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.

INTEGRIS SOUTHWEST MEDICAL CENTER 4401 SOUTH WESTERN AVENUE OKLAHOMA CITY, OK 73109 June 8, 2015
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0159
Based on review of hospital documents and staff interview, the hospital failed to identify devices used as restraints throughout the hospital.

Findings:

Review of a hospital policy, with the subject, "Restraint and Seclusion", reviewed 01/2015, documented, "...Only hospital approved restraint devices will be utilized..."

Surveyors requested a list of the hospital approved restraints. None was provided.

Hospital leadership staff stated the hospital does not have a list of approved restraint devices.

On 06/05/2015 at 2:10 p.m., Staff J stated the types of restraints used at the hospital were soft, leather, Posey vest, mittens, lap belts, and all four siderails in the up position.

On 06/08/2015 at 3:45 p.m., Staff BB stated the types of restraints used at the hospital were Posey vest, lap belt, soft, pelvic and "vail bed".
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
Based on review of hospital documents and staff interviews, the hospital failed to ensure less restrictive interventions were attempted before physical restraints were used for three (#4, 5, 6) of three patient identified with restraints.

Findings:

Review of a a hospital policy, with the subject "Restraint and Seclusion", reviewed 01/2015 documented, " ... Restraint is to be initiated only after alternative interventions have been deemed ineffective and an individualized patient assessment.."

Medical records for Patients #4, 5 and 6 documented the patients were restrained during the course of the hospitalization .

The medical records for Patients #4, 5 and 6 had no documentation the staff attempted to use less restrictive interventions before placing the patients in restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of hospital documents and interviews with hospital staff, the hospital failed to ensure restraints were applied in accordance with physician orders. This occurred in three of three (# 4, 5, 6) patients in restraints.

Findings:

1. A hospital protocol/procedure, with the subject, "Restraint Usage", reviewed 06/2013, documented, "...Once criteria for release of restraints have been met, a new physician order must be obtained unless the following conditions are present. 5.2.6.1. The need for reapplication of restraints falls within the time limits of the original order. 5.2.6.2 The reason for the reapplication of restraints is the same as noted in the original order..."

2. On 06/08/2015 at 3:45 p.m., Staff BB stated no new physician order was obtained when the restraint type is changed or when restraints are reapplied.

3. Record #4- The medical record did not contain orders for specific restraints. The physician orders were for soft restraints and all four siderails in the up position. Nursing staff documented the patient was restrained with a lap belt. There were no physician orders for the lap belt.

The medical record documented the patient was unrestrained at 12:00 p.m. on 05/21/2015. Restraints were reapplied on 05/21/2015 at 6:00 p.m. The medical record did not contain physician orders for the reapplication of the restraint.

Nursing staff documented the patient was was in a lap belt and all 4 siderails were in the up position on 05/24/2015 and 05/27/2015. The medical record did not contain physician orders for the use of restraints for 05/24/2015 and 05/27/2015.

3. Record #5- the medical record documented the patient was restrained from 04/24/2015 until 05/11/2015. Soft, enclosure"vail" bed, Posey Vest and pelvic were the types of restraints ordered by the physician. Nursing staff documented that a lap belt was also used on the patient. The medical record did not contain physician orders for the use of the lap belt.

4. Record #6- The medical record documented the patient was restrained from 05/19/2015 until 06/06/2015. Nursing staff documented that a lap belt was used on the patient. The medical record did not contain physician orders for the use of the lap belt.
VIOLATION: QAPI Tag No: A0263
Based on review of hospital documents and interviews with hospital staff, the hospital failed to ensure the Quality Assessment and Performance Improvement (QAPI) program:

a. evaluated services provided under contract;
b. analyzed and tracked grievances, pressure ulcers and restraint usage to improve patient care; See Tag A-0283
c. analyzed and tracked medication errors and adverse events. See Tag A-0286.

Findings:

In the afternoon of 06/03/2015, surveyors requested a list of all contracted services to include contracted individuals and services provided.

The contracted services list provided was updated on 07/01/2014. The list was reviewed by the surveyors. The list did not contain the shared services agreement or lease arrangements.

On 06/05/2015 at 1:55 p.m., Staff B stated the contract list provided to the surveyors did not include all services provided under contract or agreement.

The QAPI committee meeting minutes for the past 12 months were reviewed on the morning of 06/04/2015.

There was no documentation that all contracted services were evaluated through QAPI.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on review of hospital documents and interviews with hospital staff, the hospital's Quality Assessment and Performance Improvement (QAPI) program failed to analyze and track grievances, pressure ulcers and restraint usage to improve patient care.

Findings:

Review of the hospital's QAPI Plan for Fiscal Year (FY) 2015 documented, incidence and prevalence of pressure ulcers and restraint use as part of the Quality Improvement Plan for FY 2015.

The hospital QAPI meeting minutes for the past 12 months were reviewed. There was evidence that grievances, pressure ulcers and restraint data was reviewed and analyzed as a part of the QAPI program.

On 06/04/2015 at 8:55 a.m., Staff R stated restraints were not monitored or analyzed through the hospitals QAPI program.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on review of hospital documents and interviews with hospital staff, the hospital failed to ensure medication errors and adverse events were were analyzed and tracked through the Quality Assessment and Performance Improvement (QAPI) program.

Findings:

The hospital's QAPI meeting minutes for the past 12 months were reviewed.

Review of the QAPI meeting minutes did not contain evidence that medication errors and adverse events data collected by the pharmacist were tracked and analyzed through the QAPI program.

Integris Southwest Medical Center (ISMC) has an off-site rehabilitative (rehab) unit located on the campus of a different acute care hospital.

On 06/05/2015 at 1:30, the pharmacist stated ISMC did not monitor the medication errors and adverse events at the off-site campus.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of hospital documents and interviews with hospital staff, the hospital failed to ensure:

a. the supervising registered nurse assured nurses, when skin issues occurred, provided evaluations and interventions to remediate or reduce the development of open pressure ulcers. Refer to Tag A-0395.

b. nurses provided complete skin assessments with evaluation, interventions and reevaluations. Refer to Tag A-0395.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on hospital documents and medical record review, and interviews with hospital staff, the hospital failed to ensure the registered nurse (RN) assessed, planned, supervised and reassessed/evaluated the nursing needs and care for nine (Patients # 2, 4, 5, 6, 8, 9, 10, 11, 12) of twelve patient medical records reviewed.

Findings:

Pressure areas/wounds:
1. On 06/04/2015, the surveyors asked for the hospital's policies concerning wound care.

a. Only one hospital policy was furnished to the surveyors. The policy titled, "Wound Care Consult" dated 02/15/2015, documented, "a Consult for Wound Care ...Requires a physician order ...Notify the Wound Care Team (WCT) of Referral ...WCT evaluates wound within 24 hours of consultation, no inpatient wound care on Sundays and Holidays ...If wound care is appropriate to be provided by the unit nurse, the Wound Care Team will teach nursing staff the wound care and be a resource person for any needs."

b. Administrative staff provided a large poster-board chart with information on prevention, recognizing, staging and treatment of pressure ulcers/wounds.

c. On 06/08/2015 at 1:15 p.m., Staff EE told the surveyors that nursing service received education on all aspects of pressure wounds. Staff EE stated the education was based on the National Pressure Ulcer Advisory Panel's recommendations/standards. Staff EE stated that the electronic record also had the availability for nursing staff to reference the same material while charting. Staff EE stated that patients with Stage I were to use a barrier patch such as Mepilex and "cream". When asked if the pressure area was visible for assessment, she stated that, as depicted on the education board, nursing staff were to "peel and peek" every shift for accurate documentation of the skin.

d. On 06/08/2015 at 1:20 p.m., Staff GG showed the surveyor the chart/guidance available in the electronic medical record. The chart matched the poster-board chart shown prior.


2. The surveyors interview staff concerning how and when the wound care nurse would be involved or provide wound care. The surveyors were told the following:

a. On 06/03/2015 at 2:15 p.m., Staff E told the surveyors that the electronic medical record system generated a "system" order to the Wound Care Nurse (Staff G) when a nurse charged the patient had a Stage I and Staff G would come evaluate the patient's skin area.

b. On 06/03/2015 at 3:30 p.m., Staff M told the surveyor that the electronic medical record system automatically populated an order for wound care. Staff M stated Staff G would assess the patient and ask staff about the patient's condition. Staff M stated Staff G would decide what needed to be done.
c. On 06/04/2015 at 9:10 a.m., Staff G told the surveyors that she sees the patient when there was a physician's order for wound care. Staff G stated she did not place the patient on the wound care assignment when there was a decreased Braden scale. Staff G stated that "sometimes" she would receive a "system order - an alert of potential problem with a patient". Staff G stated she would go talk with the nurse and ask if the patient had an open area. Staff G stated she would go assess those patients with open areas/open wounds. Staff G stated that if it was just a red prone area, she would not assess the patient - the nurses would handle. If the area progressed to a Stage II, she would have the nurses get a physician's order.


3. Nursing staff failed to prevent the development of skin breakdown as evidenced by failure to assess, monitor and report changes in skin condition and failed to consistently intervene as needed.

a. Patient #2 - The patient was admitted on [DATE] with recorded blanchable redness to the buttocks and coccyx area. The patient had limited mobility.

~ On 05/22/2015 at 8:00 p.m., the nursing assessment recorded the same area on Patient #2 as a Stage I (no dimensions or exact location documented) pressure ulcer.

~ On 05/23/2015 at 6:00 p.m., the nursing assessment recorded the same area on Patient #2 as an unstageable pressure ulcer.

~On 05/25/2015 at 4:00 a.m., the nursing assessment recorded no pressure ulcer was present and the area had blanchable redness for Patient #2.

~ On 05/26/2015 (no time recorded) the Staff G recorded, on a computerized note supplied by leadership staff, that she talked with the nurse and was told that Patient #2 had a Stage I to the coccyx; the "Wound care team" was discontinued; and Calazime cream was ordered. There was no documentation the patient was assessed by Staff G.

~ On 05/30/2015 on the assessment for 10:00 p.m., the nurse documented the same area as a Stage II (indicated an open wound) pressure area for Patient #2 (no dimensions or exact location documented).

~ On 05/31/2015 at 8:22 a.m., the nurse documented in a nursing entry/assessment that Mepilex had been ordered to cover the wound until Patient #2 was seen the by the wound care nurse.

~ The first documented assessment by Staff G was on 06/01/2015 at 6:52 a.m. Staff G recorded that the patient had two separate ulcer areas: #1 was a Stage II, located on the coccyx/sacrum, measuring 3.8 centimeters (cm) by 4.2 cm; and #2 was a Stage I, located on the left iliac crest posterior aspect, measuring 3 cm by 3 cm. Staff G also documented a specialty bed would be ordered.

~ Positioning records documented the patient was not turned every two (2) hours eight of ten days reviewed. For example, but not limited to:
On 05/25/2015, patient positioning recorded Patient #2 was on the back from 12:00 p.m. until 8:00 p.m.; and
On 05/30/2015, Patient #2 was on the back or left side the entire day and was positioned on the back from 6:00 p.m. until 10:00 p.m.

~The medical record did not contain evidence Patient #2 refused to turn every two hours.

~ The medical record did not contain evidence nurses taught Patient #2 about the importance of changing positions frequently.


b. Patient #9 - The patient was admitted on [DATE] without any skin impairment.

~ On 04/23/2015, nursing assessments identified Patient #9 as bedfast and needing total assistance.

~ Positioning records documented Patient #9 was not turned every two (2) hours thirty-two of forty-four days reviewed after identification of needing total assistance. For example, but not limited to: The patient was positioned on the left side on 04/27/2015 at 5:00 p.m. and remained on the left side until 04/28/2015 at 3:00 a.m.

~ On 04/23/2015 at 8:00 a.m., the nursing assessment recorded Patient #9 had pressure areas without redness (no dimensions or exact locations charted).

~ On 04/25/2015 at 8:00 a.m., the nursing assessment recorded Patient #9 had bruising to the left hip, pink and purple in color and warm to touch (no dimensions or exact locations charted).

~ On 04/27/2015 at 7:00 a.m., the nursing assessment recorded, in addition to the bruising on the hip, Patient #9 had a Stage I pressure area on the coccyx/sacrum (no dimensions or exact locations charted). At 1:00 p.m., the nursing assessment recorded Mepilex dressing was applied to the pressure area.

~ On 05/06/2015 at 7:30 a.m., the nursing assessment recorded Patient #9's skin was not intact and the provider was notified, but the location of the skin breakdown was not documented. The assessment recorded the coccyx/sacrum was still a Stage I (indicating intact skin) pressure area. The nurse also recorded that the pressure area on the coccyx/sacrum was present on admission. Subsequent nursing assessments recorded the skin was intact with abnormalities - the Stage I pressure area on the coccyx (no dimensions or exact locations charted).

~ On 05/11/2015 at 4:00, the nursing assessment recorded Patient #9's coccyx/sacrum pressure area was a Stage II (open) with serosanguineous drainage.

~ On 05/12/2015 at 1:10 p.m., Staff G assessed Patient #9 and documented the patient had bilateral buttock and coccyx unstageable /necrotic tissue, measuring 9 cm by 9 cm. Staff G documented a specialty bed would be ordered.

~On 05/12/2015 at 4:00 p.m., the nursing assessment recorded Patient #9's skin as intact with no abnormalities, but that Mepilex covered the patient's coccyx/sacrum area. (This assessment was inconsistent with the wound assessment performed at 1:10 p.m. by Staff G, the wound care nurse.)

~ On 05/20/2015 at 11:45, Staff G recorded, in addition to the unstageable/necrotic pressure area on the coccyx/sacrum, Patient #9 had an open Stage III area on the left ear rim area measuring 0.5 cm by 0.5 cm that was left open to air. This was the first notation of a pressure ulcer to the ear.

~ On 05/21/2015 at 12: 34 p.m., Staff G recorded the bilateral buttock and coccyx unstageable/necrotic pressure area for Patient #9 had increased to 10 cm by 9 cm.

~ On 05/26/2015 at 12:13 p.m., Staff G documented the unstageable/necrotic pressure area on the coccyx/sacrum had total area of 10 cm by 10 cm with a 2 cm by 2 cm area at the patient left ischial area. Staff G documented the left ear rim Stage III pressure ulcer was still present and measured 0.5 cm by 0.5 cm.

~ On 06/01/2015 at 10:36 a.m., Staff G documented Patient #9 had three distinct/separate pressure ulcers: 1. Unstageable/necrotic on the bilateral buttock and coccyx measuring 10 cm by 7 cm; 2. Stage III on the left ear rim measuring 0.5 cm by 0.5 cm; and 3. Stage III on the left ischial tuberosity measuring 1.5 cm by 1.5 cm.


c. Patient #12 - The patient was admitted on [DATE] without skin impairments, but the patient had lower extremity weakness.

~ On 05/13/2015 at 9:00 p.m., the nursing assessment recorded Patient #12 had Stage I pressure areas on both heels (no dimensions or exact locations charted).

~ On 05/17/2015, the a.m. nursing assessment recorded Patient #12 had Stage I pressure areas on both heels (no dimensions or exact locations charted).

~ On 05/17/2015 at 9:00 p.m., the nursing assessment recorded Patient #12 had Stage II (open wounds) pressure ulcers on both heels (no dimensions or exact locations charted). This generated a "system wound care order" for wound care team involvement.

~ Although the medical record did not contain evidence Staff G saw Patient #12, the wound care assignment sheet for 05/18/2015 contained a pencil notation with Patient #12 name; no open wounds; "did not see pt (patient) - talked with Sarah"; and discontinued.

On 06/08/2015 at 9:00, Staff D told the surveyors that she had spoken with Staff G and she confirmed that she spoke with the nurse; was told the patient's skin was not broken; and therefore she (Staff G) did not assess the patient.

~ The same inconsistent charting of Patient #12's skin pressure areas was documented on both shifts for 05/18/2015.


Turning/repositioning:
1. The surveyors interviewed staff concerning turning and repositioning of patients and when it was performed. Nursing staff told the surveyors that patients were turned every two hours when there was a physician's order, the patient was bedfast with limited mobility, and/or if a low Braden Scale score was determined.
a. Staff M stated this on 06/03/2015 at 3:35 p.m.
b. Staff FF stated this on 06/05/2015 at 4:00 p.m.
c. Staff GG stated this on 06/08/2015 at 11:20 a.m.


2. The nurse failed to assure Patients #2, 9, 10, and 11 were turned every two hours. Patients #2, 9, 10, and 11 were documented as bedfast, limited mobility, and/or low Braden Scale evaluations, which signified a patient turning schedule of every two hours was required.

a. Patient #2 was not turned every two hours eight of ten days, for the time period of 05/23/2015 through 06/01/2015 reviewed.

b. Patient #9 was not turned every two hours thirty-two of forth-four days, for the time period of 04/23/2015 through 06/07/2015 reviewed. The surveyor reviewed the medical record with Staff GG on the afternoon of 06/08/2015. Staff GG confirmed the finding and told the surveyor the medical record did not contain evidence the patient refused to turn. Staff GG told the surveyor there was no documentation that the patient was taught about the importance of changing positions frequently.

c. Patient #10 was not turned every two hours three of seven days, for the time period of 05/30/2015 through 06/05/2015 reviewed. The surveyor reviewed the medical record with Staff FF on the afternoon of 06/05/2015. Staff FF confirmed the finding and told the surveyor the medical record did not contain evidence the patient refused to turn. She stated the medical record did not contain documentation the patient was taught about the importance of changing positions frequently.

d. Patient #11 was not turned every two hours twelve of twelve days, for the time period of 05/24/2015 through 06/04/2015 reviewed. On 06/05/2015, the physician ordered the patient to be turned every four hours. The surveyor reviewed the medical record with Staff GG on 06/08/2015 at 11:20 a.m. Staff GG confirmed the finding. Staff F told the surveyor the medical record did not contain evidence the patient refused to turn except twice on 06/03/2015 and once on 06/06/2015. At 11:35 a.m., Staff GG stated the medical record did not contain documentation the patient was taught about the importance of changing positions frequently.


Assessments/Reassessments and Interventions:
1. On the afternoon of 06/03/2015, Staff B and D told the surveyors that nursing staff performed complete - "head to toe" - assessments every twelve-hour shift.

2. Patients #4, 5 and 6 were restrained. The nurse failed to reevaluate the patients to determine whether restraints were indicated. Refer to Tag A-0154.

3. On 06/03/2015 at 1:30 p.m., Patient #8 told the surveyor that nursing staff had not performed a complete, head-to-toe, assessment of her skin since admission on 05/29/2015.
VIOLATION: PHARMACY ADMINISTRATION Tag No: A0491
Based on review of hospital documents and interviews with hospital staff the hospital failed to ensure pharmacy oversight for medications used in the hospital.

Findings:

Integris Southwest Medical Center (ISMC) has an off-site rehabilitative (rehab) unit located on the campus of a different acute care hospital.

Review of a hospital policy, with the subject "Periodic Inspection of Medication Areas", reviewed 04/2015, documented, "...To assure that all areas that store medications are reviewed periodically by pharmacy personnel to confirm that such areas meet all standards of safety, security and environmental conditions..."

On 06/05/2015 at 1:30 p.m., the hospital pharmacist was interviewed. The pharmacist stated that pharmacy services for the off-site rehab unit were not overseen by ISMC pharmacy. The pharmacist stated ISMC did not monitor adverse events and medication errors at the off site location.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of hospital documents, surveyor observations and staff interviews, the hospital failed to:

a. recognize grievances and follow its grievance process; See Tag A-0118

b. ensure restraints were applied for therapeutic reasons and were not used for the convenience of staff and discontinued/removed as soon as possible; See Tag A-0154

c. identify devices used as restraints throughout the hospital; See Tag A-0159

d. ensure restraints were applied in accordance with physician orders. See Tag A-0168.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on review of hospital documents and interviews with staff, the hospital failed to recognize grievances and follow its grievance process in three (Records #5, 9, and 13) of four grievance records reviewed.

Findings:

1. On 06/03/2015, Patient #9's representative stated a grievance was filed with the hospital concerning patient care issues. The grievance log did not show a grievance for Record #9.

~ On 06/05/2015 at 2:20 p.m., Staff R told the surveyors current patient grievances were not in the log. Staff R stated the hospital had until seven days after discharge to finish and send letters to complainants.

~ On 06/05/2015 at 2:50 p.m., Staff K told the surveyors that she did not "usually" fill out a grievance for current patients.

Staff K told the surveyor about a recent concern voiced by a family member concerning a patient's care. Staff K stated she told the complainant that she (Staff K) would investigate and review the concerns with staff. Staff K stated she communicated the concerns with other staff and to the physician.

When asked if she documented her investigation or provided a written response to the complainant, Staff K said she did not. Staff K stated she would only enter the complaint into the grievance system if the complainant was not satisfied with the results.

2. Record #5 - The grievance log recorded the grievance was resolved. The grievance investigation documentation and written response did not address all the concerns expressed in the grievance, including the allegation that the patient was placed in restraints.

~ On 06/05/2015 at 2:10 p.m., the above finding was reviewed with Staff R. No further documentation of investigation was provided.

3. Record #13 - The grievance log recorded the grievance was resolved. The documents provided recorded an attempt was made to contact the physician about the complaint. The document did not show an investigation of the complainants issues were completed. No written notice was provided to the complainant. Staff R stated on 06/05/2015 at 2:10 p.m. that the physician had not responded and no further information was available.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on review of hospital documents, surveyor observations and interviews, with hospital staff, the hospital failed to ensure restraints were applied for therapeutic reasons and were not used for the convenience of staff and discontinued/removed as soon as possible. This occurred in three of three (#4, 5, 6) medical records reviewed for restraint usage.

Findings:

A tour of the hospital was conducted on the afternoon of 06/03/2015.

Review of a hospital policy titled, "Restraint and Seclusion", reviewed 01/2015, documented, "...Restraint is to be initiated only after alternative interventions have been deemed ineffective and an individualized patient assessment identifies:..."

On 06/05/2015 at 2:00 p.m., Staff J stated the type of restraint devices used at the hospital were soft, Posey vest, mittens, all four bedrails in the up position, lap belts, leather and enclosure "vail" beds.

On 06/08/2015 at 3:45 p.m., Staff BB stated the hospital used lap belts on the stroke patients as a positioning device and to prevent the patient from falling. Staff BB was asked if the patients are able to remove the lap belts, Staff BB stated no. Staff BB stated that the restraints are tied either in the back or underneath the wheelchair. Staff BB also stated that the vail beds were used on patients with brain injuries. When asked if the vail beds are used on stroke patients, Staff BB stated not that often.

On 06/03/2015 between 4:15 p.m. and 4:30 p.m., surveyors observed Patient # 4 sitting in a wheelchair wearing a lap belt restraint. The lap belt was tied in the back of the wheelchair and the patient could not remove the belt without assistance. The patient did not attempt to remove medical devices, to get out of the wheelchair or exhibit any combative behaviors. The surveyors observed the patient using the nurse call light system to request help to the restroom.

Review of the medical records for Patients #4, 5 and 6 contained documentation the patients were restrained the duration of their hospitalization . The patients were unrestrained during rehabilitative therapy and during family visits.

Medical records for Patients #4, 5 and 6 documented the patients "affect/behavior" while restrained as "impulsive" on the following dates and times:

Patient #4
~05/22/2015- 8:00 a.m. and 8:00 p.m.
~05/23/2015- 8:00 a.m., 12:00 p.m.. and 4:00 p.m.
~05/24/2015, 05/30/2015 and 06/04/2015- From 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m. and 6:00 p.m.
~05/25/2015- 12:00 p.m.
~05/28/2015- 8:00 a.m., 12:00 p.m., 4:00 p.m. and 6:00 p.m.
~05/29/2015- 8:00 a.m., 10:00 p.m., 12:00 p.m. and 2:00 p.m.
~06/05/2015- 8:00 a.m. and 10:00 a.m.

Patient #5
~04/25/2015- 3:00 p.m. and 11:00 p.m.
~04/26/2015- 1:00 a.m., 3:00 a.m. and 5:00 a.m.
~05/01/2015- 3:00 a.m. and 7:00 a.m.
~05/02/2015- 3:00 a.m., 7:00 a.m., and 7:00 p.m.
~05/04/2015- 7:00 a.m., 11:00 a.m. and 1:00 p.m.
~05/05/2015- 3:00 p.m. and 5:00 p.m.
~05/06/2015- 11:00 a.m. and 11:00 p.m.
~05/07/2015- 1:00 a.m. and 3:00 a.m.
~05/08/2015- 9:00 a.m., 11:00 a.m. and 5:00 p.m.
~05/09/2015- 7:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m. and 5:00 p.m.
~05/10/2015- 3:00 p.m. and 5:00 p.m.

Patient #6
~05/22/2015- 3:00 p.m. and 5:00 p.m.
~05/23/2015- 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m. and 5:00 p.m.
~05/24/2015- 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m. and 5:00 p.m.
~05/25/2015- 9:00 a.m.
~05/26/2015- 7:00 a.m., 9:00 a.m. and 1:00 p.m.
~05/28/2015- 9:00 a.m., 1:00 p.m., 3:00 p.m., 5:00 p.m., and 7:00 p.m.
~05/29/2015- 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m. and 3:00 p.m.
~05/30/2015- 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m., 5:00 p.m., and 7:00 p.m.
~05/31/2015- 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m., 5:00 p.m., and 7:00 p.m.

Other recorded dates and times in the medical records for Patients #4, 5 and 6 documented the patients "affect/behavior" as "appropriate", "cooperative" and/or "calm". The medical records did not contain a rationale for the continued use of the restraints.