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.

BON SECOURS ST FRANCIS MEDICAL CENTER 13710 ST FRANCIS BOULEVARD MIDLOTHIAN, VA 23114 Aug. 29, 2018
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
Based on interviews and the review of documents, it was determined the facility staff failed to use the least restrictive restraint for one (1) of five (5) patients sampled for restraint use (Patient #8).

The findings include:

The facility staff failed to attempt to remove Patient #8's bilateral ankle restraints when the patient's behaviors resulting in the use of restraints subsided.

Patient #8's clinical record included the following restraint order: on 6/16/18 at 1:12 p.m., "RESTRAINTS (NON-VIOLENT)" were ordered for the frequency of "RESTRAIN FOR 24 HOURS". The restraints ordered were bilateral soft wrist and bilateral soft ankle restraints. The "Reason for restraints:" was documented as "Interference with medical treatment". This order included the following comment: "Restraints must be removed when an alternative is available and effective and/or patient no longer meets criteria."

Patient #8's clinical documentation included, but was not limited to:
- On 6/16/18 at 5:30 p.m., "Confused; Agitated";
- On 6/16/18 at 7:34 p.m., "Agitated; Combative; Confused";
- On 6/16/18 at 9:00 p.m., "Agitated";
- On 6/16/18 at 11:00 p.m., "Confused; Resting";
- On 6/17/18 at 1:00 a.m., "Resting";
- On 6/17/18 at 3:11 a.m., "Resting";
- On 6/17/18 at 5:00 a.m., "Resting";
- On 6/17/18 at 7:29 a.m., "Resting";
- On 6/17/18 at 8:00 a.m., "Resting";

No documentation was found by or provided to the surveyor to indicate an attempt was made to remove Patient #8 ankle restraints when the patient's 'psychological status' changed from 'agitated', 'confused', and/or 'combative' to 'resting'. (Patient #8's wrist restraints were discontinued at 1:00 a.m. on 6/17/18 but the bilateral soft ankle restraints remained in use.)

The following information was found in a facility policy with the title 'Restraints and Seclusion' (the most recent revision date was 4/2018): "Violent or Self-Destructive Restraint or Seclusion (Behavioral) ... - The use of restraints, medication, or seclusion must be limited to only the duration of the behavior causing the use of the restraint or termination of the standard has been met. - If the length of the order is still in effect and the behavior improves, then least restrictive alternatives must be attempted and evaluated. ... Consider Criteria for Discontinuation of restraint/seclusion: 1. Displays improvement in descriptive behaviors and/or; 2. No longer at risk to self or others and/or; 3. Able to understand and follow instructions for safety."

The failure of the facility staff to attempt to remove Patient #6's restraints when he/she was documented as 'resting' was discussed during a survey team meeting on 8/28/18 at 5:30 p.m. with the facility's Director of Quality and the facility's Regional Coordinator.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on a review of clinical records, facility documents and staff interviews, it was determined that for three (3) of five (5) patients sampled for review of restraint use (Patient #3, #6, and #8), the patients' plan of care failed to address the use of restraints for self-destructive or violent behaviors.

The findings were:

1. Patient #3's care plan did not address the use of restraints for violent behaviors.

The review of Patient #3's clinical record provided evidence the patient was admitted to the unit with a diagnosis of bowel perforation and sepsis (systemic infection). The review of Patient #3's clinical record provided the following additional evidence:
A progress note by a registered nurse (RN) dated 05/29/18 at 09:30 a.m., "Attempted to draw patients [sic] labs and patient became combative hitting and kicking. Intensivist notified and at bedside."
An order from the Intensivist (physician/Staff Member SM #17) dated 05/29/18 at 9:30 a.m. for "Haldol 5 milligrams (mg) IV (Intravenous) once." Note: Haldol is an antipsychotic medication used to treat psychotic disorders.
A progress note by an RN dated 05/29/18 at 09:35 a.m., "5 mg IV Haldol given."
A progress note by an RN dated 05/29/18 at 6:05 p.m., "Patient very agitated. Hitting and kicking."
A shift assessment documented by Nurse #1 dated 05/29/18 at 8:00 p.m., "Psychosocial Patient Behaviors: Aggressive verbally; Aggressive physically; Agitated; Manipulative; Non-Compliant; Restless; Uncooperative."
A progress note by Nurse #1, dated 05/29/18 at 8:55 p.m., "Intensivist called to inform of status change......Pt became agitated and combative requiring 4 point restraints."
An order from the Intensivist (physician/SM #26) dated 05/29/18 at 9:05 p.m., for "Non- Violent" restraints of "Soft restraint" to "right ankle, right wrist, left ankle, and left wrist" and documents the "Reason for the restraints" as "Interference with medical treatment."
An order from the Intensivist (physician/SM #26) dated 05/29/18 at 9:13 p.m. for "Haldol Injection 2 mg IM (Intramuscularly) once."
A MAR (Medication Administration Record) entry by Nurse #1 dated 05/29/18 at 9:42 p.m., documenting that Haldol 2 mg was administered Intramuscularly in the left deltoid.
The record failed to contain evidence the careplan addressed the use of restraints used for violent behaviors documented as outlined above. Related to restraints, the careplan addressed only the use of "Non-Violent restraints."

During the review of the clinical record of Patient #3 on 08/28/18 at 10:15 a.m., the Quality Coordinator (SM # 27) assisted with navigating the electronic health record. The Regulatory Compliance Coordinator (SM #6) was present during the review as well. During the review, SM #27 acknowledged the two doses of Haldol given to Patient #3, on 05/29/18 were not a part of the patient's alcohol withdrawal protocol (CIWA) nor was it being used to treat a medical condition. SM #27 acknowledged the Haldol doses were used to treat a behavior of hitting and kicking. SM #27 stated, "I don't think they recognized they were giving a chemical restraint, and SM #6 stated, I would agree with that statement." SM # 6 acknowledged that because the restraints were not identified as being used for the management of violent or self destructive behaviors, the care plan only addressed restraints for non-violent behaviors. SM # 6 stated the staff and/or physicians "chose Non-Violent as this was the understanding of how that should have been handled at the time, but we understand the explanation given regarding the COPs [regulations] and moving forward that will require changes in our Policies and Procedures."

A review of the facility's 27 page policy titled, "Restraints and Seclusion" (Policy No. BSR 02-03, Rev.: 4/18) took place ongoing throughout the survey. The policy read, in part, as follows:
"...Restraint or seclusion may only be used to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time."
"Documentation Requirements:...The use of restraint and/or seclusion requires documenting the situation thoroughly in the patient's medical record. That documentation will include:.....3. Description of patient's behavior and interventions used; 4. Alternatives or other less restrictive interventions attempted (if applicable). "
"The decision to use a restraint or seclusion is not driven by diagnosis, but by a comprehensive individual patient assessment."
"Restraint for Non-Violent, Non-Behavioral (Medical and Surgical) Care"..."Purpose - To protect or prevent injury by limiting mobility or temporarily immobilizing a patient in the provision of medical and/or post-surgical care"
"Violent or Self-Destructive Restraint or Seclusion (Behavioral)"..."Definition - Use for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member or others and when non-physical interventions would not be effective."





2. Patient #6's care plan did not address the use of restraints for violent behaviors.

Review of Patient #6's care plan revealed the patient was care planned for "Non-violent Restraints". No evidence of Patient #6's care plan addressing restraints for violent and/or aggressive behaviors was found by or provided to the surveyor.

Patient #6's initial restraint order was written on 8/14/18 at 5:17 p.m. This order was written for "RESTRAINTS (NON-VIOLENT)" for a frequency of "RESTRAIN FOR 24 HOURS"; this was for bilateral soft wrist restraints. The reason for restraints documented as part of this order was "Interference with medical treatment".

Patient #6's documentation for 8/14/18 at 5:17 p.m. included the following assessment information: "Agitation; Combative; Confused; Delusional; Hallucinating; Paranoid".

Patient #6's clinical documentation included an order for restraints on 8/14/18 at 6:46 p.m.; this order was for bilateral soft wrist restraints and bilateral soft ankle restraints. The reason for restraints documented as part of this order was "Interference with medical treatment".

Patient #6's clinical documentation included, but was not limited to, the following:
- On 8/14/18 at 6:00 p.m., bilateral soft ankle restraints were documented as being initiated (these were documented as being discontinued on 8/14/18 at 8:00 p.m.);
- On 8/15/18 at 12:02 a.m., "Confused; Agitated; Combative; Delusional; Hallucinating";
- On 8/15/18 at 7:00 a.m., "Agitated; Combative; Confused; hallucinating; Restless";
- On 8/15/18 at 8:00 a.m., "Agitated; Combative; Confused; Hallucinating";
- On 8/16/18 at 12:15 a.m., "Combative; Confused; Restless";
- On 8/16/18 at 2:00 a.m., "Combative; Agitated; Restless; Confused";
- On 8/18/18 at 2:43 p.m., "Agitated; Combative; Confused; Restless; Verbally Abusive";
- On 8/18/18 at 6:09 p.m., "Agitated; Combative; Confused; Paranoid; Restless; Sedated; Verbally abusive".

The following information was found in a facility policy with the title 'Restraints and Seclusion' (with the most recent revision date of 4/2018): "Violent or Self-Destructive Restraint or Seclusion (Behavioral) ... Documentation and Reassessment of Emergency Use for Violent or Self-Destructive Behavior (Behavioral) Restraints ... Initiation and on-going use of restraints or seclusion will be documented in the nursing notes, on the Restraint Documentation Form and in the Plan of Care ..."

The failure of the facility staff to develop Patient #6's care plan to address the use of restraints for violent behavior was discussed during a survey team meeting on 8/28/18 at 5:30 p.m. with the facility's Director of Quality and the facility's Regional Coordinator.

3. Patient #8's care plan did not address the use of restraints for violent behaviors.

Review of Patient #8's care plan revealed the patient was care planned for "Non-violent Restraints". No evidence of Patient #8's care plan addressing restrains for violent and/or aggressive behaviors was found by or provided to the surveyor.

The following documentation was found in Patient #8's clinical record:
- A registered nurse note dated 6/15/18 at 9:00 a.m.: "The patient has been combative, screaming and hitting, (his/her) head off of padded siderails [sic]. (He/She) is wearing (his/her) helmet ..."
- A physician note dated 6/16/18 at 1:20 p.m.: "Came and evaluated by myself, (two other physician names omitted). (Type of Code) called on patient, as (he/she) was combative and refused all PO medications. Pt kicked techs and base of bed. Haldol 2mg IM given stat. Bilateral wrist and ankle soft restraints applied ... Reason for restraints: interfernce [sic] with care, violent ..."
- A physician note dated 6/16/18 at 10:40 p.m.: "Patient seen and examined at bedside with sitter present. Patient has been agitated and required 1 mg ativan (times) 1, Seroquel 300mg (by mouth) (times) 2, and Haldol 2mg (intramuscular injection). The patient has not required more Haldol but is still occasionally combative and requiring soft non-violent restraints. These restraints were necessary as patient's agitation was interfering with medical therapy."
- A physician note dated 6/17/18 at 1:23 p.m.: "(He/She) continues to have outbursts and become combative requiring chemical and mechanical restraint ..."
(A 'Code _____' is used by the facility to request additional people to assist with individuals exhibiting various behaviors.)

Patient #8's care plan was reviewed with a registered nurse (Staff Member (SM) #15) on the afternoon of 8/28/18. SM #15 acknowledged Patient #8's intellectual/developmental disability has not been care planned. Patient #8's care plan addressed the use of restraints but care planned the restraints as 'non-violent'.

The failure of the facility staff to develop Patient #8's care plan to address the use of restraints for violent behavior was discussed during a survey team meeting on 8/28/18 at 5:30 p.m. with the facility's Director of Quality and the facility's Regional Coordinator.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
Based on a review of clinical records, facility documents and staff interviews, it was determined that for three (3) of five (5) adult patients sampled for review of restraint use (Patient #3, #6, and #8), the facility's staff failed to ensure the orders for restraints, used for the management of violent or self-destructive behaviors, were renewed every four (4) hours.

The findings were:

The review of Patient #3's clinical record provided evidence the patient was admitted to the unit with a diagnosis of bowel perforation and sepsis (systemic infection). The review of Patient #3's clinical record provided the following additional evidence:
A progress note by a registered nurse (RN) dated 05/29/18 at 09:30 a.m., "Attempted to draw patients [sic] labs and patient became combative hitting and kicking. Intensivist notified and at bedside."
An order from the Intensivist (physician/Staff Member SM #17) dated 05/29/18 at 9:30 a.m. for "Haldol 5 milligrams (mg) IV (Intravenous) once." Note: Haldol is an antipsychotic medication used to treat psychotic disorders.
A progress note by an RN dated 05/29/18 at 09:35 a.m., "5 mg IV Haldol given."
A progress note by an RN dated 05/29/18 at 6:05 p.m., "Patient very agitated. Hitting and kicking."
A shift assessment documented by Nurse #1 dated 05/29/18 at 8:00 p.m., "Psychosocial Patient Behaviors: Aggressive verbally; Aggressive physically; Agitated; Manipulative; Non-Compliant; Restless; Uncooperative."
A progress note by Nurse #1, dated 05/29/18 at 8:55 p.m., "Intensivist called to inform of status change......Pt became agitated and combative requiring 4 point restraints."
An order from the Intensivist (physician/SM #26) dated 05/29/18 at 9:05 p.m., for "Non- Violent" restraints of "Soft restraint" to "right ankle, right wrist, left ankle, and left wrist" and documents the "Reason for the restraints" as "Interference with medical treatment."
An order from the Intensivist (physician/SM #26) dated 05/29/18 at 9:13 p.m. for "Haldol Injection 2 mg IM (Intramuscularly) once."
A MAR (Medication Administration Record) entry by Nurse #1 dated 05/29/18 at 9:42 p.m., documenting that Haldol 2 mg was administered Intramuscularly in the left deltoid.
Related to restraints, the careplan addressed only the use of "Non-Violent restraints."

During the review of the clinical record of Patient #3 on 08/28/18 at 10:15 a.m., the Quality Coordinator (SM # 27) assisted with navigating the electronic health record. The Regulatory Compliance Coordinator (SM #6) was present during the review as well. During the review, SM #27 acknowledged the two doses of Haldol given to Patient #3, on 05/29/18 were not a part of the patient's alcohol withdrawal protocol (CIWA) nor was it being used to treat a medical condition. SM #27 acknowledged the Haldol doses were used to treat a behavior of hitting and kicking. SM #27 stated, "I don't think they recognized they were giving a chemical restraint, and SM #6 stated, I would agree with that statement." SM # 6 acknowledged that because the restraints were not identified as being used for the management of violent or self destructive behaviors, the orders were not renewed in the required time frames. SM #6 stated the staff and/or physicians "chose Non-Violent as this was the understanding of how that should have been handled at the time, but we understand the explanation given regarding the COPs [regulations] and moving forward that will require changes in our Policies and Procedures."

A review of the facility's 27 page policy titled, "Restraints and Seclusion" (Policy No. BSR 02-03, Rev.: 4/18) took place ongoing throughout the survey. The policy read, in part, as follows:
"Restraint for Non-Violent, Non-Behavioral (Medical and Surgical) Care"..."Purpose - To protect or prevent injury by limiting mobility or temporarily immobilizing a patient in the provision of medical and/or post-surgical care"
"Violent or Self-Destructive Restraint or Seclusion (Behavioral)"..."Definition - Use for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member or others and when non-physical interventions would not be effective."
"Violent or Self-Destructive Restraint or Seclusion (Behavioral)...Physician Order...Time limits for verbal and written orders are limited to: 1. 4 hours for individuals 18 years and older."...




2. Patient #6's restraint orders were written as 'NON-VIOLENT' restraints when documentation frequently indicated Patient #6 was exhibiting 'Combative' behaviors. The order being written as 'NON-VIOLENT' instead of 'VIOLENT' resulted in restraint orders, addressing violent/combative behaviors, not being renewed within the required time limits. (Patient #6 was an adult patient.)

Patient #6's clinical record included the following orders for restraints:
- On 8/14/18 at 5:17 p.m., an order for bilateral soft wrist restraints;
- On 8/14/18 at 6:46 p.m., an order for bilateral soft wrist restraints and bilateral soft ankle restraints;
- On 8/14/18 at 10:26 p.m., an order for bilateral soft wrist restraints;
- On 8/16/18 at 12:06 a.m., an order for bilateral soft wrist restraints;
- On 8/17/18 at 4:41 a.m., an order for bilateral soft wrist restraints;
- On 8/18/18 at 2:16 a.m., an order for bilateral soft wrist restraints;
- On 8/19/18 at 6:25 a.m., an order for bilateral soft wrist restraints.
All of the aforementioned orders indicated the restraints were ordered as 'NON-VIOLENT' restraints with the 'Frequency' of "RESTRAIN FOR 24 HOURS".

Patient #6's clinical documentation included, but was not limited to, the following:
- On 8/14/18 at 5:17 p.m., "Agitated; Combative; Confused; Delusional; Hallucinating; Paranoid" and bilateral soft wrist restraints were documented as being initiated;
- On 8/14/18 at 6:00 p.m., bilateral soft ankle restraints were documented as being initiated (these were documented as being discontinued on 8/14/18 at 8:00 p.m. (the bilateral wrist restraints were still in use);
- On 8/15/18 at 12:02 a.m., "Confused; Agitated; Combative; Delusional; Hallucinating";
- On 8/15/18 at 7:00 a.m., "Agitated; Combative; Confused; Hallucinating; Restless";
- On 8/15/18 at 8:00 a.m., "Agitated; Combative; Confused; Hallucinating";
- On 8/16/18 at 12:15 a.m., "Combative; Confused; Restless";
- On 8/16/18 at 2:00 a.m., "Combative; Agitated; Restless; Confused";
- On 8/18/18 at 2:43 p.m., "Agitated; Combative; Confused; Restless; Verbally Abusive";
- On 8/18/18 at 6:09 p.m., "Agitated; Combative; Confused; Paranoid; Restless; Sedated; Verbally abusive".

The following information was found in a facility policy with the title 'Restraints and Seclusion' (with the most recent revision date of 4/2018): "Violent or Self-Destructive Restraint or Seclusion (Behavioral) ... Definition ... Use for the management of violent or self-destructive behavior that jeopardized the immediate physical safety of the patient, staff member or others and when non-physical interventions would not be effective ... Physician Order ... Time limits for verbal and written orders are limited to: ... 4 hours for individuals 18 years and older ..."

The failure of the facility staff to ensure restraint orders were correctly identified as addressing 'violent' behaviors resulting in the restraint orders not being renewed within the required time limit was discussed during a survey team meeting on 8/28/18 at 5:30 p.m. with the facility's Director of Quality and the facility's Regional Coordinator.

3. Patient #8's restraint orders were written as 'NON-VIOLENT' restraints when documentation indicated Patient #8 was exhibiting 'combative' behaviors; this resulted in restraint orders, addressing violent behaviors, not being renewed within the required time limits. (Patient #8 was an adult patient.)

Patient #8's clinical record included the following restraint orders:
- On 6/16/18 at 1:12 p.m., "RESTRAINTS (NON-VIOLENT)" were ordered for the frequency of "RESTRAIN FOR 24 HOURS". The restraints ordered were bilateral soft wrist and bilateral soft ankle restraints.
- On 6/17/18 at 11:55 a.m., "RESTRAINTS (NON-VIOLENT)" were ordered for the frequency of "RESTRAIN FOR 24 HOURS". The restraints ordered were bilateral soft wrist and bilateral soft ankle restraints.

The following documentation was found in Patient #8's clinical record:
- A registered nurse note dated 6/15/18 at 9:00 a.m.: "The patient has been combative, screaming and hitting, (his/her) head off of padded siderails [sic]. (He/She) is wearing (his/her) helmet ..."
- A physician note dated 6/16/18 at 1:20 p.m.: "Came and evaluated by myself, (two other physician names omitted). Code Atlas called on patient, as (he/she) was combative and refused all PO medications. Pt kicked techs and base of bed. Haldol 2mg IM given stat. Bilateral wrist and ankle soft restraints applied ... Reason for restraints: interfernce [sic] with care, violent ..."
- A physician note dated 6/16/18 at 10:40 p.m.: "Patient seen and examined at bedside with sitter present. Patient has been agitated and required 1 mg ativan (times) 1, Seroquel 300mg (by mouth) (times) 2, and Haldol 2mg (intramuscular injection). The patient has not required more Haldol but is still occasionally combative and requiring soft non-violent restraints. These restraints were necessary as patient's agitation was interfering with medical therapy."
- A physician note dated 6/17/18 at 1:23 p.m.: "(He/She) continues to have outbursts and become combative requiring chemical and mechanical restraint ..."

The failure of the facility staff to ensure Patient #8's restraint orders were correctly identified as addressing 'violent' behaviors resulted in the restraint orders not being renewed within the required time limit; this was discussed during a survey team meeting on 8/28/18 at 5:30 p.m. with the facility's Director of Quality and the facility's Regional Coordinator.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on a review of clinical records, facility documents and staff interviews, it was determined that for three (3) of five (5) adult patients sampled for review of restraint use (Patient #3, #6, and #8), the facility's staff failed to ensure the patients were monitored per the facility's policy for restraints used for the management of violent or self-destructive behaviors.

See also Tag A-0171 for additional details.

The findings were:

1. The review of Patient #3's clinical record provided evidence the patient was admitted to a unit with a diagnosis of bowel perforation and sepsis (systemic infection). The review of Patient #3's clinical record provided evidence the patient's restraints, though not monitored as such, were used to manage violent or self-destructive behaviors. The review of the clinical record provided the following additional evidence:
A progress note by a registered nurse (RN) dated 05/29/18 at 09:30 a.m., "Attempted to draw patients [sic] labs and patient became combative hitting and kicking. Intensivist notified and at bedside."
An order from the Intensivist (physician/Staff Member SM #17) dated 05/29/18 at 9:30 a.m. for "Haldol 5 milligrams (mg) IV (Intravenous) once." Note: Haldol is an antipsychotic medication used to treat psychotic disorders.
A progress note by an RN dated 05/29/18 at 09:35 a.m., "5 mg IV Haldol given."
A progress note by an RN dated 05/29/18 at 6:05 p.m., "Patient very agitated. Hitting and kicking."
A shift assessment documented by Nurse #1 dated 05/29/18 at 8:00 p.m., "Psychosocial Patient Behaviors: Aggressive verbally; Aggressive physically; Agitated; Manipulative; Non-Compliant; Restless; Uncooperative."
A progress note by Nurse #1, dated 05/29/18 at 8:55 p.m., "Intensivist called to inform of status change......Pt became agitated and combative requiring 4 point restraints."
An order from the Intensivist (physician/SM #26) dated 05/29/18 at 9:05 p.m., for "Non- Violent" restraints of "Soft restraint" to "right ankle, right wrist, left ankle, and left wrist" and documents the "Reason for the restraints" as "Interference with medical treatment."
An order from the Intensivist (physician/SM #26) dated 05/29/18 at 9:13 p.m. for "Haldol Injection 2 mg IM (Intramuscularly) once."
A MAR (Medication Administration Record) entry by Nurse #1 dated 05/29/18 at 9:42 p.m., documenting that Haldol 2 mg was administered Intramuscularly in the left deltoid.
The Restraint Flowsheet failed to include monitoring for the use of a restraint at the time of the first dose of Haldol on 05/29/18 at 9:35 a.m. The first monitoring of restraints was documented on 05/29/18 at 9:00 p.m., and thereafter occurred every 1 to 2 hours until 8:00 a.m. the morning of 05/30/18. From 8:00 a.m., the next monitoring was documented four (4) hours later, at 12:00 noon. From 12:00 noon the monitoring was documented every 1 to 2 hours until 6:00 p.m. From 6:00 p.m. there was no further documentation of the restraints, until a progress note by an RN dated 05/31/18 at 08:00 a.m. (14 hours later) documented, "The patient is not restrained."
The clinical record failed to contain evidence of when, why, or by whom, the restraints were discontinued.
The record failed to contain evidence the patient was assessed/monitored related to the restraints in use, per the hospital's policy for non-violent behaviors of every 2 hours, or for violent/ self- destructive behaviors every 15 minutes.

During the review of the clinical record of Patient #3 on 08/28/18 at 10:15 a.m., the Quality Coordinator (SM # 27) assisted with navigating the electronic health record. The Regulatory Compliance Coordinator (SM #6) was present during the review as well. During the review, SM #27 acknowledged the two doses of Haldol given to Patient #3, on 05/29/18 were not a part of the patient's alcohol withdrawal protocol (CIWA) nor was it being used to treat a medical condition. SM #27 acknowledged the Haldol doses were used to treat a behavior of hitting and kicking. SM #27 stated, "I don't think they recognized they were giving a chemical restraint, and SM #6 stated, I would agree with that statement." SM # 6 acknowledged that monitoring and reassessment did not occur every 2 hours, which would have been the expectation if the restraints were used for non-violent behaviors. SM #6 acknowledged that because the restraints were not identified as being used for the management of violent or self destructive behaviors, the monitoring and reassessing did not occur every 15 minutes as the policy requires. SM #6 stated the staff and/or physicians "chose Non-Violent as this was the understanding of how that should have been handled at the time, but we understand the explanation given regarding the COPs [regulations] and moving forward that will require changes in our Policies and Procedures."

A review of the facility's 27 page policy titled, "Restraints and Seclusion" (Policy No. BSR 02-03, Rev.: 4/18) took place ongoing throughout the survey. The policy read, in part, as follows:
"Restraint for Non-Violent, Non-Behavioral (Medical and Surgical) Care"..."Documentation and Reassessment of Non-Violent, Non-Behavioral (Medical and Surgical) Restraints..Reassess at least every 2 hours or more frequently based on patient needs."
"Violent or Self-Destructive Restraint or Seclusion (Behavioral)"..."Continuous Monitoring..Each patient with Violent or Self-Destructive behavior and restrained will be observed continuously 1:1 and their care documented as frequently as their condition warrants and every 15 minutes for the Management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member or others."





2. Patient #6's restraints were documented as 'non-violent' although documentation included 'combative' behaviors. Incorrectly identify the restraints as 'non-violent' resulted in incomplete restraint monitoring. Patient #6 clinical documentation also included restraint-monitoring assessments that were not documented in a timely manner.

The following information was found in a facility policy with the title 'Restraints and Seclusion' (with the most recent revision date of 4/2018): "Violent or Self-Destructive Restraint or Seclusion (Behavioral) ... Documentation and Reassessment of Emergency Use for Violent or Self-Destructive Behavior (Behavioral) Restraints ... - Every 15 minutes for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member or others. - Initiation and on-going use of restraints or seclusion will be documented in the nursing notes, on the Restraint Documentation Form and in the Plan of Care. - Reassess: 1. Circulation check 2. Vital Signs as indicated 3. Signs of Injury 4. Skin Integrity 5. Mental Status and Behavior 6. Touch/Sensation 7. Pulse oximetry as indicated 8. Check application of restraint 9. Whether less restrictive measures are possible 10. Readiness to discontinue 11. Restraint release and patient's response".

Evidence of consistent fifteen (15) minute restraint monitoring for Patient #6, as required in the aforementioned facility's policy/procedure, was neither found by nor provide to the surveyor.

Patient #6's clinical documentation included the following:
- An entry for 8/15/18 at 6:00 a.m. that was documented on 8/21/18 at 12:42 p.m. This entry addressed if restraints were still in use including the patient's psychological status, circulation, range of motion, fluids, food/meal, and elimination.
- An entry for 8/16/18 at 6:00 p.m. that was documented on 8/21/18 at 12:02 p.m. This entry addressed if restraints were still in use including the patient's psychological status, circulation, range of motion, fluids, food/meal, and elimination.
- Entries for 8/16/18 at 8:00 p.m., 8/17/18 at 12:00 midnight, 8/17/18 at 2:00 a.m., and 8/17/18 at 4:00 a.m. were all documented on 8/17/18 at 4:44 a.m. These entries addressed if restraints were still in use including the patient's psychological status, circulation, range of motion, fluids, food/meal, and elimination.

The failure of the facility staff to ensure restraint monitoring was completed and/or documented according to facility policy/procedure was discussed during a survey team meeting on 8/28/18 at 5:30 p.m. with the facility's Director of Quality and Regional Coordinator.

3. Patient #8's restraints were ordered and documented as 'non-violent' although 'combative' behaviors were documented; this resulted in incomplete restraint monitoring. Patient #8 clinical documentation also included restraint-monitoring assessments that were not documented in a timely manner.

Evidence of consistent fifteen (15) minute restraint monitoring for Patient #8, as required in the aforementioned facility's policy/procedure, was neither found by nor provided to the surveyor.

Patient #8's clinical restraint documentation included entries for 8/19/18 at 8:00 a.m., 10:00 a.m., 12:00 noon, 2:00 p.m., 4:00 p.m., and 6:00 p.m.; these entries were all entered/documented on 8/19/18 at 6:36 p.m. These entries addressed if restraints were still in use including the patient's psychological status, circulation, range of motion, fluids, food/meal, and elimination.

The failure of the facility staff to ensure Patient #8's restraint monitoring was completed and/or documented according to facility policy/procedure was discussed during a survey team meeting on 8/28/18 at 5:30 p.m. with the facility's Director of Quality and the facility's Regional Coordinator.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0176
Based on staff interviews, facility document review, and during the course of a complaint investigation it was determined a physician who wrote restraint orders did not have a working knowledge of the facility's restraint policy.

The findings were:

One of the facility's physicians (Staff Member - SM#26) was interviewed via phone on 8/29/18 at 9:34 a.m. The physician had signed a restraint order for Patient #3 which included restraining both wrists and both ankles and was classified as non-violent. The survey team asked the physician about the differences between when to order violent versus non-violent restraints. The physician stated that violent restraints were only "tough cuffs" or "maybe leather" restraints because they were harder to break. The physician said they had rarely had to order violent restraints because the soft restraints usually work, but added that soft restraints may not work for young, strong men. The doctor reiterated that unless they were ordering tough cuffs, they would not classify the order as violent restraints and stated they think that's the understanding of many other providers at the facility. When asked if ordering violent versus non-violent restraints had anything to do with behavioral health concerns such as suicidal ideations and/or homicidal ideations, the physician said "no," it depends on which type of restraints were being applied - leather versus soft. The physician was asked about whether they had received training from the facility related to restraint usage. The doctor said he/she didn't really remember having training, receiving a policy or signing anything about restraint training.

The facility's regulatory coordinator provided the survey team with a copy of the facility's "Provider Orientation Compliance Tips" and stated physicians receive this 21 page document upon hire and with each reappointment. Physicians were expected to sign the last page acknowledging receipt of the information. The 21 page document included one and a half pages related to restraint and seclusion that spoke to the facility's philosophy regarding restraint and seclusion as well as requirements of ordering and re-ordering restraints for both violent (Behavioral Management Restraints) and non-violent (Non-behavioral Restraints). The information did not include the specific types of restraints used such as soft versus leather. The regulatory coordinator provided a copy of the physician's (SM #26) acknowledgement form that the physician had signed on 4/02/18. The signed last page listed 20 items the physicians were acknowledging which included "4. I have read and will comply with restraint and seclusion standards." There was no evidence provided that physicians had received the facility's entire restraint and seclusion policy.

The facility's Chief Medical Officer (CMO - SM #21) was interviewed in person on 8/29/18 at 3:42 p.m. The physician stated he/she doesn't practice at the facility but felt the staff had a good understanding of the restraint policy. The CMO's expectation was that a restraint order would be based on a combination of behaviors and diagnosis. The physician gave an example of non-violent restraints being needed when a patient was confused with potential self-harm because of their transient circumstances whereas an example of violent restraints being necessary if a patient was "purposefully" trying to harm themselves or others such as someone having a psychotic break and "intentionally" going after staff.

The facility's policy titled, "Restraints and Seclusion" (Policy No. BSR 02-03, Rev.: 4/18) was reviewed throughout the survey. The 27 page policy read in part, "The decision to use a restraint or seclusion is not driven by diagnosis, but by a comprehensive individual patient assessment." The policy also read "9. Restraint for Non-Violent, Non-Behavioral (Medical and Surgical) Care 9.1 Purpose - To protect or prevent injury by limiting mobility or temporarily immobilizing a patient in the provision of medical and/or post-surgical care" and also, "10. Violent or Self-Destructive Restraint or Seclusion (Behavioral). 10.1 Definition - Use for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member or others and when non-physical interventions would not be effective. 10.2 Purpose - The use of a physical or chemical restraint (medication), or seclusion to manage behavior in an emergency situation or crisis and only for the duration of that situation. This measure is reserved for those occasions when unanticipated, severely aggressive, violent or destructive behavior places the patient, staff, or others in imminent danger."
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on the systemic nature of the standard-level deficiencies related to patient rights, the facility staff failed to substantially comply with this condition.

The findings were:

These following standards were cited and show a systemic nature of non-compliance with regards to patient's rights as follows:

(482.13 Tag A-0145)
The information reviewed during the survey provided evidence that one (1) of five (5) patients sampled for a review of restraint use (Patient #3), was verbally and physically abused, by one or more of the facility's nursing staff.

(482.13 Tag A-0154)
The information reviewed during the survey provided evidence that (1) of five (5) patients sampled for a review of restraint use (Patient #3), was placed in restraints as a form of discipline or retaliation, by one or more of the facility's nursing staff.

482.13 Tag A-0164
The information reviewed during the survey provided evidence the facility's nurses failed to use less restrictive interventions before applying four (4) point restraints for one (1) of five (5) patients sampled for a review of restraint use (Patient #3).

482.13 Tag A-0165
The information reviewed during the survey provided evidence the facility staff failed to use the least restrictive restraint for one (1) of five (5) patients sampled for restraint use (Patient #8).

482.13 Tag A-0166
The information reviewed during the survey provided evidence that for three (3) of five (5) patients sampled for review of restraint use (Patient #3, #6, and #8), the patients' plan of care failed to address the use of restraints for self-destructive or violent behaviors.

482.13 Tag A-0171
The information reviewed during the survey provided evidence that for three (3) of five (5) adult patients sampled for review of restraint use (Patient #3, #6, and #8), the facility's staff failed to ensure the orders for restraints, used for the management of violent or self-destructive behaviors, were renewed every four (4) hours.

428.13 Tag A-0175
The information reviewed during the survey provided evidence that for three (3) of five (5) adult patients sampled for review of restraint use (Patient #3, #6, and #8), the facility's staff failed to ensure the patients were monitored per the facility's policy for restraints used for the management of violent or self-destructive behaviors.

428.13 Tag A-0176
The information reviewed during the survey provided evidence that a physician who wrote restraint orders did not have a working knowledge of the facility's restraint policy.

428.13 Tag A-0185
The information reviewed during the survey provided evidence the facility staff failed to document regarding behaviors which resulted in the addition of bilateral leg/ankle restraints, to a patient who already had bilateral arm/wrist restraints being used. This was for one (1) of five (5) patients sampled for restraint review (Patient #6).

A discussion took place with the survey team and the facility's administrative staff (Staff Members #3, #6, and #8) about the survey team's concerns related to Patient's Rights, on 08/23/18 at an end of day meeting. The survey team met again with the facility's administrative staff (Staff Members #6 and #8) on 08/28/18 at an end of day discussion where the survey team's concerns related to Patient's Rights was discussed.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on staff interviews, a review of facility documents and the clinical record, it was determined that one (1) of five (5) patients sampled for a review of restraint use (Patient #3), was verbally and physically abused, by one or more of the facility's nursing staff.

The findings were:

1. The Administrative Director of Quality (Staff Member/SM #8), on 08/21/18 at 11:20 a.m., provided the surveyor with the hospital's documentation of an allegation of verbal and physical abuse on a patient. The document described the review and actions of the hospital beginning 05/31/18 to 06/05/18. The document provided evidence that SM #15 (a sitter) reported on the morning of 05/31/18, that on 05/29/18 he/she witnessed two registered nurses (RNs) "verbally and physically abuse the patient (yanking on the patient and slapping [him/her])." SM #8 confirmed the patient referred to in the document was Patient #3 and the unit where the alleged actions took place. The document provided evidence that as a part of the review, the hospital's leadership members were notified, a forensic nurse was consulted, APS [Adult Protective Services] and the local law enforcement officers were notified.

The documentation provided evidence the Administrative Director of the unit where Patient #3 had been (SM #9), worked with the facility's HR (Human Resources) staff to conduct interviews (on 05/31 18) with the nurses named in the allegation.
SM #9's documented interview of Nurse #2 dated 05/31/18 at 10:00 a.m., included in part the following: [Nurse #2] stated that he/she came in to help [Nurse #1] with a confused patient who was grabbing, kicking, and flailing and they were having difficulty getting the patient into four (4) point restraints [restraints of all four (4) extremities]. [Nurse #2] stated that [Nurse #1] said "shut up" a couple of times to the patient, and "may have slapped that patient." Nurse #2 stated the restraints were not too tight and that comment about the drug use [of Patient #3] were at the nurse's station and not in the room. SM #9 documented that Nurse #2 was suspended pending the outcome of the investigation.
SM #9's documented interview of Nurse #1 (a traveler nurse) dated 05/31/18 at 11:00 a.m., included in part the following: [Nurse #1] stated that the patient "was kicking and hitting- the nursing staff was trying to protect themselves." Nurse #1 stated they "did ask information about heroin because they were trying to determine what [the patient] took." Nurse #1 stated he/she did ask the patient to "hush" multiple times explaining there were other patients being disturbed. Nurse #1 stated that [Nurse #3] "open handed slapped the patient on the leg." Nurse #1 stated he/she was able to get two fingers "in between" the restraints to ensure they were not too tight. Nurse #1 stated he/she "felt frustrated" when leaving the shift. SM #9 documented that Nurse #1's "contract has been canceled [sic]" with a follow up call and email sent to the contracting company regarding the events involving Nurse #1.
SM #9's documented interview of Nurse #3 dated 05/31/18 at 5:30 p.m., included in part the following: [Nurse #3] stated "the patient was fighting all over the place" and that he/she "was pushing the patient over to the side to get [the patient] cleaned up." [Nurse #3] stated the patient grabbed his/her side and he/she "tapped" the patient on the leg to get the patient to roll the rest of the way over. [Nurse #3] stated that [Nurse #1] "was using foul language towards the patient." SM #9 documented that Nurse #3 was suspended pending the outcome of the investigation.

The facility's review included documentation by the Director of Forensic Nursing (SM #14) dated 06/01/18. SM #14 documented the local law enforcement "reports that due to patient not wanting to speak with law enforcement, they would respect [his/her] wishes."

2. SM #8, on 08/28/18, provided documents related to the outcomes of Nurse #1, 2, and 3, after the aforementioned hospital review was completed. Those documents included evidence that Nurses #1, #2 and #3 were no longer working at the hospital.

3. Two surveyors conducted a phone interview with SM #15 on 08/22/18 at 1:50 p.m. SM #15 stated he/she was assigned as a sitter for Patient #3 on 05/29/18 from 3:00 p.m. to 11:00 p.m., as a safety precaution for Patient #3. SM #15 stated the patient was "in and out of it" was having "withdrawal" and was "restless and lacked safety judgements." SM #15 stated as a sitter, he/she would help the nurses, keep [the patient] from pulling out the IV (intravenous line) or wires, keep [the patient] from falling out of bed, and assist [the patient] to the bathroom. He/she stated that since this was one to one (1:1) supervision of the patient, he/she was not allowed to leave the room unless there were other hospital staff present to cover his/her brief absence. SM #15 stated that from 3:00 p.m. to 7:00 p.m. "everything was ok." SM #15 stated that at 7:00 p.m. a new shift started and there was a different nurse [Nurse #1]. SM #15 stated that Nurse #1 asked SM #15 to help with a bed bath and changing the bed linens for Patient #3. SM #15 stated that Nurse #1 left and returned about 1 to 2 hours later with bathing supplies, and they began the bath. SM #15 stated that Patient #3 was "sort of awake" and that Nurse #1 asked the patient if he/she was enjoying the bath, to which the patient replied, "No." SM #15 stated, Nurse #1 was on the patient's left side and SM #15 was on the patient's right side, and they began trying to turn the patient on his/her side facing SM #15, in order to change the sheets and wash the patient's back. SM #15 stated the patient "did not like that" and began moaning and "yelling out a little maybe" while trying to push back onto his/her back. SM #15 stated, "then [Nurse #2] "came in and was on the patient's right side with me." SM #15 stated, "from the get go" Nurse #2 "was extremely aggressive with the patient and began pulling the left leg - literally yanked it so hard I thought the bedrails might pop off." SM #15 stated the patient was then on his/her side and began "really screaming out at this point" saying, "it hurts, it hurts" and "I can't breath." SM #15 stated that Nurse #2 then said to the patient, "if you couldn't breath you wouldn't be talking right now." SM #15 stated the patient was still trying to roll his/her self onto his/her back, and Nurse #2 "open handed slapped" the patient on the left back area, between the lower back and thigh and "yanked the patient's whole body again toward [Nurse #2]" to get the patient back on his/her side. SM #15 stated, "I was totally shocked" and "I froze." He/she stated, "I couldn't believe what was happening" and "I definitely froze, but I'd do things differently now." SM #15 stated he/she realized that he/she had "blood all over me" from the patient's IV that had become loose or dislodged. SM #15 stated, the patient yelled out, "that hurts" and said to Nurse #2, "you're man-handling me." SM #15 stated that Nurse #2 replied, "you're right, I am man-handling you because you're not listening or cooperating." SM #15 stated, he/she wasn't sure what the patient said to prompt it but [Nurse #1] was "within 6 inches" of Patient #3's face, "looking right into [his/her] eyes," and in a "loud" voice said "Shut up." SM #15 said, "It scared me" and "it sounded threatening to me" and "I was afraid [Nurse #1] who was visibly upset and angry was losing [his/her] temper." SM #15 stated, "they got the patient on [his/her] back and [Nurse #1] and [Nurse #2] agreed they were going to use 4 point restraints [restraints to all four (4) extremities]. SM #15 stated there was a portion of time during this event, when a third nurse [Nurse #3] was present in the room, but SM #15 doesn't recall when, in the course of the events, that occurred. SM #15 stated that he/she left the room at that point to change clothes, and was gone for about 15 minutes. SM #15 stated that when he/she returned to the room, [Nurse #1 and Nurse #2] were "working on getting [the patient] in the restraints" and that once they were finished the restraints "looked tighter than usual to me." SM #15 stated that Patient #3 was never aggressive or physical toward him/her in any way while caring for the patient. SM #15 stated that he/she was not scheduled to work the next day (05/30/18) but returned to work on 05/31/18, and was assigned to cover for Patient #3's sitter while he/she took a break, and while doing so, [Nurse #1] was present in the room giving report to the oncoming nurse. SM #15 stated that after the nurses left the room, Patient #3 stated, "I've got to get out of here," and "they hit me," and when asked who, the patient stated, "those nurses." SM #15 stated that because of the statements made to him/her by Patient #3 that morning, as soon as the patient's assigned sitter returned, he/she (SM #15) immediately reported to his/her supervisor what he/she had witnessed on 05/29/18. SM #15 stated that was the first time he/she had witnessed that level of aggression and abuse to a patient and described having regrets that he/she "froze" and didn't intervene or know how to better handle the situation.

4. Two surveyors conducted an in-person follow up interview with SM #15 on 08/29/18 at 1:25 p.m. SM #15 stated he/she never felt threatened by Patient #3, and the patient's verbal and physical behaviors were triggered by the attempts to turn the patient on their side for a bath, which was painful for the patient. SM #15 stated that during the above described events with Patient #3 (on 05/29/18), there was no discussion by the nurses of stopping the attempted bed bath to allow the patient time to calm down, and SM #15 does not know if the bed bath was completed or not. SM #15 was asked if the restraints applied to Patient #3 on 05/29/18, and described above, were applied for patient safety or as a form of punishment. SM #15 stated that in his/her opinion, the restraint use was "100% personal against the patient and not for safety." When asked if there was anything specific that caused him/her to have that opinion, SM #15 stated there were many inappropriate comments made to the patient by Nurse #1 and Nurse #2, "they [Nurse #1 and Nurse #2] were angry," and "you could just tell." He/she stated there were lots of scabs on the skin of Patient #3 and Nurse #1 made the comment, "that's what happens when you do drugs" and asked Patient #3 "how do you take your heroin, snort it or shoot it." SM #15 stated that at some point during the events of 05/29/18, Patient #3 "called the nurse out" on his/her actions and Nurse #1 stated, "If you say that again, I'll call the police and the handcuffs will be worse than what you have now." SM #15 stated that in the presence of Patient #3, Nurse #1 stated that "users" and "addicts" were his/her least favorite kind of patients and that he/she hates what drugs do to people. SM #15 stated there were other inappropriate comments as well, but these were the ones he/she specifically recalls.

5. The surveyor conducted an interview with the Director of Forensic Nursing (SM #14) on 0822/18 at 2:50 p.m. SM #14 stated the forensic nurse who examined Patient #3 was on vacation and unavailable for interview, but offered that nurse's documentation for review. SM #14 stated, "we make a head to toe assessment and document what we find" and "we make no judgements or conclusions of how they [injuries] occurred, or the timeframe in which they occurred." After reviewing the forensic nurse's documentation of the examination occurring on 06/01/18, SM #14 acknowledged the documentation describes a total of 39 alterations in skin integrity or appearance. Documentation of the following was also noted, "...the patient was on a blood thinner, which could contribute to [the patient's] bruising from a number of causes and the abdomen is the injection site for Heparin." Note: A review of the patient's clinical record and medication list provided evidence the patient was on Heparin 5,000 units subcutaneously every 8 hours from admission through discharge.

6. Two surveyors interviewed the Administrative Director of the unit where Patient #3 had been (SM #9), on 08/23/18 at 3:04 p.m. SM #9 acknowledged he/she conducted the interviews with Nurse #1, Nurse #2, and Nurse #3 which were documented on the hospital's review document, described in #1 above. SM #9 stated that when the complaint was first made known, there were only two nurses (Nurse #1 and Nurse #2) named in the allegation, but as the interviews took place, a third nurse (Nurse #3) was identified as being involved. SM #9 stated, he/she had "never had an abuse case before" but after interviewing the three (3) nurses it was clear that something did happen.
SM #9 reviewed the staffing documents for the unit dated 05/29/18 and 05/30/18. He/she confirmed the following:
There was a census of thirteen (13) patients on day shift and thirteen (13) patients on night shift, on 05/29/18; there were six (6) RNs and two (2) Techs (aides) for day shift and six (6) RNs and one (1) Tech for night shift on 05/29/18.
There was a census of eleven (11) patients on day shift and nine (9) patients on night shift, on 05/30/18; there were six (6) RNs and two (2) Techs for day shift and six (6) RNs and one (1) Tech for night shift on 05/30/18.

7. Two surveyors interviewed the Chief Nurse Executive/CNE, on 08/23/18 at 1:34 p.m., regarding the complaint allegation of verbal and physical abuse investigated by the hospital, and described in the hospital review document described above. The CNE stated, "it likely did occur and was not in accordance with our core values." The CNE stated it resulted in the termination of three (3) nurses and described how the hospital was implementing resources for staff to ensure that it does not happen again. The CNE described a planned change in approach for nursing services, as well as a "culture change" for all staff that touch patients. He/she described the plan included, in part, a mechanism for staff to "tag out" when they feel they are reaching their limit, and assignments that allow staff relief from continual assignments of challenging cases. The CNE acknowledged the changes were "being rolled out' and were "in process" but not fully implemented yet.

8. The review of Patient #3's clinical record provided evidence the patient was admitted to the unit with a diagnosis of bowel perforation and sepsis (systemic infection). The clinical record did not contain documentation of the aforementioned events (described above) occurring on 05/29/18. The record contained a progress note by Nurse #1, dated 05/29/18 at 8:55 p.m. which documented, "Pt became agitated and combative requiring 4 point restraints." There was no documentation within the clinical record of the eyewitness accounts, of an attempt to give a bed bath and the resulting escalation of patient discomfort and behaviors when turned on his/her side. The record contained physician's orders from SM #26, dated 05/29/18 and timed as 9:05 p.m., for "Soft restraint" to "right ankle, right wrist, left ankle, and left wrist" and documents the "Reason for the restraints" as "Interference with medical treatment."

9. Two surveyors conducted a phone interview, on 08/29/18 at 9:30 a.m., with the facility's physician (SM #26). The physician had ordered four (4) point restraints (restraints of all four (4) extremities) for Patient #3 on 05/29/18. The physician stated he/she did not remember Patient #3, that he/she never met or took care of the patient. The physician stated he/she was on-call and was paged by the nurse at night. The physician stated that in general when called, the physicians put a lot of trust in what they are being told by the nurse, but they do usually ask what's going on. The physician was asked if he/she had been made aware that the behaviors of Patient #3, for which 4 point restraints were being requested, were triggered during an attempted bed bath when the staff tried to turn the patient on his/her side. The physician stated he/she was not aware of that, and further stated, "I would not approve of restraints for that, the bath could be delayed." The physician stated that a patient who is placed in four (4) point restraints is usually a danger to staff or to themselves, but doesn't see that as being a restraint for "violent" behaviors. The Physician stated that he/she rarely uses "violent" restraints and described those to be "tough cuffs or leather restraints." He/she stated, "unless I'm ordering the tough cuffs or leather restraints, I would not classify them as a "violent" restraint.

10. The surveyor conducted a phone interview with the Director of the unit where Patient #3 had been (SM #13), on 08/29/18 at 2:30 p.m. SM #13 stated being familiar with the allegations made by an employee that nurses committed verbal and physical abuse against Patient #3, while the patient was in the ICU. SM #13 stated, "I have talked to my staff about this." SM #13 stated the use of restraints, triggered because the patient had aggressive behaviors while a bed bath was being attempted, was troubling. When asked what he/she would have expected the nurses to do in that situation, SM #13 stated they could have called a "Code ____" which would have brought security staff to the room to assist, or they could have aborted the idea of a bath and let the situation de-escalate. SM #13 stated that as a nurse, if your stressors are being triggered, you have to find a way to take a time out or step away from the situation to regain composure.

11. A review of the facility's 27 page policy titled, "Restraints and Seclusion" (Policy No. BSR 02-03, Rev.: 4/18) took place ongoing throughout the survey. The policy read, in part, as follows:
"The use of restraints and/or seclusion is never used to punish, for coercion, as a means or [sic] discipline or retaliation or used solely for staff convenience. Restraint or seclusion may only be used to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time."
"The decision to use a restraint or seclusion is not driven by diagnosis, but by a comprehensive individual patient assessment."
"Restraint for Non-Violent, Non-Behavioral (Medical and Surgical) Care"..."Purpose - To protect or prevent injury by limiting mobility or temporarily immobilizing a patient in the provision of medical and/or post-surgical care"
"Violent or Self-Destructive Restraint or Seclusion (Behavioral)"..."Definition - Use for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member or others and when non-physical interventions would not be effective."

12. A review of the facility's 16 page policy titled, "Care of Victims & Perpetrators of Abuse, Neglect, or Exploitation" (Policy No. BSR 01-11, Rev.: 8/16) took place on 08/28/18. The policy read, in part, as follows on page 1,..."Any individual working in their designated capacity for (initials of facility) including employees, physicians, and contracted employees are responsible for making an immediate report of any incidents of suspected abuse, neglect or exploitation as outlined in mandated reporting requirements."
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on staff interviews, a review of facility documents and the clinical record, it was determined that one (1) of five (5) patients sampled for a review of restraint use (Patient #3), was placed in restraints as a form of discipline or retaliation, by one or more of the facility's nursing staff.

See also Tag A-0145 for additional details.

The findings were:

1. The Administrative Director of Quality (Staff Member/SM #8), on 08/21/18 at 11:20 a.m., provided the surveyor with documentation of the hospital's review of an allegation of verbal and physical abuse on a patient. SM #15 (a sitter) reported on the morning of 05/31/18, that on 05/29/18 he/she witnessed two registered nurses/RNs "verbally and physically abuse the patient (yanking on the patient and slapping [him/her])." SM #8 confirmed the patient referred to in the document was Patient #3, the unit where the alleged actions took place, and the nurses involved were [Nurse #1, Nurse #2, and Nurse #3]. A review of the hospital's review documentation revealed that it addressed the fact that during the time of the alleged verbal and physical abuse of patient #3, there were restraints applied. The internal review documentation did not address a review of those restraints, in terms of were they an appropriate intervention for the patient at that time, or were they being used as a form of punishment or retaliation against Patient #3. The internal review provided evidence that on 05/29/18, there was verbal and physical abuse of Patient #3, and as a result [Nurse #1, #2, and #3] were terminated.

2. Two surveyors conducted a phone interview with SM #15 on 08/22/18 at 1:50 p.m. SM #15 stated he/she was assigned as a sitter for Patient #3 on 05/29/18 from 3:00 p.m. to 11:00 p.m., as a safety precaution for Patient #3. SM #15 stated the patient was "in and out of it" was having "withdrawal" and was "restless and lacked safety judgements." SM #15 stated he/she would help the nurses, keep [the patient] from pulling out the IV (intravenous line) or wires, keep [the patient] from falling out of bed, and assist [the patient] to the bathroom. He/she stated that since this was one to one (1:1) supervision of the patient, he/she was not allowed to leave the room unless there were other hospital staff present to cover his/her brief absence. SM #15 stated that in the evening hours of 05/29/18, he/she and Nurse #1 were trying to give Patient #3 a bed bath. SM #15 stated they began turning the patient on his/her side to change the sheets and wash the patient's back and the patient "did not like that." SM #15 said the patient began moaning and "yelling out a little maybe" while trying to push back onto his/her back. SM #15 stated that another nurse [Nurse #2] came in the room to help. SM #15 stated that the situation escalated and Nurse #1 was verbally abusive toward the patient and Nurse #2 was both verbally and physically abusive toward the patient, when the patient would not cooperate with the bath and began yelling out. SM #15 stated, "from the get go" Nurse #2 "was extremely aggressive with the patient and began pulling the left leg - literally yanked it so hard I thought the bedrails might pop off." SM #15 stated, "I was totally shocked" and "I froze." He/she stated, "I couldn't believe what was happening" and "I definitely froze, but I'd do things differently now." SM #15 stated, the patient yelled out, "that hurts" and said to Nurse #2, "you're man-handling me." SM #15 stated that Nurse #2 replied, "you're right, I am man-handling you because you're not listening or cooperating." SM #15 stated, he/she wasn't sure what the patient said to prompt it but [Nurse #1] was "within 6 inches" of Patient #3's face, "looking right into [his/her] eyes," and in a "loud" voice said "Shut up." SM #15 said, "It scared me" and "it sounded threatening to me" and "I was afraid [Nurse #1] who was visibly upset and angry was losing [his/her] temper." SM #15 stated, "they got the patient on [his/her] back and [Nurse #1] and [Nurse #2] agreed they were going to use 4 point restraints [restraints to all four (4) extremities]. SM #15 stated that [Nurse #1 and Nurse #2] applied the four (4) point restraints and that once they were finished, the restraints "looked tighter than usual to me." SM #15 stated that on the morning of 05/31/18, he/she reported to his/her supervisor what he/she had witnessed on 05/29/18. SM #15 stated that was the first time he/she had witnessed that level of aggression and abuse to a patient and described having regrets that he/she "froze" and didn't intervene or know how to better handle the situation.

3. Two surveyors conducted an in-person follow up interview with SM #15 on 08/29/18 at 1:25 p.m. SM #15 stated he/she never felt threatened by Patient #3, and the patient's verbal and physical behaviors were triggered by the attempts to turn the patient on their side for a bath, which was painful for the patient. SM #15 stated that during the above described events with Patient #3 (on 05/29/18), there was no discussion by the nurses of stopping the attempted bed bath to allow the patient time to calm down. SM #15 was asked if the restraints applied to Patient #3 on 05/29/18, and described above, were applied for patient safety or as a form of punishment. SM #15 stated that in his/her opinion, the restraint use was "100% personal against the patient and not for safety." When asked if there was anything specific that caused him/her to have that opinion, SM #15 stated there were many inappropriate comments made to the patient by Nurse #1 and Nurse #2, "they [Nurse #1 and Nurse #2] were angry," and "you could just tell." He/she stated there were lots of scabs on the skin of Patient #3 and Nurse #1 made the comment, "that's what happens when you do drugs" and asked Patient #3 "how do you take your heroin, snort it or shoot it." SM #15 stated that at some point during the events of 05/29/18, Patient #3 "called the nurse out" on his/her actions and Nurse #1 stated, "If you say that again, I'll call the police and the handcuffs will be worse than what you have now." SM #15 stated that in the presence of Patient #3, Nurse #1 stated that "users" and "addicts" were his/her least favorite kind of patients and that he/she hates what drugs do to people. SM #15 stated there were other inappropriate comments as well, but these were the ones he/she specifically recalls.

4. The review of Patient #3's clinical record provided evidence the patient was admitted to the unit with a diagnosis of bowel perforation and sepsis (systemic infection). The record contained a progress note by Nurse #1, dated 05/29/18 at 8:55 p.m. which documented, "Pt became agitated and combative requiring 4 point restraints." There was no documentation within the clinical record of the events described by eyewitness accounts as occurring on 05/29/18 during the timeframe that restraints were initiated: the attempted bed bath, the patient crying out in pain when being turned on his/her side for that bath, the nurses' actions of force to keep the patient in a side lying position, or the inappropriate verbal comments made to the patient during the events. The record contained physician's orders from SM #26, dated 05/29/18 and timed as 9:05 p.m., for "Soft restraint" to "right ankle, right wrist, left ankle, and left wrist" and documents the "Reason for the restraints" as "Interference with medical treatment."

5. Two surveyors interviewed the Administrative Director of the ICU (SM #9), on 08/23/18 at 3:04 p.m. SM #9 acknowledged he/she conducted interviews with Nurse #1, Nurse #2, and Nurse #3 and documented them on the internal review document (described above). SM #9 stated that Nurse #3's statement was that Nurse #1 made a statement using an expletive, and in the presence of Patient #3. SM #9 stated, he/she had "never had an abuse case before" but after interviewing the three (3) nurses it was clear that something did happen.

6. The surveyor conducted a phone interview with the Director of the unit where Patient #3 had been (SM #13), on 08/29/18 at 2:30 p.m. SM #13 stated being familiar with the allegations made by an employee that nurses committed verbal and physical abuse against Patient #3, while the patient was in the unit. SM #13 stated, "I have talked to my staff about this." SM #13 stated the use of restraints, triggered because the patient had aggressive behaviors while a bed bath was being attempted, was troubling. When asked what he/she would have expected the nurses to do in that situation, SM #13 stated they could have called a "Code ____" which would have brought security staff to the room to assist, or they could have aborted the idea of a bath and let the situation de-escalate. SM #13 stated that as a nurse, if your stressors are being triggered, you have to find a way to take a time out or step away from the situation to regain composure.

7. Two surveyors conducted a phone interview, on 08/29/18 at 9:30 a.m., with the facility's physician (SM #26). The physician had ordered four (4) point restraints (restraints of all four (4) extremities) for Patient #3 on 05/29/18. The physician stated he/she did not remember Patient #3, that he/she never met or took care of the patient. The physician stated he/she was on-call and was paged by the nurse at night. The physician stated that in general when called, the physicians put a lot of trust in what they are being told by the nurse, but they do usually ask what's going on. The physician was asked if he/she had been made aware that the behaviors of Patient #3, for which 4 point restraints were being requested, were triggered during an attempted bed bath when the staff tried to turn the patient on his/her side. The physician stated he/she was not aware of that, and further stated, "I would not approve of restraints for that, the bath could be delayed."

8. Two surveyors interviewed the Chief Nurse Executive/CNE, on 08/23/18 at 1:34 p.m., regarding the complaint allegation of verbal and physical abuse, and described in the hospital's review document described above. The CNE stated, "it likely did occur and was not in accordance with our core values." The CNE stated it resulted in the termination of three (3) nurses and described how the hospital was implementing resources for staff to ensure that it does not happen again.

9. A review of the facility's 27 page policy titled, "Restraints and Seclusion" (Policy No. BSR 02-03, Rev.: 4/18) took place ongoing throughout the survey. The policy read, in part, as follows: "The use of restraints and/or seclusion is never used to punish, for coercion, as a means or [sic] discipline or retaliation or used solely for staff convenience. Restraint or seclusion may only be used to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
Based on staff interviews, a review of facility documents and the clinical record, it was determined the facility's nurses failed to use less restrictive interventions before applying four (4) point restraints for one (1) of five (5) patients sampled for a review of restraint use (Patient #3).

See also Tag A-0145 for additional details.

The findings were:

1. The Administrative Director of Quality (Staff Member/SM #8), on 08/21/18 at 11:20 a.m., provided the surveyor with documentation of the hospital's internal review of an allegation of verbal and physical abuse on a patient. SM #15 (a sitter) reported on the morning of 05/31/18, that on 05/29/18 he/she witnessed two registered nurses/RNs "verbally and physically abuse the patient (yanking on the patient and slapping [him/her])." SM #8 confirmed the patient referred to in the document was Patient #3, the unit where the alleged actions took place, and the nurses involved were [Nurse #1, Nurse #2, and Nurse #3]. A review of the hospital's internal review documentation revealed that it addressed the fact that during the time of the alleged verbal and physical abuse of Patient #3, restraints were applied. The internal review documentation did not address a review of those restraints, in terms of why lesser restrictive interventions were not used, prior to applying four (4) point restraints for Patient #3. The internal review provided evidence that on 05/29/18, there was verbal and physical abuse of Patient #3, and as a result [Nurse #1, #2, and #3] were terminated.

2. Two surveyors conducted a phone interview with SM #15 on 08/22/18 at 1:50 p.m. SM #15 stated he/she was assigned as a sitter for Patient #3 on 05/29/18 from 3:00 p.m. to 11:00 p.m., as a safety precaution for Patient #3. SM #15 stated the patient was "in and out of it" was having "withdrawal" and was "restless and lacked safety judgements." SM #15 stated he/she would help the nurses, keep [the patient] from pulling out the IV (intravenous line) or wires, keep [the patient] from falling out of bed, and assist [the patient] to the bathroom. He/she stated that since this was one to one (1:1) supervision of the patient, he/she was not allowed to leave the room unless there were other hospital staff present to cover his/her brief absence. SM #15 stated that in the evening hours of 05/29/18, he/she and Nurse #1 were trying to give Patient #3 a bed bath. SM #15 stated they began turning the patient on his/her side to change the sheets and wash the patient's back and the patient "did not like that." SM #15 said the patient began moaning and "yelling out a little maybe" while trying to push back onto his/her back. SM #15 stated that another nurse [Nurse #2] came in the room to help. SM #15 stated that the situation escalated and Nurse #1 was verbally abusive toward the patient and Nurse #2 was both verbally and physically abusive toward the patient, when the patient would not cooperate with the bath and began yelling out. SM #15 stated, "from the get go" Nurse #2 "was extremely aggressive with the patient and began pulling the left leg - literally yanked it so hard I thought the bedrails might pop off." SM #15 stated, "I was totally shocked" and "I froze." He/she stated, "I couldn't believe what was happening" and "I definitely froze, but I'd do things differently now." SM #15 stated, the patient yelled out, "that hurts" and said to Nurse #2, "you're man-handling me." SM #15 stated that Nurse #2 replied, "you're right, I am man-handling you because you're not listening or cooperating." SM #15 stated, he/she wasn't sure what the patient said to prompt it but [Nurse #1] was "within 6 inches" of Patient #3's face, "looking right into [his/her] eyes," and in a "loud" voice said "Shut up." SM #15 said, "It scared me" and "it sounded threatening to me" and "I was afraid [Nurse #1] who was visibly upset and angry was losing [his/her] temper." SM #15 stated, "they got the patient on [his/her] back and [Nurse #1] and [Nurse #2] agreed they were going to use 4 point restraints [restraints to all four (4) extremities]. SM #15 stated that [Nurse #1 and Nurse #2] applied the four (4) point restraints and that once they were finished, the restraints "looked tighter than usual to me." SM #15 stated that on the morning of 05/31/18, he/she reported to his/her supervisor what he/she had witnessed on 05/29/18. SM #15 stated that was the first time he/she had witnessed that level of aggression and abuse to a patient and described having regrets that he/she "froze" and didn't intervene or know how to better handle the situation.

3. Two surveyors conducted an in-person follow up interview with SM #15 on 08/29/18 at 1:25 p.m. SM #15 stated he/she never felt threatened by Patient #3, and the patient's verbal and physical behaviors were triggered by the attempts to turn the patient on their side for a bath, which was painful for the patient. SM #15 stated that during the above described events with Patient #3 (on 05/29/18), there was no discussion by the nurses of other options, such as stopping the attempted bed bath to allow the patient time to calm down. SM #15 was asked if the restraints applied to Patient #3 on 05/29/18, and described above, were applied for patient safety or as a form of punishment. SM #15 stated that in his/her opinion, the restraint use was "100% personal against the patient and not for safety." When asked if there was anything specific that caused him/her to have that opinion, SM #15 stated there were many inappropriate comments made to the patient by Nurse #1 and Nurse #2, "they [Nurse #1 and Nurse #2] were angry," and "you could just tell." He/she stated there were lots of scabs on the skin of Patient #3 and Nurse #1 made the comment, "that's what happens when you do drugs" and asked Patient #3 "how do you take your heroin, snort it or shoot it." SM #15 stated that at some point during the events of 05/29/18, Patient #3 "called the nurse out" on his/her actions and Nurse #1 stated, "If you say that again, I'll call the police and the handcuffs will be worse than what you have now." SM #15 stated that in the presence of Patient #3, Nurse #1 stated that "users" and "addicts" were his/her least favorite kind of patients and that he/she hates what drugs do to people. SM #15 stated there were other inappropriate comments as well, but these were the ones he/she specifically recalls.

4. The review of Patient #3's clinical record provided evidence the patient was admitted to the unit with a diagnosis of bowel perforation and sepsis (systemic infection). The record contained a progress note by Nurse #1, dated 05/29/18 at 8:55 p.m. which documented, "Pt became agitated and combative requiring 4 point restraints." There was no documentation within the clinical record of the events described by eyewitness accounts as occurring on 05/29/18 during the timeframe that restraints were initiated: the attempted bed bath, the patient crying out in pain when being turned on his/her side for that bath, the nurses' actions of force to keep the patient in a side lying position, or the inappropriate verbal comments made to the patient during the events. The record failed to contain evidence that lesser restrictive interventions were used or determined to be ineffective, prior to the decision to apply four (4) point restraints. The record contained physician's orders from SM #26, dated 05/29/18 and timed as 9:05 p.m., for "Soft restraint" to "right ankle, right wrist, left ankle, and left wrist" and documents the "Reason for the restraints" as "Interference with medical treatment."

5. Two surveyors interviewed the Administrative Director of the unit where Patient #3 had been (SM #9), on 08/23/18 at 3:04 p.m. SM #9 acknowledged he/she conducted interviews with Nurse #1, Nurse #2, and Nurse #3 and documented them on the facility document (described above). SM #9 stated that Nurse #3's statement was that Nurse #1 made the statement, "I f_ _ _ing hate [him/her]" referring to Patient #3, and in the presence of Patient #3. SM #9 stated, he/she had "never had an abuse case before" but after interviewing the three (3) nurses it was clear that something did happen.

6. The surveyor conducted a phone interview with the Director of the unit where Patient #3 had been (SM #13), on 08/29/18 at 2:30 p.m. SM #13 stated being familiar with the allegations made by an employee that nurses committed verbal and physical abuse against Patient #3, while the patient was in the unit. SM #13 stated, "I have talked to my staff about this." SM #13 stated the use of restraints, triggered because the patient had aggressive behaviors while a bed bath was being attempted, was troubling. When asked what he/she would have expected the nurses to do in that situation, SM #13 stated they had other options available and they could have called a "Code ___" which would have brought security staff to the room to assist, or they could have aborted the idea of a bath and let the situation de-escalate. SM #13 stated that as a nurse, if your stressors are being triggered, you have to find a way to take a time out or step away from the situation to regain composure.

7. Two surveyors conducted a phone interview, on 08/29/18 at 9:30 a.m., with the facility's physician (SM #26). The physician had ordered four (4) point restraints (restraints of all four (4) extremities) for Patient #3 on 05/29/18. The physician stated he/she did not remember Patient #3, that he/she never met or took care of the patient. The physician stated he/she was on-call and was paged by the nurse at night. The physician stated that in general when called, the physicians put a lot of trust in what they are being told by the nurse, but they do usually ask what's going on. The physician was asked if he/she had been made aware that the behaviors of Patient #3, for which 4 point restraints were being requested, were triggered during an attempted bed bath when the staff tried to turn the patient on his/her side. The physician stated he/she was not aware of that, and further stated, "I would not approve of restraints for that, the bath could be delayed."

8. Two surveyors interviewed the Chief Nurse Executive/CNE, on 08/23/18 at 1:34 p.m., regarding the complaint allegation of verbal and physical abuse investigated by the hospital, and described in the internal review document described above. The CNE stated, "it likely did occur and was not in accordance with our core values." The CNE stated it resulted in the termination of three (3) nurses and described how the hospital was implementing resources for staff to ensure that it does not happen again.

9. A review of the facility's 27 page policy titled, "Restraints and Seclusion" (Policy No. BSR 02-03, Rev.: 4/18) took place ongoing throughout the survey. The policy read, in part, as follows: "The use of restraints and/or seclusion is never used to punish, for coercion, as a means or [sic] discipline or retaliation or used solely for staff convenience. Restraint or seclusion may only be used to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. Documentation Requirements: The use of restraint and/or seclusion requires documenting the situation thoroughly in the patient's medical record. That documentation will include:.....3. Description of patient's behavior and interventions used; 4. Alternatives or other less restrictive interventions attempted (if applicable). "
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0185
Based on interviews and the review of documents, it was determined the facility staff failed to ensure the documentation of behaviors that resulted in the addition of bilateral leg/ankle restraints to a patient who already had bilateral arm/wrist restraints being used. This is for one (1) of five (5) patients sampled for restraint review (Patient #6).

The findings include:

Patient #6's clinical documentation failed to include documentation of what behaviors were being addressed with the addition of bilateral soft leg/ankle restraints.

Patient #6's clinical documentation included an order for bilateral soft wrist restraints on 8/14/18 at 5:17 p.m. The reason for restraints documented as part of this order was "Interference with medical treatment".

Patient #6's clinical documentation included an order for restraints on 8/14/18 at 6:46 p.m.; this order was for bilateral soft wrist restraints and bilateral soft ankle restraints. The reason for restraints documented as part of this order was "Interference with medical treatment".

Patient #6's documentation for 8/14/18 at 5:17 p.m. included the following assessment information: "Agitation; Combative; Confused; Delusional; Hallucinating; Paranoid". Documentation indicated on 8/14/18 at 6:00 p.m. bilateral soft ankle restraints were applied. No documentation was found by or provided to the surveyor to detail what behavior changes resulted in the addition of bilateral ankle restraints to the bilateral wrist restraints previously ordered. (The bilateral soft ankle restraints were documented as being discontinued on 8/14/18 at 10:00 p.m.)

Staff Member (SM) #13 (a registered nurse) was asked about documentation of why the restraint was increased from bilateral wrist to bilateral wrist and bilateral ankle. SM #13 reported he/she was unable to find documentation to explain why the bilateral ankle restraints were added.

The following information was found in a facility policy with the title 'Restraints and Seclusion' (with the most recent revision date of 4/2018): "Documentation Requirement ... The use of restraint and/or seclusion requires documenting the situation thoroughly in the patient's medical record. The documentation will include: ... Description of patient's behavior and intervention used ..."

The failure of the facility staff to document changes in Patient #6's behavior which resulted in the addition of bilateral ankle restraints to the already ordered/applied bilateral wrist restraints was discussed during a survey team meeting on 8/28/18 at 5:30 p.m. with the facility's Director of Quality and the facility's Regional Coordinator. No additional information related to this issue was provided to the survey team.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on interviews and the review of documents, it was determined the facility staff failed to correctly implement provider orders for one (1) of two (2) patients reviewed for CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol-Revised) Monitoring (Patient #6).

The findings include:

Review of Patient #6's clinical documentation indicated the facility staff failed to implement physician orders for CIWA-Ar; this included not completing CIWA-Ar assessments as ordered and not administering CIWA-Ar medications as ordered.

Patient #6's clinical record included an order for "CIWA-AR MONITORING" dated 8/14/18 at 2:37 p.m.; this order included the following instructions: "CIWA-AR MONITORING - Monitor and document CIWA-Ar score a minimum of every 4 hours. If CIWA-Ar greater than 8, increase to every 2 hours while the patient is awake and every 4 hours while asleep. Once the score is less than 4 without requiring any benzodiazepine administration for 48 hours, the CIWA-Ar will be monitored and documented once every shift. If the score is less than 4 for the following 72 hours, monitoring can be discontinued."

Patient #6's clinical record included the following medication orders:
- On 8/14/18 at 2:55 p.m., was entered an order for Lorazepam injection 4 mg intravenous to "(a)dminister every hour as needed if CIWA-Ar score is greater than or equal to 12" and
- On 8/14/18 at 2:55 p.m., was entered an order for Lorazepam injection 2 mg intravenous to "(a)dminister every hour as needed if CIWA-Ar score is 8 - 11".

The facility policy/procedure with the title of "Alcohol Withdrawal Management" (with an origination date of 7/2010 and the most recent revision date of 12/2016) included wording similar to the wording in the aforementioned CIWA-Ar monitoring order. This policy did include the following information: "If benzodiazepines are administered based on CIWA-Ar scoring, reassess vital signs and CIWA-Ar after 1 hour."

Patient #6's clinical record was reviewed on 8/22/18. A failure of facility staff to correctly implement provider CIWA-Ar orders was discussed with facility staff included the facility's Director of Quality (Staff Member (SM) #8). The facility staff was asked for evidence of the implementation of Patient #6's CIWA-Ar orders for the dates beginning on 8/14 and ending on 8/17. SM #8 provided the surveyor with documentation of 19 times Patient #6's CIWA were not correctly implemented during the time period requested. Examples of incorrect implementation of the CIWA-Ar identified in Patient #6's clinical record included, but was not limited to:
- On 8/14/18 at a CIWA-Ar assessment was documented for 8:00 p.m. as '18' no evidence of medication being provided was identified and
- On 8/17/18 for 7:00 a.m. a CIWA-Ar assessment was documented as '13'; Patient #6 was administered Lorazepam 2mg instead of the ordered Lorazepam 4mg and the next CIWA-Ar assessment was not documented until 9:36 p.m.

The failure of the facility staff to provide Patient #6's CIWA-Ar monitoring and medications according to provider orders was discussed during a survey team meeting on 8/28/18 at 5:30 p.m. with the facility's Director of Quality and the facility's Regional Coordinator.