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.


Based on observation, interview and record review, the facility failed to ensure a one hour face-to face evaluation was performed according to facility policy for 1 of 15 patients (#1) reviewed for restraints, from a total sample of 15 patients, resulting in the potential for unnecessary restraints. Findings include:

On 6/9/16 at approximately 1150, while accompanied by the Acting Director of Nursing (Staff R), a tour of the Edwards Nursing Unit was conducted. The surveyor was approached by patient #1. He (#1) stated, "Nurse E assaulted me while I was in 4 point restraints on 5/19/16 or 5/20/16." When asked if he had reported the incident to a Supervisor he stated, "No." At that time the patient was agreeable to an interview at a later time.

On 6/9/16 at 1200 Staff R explained she was not aware of the aforementioned concern.

A review of patient #1's medical record with Registered Nurse (RN) Staff D was conducted on 6/9/16 at approximately 1530. According to the admission facesheet patient #1 was a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses of Bipolar disorder and antisocial personality

A review of physician orders documented the following restraint orders:

1. On 5/16/16, 6 point restraints ordered Stat (immediately).
Start Date/Time: 5/16/16 at 0715.
Stop Date/Time: 5/16/16 at 0914.

2. On 5/18/16, 4 point restraints ordered Stat.
Start Date/Time: 5/18/16 at 1615.
Stop Date/Time: 5/18/16 at 2014.

3. On 5/18/16, 4 point restraints ordered Stat.
Start Date/Time 5/18/16 at 2015.
Stop Date/Time: 5/19/15 at 0014.

4. On 5/19/16, 4 point restraints ordered Stat.
Start Date/Time: 5/19/16 at 0015.
Stop Date/Time: 5/19/16 at 0414.

Further review of the medical record review revealed that the physician performed face-to-face assessments within one hour of the initiation of restraints except on 5/16/16 when patient #1 was restrained.

Review of a Nursing Assessment note for patient #1 documented:
On 5/16/16 at 0815.
Ideations or Intent: Homicidal, harm to others. Current Behavior: Agitated. Patient's response to explanation and expectations: Patient stated he "didn't do anything wrong" but was told his actions and what he did (yelling at staff and fell ow patients, pulling down pants, swearing, and making motions like hitting people) was a clear sign for me as a nurse that he was not safe and needed to be restrained in order to create a safe environment for everyone.
Patient released from seclusion/restraint/: No.

Review of resident care assistant note dated 5/16/16 at 0845 documented:
Type of intervention: Restraint.
Patient Observations: Angry, Hostile, threatening to bite nurse, yelling.

Review of Nursing Assessment note documented:
On 5/16/16 at 0915:
Type of Intervention: Restraint.
Type of Assessment: Post Release

During an interview on 6/9/16 at 1620 Registered Nurse Staff D stated, "I'm not finding it (Physician's face-to-face) assessment for 5/16/16. There should be one."

On 6/10/16 at approximately 1330, during an interview Staff R explained that she was not aware that a Physician's face-to-face assessment had not been performed for patient #1 on 5/16/16 when the patient had been restrained. She stated, "I'll check. There should be one."

On 6/10/16 at 1350 a review of the facility's "Use of Seclusion and Restraint" policy (dated 4/9/15), documented:
"...V. Standards:...L. If the patient's violent/self-destructive behavior resolves, the restraint or seclusion shall be discontinued before the physician arrives to perform the 1 hour face-to-face evaluation, the physician shall sign the telephone order, see the patient face-to-face and conduct the evaluation within 1 hour after all initiations of the restraints or seclusions..."

On 6/10/16 at approximately 1510 Staff R stated, "We looked for it (Physician's face-to-face) assessment for 5/16/16. There is not one."