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The agency failed to provide for patient privacy (A-0142): failed to complete comprehensive individualized assessments before initiating the use of an enclosure bed (A-154); failed to employ less restrictive interventions to restraint use and failed to document less restrictive interventions (A-164); failed to prove less restrictive interventions were employed to prevent harm (A-165); failed to develop care plans for restraints that included a plan for ongoing assessment, implementation of the least restrictive device and failed to evaluate the effectiveness of the device (A-166); failed to implement restraint in accordance with facility policy (A-167); failed to ensure alternative interventions were attempted prior to the use of restraints (A-186); failed to document the patient's response to interventions used and the rational for continued use of bed enclosure restraints (A-0188); failed to provide evidence of a training program for staff and physicians in the application of the enclosure bed restraint (A-0196).

The facility failed to measure, analyze and track quality indicators regarding restraint use (A-0267); failed to collect data monitor the effectiveness and safety of services and quality of care (A-0275); failed to implement and maintain an ongoing patient safety program for restraint use (A-0311).

Based on observation, the facility failed to ensure the patients right to personal privacy as evidenced by staff not knocking before entering patients rooms and failed to ensure patients were dressed appropriately when engaged in therapy activities for 1 of 32 patients (Patient #15).

Findings include:

During the initial tour of the facility on 3/7/11 and on subsequent days, staff were observed entering patient room without knocking.



22046

Patient #15

Patient #15 was admitted to the facility on 3/4/11, with diagnoses including hemiplegia, dysphasia, and cardiomyopathy. On 3/8/11, the patient was observed in the therapy gym. There were approximately 12 patients in the gym in addition to staff members.

Patient #15 was observed climbing the stairs with assistance of a therapist. The patient was wearing a hospital gown and an adult brief. The therapist attempted to cover the patient's lower body with the hospital gown as he climbed the stairs but the gown was too small. The adult brief covering the patient's buttocks was easily observed. The patient's legs were bare but for shoes. The patient's Foley bag was visible and was carried up the steps by the therapist.

Observation of patients in the therapy gym on 3/8/11, revealed four female patients who were dressed in hospital gowns. The females were wearing two hospital gowns with openings on opposite sides of the body to lessen the exposure of their bodies. On 3/10/11, after reporting the inappropriate dress to hospital administration, the therapy gym was again observed and patients were wearing pajama bottoms to provide for modesty.

During an interview with the Chief Nursing Officer (CNO) on 3/8/11, he reported occupational therapy was to make sure patients were properly dressed for therapy. The CNO reported patients were encouraged to have their clothes brought to the facility. He reported some patients did not comply with the request.

On 3/8/11, Employee #7, an occupational therapist was interviewed. The occupational therapist reported nursing was given a schedule and was to have the patients dressed appropriately for participation in therapy. The therapist acknowledged seeing Patient #15 and confirmed he was not dressed to participate in therapy.

On 3/11/11, Resident #15 was interviewed. He was asked if he would like to wear pants or pajama bottoms during therapy. He indicated he would like to wear pants or pajamas.

Based on record review and staff interview, the facility failed to complete a comprehensive individualized assessment before initiating the use of an enclosed bed for 4 of 32 patients (Patient #1, #11, #3, and #5).

The use of restraints were the routine in the facility's fall prevention program. A history of falling without a current basis for restraint intervention failed to adequately demonstrate the need for restraints.

Findings include:

Patient #1

Patient #1 was admitted to the facility from an acute facility on 3/2/11. Diagnoses included Parkinson's, syncope and hypotension. Patient #1 had been admitted to the facility several weeks prior when she was found non-responsive, in her wheelchair. She did not, during that admission, require the use of any type of restraint. Patient #1 could not be interviewed due to her impaired mental status.

A preadmission screening, dated 2/27/11, indicated that Patient #1 had a 1:1 sitter, due to fall risk. There was no evidence in the patient record for Patient #1, of a comprehensive assessment that included a physical assessment to identify medical problems that might be attributing to the falls. An individualized comprehensive assessment was not present. The record lacked components of the assessment such as: other interventions that could be utilized, ways in which the patient could ambulate safely, assistive devices that could be employed, medications that might be contributing to the issue, and whether the patient would benefit from closer supervision.

The assessment component of the facility's Restraint Assessment and Physician Order form consisted of Observations with the sub categories of wandering, impaired memory/judgement, confused, disoriented, aggressive/destructive behavior, inability to follow instructions, recent history of falls (last 3 months), gait/balance disorder, danger to self/others and attempt to ambulate without required assistance. The brief assessment did not identify other problems that might be contributing to the issue. The facility's policy "669 Use of Restraints in Non-Psychiatric Hospital or Unit" stated that a comprehensive assessment including a physical assessment to identify medical problems that may be causing behavior changes must determine the risks associated with the use of the restraints outweighing the risk of using the restraints.

The facility's Chief Nursing Officer (CNO) was asked for the written criteria specifically for the use of the enclosed bed on two occasions during the survey process and was was unable to present such a criteria to the survey team.

The daily Restraint Assessment and Physician Order from 3/3-3/8/2011, indicated that the only less restrictive alternative used was increased supervision and monitoring. There was no documented evidence that less restrictive measures had been employed prior to the use of the enclosed bed. Patient #1's room was noted to be the last room at the end of the hallway, the furthest from the nurse's station. During each day of the survey process, Patient #1 was noted to be seated quietly in her wheelchair at the nurses station.

Patient #11

Patient #11 was admitted from an acute care facility on 3/1/2011 with diagnoses of normal pressure hydrocephalus and pulmonary emboli.

A preadmission screening, undated, completed by the facility, indicated that Patient #11 "would need a vail (enclosed bed) bed" due to a high risk for falls.

The Restraint Assessment and Physician Order forms for 3/2-3/8/2011, indicated less restrictive alternatives of increased supervision, upper side rails and bed/wheelchair alarms were employed, but the record lacked documentation these devices were utilized and failed. Patient #11's room was located at the end of the hall from the nurse's station. On one occasion, Patient #11 was noted to be seated in a chair beside the enclosed bed, eating her lunch.



23119

Patient #3

Patient #3 was admitted to the facility on 2/25/11 for rehabilitation following an anoxic brain injury. Review of the pre-admission initial rehab assessment revealed a recommendation for a bed enclosure. The admission orders included an order for the bed enclosure, and the record revealed the patient was in the bed enclosure from his admission time.

Review of Patient #3's record revealed on 2/26/11, the patient was found on the floor in the dining room and assessed as a high risk for falling. The interventions included an order for a lap buddy when the patient was in a wheelchair. Review of the documentation of the daily flowsheet/treatment records indicated on 2/26/11 the patient was out of bed for one hour, at 4:00 PM. On 2/27/11, the patient was documented as out of the bed enclosure for one hour, at 3:00 PM. On 2/28/11, the documentation indicated the patient was in the bed enclosure for 24 hours continuously.

Review of the physician orders for Patient #3 revealed orders for the bed enclosure were written each day at one minute past midnight. Different less restrictive alternatives were checked on different days, but included increased supervision, move patient closer to nurses' station, upper side rails up, low bed, reality orientation and bed/wheelchair alarms were marked as having been tried before the order for bed enclosure was written. Patient #3's room was located at the end of the hall, furthest from the nurses' station.

Review of the record failed to reveal evidence the less restrictive alternatives to the bed enclosure or measures other than the lap buddy had been attempted to lessen the risk for falls for Patient #3. The bed enclosure was documented as being used almost continually from 2/26/11 through 2/28/11.

Patient #5

Patient #5 was admitted to the facility on 3/4/11. Review of the admission orders revealed an order for a bed enclosure.

Further review of Patient #5's record failed to reveal alternatives or less restrictive interventions were attempted prior to the initial use of the bed enclosure. Review of daily orders for the bed enclosure had check marks for less restrictive alternatives that had been attempted: increased supervision, low bed, upper side rails, reality orientation, bed/wheelchair alarms, and move the patient closer to the nurses' station. Different less restrictive alternatives were checked on different days, depending on the nurse who filled out the order. There was no other documentation alternatives or less restrictive interventions had been attempted. Patient #5's room was observed to be at the end of the hall, furthest from the nurses' station.

On 3/9/11, the Chief Nursing Officer was interviewed and reported the bed enclosures were not routinely used for fall prevention but had no explanation as to why the documentation indicated Patient #3 was in the bed enclosure almost continually throughout the day and night. He was unable to provide evidence less restrictive alternatives to the bed enclosure had been used.

Based on staff interview and record review, the facility failed to employ less restrictive interventions or failed to document that less restrictive interventions were ineffective before utilizing the use of restraints for 4 of 32 patients (Patients #1, #11, #3, #5).

Findings include:

Patient #1

Patient #1 was admitted to the facility from an acute facility on 3/2/11. Diagnoses included Parkinson's, syncope and hypotension. Patient #1 had been admitted to the facility several weeks prior when she was found non-responsive, in her wheelchair. She did not, during that admission, require the use of any type of restraint. She was not able to be interviewed due to her impaired mental status.

A preadmission screening, dated 2/27/11, indicated that Patient #1 had a 1:1 sitter, due to fall risk.

The daily Restraint Assessment and Physician Order from 3/3-3/8/2011, indicated that the only less restrictive alternative used was increased supervision and monitoring. There was no documented evidence that less restrictive measures had been employed prior to the use of the enclosed bed. Patient #1's room was noted to be the last room at the end of the hallway, the furthest from the nurse's station.

Patient #11

Patient #11 was admitted from an acute care facility on 3/1/2011 with diagnoses of normal pressure hydrocephalus and pulmonary emboli.

An undated preadmission screening, completed by the facility, indicated Patient #11 "would need a vail (enclosed) bed" due to a high risk for falls.

The Restraint Assessment and Physician order forms for 3/2-3/8/2011 indicated that less restrictive alternatives of increased supervision, upper side rails and bed/wheelchair alarms were employed, but the record lacked documentation that these devices were utilized and failed. Patient #11's room was located at the end of the hall from the nurse's station.

In an interview with Employee #2 early in the survey, it was indicated the facility did not have any low beds which could be utilized as a less restrictive intervention for falls.



23119

Patient #3

Patient # 3 was admitted to the facility on 2/25/11. Review of his pre-admission rehab assessment revealed he was to have a bed enclosure on admission.

Review of Patient #3's record revealed daily orders for the bed enclosure restraint. The orders for the bed enclosure had check marks to designate less restrictive alternatives had been attempted. The less restrictive alternatives included low bed, upper side rails, reality orientation, increased supervision, bed/wheelchair alarms, diversion activities, and move the patient closer to the nurses' station. The less restrictive alternatives marked differed from day to day, depending on the nurse filling out the order. Review of the record failed to reveal the less restrictive interventions had been determined to be ineffective before use of the bed enclosure.

Patient #5

Patient #5 was admitted to the facility on 3/4/11. Review of the admission orders revealed an order for a bed enclosure.

Further review of Patient #5's record failed to reveal alternatives or less restrictive interventions were attempted prior to the initial use of the bed enclosure. Review of daily orders for the bed enclosure had check marks for the less restrictive alternatives that had been attempted: increased supervision, low bed, upper side rails, reality orientation, bed/wheelchair alarms, and move the patient closer to the nurses' station. Different less restrictive alternatives were checked on different days, depending on the nurse who filled out the order. There was no other documentation of alternatives or that less restrictive interventions had been attempted.

On 3/9/11, the Chief Nursing Officer (CNO), Director of Risk/Quality Management and the Infection Control Coordinator were interviewed. The CNO reported the facility had no low beds, was not able to explain how side rails were tried as a less restrictive alternative when the bed enclosure was on the bed, and reported they did not use the bed alarms as they increased the risk of developing pressure sores.

Based on interview and record review, the facility failed to prove that the less restrictive interventions were being employed to protect the patients from harm for 4 of 32 patients. (Patient #1, #11, #3, #5 ).

Findings include:

Patient #1

Patient #1 was admitted to the facility from an acute care facility on 3/2/11. Diagnoses included Parkinson's, syncope and hypotension. Patient #1 had been admitted to the facility several weeks prior when she was found non-responsive, in her wheelchair. She did not, during that admission, require the use of any type of restraint. A preadmission screening, dated 2/27/11, indicated that Patient #1 had a 1:1 sitter, due to fall risk. The patient was unable to be interviewed due to her impaired mental status.

The daily Restraint Assessment and Physician Orders from 3/3-3/8/2011, indicated the only less restrictive alternative used was increased supervision and monitoring. There was no documented evidence that less restrictive measures had been employed prior to the use of the enclosed bed. Patient #1's room was noted to be the last room at the end of the hallway, the furthest from the nurse's station.

Patient #11

Patient #11 was admitted from an acute care facility on 3/1/2011 with diagnoses of normal pressure hydrocephalus and pulmonary emboli.

A preadmission screening, undated, completed by the facility, indicated that Patient #11 "would need a vail bed (enclosed bed)" due to a high risk for falls.

The Restraint Assessment and Physician Orders from 3/2-3/8/2011, indicated less restrictive alternatives of increased supervision, upper side rails and bed/wheelchair alarms were employed, but the record lacked documentation that these devices were utilized and failed. Patient #11's room was located at the end of the hall from the nurse's station.

In an interview with Employee #2 early in the survey, it was revealed the facility did not have any low beds which could be utilized as a less restrictive intervention for falls.



13812

Patient #19

Patient #19 was admitted to the facility on 2/8/11 with diagnoses including traumatic brain injury, and gastrostomy tube. The pre-admission screening indicated mitten restraints to prevent medical tube removal.

Patient #19 received mitten restraints on admission and the patient was documented as being confused and easily agitated. The patient refused the mitten restraints after a few days and the mitten restraints were removed. However, on 2/10/11 physician and nursing notes indicated the patient had a near fall (found sitting near bed), and the physician ordered a bed enclosure.

There was no documented evidence the facility attempted less restrictive methods or devices to keep Patient #19 safe other than a check box form indicating other methods were tried. Interview with the Chief Nursing Officer (CNO) indicated several of the less restrictive devices were unavailable.



23119

Patient #3

Patient #3 was admitted to the facility on 2/25/11 for rehabilitation following an anoxic brain injury. Review of the pre-admission rehab assessment revealed he was to have a bed enclosure on admission.

Review of Patient #3's record revealed daily orders for the bed enclosure restraint. The orders for the bed enclosure had check marks to designate less restrictive alternatives had been attempted. The less restrictive alternatives included low bed, upper side rails, reality orientation, increased supervision, bed/wheelchair alarms, diversion activities, and move the patient closer to the nurses' station. The less restrictive alternatives marked differed from day to day, depending on the nurse filling out the order. There was no evidence the less restrictive alternatives had been attempted and failed prior to use of the bed enclosure. Patient #3's room was at the end of the hall, furthest from the nurses' station.

Patient #5

Patient #5 was admitted to the facility on 3/4/11 for rehabilitation following a motorcycle accident. Review of the admission orders revealed an order for a bed enclosure.

Further review of Patient #5's record failed to reveal alternatives or less restrictive interventions were attempted prior to the initial use of the bed enclosure. Review of daily orders for the bed enclosure had check marks for the less restrictive alternatives that had been attempted: increased supervision, low bed, upper side rails, reality orientation, bed/wheelchair alarms, and move the patient closer to the nurse's station. Different less restrictive alternatives were checked on different days, depending on the nurse filling out the order. There was no documentation of alternatives or less restrictive interventions attempted. Patient #5's room was located at the end of the hall, furthest away from the nurse's station.

On 3/9/11, the Chief Nursing Officer was interviewed and reported the facility had no low beds. He was not able to explain how side rails were tried as a less restrictive alternative when the bed enclosure was on the bed. He reported they did not use the bed alarms as they increased the risk of developing pressure sores.

Based on record review and staff interview, the facility failed to develop care plans for restraints that included a plan for the ongoing assessment of the patient, for implementation of a lesser restrictive device and plans to evaluate the effectiveness of the device employed for 2 of 32 patients (Patient #1, #11).

Findings include:

Patient #1

Patient #1 was admitted to the facility from an acute care facility on 3/2/11. Diagnoses included Parkinson's, syncope and hypotension. Patient #1 had been admitted to the facility several weeks prior when she was found non-responsive, in her wheelchair. She did not, during that admission, require the use of any type of restraint. A preadmission screening, dated 2/27/11, indicated that Patient #1 had 1:1 sitter, due to fall risk. The patient was in an enclosed bed. She was unable to be interviewed due to her impaired mental status.

Page 1 of the form entitled Interdisciplinary Plan of Care contained columns identified as "Safety Concerns," "Interventions?Treatment Plan," and Long Term Goals." The Safety Concerns identified the problems of lack of safety awareness and frequent falls for Patient #1. The Interventions/Treatment Plan identified the interventions of reviewed strict use of call light and patient/family safety education for fall prevention and use of call light. The long term goals were for discharge safety awareness. The care plan was developed 3/2/2011. An enclosed bed was not identified as an intervention for the prevention of falls or was addressed at all in the care plan. Patient #1 was first placed in the enclosed bed on 3/2/2011.

Page 2 of the form Interdisciplinary Plan of Care, entitled Short Term Goals/Status Updates, contained a section addressing safety with columns for week 1, 2, and 3. There was no data in the column for week 1 that addressed history of falls, secondary diagnoses, use of ambulatory aid, high risk fall medication, impaired gait, mental status, Morse scale, adequate fall precautions in place, restraints in use, bed entrapment safety pads in place or accomplishment of goals notes.

Patient #11

Patient #11 was admitted from an acute care facility on 3/1/2011 with diagnoses of normal pressure hydrocephalus and pulmonary emboli. A preadmission screening, undated, completed by the facility, indicated that Patient #11 "would need a vail (enclosed bed) bed" due to a high risk for falls.

Page 1 of the form entitled Interdisciplinary Plan of Care contained columns identified as "Safety Concerns", "Interventions/Treatment Plan", and Long Term Goals". The Safety Concerns identified the problems of lack of safety awareness. There was a fall risk score of 75. The Interventions/Treatment Plan identified the interventions of a bed enclosure. The long term goals were for discharge safety awareness. The care plan was developed 3/1/2011. There were no goals for reduction to less restrictive devices or evidence that the care plan had been reviewed as of 3/8/2011.

Page 2 of the form Interdisciplinary Plan of Care, entitled Short Term Goals/Status Updates,contained a section addressing safety with columns for week 1, 2, and 3. There was no data in the column for week 1 that addressed history of falls, secondary diagnoses, use of ambulatory aid, high risk fall medication, impaired gait, mental status, Morse score, adequate fall precautions in place, restraints in use, bed entrapment safety pads in place or accomplishment of goals notes.

Employee #2 was asked if additional data was available. No additional information was submitted.

Based on record review, policy review and staff interview, the facility failed to implement restraints in accordance with facility policy for the 5 patients identified as being in restraints (Patient #1, #3, #5, #11, #19).

Findings include:

Review of facility policy, "669 Use of Restraints in Non-Psychiatric Hospital or Unit," last reviewed 1/09 revealed that the facility "utilizes measures to decrease or eliminate restraint use through least restrictive strategies. However, when these methods prove to be ineffective, restraints may be clinically appropriate." The policy further stated that the need for the use of restraints will be determined only after an appropriate assessment of the patient and evaluation of the effectiveness of the non-restraint interventions.

Comprehensive assessments of the patients (#1, #3, #5, #11, #19), specific for the use of restraints, were not evident, nor was there comprehensive documentation of the use and effectiveness of less restrictive interventions.

Based on record review and interview, the facility failed to ensure alternatives or less restrictive interventions were attempted prior to use of the bed enclosure for 5 of 32 patients (Patient #3, #5, #19, #1 and #11).

Findings include:

Patient #3

Patient #3 was admitted to the facility on 2/25/11. Review of the pre-admission rehab assessment revealed he was to have a bed enclosure on admission.

Review of Patient #3's record revealed daily orders for the bed enclosure restraint. The orders for the bed enclosure had check marks to designate less restrictive alternatives had been attempted. The less restrictive alternatives included low bed, upper side rails, reality orientation, increased supervision, bed/wheelchair alarms, diversion activities, and move the patient closer to the nurse's station. The less restrictive alternatives marked differed from day to day, depending on the nurse filling out the order.

Patient #5

Patient #5 was admitted to the facility on 3/4/11. Review of the admission orders revealed an order for a bed enclosure.

Further review of Patient #5's record failed to reveal alternatives or less restrictive interventions were attempted prior to the initial use of the bed enclosure. Review of daily orders for the bed enclosure had check marks for the less restrictive alternatives attempted: increased supervision, low bed, upper side rails, reality orientation, bed/wheelchair alarms, and move the patient closer to the nurses' station. Different less restrictive alternatives were checked on different days, depending on the nurse who filled out the order. There was no documentation of alternatives or less restrictive interventions attempted.

On 3/9/11, the Chief Nursing Officer was interviewed and reported the facility had no low beds. He was not able to explain how side rails were tried as a less restrictive alternative when the bed enclosure was on the bed. He reported they did not use the bed alarms as they increased the risk of developing pressure sores.



13812

Patient #19

Patient #19 was admitted to the facility on 2/8/11 with diagnoses including traumatic brain injury, and gastrostomy tube. The pre-admission screening indicated mitten restraints to prevent medical tube removal.

Patient #19 received mitten restraints on admission and the patient was documented as being confused and easily agitated. The patient refused the mitten restraints after a few days and the mitten restraints were removed. On 2/10/11, physician and nursing notes indicated the patient had a near fall (found sitting near bed), and the physician ordered a bed enclosure.

A review of the daily flowsheet/treatment record of 2/9/11 indicated Patient #19 was already in an enclosed bed and mittens.

There was no documented evidence the facility attempted less restrictive methods or devices to keep Patient #19 safe. There was no evidence of a detailed re-evaluation of the patient each day to determine if the bed enclosure was necessary. The restraint assessment and physician order consisted of a check box form. There was no documentation of the patient's response to the use of the mittens or reason for their continued use. After the patient's mittens were discontinued due to patient's refusal, there was no documented evidence the patient attempted to remove any medical tubing. The patient continued with the bed enclosure from 2/10/11 until conclusion of the survey on 3/11/11.

A psychiatric consult conducted on 2/28/11 indicated Patient #19's speech was coherent, thought process logical, congruent affect, cognitive function intact. "At the current time does not appear to be confused." The only diagnosis was depression.

An interview with the Chief Nursing Officer (CNO) on 3/9/11, revealed he had no explanation of why Patient #19 remained in the bed enclosure after the psychiatric consultation.

The documentation of the daily flowsheet/treatment records indicated on 2/28/11, the patient was in the bed enclosure for 24 hours continuously. However, daily progress/narrative notes indicated the patient was up in a wheelchair at 4 PM responsive without confusion on 2/28/11. There were other days that indicated the patient was in the bed enclosure 24 hours continuously.



19948

Patient #1

Patient #1 was admitted to the facility from an acute care facility on 3/2/11. Diagnoses included Parkinson's, syncope and hypotension. Patient #1 had been admitted to the facility several weeks prior when she was found non-responsive, in her wheelchair. The patient did not, during that admission, require the use of any type of restraint. Patient #1 was not able to be interviewed due to her impaired mental status.

A pre-admission screening dated 2/27/11, indicated Patient #1 had a 1:1 sitter, due to fall risk. The daily Restraint Assessment and Physician Orders from 3/3-3/8/2011, indicated the only less restrictive alternative used was increased supervision and monitoring. There was no documented evidence less restrictive measures had been employed prior to the use of the enclosed bed. Patient #1's room was noted to be the last room at the end of the hallway, the furthest from the nurse's station.

Patient #11

Patient #11 was admitted from an acute care facility on 3/1/2011 with diagnoses of normal pressure hydrocephalus and pulmonary emboli.

A pre-admission screening, undated, completed by the facility, indicated Patient #11 "would need a vail (enclosed bed) bed" due to a high risk for falls.

The Restraint Assessment and Physician Orders from 3/2-3/8/2011, indicated less restrictive alternatives of increased supervision, upper side rails and bed/wheelchair alarms were employed, but the record lacked documentation that the devices were utilized and failed. Patient #11's room was located at the end of the hall from the nurse's station.

Based on record review and interview the facility failed to ensure there was documentation for the patient's response to the interventions used and the rationale for continued use of the bed enclosure restraint for 3 of 32 patients (Patient #3, #5, #19).

Findings include:

Patient # 3

Patient #3 was admitted to the facility on 2/25/11 for rehabilitation following an anoxic brain injury. Review of the initial rehab assessment revealed a recommendation for a bed enclosure. The admission orders included an order for the enclosure bed.

Review of Patient #3's record revealed on 2/26/11, the patient was found on the floor in the dining room and assessed as a high risk for falling. The interventions included an order for a lap buddy when the patient was in a wheelchair. Review of the documentation of the daily flowsheet/treatment records indicated on 2/26/11 the patient was out of bed for one hour, at 4:00 PM. On 2/27/11, the patient was documented as out of the bed enclosure for one hour, at 3:00 PM. On 2/28/11, the documentation indicated the patient was in the bed enclosure for 24 hours continuously.

Review of the physician's orders for Patient #3 revealed orders for the bed enclosure were written each day at one minute past midnight. The medical need/clinical issue indicating the need for a protective intervention to prevent the patient from walking/getting out of bed was documented as poor safety awareness. The less restrictive alternatives that were marked included increased supervision, move patient closer to nurses' station, low bed, upper side rails up, reality orientation and bed/wheelchair alarms. The less restrictive alternatives were marked with a check mark. The orders were written at one minute past midnight each night. There was no evidence less restrictive alternatives had been adequately evaluated. Patient #3's room was observed to be at the end of the hall, furthest from the nurse's station.

Review of the daily progress/narrative notes revealed on 3/5/11, Patient #3 began to refuse to have his bed enclosure zipped. On 3/5/11, the nurse advised the patient of safety concerns and he agreed to have the enclosure zipped. On 3/6/11, the patient again refused to have his enclosure zipped. The risks and consequences of leaving the bed enclosure with one side open were explained to the patient and his wife, and the bed enclosure was left open. On 3/6/11, at 9:00 PM, the bed enclosure was still open, the patient was getting up on his own to use the toilet, and stated he did not need the bed enclosure. On 3/7/11, at 6:00 PM, an order was written to discontinue the bed enclosure per request of the patient and the wife.

Patient #5

Patient #5 was admitted to the facility on 3/4/11. Review of the admission orders revealed an order for a bed enclosure.

Further review of Patient #5's record failed to reveal alternatives or less restrictive interventions were attempted prior to the initial use of the bed enclosure. Review of daily medical need/clinical issue indicating the need for a protective intervention to prevent the patient from walking/getting out of bed was documented as poor safety awareness. The orders for the bed enclosure had check marks for the following less restrictive alternatives that had been attempted: increased supervision, low bed, upper side rails, reality orientation, bed/wheelchair alarms, and move the patient closer to the nurses' station. Different less restrictive alternatives were checked on different days, depending on the nurse who filled out the order. There was no documentation of alternatives or less restrictive interventions attempted for Patient #5. Patient #5's room was observed to be the first room as the hallway was entered, and furthest from the nurse's station.

On 3/9/11, the Chief Nursing Officer (CNO) was interviewed and reported there were no low beds in the facility, and they did not use pressure alarms for the beds as they increased the risk of developing pressure sores. The CNO reported they did not routinely use the bed enclosures for fall prevention. The CNO was not able to explain how the less restrictive alternatives had been evaluated at that time of night, or how they had been attempted while the bed enclosure was in place. The CNO was not able to explain why Patient #3 continued to have a bed enclosure after 3/5/11, when the patient began to refuse to have the enclosure zipped.

On 3/10/11, the Administrator was interviewed and reported the facility had fifteen beds which were able to go to a low position, approximately twelve inches from the floor. The Administrator reported the beds were located on the brain injury unit. Tour of the brain injury unit with the Administrator failed to locate any low beds. A room-to-room search of the facility revealed four low beds on the comprehensive unit.



13812

Patient #19

Patient #19 was admitted to the facility on 2/8/11 with diagnoses including traumatic brain injury, and gastrostomy tube. The pre-admission screening indicated mitten restraints to prevent medical tube removal.

Patient #19 was placed in a bed enclosure on 2/10/11 due to a near fall. The patient continued with the bed enclosure from 2/10/11 until conclusion of the survey on 3/11/11.

There was no documentation of the patient's response to the bed enclosure or a detailed assessment for the continued use of the bed enclosure.

Based on policy review and interview, the facility failed to provide evidence of a training program for staff and physicians in the application and use of the enclosure bed restraint.

Findings include:

A review of the facility restraint policy did not reveal any instruction in the use or application of the enclosure bed for staff and physicians.

An interview with the Chief Nursing Officer (CNO) on 3/10/11, verified there was no training program for the use of the enclosed bed. During an interview with the Regional Director of Risk and Quality Management on 3/11/11, she confirmed physicians did not receive training in restraint use but were asked to read the restraint policy and sign an acknowledgement of reading the policy.

Based on interview and record review, the facility failed to ensure all medical entries were legible for 1 of 32 records sampled (Patient #19).

Findings include:

Patient #19

Resident #19 was admitted to the facility on 2/8/11, with diagnoses including traumatic brain injury and pneumonia. Record review revealed a physician progress note entry that was largely illegible. The entry date could not be determined with certainty.

In an interview with the medical records director on 3/10/11, she reported her department will report illegible writing issues to the medical director to correct the problem.

Based on record review and interview, the facility failed to ensure physician orders were dated and timed for 4 of 32 patients (Patient #28, #30, #3 ,#1).

Findings include:

Patient #28

Patient #28 was admitted to the facility on 2/23/11, with diagnoses including cerebrovascular accident. Record review revealed a physician's order for MS Contin and Xanax written on 3/2/11, was signed and dated. The time the physician's order was written was not identified.

Patient #28's record revealed a telephone order was received on 3/2/11. The telephone order did not identify the time the physician's order was given.

Record review revealed an order for physical therapy, written 3/6/11, did not include the time the order was written.

Patient # 30

Patient #30 was admitted to the facility on 3/3/11, with diagnoses including left ankle fusion. Record review revealed a physician's order for physical therapy, written on 3/6/11, did not identify the time the order was written.

On 3/10/11, the medical records director was interviewed. The director reported the facility was aware physicians did not consistently time their orders. She reported the facility was working to correct the problem.



19948

Patient #1

Patient #1 was admitted to the facility from an acute care facility on 3/2/11. Diagnoses included Parkinson's, syncope and hypotension. Patient #1 had been admitted to the facility several weeks prior when she was found non-responsive, in her wheelchair. The patient did not, during that admission, require the use of any type of restraint. Patient #1 could not be interviewed due to her impaired mental status.

Review of Patient #1's record revealed that the daily orders for the bed enclosure lacked the following:

3/3/2011 No time of the physician's signature.
3/4/2011 No time of the physician's signature.
3/5/2011 No time of the physician's signature.
3/6/2011 No time of the physician's signature.
3/7/2011 No date and time of nurse's signature.



23119

Patient #3

Patient # 3 was admitted to the facility on 2/25/11 for rehabilitation following an anoxic brain injury.

Review of Patient #3's record revealed he had an order for a bed enclosure beginning on 2/25/11. The daily orders to continue the bed enclosure revealed the following:

2/26/11: No time of the physician's signature
2/27/11: No time of the physician's signature
2/28/11: No time of the physician's signature
3/1/11: No time of the physician's signature, dated 3/2/11 by physician
3/2/11: No time of the physician's signature, dated 3/1/11 by physician
3/4/11: No time of the physician's signature
3/5/11: No time of the physician's signature
3/6/11: No physician's signature
3/7/11: No time of the physician's signature

Based on review of facility documents and interview, the facility failed to ensure policies and procedures were followed for changing the gloves weekly on the MicroSphere compounding equipment.

Findings include:

On 3/7/11, the facility pharmacy policies and procedures were reviewed. Review of Policy number 3.955, Maintenance of the MicroSphere C.A.I., with an original date of 8/07, revealed the gloves "must be changed weekly."

Review of the IV Hood and Floor log revealed the gloves were documented as changed on 7/3/10, 9/1/10, 10/19/10, and 2/24/11. A pharmacy technician was interviewed and reported he was taught the gloves on the machine were changed as needed.

On 3/9/11, the Director of Pharmacy was interviewed and reported the gloves were to be changed weekly.

Based on observation and staff interview, the facility failed to ensure all drugs were locked and in a secure area.

Findings include:

On 3/9/11, medication administration was observed. During medication administration it was observed that three medication carts on the comprehensive unit could not be locked. The contents of each cart was observed and multiple syringes containing Heparin Flushes were found in each cart. Three RNs (Registered Nurses), Employees #8, #9, #10, were interviewed on 3/9/11 and reported the medication cart drawers were unlocked at all times. RNs #8, #9, #10 reported the carts were always kept within their sight or kept at the nurse's station.

On 3/9/11, at approximately 8:30 AM, RN Employee #8, placed her medication cart at the entrance way of the patient's room. She left the medication cart and went behind a patient's privacy curtain to tend to his needs. The cart could not be observed from behind the privacy curtain.

On 3/9/11, at approximately 9 AM, RN Employee #10, left her medication cart in the entrance way of a patient's room. The RN went behind the patient's privacy curtain and provided care. She could not see the medication cart from behind the curtain.

On 3/9/11, on the brain injury unit, medication administration was observed. The medication cart used by the Licensed Practical Nurse (LPN), Employee #11, could not be locked. The contents of the cart were observed and multiple syringes of Heparin Flushes were observed.

During medication administration, the LPN Employee #11, unlocked the medication cabinet in room 129 to prepare medications for a patient. During medication preparation the nurse reported she left her pill cutter at the nurse's station. The nurse left the patient's room without locking the medication cabinet which contained Norvasc and Prevacid. She returned to the unlocked cabinet after several minutes.

At approximately 9:30 AM, LPN Employee #11, reported she needed to obtain medication from the Medispense device. The LPN returned the unlocked medication cart to the nurse's station and proceeded to the locked room where the Medispense was located. There was no staff at the nurses station to monitor the medication cart. The cart could not be observed from the area where the Medispense was located.

Based on document review and an interview with Employee #13, the radiology department did not ensure that the facility's lead apron provided adequate protection from radiation.

Findings include:

Employee #13 produced a document which indicated that the last three times the lead apron had been inspected were "Jan 09," "July 09," and "April 10." Employee #13 stated that she had performed the inspection every month since, but that she had not recorded the information nor kept the films from the inspections.

Based on random chart review and confirmation by Employee #12, a sonography procedure was carried out on a patient upon the order of a physician without current privileges at the hospital.

Findings include:

A physician without current privileges at the hospital ordered a 2D Echo on Patient #15 on 3/5/11. The procedure and a preliminary reading were performed by Employee #15 of the contracted service Vision Medical on 3/6/11.

Based on a policy review and an interview with Employee #14, a pathologist did not define the examination requirements for tissue specimens collected at the facility.

Findings include:

Employee #14 confirmed that the medical staff and the medical executive committee did not include a pathologist when determining which specimens needed a macroscopic examination and which specimens required both macroscopic and microscopic examinations.

Based on a review of the facility's policy titled "Blood Products: Call Back of Tainted Blood," the facility did not have a comprehensive procedure outlining the steps to be taken in the event of notification from the blood supplier of HIV or HCV infected blood products.

Findings include:

1. The policy did not contain adequate reference to HCV-infected blood products.

2. The policy did not account for patients who were minors.

3. The policy's notification time frames did not follow the current regulation.

4. The notification parameters did not contain reference to HCV.

5. The policy did not state that the facility will conform to confidentiality requirements for patient information not contained in the medical record.

6. The policy did not contain information defining the record keeping requirements of the facility.

Based on document review and staff interview, the facility failed to adequately measure, analyze and track restraint use.

Findings include:

The facility policy numbered 3.760, entitled "669 Use of Restraints in Non Psychiatric Hospital or Unit" last reviewed 1/09, was reviewed. Section C of the policy identified as "Restraint Use Monitoring and Reduction and Evaluation of Risk," revealed evaluation and measurement regarding the use of restraints would be performed at least quarterly as part of the facility's performance improvement activities. The quarterly evaluation and measurement was to include the following:

- 100% review of all restraint cases
- Data reviewed by patient case unit, shift, Registered Nurses requesting orders, LIP writing order
- Reasons for restraint include only those used to ensure physical safety of the patient, staff or others
- Identification of trends in type of restraint, condition/diagnosis of patient and frequency of injury related to restraint use
- Compliance with the facility's policy requirements, as well as joint Commission, state and federal law

During an interview with the Regional Director of Risk and Quality Management on the afternoon of 3/8/11, she presented the latest quarterly report which only identified the restraint rate. The report contained no other data or evaluation of restraint use. The director did not know if additional data was collected.

On 3/9/11, the Chief Nursing Officer (CNO) and the Risk Manager of the facility were interviewed. They both reported the restraint use rate was monitored but no other data was collected or analyzed regarding restraint use. When specifically asked if they reviewed all restraint cases and analyzed data as indicated in policy 3.760, the CNO and Risk Manager responded they did not. The CNO provided a copy of a restraint audit tool but reported the tool had not been initiated.

Based on document review and interview, the facility failed to monitor the effectiveness and safety of restraint use.

Findings include:

The facility policy numbered 3.760, entitled "669 Use of Restraints in Non Psychiatric Hospital or Unit" last reviewed on 1/09 was reviewed. Section C of the policy identified as "Restraint Use Monitoring and Reduction and Evaluation of Risk" revealed that evaluation and measurement regarding the use of restraints would be performed at least quarterly as part of the facility's performance improvement activities. The quarterly evaluation and measurement was to include the following:

- 100% review of all restraint cases
- Data reviewed by patient case unit, shift, Registered Nurses requesting orders, LIP writing order
- Reasons for restraint include only those used to ensure physical safety of the patient, staff or others
- Identification of trends in type of restraint, condition/diagnosis of patient and frequency of injury related to restraint use
- Compliance with the facility's policy requirements, as well as joint Commission, state and federal law

During an interview with the Regional Director of Risk and Quality Management on the afternoon of 3/8/11, she presented the latest quarterly report that only identified the restraint rate. The report contained no other data or evaluation of restraint use. The director did not know if additional data was collected.

On 3/9/11, the Chief Nursing Officer (CNO) and the Risk Manager of the facility were interviewed. They both reported the restraint use rate was monitored but no other data was collected or analyzed regarding restraint use. When specifically asked if they reviewed all restraint cases and analyzed data as indicated in policy 3.760, the CNO and Risk Manager responded they did not. The CNO provided a copy of a restraint audit tool but reported the tool had not been initiated.

Based on document review and staff interview, the facility failed to implement and maintain an ongoing patient safety program for restraint use.

Findings include:

The facility policy numbered 3.760, entitled "669 Use of Restraints in Non Psychiatric Hospital or Unit" last reviewed on 1/09, was reviewed. Section C of the policy identified as "Restraint Use Monitoring and Reduction and Evaluation of Risk" revealed evaluation and measurement regarding the use of restraints would be performed at least quarterly as part of the facility's performance improvement activities. The quarterly evaluation and measurement was to include the following:

- 100% review of all restraint cases
- Data reviewed by patient case unit, shift, Registered Nurses requesting orders, LIP writing order
- Reasons for restraint include only those used to ensure physical safety of the patient, staff or others
- Identification of trends in type of restraint, condition/diagnosis of patient and frequency of injury related to restraint use
- Compliance with the facility's policy requirements, as well as joint Commission, state and federal law

During an interview with the Regional Director of Risk and Quality Management on the afternoon of 3/8/11, she presented the latest quarterly report that only identified the restraint rate. The report contained no other data or evaluation of restraint use. The director did not know if additional data was collected.

On 3/9/11, the Chief Nursing Officer (CNO) and the Risk Manager of the facility were interviewed. They both reported the restraint use rate was monitored but no other data was collected or analyzed regarding restraint use. When specifically asked if they reviewed all restraint cases and analyzed data as
indicated in policy 3.760, the CNO and Risk Manager reported they did not. The CNO provided a copy of a restraint audit tool but reported the tool had not been initiated.