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Based on observation, interview, record review, and policy review, the facility failed to ensure patients were provided a safe environment by restraining one (#3) of one patient in restraints with a transfer belt (a heavy-duty, two inch wide cotton webbed belt with a toothed buckle closure), and leaving the patient without supervision or a call light. The transfer belt was applied around the patient's upper chest and around the back of a wheel chair, placing the patient at risk for entanglement, suffocation, or aspiration (when vomit or secretions are inhaled into the lungs). Patient #3 had a recent history of new-onset seizures, suffered from severe oral motor dysfunction (preventing the patient from communicating), had a tracheostomy (a tube inserted through the front of the neck and into the throat for breathing) which required frequent suctioning (a procedure which requires a sterile tube to be passed through the patient's tracheostomy and into the patient's lungs to remove secretions) to remove thick secretions, and had recently been treated for aspiration pneumonia.

The facility also failed to recognize that the use of a transfer belt to restrict a patient's movement was considered a restraint, failed to obtain a physician's order for the use of the restraint, and failed to modify the patient's care plan to include restraints, according to facility policy.

The severity and cumulative effect of the systemic practices resulted in the facility being out of compliance with 42 CFR 482.13 - Condition of Participation: Patient Rights, and resulted in the facility's failure to provide a safe environment for Patient #3 and potentially any patients restrained in this manner. Subsequently the situation constituted a condition of immediate jeopardy (IJ). The hospital administration was notified of the IJ on 08/12/11 and an immediate plan of correction was received, accepted, and implemented prior to exit, therefore, the IJ was abated. The facility immediately stopped the use of gait belts for positioning and the use of waist and self releasing waist restraints. The facility immediately began education to all clinical staff and revising the facility policies regarding restraints. The facility census was 49.

Please refer to tags A0144, A0159, A0166, and A0168.

Based on observation, interview, record review, and policy review, the facility failed to ensure patients were provided a safe environment by using a transfer belt (a heavy-duty, two inch wide cotton webbed belt with a toothed buckle closure) as a restraint, while unsupervised, on one (#3) of one patient observed in restraints. The patient was alone, unable to call for help, and was on aspiration precautions (steps taken to prevent vomit or secretions from being inhaled into the lungs) while the transfer belt was secured around the patient's chest and around the back of the patient's wheelchair. This had the potential to affect any patient restrained in this manner. The facility census was 49.

Findings included:

1. Record review of the facility's policy titled, "Restraints" revised on 10/21/10, showed the definition of a restraint was any equipment attached to the patient's body that cannot be easily removed, that restricts freedom of movement or access to one's body.

2. Record review of the facility's form titled, "Daily Restraint Documentation" dated 08/08, showed the types of restraints used in the facility were:
-Mittens;
-Soft Wrist;
-Soft Leg;
-Waist;
-Side Rails;
-Bed Enclosures.
The form did not indicate that a transfer belt was a type of restraint to be used by the facility.

3. Record review on 08/11/11 at 1:50 PM of Patient #3's current medical record showed the following:
-The patient had significant functional disabilities due to a stroke;
-The patient had a tracheostomy (a tube inserted through the front of the neck and into the throat for breathing);
-The patient had recently been treated for pneumonia and seizures;
-The patient was restless and ataxic (uncontrolled movements of the body);
-The patient had difficulty swallowing, difficulty communicating, and would be seen by speech therapy for poor communication as well as a swallow evaluation (to determine if the patient was at risk for choking);
-There were no physician orders for restraints;
-The patient's care plan for safety dated 08/08/11 included constant supervision;
-Communication from a Registered Nurse (RN) to a physician dated 08/09/11 documented that the patient required suction (a procedure which requires a sterile tube to be passed through the patient's tracheostomy and into the patient's lungs to remove secretions) six times during a two hour period (indicating the patient required frequent suctioning because the patient did not have the ability to clear his/her secretions on his/her own);
-A medical management consult dated 08/09/11 showed the plan for the patient included strict aspiration precautions and frequent suctioning;
-A pulmonary note dated 08/11/11 at 10:30 AM showed that Respiratory Therapist (RT) suctioned the patient and that a moderate to large amount of thick secretions was removed. RT did not replace the patient's speaking valve he/she was wearing because of the thick secretions, but changed it to a heat and moisture exchanger (adds moisture during breathing to loosen secretions) and documented that the nurse was aware;
-A nurse's noted dated 08/11/11 at 11:30 AM showed that Respiratory Therapy suctioned the patient again;
-A nurse's flowsheet dated 08/11/11 showed the patient was suctioned at 8:00 AM, 9:00 AM, and 11:00 AM with large amounts of secretions removed. The flowsheet also showed that the patient was not able to express basic needs appropriately.

4. Observation on 08/11/11 at 12:40 PM showed Patient #3 was sitting in the day room by him/herself and was red faced from attempting to cough. The patient was restrained in a wheelchair by a transfer belt which had been placed around the patient's chest and around the back of the wheelchair, with his/her back facing the nurses' station. The patient did not have a call light, nor was the patient able to communicate verbally by calling for someone if he/she needed help. Staff were not visible in the nurses' station from where the patient was sitting, indicating that the patient was not being observed by staff from the nurses' station.

5. During an interview on 08/11/11 at 12:45 PM, Staff A, RN stated that the transfer belt was not considered a restraint, but a safety measure to prevent the patient from moving, because the Patient #3 moved so much and was at risk for falls.

6. During an interview on 08/11/11 at 3:05 PM, Staff E, Medical Director stated that the facility only used transfer belts to assist with patient transfers and would never use a transfer belt to secure a patient to a wheelchair. Staff E added that if a patient was placed in the day room, left unattended, and without a call light, it should only be a patient who would be considered "low risk" for complications or injury.

7. Observation on 08/11/11 at 3:40 PM showed Patient #3 was sitting in his/her room with a gait belt around his/her chest which was secured around the back of the wheelchair. This observation was also made by Staff E and Staff D, Director of Nursing. Staff E immediately requested staff to remove Patient #3 from the restraint, and the patient was placed in bed.

8. During an interview on 08/11/11 at 4:00 PM, Patient #3's family stated that the patient:
-Was restrained in the wheelchair using the gait belt on 08/09/11, 08/10/11, and 08/11/11;
-Becomes choked when he/she cannot clear his/her secretions;
-Has a sitter (staff who provide continuous monitoring) at night because he is a choking hazard.

9. During an interview on 08/12/11 at 10:30 AM, Staff M, Speech Therapist stated that he/she was not able to complete a swallow study on Patient #3 because he/she:
-Had "severe oral motor dysfunction" (inability to coordinate and/or initiate movement of the jaw, lips and tongue);
-Was at high risk for aspiration pneumonia;
-Could not manage his/her airway if he vomited;
-Was very ataxic (lack of coordination or movements).
Staff M added that if he/she attempted to complete a swallow study on Patient #3, the patient would aspirate.

10. During an interview on 08/11/11 at 4:30 PM, Staff G, Patient Care Associate (PCA) stated that Patient #3 had been restrained with the transfer belt around the back of the chair on at least 08/10/11 and 08/11/11 and that the use of transfer belts to restrain patients in wheelchairs was a routine facility practice for patients' on the Stroke, Brain Injury, and Spinal Cord Injury Units.

11. During an interview on 08/17/11 at 9:55 AM, Staff V, RN stated that:
-Patient #3 was returned from therapy on 08/10/11 in a transfer belt, which was secured around his/her wheelchair;
-Patient #3 was at risk for aspiration and that staff were not to recline the patient because of the risk;
-Transfer belts are used as restraints more on the Spinal Cord Injury Unit than any other unit.

11. During an interview on 08/17/11 at 10:33 AM, Staff W, Occupational Therapist (OT) stated that:
-Patient #3 was in the transfer belt secured around the back of a wheelchair on 08/08/11 when another OT saw the patient in the day room and felt the patient wasn't safe in the day room alone without staff observing him/her;
-The RN and PCT were instructed by the OT to get a physician's order for Patient #3's restraint, but never did;
-Staff W placed the patient in the transfer belt restraint on 08/10/11, took the patient to the day room, and believed someone was in the day room to watch him/her, but cannot remember;
-The facility had been using transfer belts to restrain patients around their chest for years.

12. During an interview on 08/12/11 at 9:30 AM, Staff J, Facility Educator stated that the use of a transfer belt to restrain a patient in a wheelchair should never and would never be used in the facility.

13. During an interview on 08/12/11 at 9:15 AM, Staff I, RN stated that the use of a transfer belt around a patient and around a patient's chair was appropriate if there was a physician order and only if the patient was not going to be supervised.

14. During an interview on 08/15/11 at 3:50 PM, Staff O, Patient Care Technician (PCT) stated that the facility had used transfer belts as restraints on the Spinal Cord Injury Unit and at times a patient would be found with their transfer belt around their chest after sliding down in their chair. Staff O added that staff would pull the patient up in the chair and reposition the transfer belt, but the patients were never injured.

15. During an interview on 08/17/11 at 8:20 AM, Staff U, Therapy Manager stated that therapy staff use the transfer belts around a patient and around the back of a chair to position a patient with poor trunk (chest, abdomen, and pelvis) control and that alternatives to using the transfer belt as a restraint would be:
-Lateral supports (pads that fit snug to the sides of the upper torso);
-Positioning "dump" (raising the front of a seat to decrease the angle to the back);
-"Tilt and Space" (maintains a 90 degree sitting angle between the seat and back, but reclines the patient);
-"Hemi lap board" (similar to a half table that secures to the side of a chair and sits above half of the patient's lap);
-Bed and chair alarms;
-"Seat Pummel" (wedged pad that fits between a patient's thighs to prevent a patient from sliding down in a chair).

Based on observation, interview, record review, and policy review, the facility failed to identify that a patient secured to a wheelchair with a transfer belt (a heavy-duty, two inch wide cotton webbed belt with a toothed buckle closure) was a restraint when used on one (#3) of one patient observed in restraints. This had the potential to affect any patient restrained in this manner. The facility census was 49.

Findings included:

1. Record review of the facility's policy titled, "Restraints" revised on 10/21/10, showed the definition of a restraint was any equipment attached to the patient's body that cannot be easily removed, that restricts freedom of movement or access to one's body.

2. During an interview on 08/11/11 at 2:13 PM, Staff B, Executive Director stated that the facility did not have any patients in restraints.

3. Observation on 08/11/11 at 12:40 PM showed Patient #3 was restrained in a wheelchair by a transfer belt which was secured around the patient's upper chest and around the back of the wheelchair, restricting the patient from moving his/her upper torso (chest and shoulders).

4. During an interview on 08/11/11 at 12:45 PM, Staff A, Registered Nurse (RN) stated that the transfer belt used to secure a patient to a wheelchair was not considered a restraint.

5. Observation on 08/11/11 at 3:40 PM showed Patient #3 was restrained in a wheelchair by a transfer belt which was secured around the patient's upper chest and around the back of the wheelchair, restricting the patient from moving his/her upper torso. This observation was also made by Staff E, Medical Director and Staff D, Director of Nursing. Staff E immediately requested staff to remove Patient #3 from the restraint, and the patient was placed in bed

6. Record review of Patient #3's current medical record showed that there were no physician orders for Patient #3 to be placed in restraints until 08/12/11 at 4:45 PM.

7. During an interview on 08/11/11 at 4:00 PM, Patient #3's family stated that the patient was restrained with the transfer belt in the wheelchair on 08/09/11, 08/10/11, and 08/11/11.

8. During an interview on 08/11/11 at 4:30 PM, Staff G, Patient Care Associate (PCA) stated that Patient #3 had been restrained with the transfer belt around the back of the chair on 08/10/11 and 08/11/11 when he/she was assigned to care for the patient.

9. During an interview on 08/11/11 at 4:30 PM, Staff G added that the use of transfer belts to restrain patients in wheelchairs was a routine facility practice for patients' on the Stroke, Brain Injury, and Spinal Cord Injury Units.

10. During an interview on 08/17/11 at 8:20 AM, Staff U, Therapy Manager stated that therapy staff secure transfer belts around a patient and around the back of a chair to position a patient with poor trunk (chest, abdomen, and pelvis) control. Staff U did not realize the transfer belts were considered a restraint when used to secure a patient in a chair until 08/16/11, during the survey.

Based on observation, interview, record review, and policy review, the facility failed to include restraints in the patient's plan of care for one (#3) of one patient observed in restraints. This had the potential to affect any patient in restraint. The facility census was 49.

Findings included:

1. Record review of the facility's policy titled, "Restraints" revised on 10/21/10, showed the definition of a restraint was any equipment attached to the patient's body that cannot be easily removed, that restricts freedom of movement or access to one's body and that the patient's written plan of care must be revised to reflect use of restraints and appropriate interventions.

2. Observation on 08/11/11 at 12:40 PM showed Patient #3 was sitting in the day room and was restrained in a wheelchair by a transfer belt which had been placed around the patient's chest and around the back of the wheelchair.

3. Observation on 08/11/11 at 3:40 PM showed Patient #3 was sitting in his/her room with a gait belt around his/her chest which was secured around the back of the wheelchair. This observation was also made by Staff E, Medical Director, and Staff D, Director of Nursing.

4. During an interview on 08/11/11 at 4:00 PM, Patient #3's family stated that the patient was restrained in the wheelchair using the transfer belt on 08/09/11, 08/10/11, and 08/11/11.

5. During an interview on 08/11/11 at 4:30 PM, Staff G, Patient Care Associate (PCA) stated that Patient #3 had been restrained with the transfer belt around the back of the chair on 08/10/11 and 08/11/11 when he/she was assigned to care for the patient.

6. During an interview on 08/17/11 at 10:33 AM, Staff W, Occupational Therapist (OT) stated that he/she placed Patient #3 in a transfer belt which was secured around the patient's chest and around the back of the wheelchair on 08/10/11.

7. Record review on 08/11/11 at 1:50 PM of Patient #3's current medical record showed the patient's plan of care did not include the use of restraints.

Based on observation, interview, record review, and policy review, the facility failed to obtain restraint orders for one (#3) of one patient observed in restraints. This had the potential to affect any patient in restraints. The facility census was 49.

Findings included:

1. Record review of the facility's policy titled, "Restraints" revised on 10/21/10, showed that:
-A physician or others authorized to write orders under the direction of the physician were responsible for authorizing the use and continued use of restraints;
-Each restraint intervention requires a physician's order;
-Orders must indicate duration of time restraints are to be used, clinical justification for use, and type of restraint.

2. Observation on 08/11/11 at 12:40 PM showed Patient #3 was restrained in a wheelchair by a transfer belt which was secured around the patient's upper chest and around the back of the wheelchair, restricting the patient from moving his/her upper torso (chest and shoulders).

3. Observation on 08/11/11 at 3:40 PM showed Patient #3 was restrained in a wheelchair by a transfer belt which was secured around the patient's upper chest and around the back of the wheelchair, restricting the patient from moving his/her upper torso. This observation was also made by Staff E, Medical Director and Staff D, Director of Nursing. Staff E immediately requested staff to remove Patient #3 from the restraint, and the patient was placed in bed.

4. During an interview on 08/11/11 at 4:00 PM, Patient #3's family stated that the patient was restrained in the wheelchair using the transfer belt on 08/09/11, 08/10/11, and 08/11/11.

5. During an interview on 08/11/11 at 4:30 PM, Staff G, Patient Care Associate (PCA) stated that Patient #3 had been restrained with the transfer belt around the back of the chair on 08/10/11 and 08/11/11 when he/she was assigned to care for the patient.

6. During an interview on 08/17/11 at 10:33 AM, Staff W, Occupational Therapist (OT) stated that he/she placed Patient #3 in a transfer belt which was secured around the patient's chest and around the back of the wheelchair on 08/10/11. Staff W added that another OT instructed the RN and PCT caring for the patient on 08/10/11 to get a physician's order for Patient #3's restraint, but never did.

7. Record review of Patient #3's current medical record showed that there were no physician orders for Patient #3 to be placed in restraints until 08/12/11 at 4:45 PM.