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.

CHI ST LUKES HEALTH MEMORIAL LUFKIN 1201 WEST FRANK STREET LUFKIN, TX 75901 Sept. 17, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on medical records review and interviews, the facility failed to:


1. provide safe environment to patients and perform a timely nursing assessment after a fall in 1 (#1) out of 5 (#1-5) patients reviewed.

See Tag A0144


2. follow its own guidelines for restraints. The facility failed to obtain orders for restraints, failed to discontinue restraints at the earliest possible time, failed document physician assessment of restraint or documentation to justify a medical restraint in 1 (#1) out of 5 (#1-5) patients reviewed.

See Tag A0154


3. follow its own guidelines to obtain orders to administer medications, orders for chemical restraints, document physician notification of medication holds for "now" orders, and documentat intervention or alternatives to prevent chemical restraints in 1 (#1) out of 5 (#1-5) charts reviewed.

See Tag A0160


4. ensure the use of a restraint or seclusion intervention would be reflected and ongoing in the patient's plan of care, or treatment plan based on an assessment, and evaluation of the patient.

See Tag A0166



5. follow its own guidelines for restraints. The facility failed to obtain orders for restraints, documentat physician assessment of restraint or documentation to justify a medical restraint in 1 (#1) out of 5 (#1-5) patients reviewed.

See Tag A0168



6. discontinue restraints at the earliest possible time in 1 (#1) out of 5 (#1-5) charts reviewed.

See Tag A0174



7. ensure a physician conducts a face to face evalluation of patients within one hour of the behavioral restraint application. The physician failed to document the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion in 1 (#1) of 5 (#1-5) patient charts reviewed.

See Tag A0179
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on medical records review and interviews, the facility failed to provide safe environment to patients and failed to perform a timely nursing assessment after a fall in 1 (#1) out of 5 (#1-5) patients reviewed.

Review of Daily Focus Assessment Report (DFAR) dated 3/24/14, at 9:43 AM, revealed that the patient received an occupational therapy visit starting at 9:43 AM. The following entries were noted:

1.) Staff #6 documented in the DFAR on 3/24/14, at 10:03 AM, "Group note: brushing teeth, washing face & combing hair at bedside chair level."

2.) Review of Staff #6 entry on 3/24/14, revealed assessment time 9:43 AM. The documented time for the following statement was entered at 12:17 PM, "Group Note: Pt. left sitting at bedside chair level w/call light and phone within reach. Nurse #11 informed."

Review of the DFAR on 3/24/2014, staff #11 documented, "Category note: pt found on the floor by kitchen staff -pt alert/oriented x 2, no s/s of distress/discomfort, places pt back in bed w/lift, v/s stable, Dr. Narra notified of fall-no orders-will monitor-bed alarm set." The assessment date and time on the note was 3/24/14, at 10:05 AM, but the documentation time was 3/25/2014, at 7:42 PM, 33.5 hours later. There was no further documentation found in the DFAR on patient #1's assessment from the fall or notifications to family.

Review of the DFAR on 3/24/2014, revealed that the patient was receiving a swallow test by the Speech Therapist at 10:08 AM. The Speech Therapist documented, "patient presented awake, alert, and oriented x4. He followed 3 part commands, answered questions appropriately, finding, and solved basic problems. Moderate dysarthric speech present. Bedside swallow complete."

Review of the DFAR on 3/24/2014, at 10:18 AM, physical therapy was seeing the patient for an initial evaluation. Staff # 10 documented, "Category Note: Pt is no longer working. Admits to smoking and drinking all day- and asked PT to take him outside for a cigarette and a beer. " At 10:24 AM, staff #10 documented,"Category Note; Leans L in sitting w/consistent response to cues to correct posture. Leans L in standing. Cannot stand Statically unsupported."

A telephone call was made on 10/2/14, to staff #2 and staff #3 concerning a confirmation on the computer documentation. Staff #2 reported an incident report was done on patient #1. Staff #3 confirmed there was no "nursing assessment" documentation found in the computer for the fall, on 3/24/14 at 10:05 AM.

Staff #2 sent an email with documentation that was on the incident report submitted by staff #11. The email stated, " Nature of Injury = None, Seen by ER attending = No, MD notified = Yes Dr. Narra, Date: 3/24/2014 Hour: 1005, Medications within the last 6 hours = Ativan, Protonix, Admitting Diagnosis = CVA, Activity orders: Up privileges with assistance, Adjustable height bed= Yes, Position low = Yes, Bedrails up = Yes, Type of incident = Fall, Nature and extent of damage or loss = Fall form bedside chair, Incident facts: (Verbatim) " O.T. placed pt in bedside chair. Kitchen staff notified us of fall. Lifted patient to bed. "

There was no nursing assessment found until 3/23/14, at 11:00 AM. The DFAR revealed the assessment date and time was on 3/23/14, at 11:00 AM. The nurse documentation was entered on 3/23/14, at 12:19 PM. The documentation consisted of a neurological assessment, swallow assessment, and extremity strength. There was no skin assessment found or notification of family concerning fall.

A telephone interview with staff #2 and #3 on 10/2/2014, revealed there was no policy concerning timely charting. Staff #2 stated, "We don't have a policy concerning timely charting. We prefer our staff care for our patients then chart when patient care is completed."

The DFAR on the left side of the page has "Assessment Date." On the right side of the page reads "Entry Date." Staff #2 and Staff #3 confirmed the "Assessment Date" entry is when the staff members open the chart. The "Entry Date" time is when the staff member actually documented. Staff #3 confirmed that the computer program automatically dates and times the entries.

Staff #11 documented on the DFAR that the patient was found at 10:05 AM, was lifted back into the bed with a lift, an assessment done, and physician notified in 3 minutes. Speech therapist started documentation of therapy beginning at 10:08 AM.

Review of the DFAR assessment date and time 3/27/2014, at 7:30 PM, staff #13 documented, "skin tear to right hand." Entry date and time 3/28/14 at 1:04 AM. No further documentation of skin tear location, skin assessment, treatment, physician notification, or family notification.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based upon medical records review, the facility failed to follow its own guidelines for restraints. The facility failed to obtain orders for restraints, failed to discontinue restraints at the earliest possible time, failed to document physician assessment of restraint, or document justification of a medical restraint in 1 (#1) out of 5 (#1-5) patients reviewed.


Review of the Daily Focus Assessment Report (DFAR) on 3/27/14, at 6:40 PM, stated, "Patient's been agitated, trying to get off the bed, pulled IV out. Called Security and Police officers to try to calm the patient down. MD notified. Geodon 10mg IM given at 6:20 PM; another dose given at 6:35 PM per MD order."


Review of the DFAR on 3/27/2014, at 10:55 PM, stated, "Pt agitated and trying to get out of bed, hitting and kicking at staff, physician notified and new orders noted." There was no documentation of patient attempt to discontinue IV line or telemetry on 3/27/14 at 10:50 PM.


Review of the telephone physician orders on 3/27/14, at 10:50 PM, stated, "Restraints per protocol. Ativan 2 mg IV or IM q2h prn anxiety/ agitation." The order did not verify what type of restraint to be applied to patient #1.


Review of the DFAR 3/27/14, 11:00 PM, revealed patient #1 was placed in a non- destructive non- violent restraint.


The definition on the restraint care record for the Acute Medical/Surgical care Standard (non violent non destructive restraint) stated, "Patient's behavior is jeopardizing his/her safety and/or interfering with necessary medical treatments but the patient is not acutely violent aggressive or destructive. No safety risk to others is present."


The nurse checked the box on the restraint care record that the patient restraint was for "potential removal of IV line and telemetry."


Review of the DFAR on 3/28/14, at 9:00 AM, stated, "Restraint Behavioral (Violent/Destructive) Reason for restraint- Removing medical devices and aggressive behavior."


Review of the guidelines "Use of Least Restrictive Devices and Restraints" stated, "Orders: A violent, self-destructive restraint will be initiated or continued upon the order of a treating physician or LIP with current privileges at this institution. The order for restraint will include the type of restraint to be applied and will be based on specific behaviors that indicate restraint. A behavioral restraint may not be ordered for longer than 4 hours for an adult patient."


Review of the physician orders revealed no behavioral restraint order was found for 3/28/14, at 9:00 AM, nor a description on the type of restraint to be used.


Review of the DFAR on 3/28/14, at 1:00 PM, stated, "pt alert/ oriented, sitting up in bed, states has no pain, no personal needs, brief dry, no restraints at present.


Review of the DFAR on 3/28/14, at 3:00 PM, stated, pt alert/ oriented, sitting up in bed, states has no pain, no personal needs, brief dry- will continue to monitor. There is no documentation found on restraint release.


Review of the DFAR on 3/28/14, at 6:00 PM, and 6:23 PM, revealed patient #1 was assessed for restraints but does not indicate if patient #1 is in restraints. No further documentation found of patient restraints for 3/28/14- 3/29/14.


Review of the DFAR on 3/30/2014, at 2:04 PM, stated, "Pt refused to cooperate. Patient has delusions and hallucinations. Attempted to reorient. Wife contacted unable to come visit. Transferred call into room in attempt to reorient which was unsuccessful."

Review of the progress notes staff #14 documented, "At approximately 0230 on 3/30/14 the patient would not stay in his room and was wondering into other patient rooms. The PCT and I asked him to return to his room because he was disturbing the other patients. The patient became angry and did not want to return to his room. He began to try to leave the floor. Another nurse and PCT tried to stop him from leaving and he threw coffee into the nurse's face and scratched the PCT's arm. I called security, and then the Lufkin police and physician. Upon return to the floor it was clear that the patient had a knife in his pocket and threatened myself, the PCT, and nurse with it. An EPOW was obtained and the Burke Center was called out to evaluate patient."

Review of the progress notes on 3/30/14, at 3:30 AM, revealed the physician hospitalist had seen the patient. The physician stated, "I think the patient is not psychologically stable to even sign out AMA. He is aggressive. He needs a psych evaluation ASAP."

Review of the Mental Health Authority Assessment revealed the patient was assessed on 3/30/2014, at 5:15 AM.

There was no nursing documentation noted on the DFAR for 3/30/13, for patient #1 from 3:00 AM until 7:15 AM.

Review of the DFAR on 3/31/14, at 12:10 AM, revealed the patient was placed on a Medical-Surgical non-violent/ non- destructive restraint. Patient #1 was placed on wrist and ankle restraints. There was no physician orders or restraint care record found to place the patient in restraints. There was no documentation on the DFAR why the patient was put into restraints.

Review of the progress notes dated 3/31/2014, at 6:06 AM, staff #14 documented, "Patient #1 became confused and left his room and would not return. He went down the hall into a patients room turned out her light and then walked out. The patient became very upset. I called security and he was put in restraints and I gave him Geodon. Patient #1 was not restrained during the day and had no security guard watching him when I came on at 7:20 PM. The patient remained in his room until 12:40 AM when this problem started. There was no documentation of how patient #1 removed his restraints that were documented on at 12:10 AM.

Review of the DFAR on 3/31/14, at 12:40 AM, revealed that the patient was changed to a Behavioral (Violent/ Destructive) restraint. Staff #14 stated, "Security Guard has key to restraints, behavior was uncooperative, shackles on. Hospital security staff guarding patient."

There was no physician orders or restraint care record found to place the patient in behavioral restraints.

Review of the physician orders for 3/31/2014, at 2:00 AM, a telephone order stated "Keep patient restrained." There was no description of what type of restraints or behaviors indicating the restraint.

Review of the DFAR on 3/31/14, at 2:10 AM, revealed the patient was changed back to a Medical- Surgical Restraint (non-violent non- destructive). sitter at bedside.

Review of the DFAR on 3/31/14, at 2:10 AM, revealed the patient is back in a Behavioral Restraint ( Violent and Destructive behavior).

Review of the DFAR on 3/31/14, at 6:45 AM, stated, " Pt is calm, sleeping and easily aroused. No c/o pain. resp is unlabored in RA. Pt is on 4 points shackle restraints per security d/t violent behavior will monitor q 2 hours prn."

Review of the DFAR on 3/31/14, at 6:45 AM, revealed patient #1 was calm and sleeping but was not released from behavioral restraints. Patient #1 was assessed at 7:15 AM and revealed he was still sleeping in restraints.

Review of a restraint care record dated 3/31/14, at 8:00 AM, revealed an order for behavioral restraints due to violent and aggressive behavior. The physician signed the order at 10:20 AM. There was no face to face documentation for the behavioral restraint by a physician or nurse.

Review of the DFAR on 3/31/14, at 7:45 AM, the nurse documented the patient was released from his wrist restraints so he could eat breakfast. The patient was calm and oriented. At 8:00 till 9:15 AM patient #1 was still out of restraints eating calmly.

Review of the DFAR on 3/31/14, at 9:45-10:00 AM, patient #1 was out of all of his restraints using the bathroom calmly. There is no documentation that patient #1 was violent or destructive.

Review of the restraint care record on 3/31/14, at 10:20 AM, an order was given for a Medical- Surgical(non-violent non-destructive) restraint for wrist restraints. The justification listed was "potential removal of IV's." There was no documentation of patient #1 trying to remove his IV's or inappropriate behaviors.

Review of the DFAR on 3/31/14, at 12:10- 6:10 PM, the nurse documented the patient was released from his wrist restraints so he could eat lunch and take a shower. There was no further documentation of restraints. patient #1 was transferred to a psychiatric Facility on 3/31/2014 at 9:00 PM.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
Based on hospital guidelines review and medical records reviews, the facility failed to follow its own guidelines to obtain orders to administer medications, orders for chemical restraints, failed to document physician notification of medication holds for "now" orders, and failed to document intervention or alternatives to prevent chemical restraints in 1(#1)out of 5 (#1-5) charts reviewed.

Review of patient #1's chart revealed that a history and physical examination was performed on 3/23/14 by staff # 7. The following was documented, "ASSESSMENT/PLAN 2. Alcohol abuse. The patient does have a history of significant alcohol use, as well as previous history of delirium tremens. He will be started on alcohol withdrawal precautions. Since he is n.p.o., he will be kept on IV banana bag. Start him on IV Ativan, scheduled and p.r.n."

1.) Review of patient #1's Daily Focus Assessment Report (DFAR) assessment date and time of 3/24/2014, revealed that staff #9 documented, "Spouse calls me to the room because patient is walking around and not listening to her. Upon entering the room, the patient is in the bathroom. Encouraged pt to come back to the bed and use the urinal. Pt refuses. I did get him to agree to sit in the chair." No further documentation.

Review of the DFAR on 3/24/2014, at 10:00 PM the following documentation was found:

A.) Assessment date and time 3/24/2014, at 10:00 PM. Patient #1 was agitated and restless.

B.) Assessment date and time 3/24/2014, at 10:00 PM, Staff #9 documented, "Gave patient his scheduled dose of Ativan 2 MG IV push."

C.) Assessment date and time 3/24/2014, at 10:30 PM, staff #9 documented, "Called the physician and explained to her the patient was walking around the room and had already fallen that day while working with physical therapy. I asked if we could give him something to keep him from hurting himself or someone else. Geodon was ordered." The rationale that the patient should be restrained because he "might" fall does not constitute an adequate basis for using a restraint for the purposes of this regulation.


Review of the hospital guidelines "PATIENT CARE SERVICES TITLE:


1. Definition: A chemical restraint is a medication used to sedate patients or restrict freedom of movement that is not a standard part of the treatment for their medical or psychiatric condition. On the rare occasion that chemical restraint is used in the acute setting, it accompanies the initiation of a violent, self-destructive restraint. The protections afforded patients for violent, self-destructive restraints also ensures patients rights for chemical restraint."

Review of telephone physician order on 3/24/2014, at 10:30 PM, stated, "Geodon 10 mg IM now. Seroquel 50mg 1 po qhs RBTO" There was no purpose or indication for the medication found on the written order. There was no physician signature of authentication for this order.

Review of the DFAR on 3/24/2014, at 11:30 PM, stated, "Patient is resting, eyes closed, resp even and unlabored. Will hold Geodon until it is needed. the physician is on the floor and is aware of pts condition."

There was no documentation found that the physician was notified or an order written to hold the Geodon. The order for Geodon was a "now" one time order, not an as needed order.

Review of the DFAR on 3/25/2014, at 12:05 AM, stated,"Patient Is attempting to get out of bed and is getting aggressive even with his wife. Instructed patient that we needed him to stay in bed for his safety. Pt. is still fighting against his wife." There was no documentation found of any interventions or alternatives to calm patient.

Review of the facility guidelines "PATIENT CARE SERVICES" revealed: Documentation: The following will be documented in the EMR under Restraints whenever violent, self-destructive restraint are applied: The less restrictive alternative(s) to restraint considered".

Review of the DFAR on 3/25/2014, at 12:16 AM, stated,"Geodon 10 mg IM drawn up and I explained to patient that I needed to give him a shot. He started kicking, kicking me in the right flank. I called for help. Several nurses came to aid but were hit and shoved back. Pt then took all of his clothes off and"

Review of the DFAR on 3/25/2014, at 12:17 AM, stated, "Started walking in the hallway. I just let him go so he could not harm me anymore, but I followed him. Security was called. Once security got there the patient was in the break room stumbling around. I stood as close as I could without getting hurt."

Review of the DFAR on 3/25/2014, at 12:55 AM, stated, "Lufkin police came to the scene, assisted pt back to bed and talked with him about his aggression. The physician gave the patient the Geodon injection I gave him a PRN dose of Ativan IV push. House supervisor was present. Incident report has been filed."

There was no physician order to administer Geodon or to administer medication as a chemical restraint found. There was no progress note found from the physician on 3/25/2013. There was no further documentation of the reason Lufkin Police Department (LPD) was asked to intervene or when they departed.

Review of the facility guidelines "PATIENT CARE SERVICES" revealed: Documentation: The following will be documented in the EMR under Restraints whenever violent, self-destructive restraint are applied: Restraint orders".

Review of a telephone physician order for 3/27/14, at 8:10 PM, stated, "Geodon 10 mg IM q 2 hours prn agitation not to exceed 40mg in 24 hours. Seroquel 50mg po tonight. RBTO" Review of the verbal order revealed the physician did not sign the order until 4/26/14.

Review of the DFAR 3/27/2014, at 12:36 AM, stated, "pt confused and agitated trying to get oob(out of bed), geodon given."

There was no documentation of patient interventions or alternatives given before chemical restraint, or medication effectiveness found. No documentation of violent destructive restraint order found.

Review of the DFAR on 3/27/2014, at 6:40 PM, stated, " Patients been agitated, trying to get out of bed, pulled IV out. Called security and police officers to try to calm the patient down. MD notified. Geodon 10 mg IM given at 6:20 PM; another dose given at 6:35 per MD order."

No documentation found of interventions or alternatives attempted before medication was given.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on medical records review, the facility failed to ensure that the use of a restraint or seclusion intervention would be reflected in the patient's plan of care, or treatment plan based on an ongoing assessment, and evaluation of the patient.


Review of the patients medical record revealed that the patient was placed in medical or behavioral restraints on the following dates:

1.) 3/27/2014 at 11:00 PM- Medical

2.) 3/28/2014 at 9:00 AM -Behavioral

3.) 3/31/2014 at 12:40 AM- Behavioral

4.) 3/31/2014 at 10:20 AM- Medical


Review of the medical record revealed that the patient was violent to staff requiring chemical restraints, assistance from the local police department, and security department.


Review of the "Patient Care Plan Report" revealed a problem of "risk for self or other directed violence (restraints) related to the diagnosis and to be completed by discharge."
Initiated on 3/26/2014, interventions found for 3/26/2014, and goal met on 3/26/2014.


There were no further dates reflected in the assessments, no further goals or interventions, no description of interventions, or if the patient was informed of changes in his treatment plan.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on the hospital guidelines and medical records review, the facility failed to follow its own guidelines for restraints. The facility failed to obtain orders for restraints, failed to document physician assessment of restraint, or failed to document justification for a medical restraint in 1 (#1) out of 5 (#1-5) patients reviewed.


Review of the Daily Focus Assessment Report (DFAR) on 3/27/14, at 6:40 PM, stated, "Patient's been agitated, trying to get off the bed, pulled IV out. Called Security and Police officers to try to calm the patient down. MD notified. Geodon 10mg IM given at 6:20 PM; another dose given at 6:35 PM per MD order."


Review of the DFAR on 3/27/2014, at 10:55 PM, stated, "Pt agitated and trying to get out of bed, hitting and kicking at staff, physician notified and new orders noted." There was no documentation of patient attempt to discontinue IV line or telemetry on 3/27/14, at 10:50 PM.


Review of the telephone physician orders on 3/27/14, at 10:50 PM, stated, "Restraints per protocol. Ativan 2 mg IV or IM q2h prn anxiety/ agitation." The order did not verify what type of restraint to be applied to patient #1.


Review of the DFAR 3/27/14, 11:00 PM, revealed that patient #1 was placed on a non- destructive non- violent restraint.


The definition on the restraint care record for the Acute Medical/Surgical care Standard (non violent non destructive restraint) stated, "Patient's behavior is jeopardizing his/her safety and/or interfering with necessary medical treatments but the patient is not acutely violent aggressive or destructive. No safety risk to others is present."


The nurse checked the box on the restraint care record that the patient restraint was for "potential removal of IV line and telemetry."


Review of the DFAR on 3/28/14, at 9:00 AM, stated, "Restraint Behavioral (Violent/Destructive) Reason for restraint- Removing medical devices and aggressive behavior."


Review of the hospital guidelines "Use of Least Restrictive Devices and Restraints" stated, "Orders: A violent, self-destructive restraint will be initiated or continued upon the order of a treating physician or LIP with current privileges at this institution. The order for restraint will include the type of restraint to be applied and will be based on specific behaviors that indicate restraint. A behavioral restraint may not be ordered for longer than 4 hours for an adult patient."


Review of the physician orders revealed no behavioral restraint order was found for 3/28/14, at 9:00 AM, nor a description on the type of restraint to be used.


Review of the DFAR on 3/28/14, at 1:00 PM, stated, "pt alert/ oriented, sitting up in bed, states has no pain, no personal needs, brief dry, no restraints at present.


Review of the DFAR on 3/28/14, at 3:00 PM, stated, pt alert/ oriented, sitting up in bed, states has no pain, no personal needs, brief dry- will continue to monitor. There is no documentation found on restraint release.


Review of the DFAR on 3/28/14, at 6:00 PM, and 6:23 PM revealed that patient #1 was assessed for restraints but does not indicate if patient #1 is in restraints. No further documentation found of patient restraints for 3/28/14- 3/29/14.


Review of the DFAR on 3/30/2014, at 2:04 PM, stated, "Pt refused to cooperate. Patient has delusions and hallucinations. Attempted to reorient. Wife contacted unable to come visit. Transferred call into room in attempt to reorient which was unsuccessful."

Review of the progress notes staff #14 documented, "At approximately 0230 on 3/30/14, the patient would not stay in his room and was wondering into other patient rooms. The PCT and I asked him to return to his room because he was disturbing the other patients. The patient became angry and did not want to return to his room. He began to try to leave the floor. Another nurse and PCT tried to stop him from leaving and he threw coffee into the nurse's face and scratched the PCT's arm. I called security, and then the Lufkin police and physician. Upon return to the floor it was clear that the patient had a knife in his pocket and threatened myself, the PCT, and nurse with it. An EPOW was obtained and the Burke Center was called out to evaluate patient."

Review of the progress notes on 3/30/14, at 3:30 AM, revealed that the physician hospitalist had seen the patient. The physician stated, "I think the patient is not psychologically stable to even sign out AMA. He is aggressive. He needs a psych evaluation ASAP."

Review of the Mental Health Authority Assessment revealed that the patient was assessed on 3/30/2014, at 5:15 AM.

There was no nursing documentation noted on the DFAR for 3/30/13, for patient #1 from 3:00 AM until 7:15 AM.

Review of the DFAR on 3/31/14, at 12:10 AM, revealed that the patient was placed on a Medical-Surgical (non-violent/ non- destructive restraint.) Patient #1 was placed on wrist and ankle restraints. There was no physician' orders or restraint care record found to place the patient in restraints. There was no documentation on the DFAR why the patient was put into restraints.

Review of the progress notes dated 3/31/2014, at 6:06 AM, staff #14 documented, "Patient #1 became confused and left his room and would not return. He went down the hall into a patients room turned out her light and then walked out. The patient became very upset. I called security and he was put in restraints and I gave him Geodon. Patient #1 was not restrained during the day and had no security guard watching him when I came on at 7:20 PM. The patient remained in his room until 12:40 AM when this problem started." There was no documentation of how the patient #1 removed his restraints that were documented on at 12:10 AM.

Review of the DFAR on 3/31/14, at 12:40 AM, revealed the patient was changed to a Behavioral (Violent/ Destructive) restraint. Staff #14 stated, "Security Guard has key to restraints, behavior was uncooperative shackles on. Hospital security staff guarding patient."

There was no physician orders or restraint care record found to place the patient in behavioral restraints.

Review of the physician orders for 3/31/2014, at 2:00 AM, a telephone order stated "Keep patient restrained." There was no description of what type of restraints or behaviors indicating the restraint.

Review of the DFAR on 3/31/14, at 2:10 AM, revealed that the patient was changed back to a Medical- Surgical Restraint (non-violent non- destructive) sitter at bedside.

Review of the DFAR on 3/31/14, at 2:10 AM, revealed that the patient is back in a Behavioral Restraint ( Violent and Destructive behavior).

Review of the DFAR on 3/31/14, at 6:45 AM, stated, " Pt is calm, sleeping and easily aroused. No c/o pain. resp is unlabored in RA. Pt is on 4 points shackle restraints per security d/t violent behavior. will monitor q 2 hours prn."

Review of the DFAR on 3/31/14, at 6:45 AM, revealed that patient #1 was calm and sleeping but was not released from behavioral restraints. Patient #1 was assessed at 7:15 AM and revealed he was still sleeping in restraints.

Review of a restraint care record dated 3/31/14, at 8:00 AM, revealed an order for behavioral restraints due to violent and aggressive behavior. The physician signed the order at 10:20 AM. There was no face to face documentation for the behavioral restraint by a physician or nurse.

Review of the DFAR on 3/31/14, at 7:45 AM, the nurse documented the patient was released from his wrist restraints so he could eat breakfast. The patient was calm and oriented. At 8:00 till 9:15 AM patient #1 was still out of restraints eating calmly.

Review of the DFAR on 3/31/14, at 9:45-10:00 AM patient #1 was out of all of his restraints using the bathroom calmly. There is no documentation that patient #1 was violent or destructive.

Review of the restraint care record on 3/31/14, at 10:20 AM, an order was given for a Medical- Surgical (non-violent non-destructive) restraint for wrist restraints. The justification listed was "potential removal of IV's." There was no documentation of patient #1 trying to remove his IV's or inappropriate behaviors.

Review of the DFAR on 3/31/14, at 12:10- 6:10 PM, the nurse documented the patient was released from his wrist restraints so he could eat lunch and take a shower. There was no further documentation of restraints. patient #1 was transferred to a psychiatric Facility on 3/31/2014 at 9:00 PM.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
Based on the hospital guidelines and medical records review, the facility failed to discontinue restraints at the earliest possible time in 1 (#1) out of 5 (#1-5) charts reviewed.


Review of the physician orders for 3/31/2014, at 2:00 AM, a telephone order stated "Keep patient restrained." There was no description of what type of restraints or behaviors indicating the restraint.


Review of the Daily Focus Assessment Report (DFAR) on 3/31/14, at 2:10 AM, revealed that the patient was changed back to a Medical- Surgical Restraint (non-violent non- destructive), sitter at bedside.

Review of the DFAR on 3/31/14, at 2:10 AM, revealed that the patient is back in a Behavioral Restraint ( Violent and Destructive behavior). There was no order to change to a behavioral restraint.

Review of the DFAR on 3/31/14, at 6:45 AM, stated, " Pt is calm, sleeping and easily aroused. Pt is on 4 points shackle restraints per security d/t violent behavior. will monitor q 2 hours prn."

Review of the DFAR on 3/31/14, at 6:45 AM, revealed patient #1 was calm and sleeping but was not released from behavioral restraints. Patient #1 was assessed at 7:15 AM and revealed he was still sleeping in restraints.

Review of a restraint care record dated 3/31/14, at 8:00 AM, revealed an order for behavioral restraints due to violent and aggressive behavior. The physician signed the order at 10:20 AM. There was no face to face documentation for the behavioral restraint by a physician or nurse.

Review of the DFAR on 3/31/14, at 7:45 AM, the nurse documented the patient was released from his wrist restraints so he could eat breakfast. The patient was calm and oriented from 8:00 AM till 9:15 AM.

Review of the DFAR on 3/31/14, at 9:45-10:00 AM, patient #1 was out of all of his restraints using the bathroom calmly. There is no documentation that patient #1 was violent or destructive.

Review of the restraint care record on 3/31/14, at 10:20 AM, an order was given for a Medical- Surgical(non-violent non-destructive) restraint for wrist restraints. The justification listed was "potential removal of IV's." There was no documentation of patient #1 trying to remove his IV's or inappropriate behaviors.

Review of the DFAR on 3/31/14, at 12:10- 6:10 PM, the nurse documented the patient was released from his wrist restraints so he could eat lunch and take a shower. There was no further documentation of restraints. patient #1 was transferred to a psychiatric Facility on 3/31/2014, at 9:00 PM.


Review of the guidelines "Use of Least Restrictive Devices and Restraints" stated, "Discontinuation of restraint: A violent, self-destructive restraint will be discontinued as soon as it is no longer indicated by the patient ' s behavior or the nature of the patient ' s treatment plan."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
The facility failed to ensure that a physician conducts a face to face evaluation of patients within one hour of the behavioral restraint application. The physician failed to document the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion in 1(#1) out 5(#1-5) patient charts reviewed.


Review of the DFAR on 3/28/14, at 9:00 AM, stated, "Restraint Behavioral(Violent/Destructive) Reason for restraint- Removing medical devices and aggressive behavior."


Review of the hospital guidelines "Use of Least Restrictive Devices and Restraints" stated, "Orders: A violent, self-destructive restraint will be initiated or continued upon the order of a treating physician or LIP with current privileges at this institution. The order for restraint will include the type of restraint to be applied and will be based on specific behaviors that indicate restraint. A behavioral restraint may not be ordered for longer than 4 hours for an adult patient."


Review of the physician orders revealed no behavioral restraint order was found for 3/28/14, at 9:00 AM, a description on the type of restraint to be used, or a physician face to face.


Review of the progress notes dated 3/31/2014, at 6:06 AM ,staff #14 documented, "Patient #1 became confused and left his room and would not return. He went down the hall into a patients room turned out her light and then walked out. The patient became very upset. I called security and he was put in restraints and I gave him Geodon. Patient #1 was not restrained during the day and had no security guard watching him when I came on at 7:20 PM. The patient remained in his room until 12:40 AM when this problem started. "There was no documentation of how the patient #1 removed his restraints that were documented on at 12:10 AM."

Review of the DFAR on 3/31/14, at 12:40 AM, revealed that the patient was changed to a behavioral (Violent/ Destructive) restraint. Staff #14 stated, "Security Guard has key to restraints, behavior was uncooperative shackles on. Hospital security staff guarding patient."

There was no physician orders or restraint care record found to place the patient in behavioral restraints or a documented face to face.

Review of the physician orders for 3/31/2014, at 2:00 AM, a telephone order stated "Keep patient restrained." There was no description of what type of restraints or behaviors indicating the restraint.

Review of the DFAR on 3/31/14, at 2:10 AM, revealed that the patient was changed back to a Medical- Surgical Restraint (non-violent non- destructive), sitter at bedside.

Review of the DFAR on 3/31/14, at 2:10 AM, revealed that the patient is back in a Behavioral Restraint ( Violent and Destructive behavior). There was no order found for behavioral restraint nor a physician face to face documented.

Review of the DFAR on 3/31/14, at 6:45 AM, stated, "Pt is calm, sleeping and easily aroused. No c/o pain. resp is unlabored in RA. Pt is on 4 points shackle restraints per security d/t violent behavior. will monitor q 2 hours prn."

Review of the DFAR on 3/31/14, at 6:45 AM, revealed patient #1 was calm and sleeping but was not released from behavioral restraints. Patient #1 was assessed at 7:15 AM and revealed he was still sleeping in restraints.

Review of a restraint care record dated 3/31/14, at 8:00 AM, revealed an order for behavioral restraints due to violent and aggressive behavior. The physician signed the order at 10:20 AM. There was no face to face documentation for the behavioral restraint by a physician or nurse.

Review of the DFAR on 3/31/14, at 7:45 AM, the nurse documented that the patient was released from his wrist restraints so he could eat breakfast. The patient was calm and oriented. At 8:00 till 9:15 AM, patient #1 was still out of restraints eating calmly.

Review of the DFAR on 3/31/14, at 9:45-10:00 AM, patient #1 was out of all of his restraints using the bathroom calmly. There is no documentation that patient #1 was violent or destructive.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on medical records review, the facility failed to ensure that the verbal physician orders were authenticated promptly in 2 (#1, #2) out of 3 (#1-3) charts reviewed.

Review of patient #1's chart revealed no physician signatures found or a delay in authentication on the following orders;

1.) 3/25/14, at 8:00 PM, Ativan 2 mg IV x 1 now. Geodon 10 mg IM q2hr prn agitation not to exceed 40 mg in 24 hours. No physician signature was found.

2.) Restraint Care Record dated 3/27/14, at 10:00 PM, was not signed by physician until 5/2/14 at 2:02 PM.

Review of patient #2's chart revealed no physician signatures found or a delay in authentication on the following orders:

1.) A verbal telephone order written on 3/25/2014, 10:02, Rocephin 1 gram IV now and q day.

Zithromax 500mg IV now and q day. Tylenol 500mg q 4 hrs PRN fever. Urine culture, blood culture sputum culture.

Physician signed the order on 5/12/14, at 9:47 AM

2.) Restraint Care Record dated 3/29/14, at 1:30 PM, was not signed by physician until 5/12/14, at 9:48 AM.

3). On 4/7/14, at 8:17 AM, PICC Line placement. Signed by physician on 5/12/14, at 12:48 AM.