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Based on record review, hospital policy and interview, the hospital failed to assure the plan of care was updated for 2 of 7 records reviewed for patients with restraints. This had the potential to affect all patients.

Findings include:

Hospital Policy: Restraints, Assessments, Documentation and Application in Medical/Surgical Care revised 6/30/10.

IX. Documentation
B. The use of restraint intervention should be documented in the patient's plan of care and based on an assessment and evaluation of the patient.

C. Documentation of patient and family teaching should be documented in the multidisciplinary teaching form.

Medical Record:

1. Patient Identifier (PI) # 2 was admitted to the hospital on 9/17/10 with diagnoses to include Sepsis, Acute Renal Failure, Urinary Tract Infection and Pneumonia.

A review of the interdisciplinary plan of care revealed no documentation of an update for the application of restraints. The only area addressed on the plan of care was for skin integrity. There was no documentation of any updates or reviews of the plan of care since 9/17/10, the admission date.

A review of the multidisciplinary patient/family education record revealed no documentation the patient or family was taught about the restraints.

On 10/29/10 at 4:30 PM, Employee Identifier (EI) # 1, the Chief Clinical Officer was asked where staff would document changes or updates to the patient's plan of care and she stated on the care plan.

2. Patient Identifier # 5 was admitted to the hospital on 10/01/10 with diagnoses to include Respiratory Failure and Chronic Obstructive Pulmonary Disease.

A review of the interdisciplinary plan of care revealed no documentation of an update for the application of restraints, that were initiated on 10/01/10. The only areas addressed on the plan of care was for neurological and skin integrity. There was no documentation of any updates or reviews of the plan of care since admission on 10/01/10.

Based on record review and hospital policy it was determined there was no order for restraints, restraint orders failed to identify the ordering physician, there were no assessments to determine the patient's need for a restraint and that the least restrictive measures were ineffective to protect patients prior to restraint application. This affected seven of seven records reviewed for patients with restraints.

Findings include:

Hospital Policy: Restraints in general population revised 5/07/10.

IX. Documentation
A.
1. Restraint initiation order/physician order (dated, timed and signed)
2. Less restrictive alternatives considered and/or attempted
3. Indication for restraints (Clinical justification) and type of restraint
4. Patient and family education
5. Monitoring of the patient
6. Reassessment of need of restraint (order/clinical justification) including 24 hour order sheet (dated, timed, signed by physician)

Medical Record Findings:

1. Patient Identifier (PI) # 2 was admitted to the hospital on 9/17/10 with diagnoses to include Sepsis, Acute Renal Failure, Urinary Tract Infection and Pneumonia.

A review of the following physician orders titled, "Initiation of Restraints/24 Hours Renewal Restraint Order," failed to either document the physician name or signature or the staff member who notified the physician of the need to place PI # 2 in wrist restraints on: 9/19/10, 9/20/10, 9/21/10, 9/22/10, 9/23/10, 9/28/10 at 0700 hours, 9/28/10 at 0200 hours 9/29/10 and 9/30/10.

2. Patient Identifier # 3 was admitted to the hospital on 7/21/10 with diagnosis to include Respiratory Failure.

A review of the 7/21/10 initial order for restraints failed to document the physician's name, when the physician was notified and who notified the physician. Under the "Type of device" section of the order there was no staff name, no time that the restraints were applied, and no documentation that the restraints were applied according to the manufacturer's direction.

A review of the nursing notes for 7/22/10 and the restraint flowsheet revealed that PI # 3 was restrained for a 24 hour period without a physician's order.

A review of the "Initiation of Restraints/24 Hours Renewal Restraint Order" sheet revealed there was no documentation of either the patient's assessed need for a restraint or least restrictive measures that were judged to be ineffective or the clinical justification for the application of the restraint for the following dates: 7/21/10, 7/23/10, 7/24/10, 7/25/10 and 7/26/10.

The restraint flowsheets were reviewed and there was no documentation on the flowsheets of either the patient's assessment of continued need for restraints, the type of restraint or alternatives attempted to reduce restraints for the following dates: 7/21/10, 7/22/10, 7/23/10, 7/24/10, 7/25/10 and 7/26/10.

3. Patient Identifier (PI) # 4 was admitted to the hospital on 10/19/10 with an admitting diagnosis of Respiratory Failure.

A review of the "Initiation of Restraints/24 Hours Renewal Restraint Order" sheet dated 10/20/10 at 9:30 PM, revealed there was no documentation of the physician notified, the staff who notified the physician or time. Under the "Type of device" section of the order sheet there was no documentation the restraint was applied according to the manufacturer's direction.

A review of the 10/21/10 and 10/22/10 "Initiation of Restraints/24 Hours Renewal Restraint Order" sheets revealed there were no physician signatures. The 10/21/10 order sheet failed to document the patient's need for the restraint and the 10/22/10 order sheet failed to include the nurse's signature that completed the form per policy.

The 10/24/10 and 10/25/10 order sheets were not signed by the physician.

A review of the 10/19/10 nursing notes and restraint flowsheet documented PI # 4's right and left arms were restrained at 10:00 PM. The type of restraint was not documented and PI #4 continued to be restrained until 10/20/10 at 11:00 AM. There were no alternatives or justification documented 10/19/10 at 10:00 PM through 1:00 AM. A review of the orders revealed there was no physician's order for the application of this episode of restraints in the medical record.

A review of the 10/20/10 nursing notes and restraint flowsheet documented PI #4's restraints were removed at 12 noon and PI #4 was restraint free until 8:00 PM. At 8:00 PM, the restraints were applied, but there was no new order for this new episode of restraints in the medical record.

A review of the 10/21/10 nursing notes and restraint flowsheet documented PI # 4's restraints were removed at 9:00 AM and were left off until 7:00 PM. There was no order for this new episode of restraints in the medical record.

A review of the nursing notes and restraint flowsheets either failed to document the continued need for the restraint, the type of restraint applied, alternatives to the use of the restraint or the justification for the restraints on 10/22/10 and 10/25/10.

4. Patient Identifier # 5 was admitted to the hospital on 10/01/10 with diagnoses to include Respiratory Failure and Chronic Obstructive Pulmonary Disease.

A review of the nursing notes and restraint flowsheet dated 10/01/10 documented PI # 5 was restrained at 12:30 PM until 3:00 PM, when they were removed. At 7:00 PM, PI # 5 was placed back in a restraint, the record failed to show what type of restraint was applied to what area of the body that was restrained. At 4:00 AM, PI # 5 was taken out of the restraint again. There was no documentation on the flowsheet to indicate the type of restraint applied or the area of the body that was restrained. There was no documented assessment of the need for a restraint.

A review of the physician orders revealed there was no physician's order for the application of restraints on 10/01/10 for any of the restraint episodes that were documented on the restraint flowsheet. The first order in the medical record for the use of a restraint was dated 10/02/10, but this order failed to document the name of the physician that was contacted, the staff member who contacted the physician and marked the "Initiation of Restraints/24 Hours Renewal Restraint Order" sheet as a 24 hour renewal order for restraints. There was no initial order for the use of restraints. The restraint order sheet documented that the patient's needs assessment was performed at 2:00 AM, but the order sheet is timed at 7:00 AM.

The 10/03/10 "Initiation of Restraints/24 Hours Renewal Restraint Order" sheet failed to document the least restrictive measures had been ineffective to protect the patient prior to the renewal order for the restraints.

5. Patient Identifier # 6 was admitted to the hospital on 9/23/10 with diagnosis of Respiratory Failure.

A review of the nursing notes and restraint flowsheet dated 9/29/10 documented PI # 6 was restrained. No assessment for the need of the restraint was completed or the type and location of the restraint applied. There were no alternatives to the use of the restraint or justification for the use of the restraint documented. PI # 6 was restrained at 4:00 AM, but there was no physician's order for the use of the restraint.

A review of the nursing notes and restraint flowsheet dated 9/30/10 documented PI # 6 was released from restraints at 7:00 PM. The type and location of the restraint was not documented on the flowsheet. There was no order for this episode of restraints in the medical record.

A review of the nursing notes and restraint flowsheet dated 10/01/10 documented PI #6 was released from restraints at 2:00 PM and restraints reapplied at 7:00 PM. There was no physician order for the two episodes of restraint use and no documentation of an assessment for the need of a restraint.

A review of the nursing notes and restraint flowsheet dated 10/02/10 documented PI # 6 was in restraints from 7:00 AM until 6:00 PM, when the restraints were removed. There was no physician order for this episode of the restraints.

A review of the nursing notes and restraint flowsheet dated 10/04/10 documented PI # 6 was in restraints. The type and location was not documented, nor was the assessment for the need of a restraint documented. When PI # 6 was restrained at 8:00 PM, there was no physician order for this episode of restraints in the medical record. PI # 6 remained restrained until 10/06/10 at 3:00 AM, when the restraints were removed.

The nursing notes and restraint flowsheet dated 10/08/10 documented PI # 6 was restrained from 7:00 AM until 7:00 PM. There was no physician order for this episode of restraint use.

On 10/09/10 the nursing notes and restraint flowsheet documented PI # 6 was placed in restraints at 7:00 AM and continued to be restrained until 10/13/10 at 6:00 AM. There was no physician order for this episode of restraint use. On 10/13/10 at 7:00 AM the restraints were removed. At 8:00 PM on 10/13/10, PI # 6 was placed back in restraints and remained in restraints until 10/15/10 at 2:00 PM. There was no physician order for this episode of restraint use. On 10/15/10 at 2:00 PM, PI # 6's restraints were removed.

On 10/22/10 at 2:00 AM, PI # 6 was placed back in restraints. The type of restraint was not documented and no assessment for the need for a restraint was documented on the nursing notes restraint flowsheet. The "Initiation of Restraints/24 Hours Renewal Restraint Order" sheet did not document the name of the physician that ordered the restraints, the staff member who notified the physician, the time the nurse assessed the patient's need for a restraint and the order was not signed by the physician.

On 10/23/10 at 7:00 PM, PI # 6 was released from the restraints.

The 10/26/10, 10/27/10 and 10/28/10 "Initiation of Restraints/24 Hours Renewal Restraint Order" sheets were not signed by the physician.

The 10/28/10 nursing notes and restraint flowsheet failed to document PI # 6's care related to position changes, pulse checks distal to the restraint, respiratory status, range of motion, skin integrity and toileting offered from 10:00 AM until 6:00 PM.

A review of the "Initiation of Restraints/24 Hours Renewal Restraint Order" sheets revealed there were either no physician signatures or nurse assessment time or name of the physician or name of the staff member who notified the physician of the need for a patient restraint or a patient needs assessment completed for the following dates: 10/23/10, 10/24/10, 10/25/10, 10/26/10, 10/27/10, and 10/28/10.

A review of the nursing notes and restraint flowsheets revealed there was either no assessment of the continued need for restraints or the type of restraints applied and where they were placed, or alternatives to the use of restraints or the justification for the use of the restraints for the following dates: 9/29/10, 9/30/10, 10/01/10, 10/02/10, 10/04/10, 10/05/10, 10/06/10, 10/08/10, 10/09/10, 10/10/10, 10/11/10, 10/12/10, 10/13/10, 10/14/10, 10/15/10, 10/28/10, 10/27/10, 10/26/10, 10/25/10, 10/24/10, 10/23/10 and 10/22/10.

6. Patient Identifier # 9 was admitted to the hospital on 10/07/10 with diagnoses to include Respiratory Failure and Pneumonia.

A review of the nursing notes and restraint flowsheet dated 10/29/10 revealed PI # 9's restraints were removed at 7:00 AM and reapplied at 11:00 AM. There was no physician order in the medical record for the new episode of restraint use.

A review of the "Initiation of Restraints/24 Hours Renewal Restraint Order" sheet revealed it was not signed by the physician.



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7. PI # 1 was admitted on 8/17/10 with diagnoses to include: Respiratory Failure, Pneumonia, Congestive Heart Failure and Sepsis.

The facility failed to ensure complete and accurate physician orders for the application of restraints were obtained for PI # 1 on the following dates:

8/17/10: The Initiation of Restraints/ 24 Hour Renewal Restraint Order Sheet (Restraint Order Sheet) indicates the time of the order is 0130 (1:30 AM). However, the Restraint Flow Sheet (8/17/10) reveals bilateral wrists restraints were initiated by nursing staff at 1330 (1:30 PM) when PI # 1 was admitted to the unit.

Additional errors on the Restraint Order Sheet
include failures to:
- document the name of the physician and time
notified for the initial restraint order
- document the name of the RN responsible for
physician notification
- document time/completion of Patient Need
Assessment and name of RN responsible

8/18/10: Restraint Order Sheet includes failure to:
- document the name of the physician notified
for the order and time notified
- document the name of the RN responsible for
physician notification
- document time of Patient Need Assessment
by RN
- document the time the order was obtained
- document the time the order was signed by the
physician

8/19/10: Restraint Order Sheet includes failure
to:
- document the name of the physician notified
for the order and time notified
- document the name of the RN responsible for
physician notification
- document time of Patient Need Assessment
by RN
- document the time the order was signed by the
physician

8/20/10: Restraint Order Sheet includes failure
to:
- document the name of the physician notified
for the order and time notified
- document the name of the RN responsible for
physician notification
- document time of Patient Need Assessment
by RN
- document the time the order was signed
by the physician

8/22/10: Restraint Order Sheet includes failure
to:
- document the name of the physician notified
for the order and time notified
- document the name of the RN responsible for
physician notification
- document physician's signature

8/23/10: Restraint Order Sheet includes failure
to:
- document time of Patient Need Assessment by
RN
- document date and time order signed by
physician

8/24/10: Restraint Order Sheet includes failure
to:
- document date and time order signed by RN
and physician

8/25/10: Restraint Order Sheet includes failure
to:
- document time/completion of Patient Need
Assessment and name of RN responsible

8/31/10: Restraint Order Sheet includes failure
to:
- document time of Patient Need Assessment by
RN

Based on record review, hospital policy and an interview the hospital failed to assure there were no PRN (as needed) orders written for restraints. This affected one of 7 records reviewed for patients with restraints.

Findings include:

Hospital Policy: Restraints, Assessment, Documentation and Application in Medical/Surgical Care revised 6/30/10.

IV. Time Limited Order
5. The physician order must be dated and timed and cannot be written as a PRN (as needed) or "May restrain" order.

Medical Record findings:

Patient Identifier (PI) # 4 was admitted to the hospital on 10/19/10 with an admitting diagnosis of Respiratory Failure. A review of the 10/19/10 physician orders revealed a verbal order was written at 11:00 AM for "wrist restraints PRN."

On 10/29/10 at 4:30 PM, during an interview with employee identifier (EI) # 1, the Chief Clinical Officer, confirmed that staff should not write orders for restraints as PRN.

Based on record review, hospital policy and interview the facility failed to follow the reporting requirements for patient deaths that occur while the patient is restrained. This affected Patient Identifier # 3, one of 5 closed records reviewed.

Findings include:

Hospital Policy: Restraints in general population, revised 5/07/10.

XI. Reporting of death in restraint:
A. The Administrator/Administrator On-Call will be notified immediately by the Nursing Supervisor/Charge Nurse of all patients that expire while in restraints or within 24 hours of being in restraints.

B. The Administrator or designee will report to the CMS (Centers for Medicare/Medicaid Services) office:
All patients that expire while in restraints,
Within 24 hours after removal of restraints

C. Each death must be reported to CMS by telephone by the Administrator or designee no later than the close of the next business day following knowledge of the patient's death. The Director of Regulatory Affairs (Home Office) will be notified prior to the report being made.

D. The Administrator or designee will document in the patient's medical record reporting to the CMS Regional Office. The documentation will include the date and time the death was reported to CMS.

Record Review

Patient Identifier (PI) # 3 was admitted to the hospital on 7/21/10 with Respiratory Failure.

A review of the medical record revealed that PI # 3 was physically restrained from 7/21/10 at 10:00 PM until 7/27/10 at 1:00 AM, when PI # 3 expired. There was no documentation in the medical record to indicate that PI #3's death while in restraints was reported to CMS.

On 11/03/10 at 11:30 AM, Employee Identifier # 3, the Clinical Director verified via a phone interview, that PI #3's death while in restraints was not reported to CMS.