restraints. Training records for nursing staff were reviewed. Not all staff had documentation of annual restraint training on-line. Those who did have evidence of training had documentation of a 20 minute review that included a five question test.

Staff B provided a hard copy of the "on-line" training materials. It was a sixteen part lesson, generic in nature, and was not modified for the specific practices of the hospital.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0208
Based on record review and staff interview, it was determined the hospital failed to ensure all staff were trained and demonstrated skills competency related to the use of restraints. Findings:

Staff training records were reviewed for nine clinical staff who were involved in the restraint of a patient. The sample included one agency nurse who was involved in a restraint, and one house supervisor who was on duty when a death in a restraint occurred.

Four of the nine staff, including the agency nurse, had no documentation of current training and/or competencies on restraints.

The house supervisor had no documentation of nursing management responsibilities related to the oversight of restraints.

Staff D was asked if the house supervisors received any additional training in the restraint regulation requirements. He stated he was not sure. He was asked if the house supervisors were aware of all patients currently in restraints when they are on shift. He stated he was not aware of a mechanism for that.
VIOLATION: PATIENT RIGHTS: SECLUSION OR RESTRAINT Tag No: A0214
Based on review of patient medical records and hospital documents, the hospital failed to document in the clinical record the date and time CMS (Centers for Medicare and Medicaid Services) was notified of the death of a patient during the use of restraints. Findings:

1. A hospital policy titled, "Restraints and Seclusion Behavioral Standards," documented,
"... Reporting:... The date and time the death was reported to the CMS Regional Office will be documented in the patient's medical record by the supervisor who made the call..."

2. Four clinical records were reviewed for patients who had died while in restraints. None of the clinical records had documentation CMS had been notified of the patient's death while restrained.

3. On 10/3012, Staff F stated the hospital did not document notification of CMS in the clinical record. She stated the hospital kept a log of deaths in restraints and it included the date and time CMS was notified.