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Based on observations, review of documentation and interviews, the facility failed to ensure that restraints for three (Patient #1, #2 and #3) (#1 and #2 in bilateral wrist restraints and #3 in bilateral hand mitts) were used by properly trained staff who followed and implemented the facilities policies and procedures regarding restraint use.

Please refer to Tag #: A 164, A 165, A 166, A 167, A 169, A 174, A 175, A 176, A 194, A 396 for additional information.

A total sample of ten patients were selected, 7 were not in restraints.

Based on observations, review of documentation and interviews, the facility failed to ensure that restraints used for three patients restrained (#1 and #2 in bilateral wrist restraints and #3 in bilateral hand mitts) out of a total sample of 10 patients (7 of whom were not restrained) were used only when less restrictive interventions were determined to be ineffective.

Findings include:

1) The Hospital policy titled: Patient Restraint Management indicated that the hospital will endeavor to use the least restrictive restraint possible and staff will complete the Restraint Management Flow Sheet to indicate the least restrictive interventions were determined to be ineffective.

2.) Pt. #1's physician orders and nursing notes dated 2/14/13-2/24/13 indicated that an order was written each day for bilateral soft wrist restraints. However, there was no medical or nursing documentation in Pt. #1's medical record to indicate less restrictive interventions were used and those interventions had been determined to be ineffective. Alternatives attempted or the rationale for not using alternatives were not documented.

3.) A tour of the 5th floor nursing unit was conducted on 2/26/13 from 7:30 A.M. to 7:50 A.M. with the Nurse Manager. The Surveyor observed that Pt. #2 had bilateral soft wrist restraints on his/her right and left wrists which were properly attached to the movable section of the bed frame.

4.) The Surveyor observed that Pt. #3 had bilateral mitts (mitts that could not be intentionally removed by the patient and significantly reduced the patient's ability to use his/her hands) on each hand.

5.) Pt. #2's interdisciplinary care conference record dated 1/31/13 indicated that Pt. #2 had a trachestomy, peripheral inserted central venous access catheter and a feeding tube. Physician orders indicated that the restraints were ordered to prevent Pt. #2 from removing critical medical devices.

6.) Pt #3's admitting history and physical examination dated 12/14/12 indicated that Pt. #3's diagnosis included respiratory failure with a trachestomy. Pt. #3 required bilateral mitts because of multiple attempts to pull out the trachestomy tube.

7.) Pt. #1, #2 and #3's medical records were reviewed with the Nurse Manager present to ensure proper and consistent documentation was included in each medical record. The Nurse Manager said restraint flow sheets are not used to document the care of patients in restraints because the staff just don't use them. As a result of nursing staff non-compliance with documentation of restraint use, there was no restraint flow sheet in Pt. #1, #2 and #3's record to indicate that less restrictive interventions were determined to be ineffective or indicated the rational for not using alternatives.

Based on observations, review of documentation and interviews, it was determined the facility failed to document that the type of restraints used for the care of three (Patient #1, #2 and #3) of three restrained patients out of a total sample of 10 patients, was the least restrictive intervention to protect each patient from harm.

Findings included:

The Hospital's policy and procedure related to restraints indicated that upon determination, and after all alternatives measure are attempted, the registered nurse (RN) will notify the physician of the need for the restraint. The Restraint Order Management Flow Sheet will be stamped with the patient's name and the Restraint Order Management Sheet will be completed. The checks will be every 30 minutes for non-behavioral restrained patient.

1.) The Surveyor observed on 2/26/13 at 7:30 A.M. Pt. #2 had bilateral soft wrist restraints applied to both his/her right and left wrist.

2.) The Surveyor observed on 2/26/13 at 7:35 A.M. Pt. #3 had bilateral hand mitts to both his/her right and left hand.

3.) Nursing assessments and nursing notes in patient records #1, #2 and #3 did not describe the steps or interventions used prior to the use of the restraints and did not indicate that ongoing assessments were done to demonstrate the continued need for restraint use as required by the Hospital's policies and procedures.

3.) The Nurse Manager was interviewed on 2/26/13 and 2/27/13. The Nurse Manager said the Restraint Management Flow Sheets were not used by staff and as a result, the least restrictive intervention to protect each patient was not documented.

Based on review of documentation and interviews, the Hospital failed to include in each patient's plan of care the application of restraints for 3 of 3 restrained patients (#1, #2, and #3) out of a total sample of 10 patients. Review of the care plan indicated that the nursing staff failed to include a section for restraint use which include assessments and compliance with the Restraint Order Management Flow Sheet.
Findings included:

1.) An admission history and physical examination, dated 2/8/13 indicated that Pt. #1 was admitted on 2/7/13 with diagnoses of heart and respiratory failure, seizure disorder and dementia.

2.) Physician orders and random nursing notes dated, 2/14/13-2/23/13 indicated that Pt. #1 was restrained each day with bilateral soft wrist restraints.

3.) For Pt. #2, randomly selected Physician Orders, dated from 1/19/13 to 2/1/13 indicated that orders were written to restrain Pt. #2 with bilateral wrist restraints.

4.) For Pt. #3, randomly selected Physician Orders, dated from 1/30/13 to 2/25/13 indicated that orders were written to restrain Pt. #3 with bilateral hand mitts.

5.) The nursing plans of care were reviewed for Patient #1, #2 and #3. The Nurse Manager said that the physician order for restraint usage for each of the three Patients were not added to the Nursing Plans of Care.

6.) The plans of care for Pt. #1, Pt. #2 and Pt. #3 did not indicate the requirement to complete the Restraint Order Management Flow Sheet and therefore the assessments required to complete the Restraint Order Management Flow Sheet were not performed.

Based on observations, staff interviews and review of documentation, the facility failed to ensure that restraints were implemented appropriately and safely for three Patients, (#1, #2 and #3) from a sample of 10 total, in accordance with restraint techniques as outlined by hospital policy.

Findings included:

Pt. #1's medication administration record indicated that on 2/23/13 at 6:11 P.M. Pt. #1 received scheduled medications. No further care was documented until a nursing note indicated that at 8:00 P.M. Pt. #1 was found pulseless. There were no Restraint Management Flow Sheets to indicate that 30 minute assessments were performed, in accordance with hospital policy for a non-behavioral restraint, between 6:11 P.M. to 8:00 P.M. when Pt. #1 was found pulseless and without respirations.

Nurse #1, the nurse assigned to Pt. #1 on 2/23/13, the day of Pt. #1's death, was interviewed on 2/26/13 at 12:10 P.M. Nurse #1 said that sometime between 5 to 6:00 P.M. she assessed and then administered medications to Pt. #1. Nurse #1 said the next time she eyeballed (checked on) Pt. #1 was about 7:35 P.M. Nurse #1 said she saw both soft wrist restraints on Pt. #1. The Surveyor asked Nurse #1 how often patients in restraints need to be assessed? Nurse #1 said at least every 2 hours. However, Nurse #1 failed to document the required assessments of Pt. #1 as required by hospital policy.

Nurse Technician (NT) #1, the NT assigned to Pt. #1 on 2/23/13, was interviewed at 1:50 P.M. on 2/26/13. NT #1 said that sometime around 6:30 P.M., she and NT #2 released Pt. #1's wrist restraints and turned off the bed alarm because they were repositioning Pt. #1. NT #1 said after care was provided, she reapplied Pt. #1's right wrist restraint and turned on the bed alarm. NT #1 said NT #2 applied Pt. #1's left wrist restraint. NT #1 said she did not recall having completed training/education regarding restraint use at this facility.

Nurse #2, the Nurse who found Pt. #1 pulseless, was interviewed on 2/26/13 at 10:30 A.M. Nurse #2 said she checked on Pt. #1 because she did not hear Pt. #1 calling out, which was his/her usual behavior, and noticed that he/she was not in the bed when she entered the room. Nurse #2 said she called out for help and Nurse #3 immediately came to Pt. #1's room. Nurse #2 said she observed that Pt. #1 was out of the bed with the oxygen tubing and liquid nutrition feeding tube attached to the patient. Nurse #2 said she did not remember hearing the bed alarm when she entered the room.

Nurse #3 was interviewed on 2/26/13 at 8:50 A.M. Nurse #3 said Pt. #1 had a do not resuscitate order (no cardio-pulmonary resuscitation) and a do not intubate (tube that placed in trachea for an airway) order. Nurse #3 said that Pt. #1 was found without a carotid pulse and without respirations. Pt. #1 was found out of bed, on the left side of the bed, facing away from the bed. Nurse #3 said that Pt. #1's chin was resting on the top of the left upper side rail and Pt. #1's left wrist was restrained to the bed frame in a soft wrist restraint with the left hand holding the upper left side rail. Nurse #3 said that Pt. #1's knees were folded under him/her, as in a kneeling position, with his/her feet behind her. Nurse #3 said his/her knees were not touching the floor. Nurse #3 said that the right wrist restraint was still attached to the bed frame and was found to be closed, as if the right hand slid out of the restraint. Nurse #3 said more nursing staff entered Pt. #1's room and lifted Pt. #1 onto the bed. The Surveyor asked Nurse #3 how often patients in restraints needed to be assessed. Nurse #3 said at least every 1 hour to check the circulation, sensation and motion. Nurse #3 said that he recalled that the black cord to Pt. #1's bed alarm was not connected, which disabled the bed alarm.

Pt. #1's medical record was reviewed with the Nurse Manager. The Medication administration record indicated that Patient #1 received medications at 6:11 PM. The next nursing note dated 2/23/13 indicated Pt. #1 was found pulseless at 8:00 P.M.. There was no nursing documentation on the Restraint Order Management Form to indicate that Patient #1 was offered or was provided any care related to safe restraint care from 6:11 P.M. to 8:00 P.M..

A tour of the 5th floor nursing unit was conducted on 2/26/13 from 7:30 A.M. to 7:50 A.M. with the Nurse Manager. The Surveyor observed that Pt. #2 was in room # 567 and had bilateral soft wrist restraints. The Surveyor observed that Pt. #3 was in room #569. Pt. #3 had bilateral mitts (mitts that could not be intentionally removed by the patient) on each hand.

Pt. #1's #2's and #3's medical records were reviewed with the Nurse Manager. The Nurse Manager said Restraint Order Management Forms were not used to document the care for those 3 patients in restraints. The Nurse Manager said the Restraint Order Management Forms were not used at all. As a result, there was no documentation in Pt. #1, #2 and #3's record to indicate they were monitored and provided nursing care while in restraints, according to Hospital policies and procedures.

The Hospital's policy and procedures related to restraints included the following:

a.) Soft wrist restraints were to be fastened snugly around the extremity and provide for proper positioning and good body alignment. The soft wrist is to be attached securely to the frame of the bed and NOT tied to the side rails.

b.) The Restraint Order and Flow sheet must be used in all instances where restraints are used.

c.) The nursing staff monitoring the patient will document the required periodic monitoring on the Restraint Order and Flow Sheet.

d.) For non-behavioral restrained patients, the check is every 30 minutes. The check will include an assessment for vital signs, the need for continued restraint, level of consciousness/orientation,mental and/or emotional status changes, change in functional ability, restrained extremity for color, pulses, movement, sensation, skin status and/or evidence of edema.

e.) All extremities, one at a time, must be released from restraints every 2 hours.

Based on review of documentation, staff interview and review of the
Hospital's Restraint Policy and Procedure, the facility failed to prohibit the use of PRN (abbreviation for medication as needed) orders for use of restraints for Patient #1, #2 and #3 of 3 restrained patients in a total sample of 10 patients.

Findings include:

1.) The Hospital's Restraint Policy and Procedure indicated that PRN orders, standing orders and/or protocols for restraints, regardless if medical or behavioral, are not acceptable.

2.) A Restraint Order written for Pt. #1 at 10:00 A.M. on 2/20/13 indicated that the order was written to restrain Pt. #1 with soft wrist restraints on PRN basis.

3.) Restraint Orders written for Pt. #2 at 11:45 A.M. on 1/30/13, at 11:05 A.M. on 1/31/13 and at 3:40 P.M. on 2/1/13 indicated that the orders were written to restrain Pt. #2 with soft wrist restraints on a PRN basis.

4.) Restraint Orders written for Pt. #3 at 11:40 A.M. on 1/30/13 and at 11:20 A.M. on 2/25/13 indicated that the orders were written to restrain Pt. #3 with bilateral hand mitts on a PRN basis.

5.) Attending Physician #1 was interviewed at 10:20 A.M. on 2/27/13. Attending Physician #1 said that he wrote orders for a restraints when and if a restraint was.

Based on observations, review of documentation and interviews, it was determined the facility failed to ensure that restraints placed on three (Patients, #1, #2 and #3) of three restrained patients out of a total sample of 10 patients, were discontinued at the earliest time.

Findings included:

The Hospital's policy and procedure related to restraints indicated that the facility failed to ensure restraints were discontinued as soon as it was safe for patients, visitors and staff.

The Nurse Manager was interviewed on 2/26/13 and 2/27/13 throughout the on site investigation. The Surveyor review the medical records for Patient #1, #2 and #3 with the Nurse Manager. The Nurse Manager said the Restraint Flow Sheets were not used by staff. As a result, there was no documenation to indicate that restraints used for Patients #1, #2 and #3 were discontinued at the earliest time.

Based on interviews, review of nursing education files, the Hospital's Restraint Policy and Procedure and Patient #1, #2 and #3 medical records from a total sample of 10, the Hospital failed to ensure that:
1.) Patients, #1, #2 and #3 were monitored while in wrist/mitt restraints according to the interval established by Hospital policy and
2.) Nursing Staff caring for those patients in restraints had completed restraint training.

Findings included:

The Hospital policy regarding the Restraint Management of Patients indicated that those patients requiring restraints for non-behavioral reasons shall require a check which includes an assessment every 30 minutes. The policy indicated all extremities, one at a time, must be released from the restraint every 2 hours. The Restraint Order Management Form policy indicated that the Restraint Order and Restraint Management Flow Sheet must be used for each time restraint is used.

Pt. #1, #2 and #3's medical records were reviewed on 2/26/13 with the Nurse Manager. The review indicated that restraint flow sheets were not found in three of three patient records reviewed. As a result, there was no documentation to indicate that any checks were performed.

Review of two nurse technicians (NT), NT #1 and NT #2, education files indicated that they had not attended education regarding restraint application and monitoring. There was also no documentation that they had attended education on bed or chair alarms.

Review of four registered nurse (RN) education files, Nurse #1, #2, #3 and the Evening Nursing Supervisor, indicated that a questionnaire competency was present in each file reviewed. Question #7, that the RN signs for an assessment of every patient in restraint every 30 minutes, was answered correctly by the nurses. However, there was no indication that 4 of the 4 RNs attended any education or training on restraint use. There was a total of 6 of 6 nursing staff not trained in restraint use.

Based on review of documentation and interview with Attending Physician #1, Attending Physician #1 did not have a working knowledge of the Hospital's restraint policy and procedure which indicated restraints may never be ordered PRN.

See tag A-0169

Based on interviews and review of documentation which included of six of six nursing education files, the Hospital failed to ensure that Nursing Staff caring for patients in restraints attended and completed restraint training.

Findings included:


Review of two Nurse Technician (NT) education files, NT #1 and NT #2, indicated that they had not attended any restraint education or education regarding patient bed/chair alarms.

Review of four registered nurse (RN) education files, Nurse #1, #2, #3 and the Evening Nursing Supervisor, indicated that a questionnaire competency was present in each file reviewed. Question #7, that the RN signs for an assessment of every patient in restraint every 30 minutes, was answered correctly by the nurses. However, there was no indication that 4 of the 4 RNs attended any education or training on restraint use.


The Nurse Educator was interviewed at 10:30 A.M. on 2/27/13. The Surveyor reviewed NT #1's, NT #2's, Nurse #1's, Nurse #2's, Nurse #3's and the Nursing Supervisor's educational files with the Nurse Educator. The Nurse Educator said that there were no attendance records of any educational programs on restraints use.

The Nurse Educator said there was no training or competencies for the use of patients chair or bed alarms.

Based on observations, review of documentation and interviews, the facility failed to ensure that the nursing staff developed a nursing plan of care that included restraints used for three patients (#1 and #2 in bilateral wrist restraints and #3 in bilateral hand mitts) out of a total sample of 10 patients (7 of whom were not restrained).

Findings include:

Documentation in a nursing note dated 2/23/13 indicated that Pt. #1 was found without respirations and without a pulse. A soft left wrist restraint was on Pt. #1 and the a right wrist restraint was attached to his/her bed. However, the Plan of Care, dated 2/14/13 did not identify a plan that incorporated restraint use.

Pt. #2 and Pt. #3 were observed by the Surveyor during a tour of the 5th floor nursing unit at 7:30 A.M. to 7:50 A.M. on 2/26/13. The Surveyor observed that Pt. #2 had bilateral soft wrist restraints on his/her right and left wrists. The Surveyor observed that Pt. #3 had bilateral mitts on each hand.

Pt. #1, #2 and #3's medical records were reviewed on 2/27/13 with the Nurse Manager. The review indicated that the use of restraints were not incorporated into each of the three Plans of Care reviewed.