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Based on review and interview the facility failed to ensure

A. patients were not restrained for staff convenience, and that appropriate orders were written for non-violent vs violent restraints. The facility failed to release the patient from restraints when no longer required, the physician failed to document the continuation or need for restraint in daily progress notes, and patients were not monitored, assessed, and released for range of motion every two hours per facility policy in 3 of 3 (#1, 5, and 3) patient charts reviewed.

Refer to Tag A 154


B. chemical restraints that were given or may be administered Intramuscular (IM) or Intravenous (IV) for behavioral emergencies were identified and monitored as chemical restraints, ensure the policy and procedures instructed on the assessment and re-assessment of the patient after the administration of a chemical restraint, ensure all restraints were addressed in the patient plan of care, ensure staff was educated on the administration of chemical restraints and safe monitoring after administration, ensure chemical restraints were added to the restraint log and monitored through Risk and Quality in 1 of 1(#1) patient chart reviewed.

Refer to Tag A160

Based on review and interview the facility failed to ensure patients were not restrained for staff convenience, and that appropriate orders were written for non-violent vs violent restraints. The facility failed to release the patient from restraints when no longer required, the physician failed to document the continuation or need for restraint in daily progress notes, and patients were not monitored, assessed, and released for range of motion every two hours per facility policy in 3 of 3 (#1, 5, and 3) patient charts reviewed.


A review of patient #1's chart was conducted with staff # 2. Staff #2 stated that she was very familiar with the patient, his care, discharge, and family involvement during his stay at the facility.

A review of Staff #1's chart revealed he was admitted to the facility on 02/01/2024 at 1630 (4:30 p.m.) review of the patient's physician history and physical dated 2/1/24 stated,
"Chief Complaint:
Confusion
Fall
Vomiting
Altered mental status- improving
_____ (patient #1) is a 72 y.o. male presented to the ED with altered mental status for one day duration following a GLF (ground level fall)... Code stroke initiated, CT head negative...Infectious disease was consulted at Longview and recommended IV Vancomycin and Ceftazidime until March 6, 2024.Patient transferred to Tyler Continuity Care Hospital LTAC for IV antibiotics, and further care."

A review of patient #1's chart revealed he had episodes of agitation being combative with staff and family. A review of the physician orders revealed a verbal telephone order was taken on 2/3/24 at 2306 (11:06 p.m.) for bilateral wrist restraints. The order stated the patient required restraints due to a "Lack of safety awareness. Climbing/getting OOB and Pulling out tubes/lines." The order stated, "Frequency: Routine Until Discontinued- Until Specified." The restraints were discontinued on 2/4/24 at 0310.

A review of patient #1's chart revealed a physician's note on 2/12/202. The note stated, "Patient agitated and combative this morning. Not cooperating for IV-line placement. He is refusing medications. Will put him back on restraints and low-dose Seroquel."

A review of patient #1's chart revealed a physician order written on 2/12/24 at 8:36 a.m. to apply mittens bilaterally for altered LOC, Lack of safety awareness, climbing/getting OOB, Inappropriate wandering, pulling out tubes/lines. The order stated under process instructions, "The restraint event order remains in effect until the restraints are removed. It is recommended that a time limit be noted in the restraint order. At that time, the order is considered complete/ discontinued, and a new order must be obtained if it becomes necessary to re-apply the restraints." The physician's order did not give a specific time frame to discontinue. The order read, "Frequency: Routine Until Discontinued 02/12/24 0836 - Until Specified."

A review of the case manager's progress note dated 2/13/24 at 11:11 a.m. revealed patient # 1's daughter wanted to speak with her concerning patient #1's restraints. The case manager documented, "Received notification that the patient's daughter wanted to speak with me. Reviewed chart and noted that pt in restraints r/t hitting staff and agitation. Met with ____ (patient #1's daughter) at bedside who verbalizes frustration that staff were not able to handle patient better yesterday. ____ (patient #1's daughter) notes that pt went several days without behaving in an agitated manner and feels there must have been something that prompted his agitation because patient does not act that way when she is present. "The case manager documented that she explained to the daughter about dementia and how patients become uneasy when surrounded by unfamiliar faces and sounds. The case manager documented, "____ (patient #1's daughter) notes frustration that physical restraints had to be used and that she would have preferred a sitter. Expressed to ____ (patient #1's daughter) that we have used sitters when there was available staffing, however, due to staffing limitations there was not flexibility for sitters and for the protection of the patient, and staff restraints were used. ____ (patient #1's daughter) notes that she does not agree, and sitters should have been provided and TCCH should have found the staffing to accommodate the patient."

The physician ordered non-violent restraints for patient #1 however, nursing documented the patient was hitting, attempted to kick a staff member in the face, and was very agitated. The patient was not ordered a violent restraint to control the agitated behavior. An interview was conducted with staff #2 on 2/29/24. Staff #2 stated that sitters are only available if they have extra staff scheduled or they can call in a nursing assistant. Staff #2 stated they did not have a sitter pool and it was difficult to get a sitter so they will restrain the patients if needed.

A review of the policy and procedure, "Patient Restraints or Seclusions stated, "2.0 POLICY.
2.1 All patients have the right to be free from restraints that are not medically necessary or are used for purposes other than patient benefit and safety. Restraints shall be used only where alternative methods are not sufficient to protect patients or others from injury and are not substituted for less restrictive forms of protective restraint. All patients will have an assessment performed by a competent and appropriate staff member to determine the safety and protective needs of the patient prior to the application of restraints or medical protective device ... 3.4 Violent or self-destructive behavior is Behavior that jeopardizes the immediate physical safety of and/or presents an immediate and serious danger to self, staff, or others ... Restraints or seclusion must be discontinued as soon as is safely possible, regardless of the length of time, if identified in the order. The decision to discontinue the intervention is based on the ongoing assessment be a Registered Nurse ... 7.6 Discontinuation: Restraints are discontinued at the earliest possible time. Restraints are only used while the unsafe situation continues."


40989



An observation of Patient #5 was conducted on 2/29/2024 at 10:45 AM with RN Staff #13.

Patient #5

Patient #5 was a 93-year-old female admitted to the facility on 2/16/2024 after a motor vehicle accident (MVA). During the observation, Patient #5 was observed in her private room with a soft left wrist restraint tied to the bedrail and all 4 side rails were up on the bed. Her right hand was not in restraints but was noted to have a soft wrist brace due to an injury that occurred in the MVA.

A review of the medical record revealed a verbal order dated 2/23/2024 at 2:59 AM from Physician #12 that read, " ...Continuous Non-Violent Restraints due to lack of safety awareness, confusion, Climbing/getting out of bed, pulling out tubes/lines. Soft restraint wrist-LUE (left upper extremity) ..."

RN Staff #13 was asked why the patient was placed in restraints. She replied, "She was pulling at the EKG leads". She was then asked if they ever removed the restraint from the patient to see if she would be safe without it. RN Staff #13 released the restraint to the left wrist on 2/29/2024 at 10:45 AM. This surveyor noted RN Staff #13 did not perform an assessment or Range of Motion (ROM) as she stood at the bedside while the patient was released from the restraint. The patient did not attempt to pull at lines or cause harm to self or the staff. She was noted to raise her left arm to her nose and rub her nose on two occasions. After 9 minutes this surveyor left the room and observed RN Staff #13 reapply the restraint to the left wrist and restrain the patient to the bed restricting movement of the left arm.

An interview was conducted with RN Staff #13 on 2/29/2024 at 11:00 AM. Staff # 13 was asked why she placed Patient #5 back into restraints when the patient did not exhibit any signs of needing to be restrained. She stated, "I was thinking of that. I am going to see if I can get an order for some mittens and have the charge nurse call the doctor."

RN Staff #13 confirmed there was no physician order to restart the restraint on the left wrist after Patient #5 was released for 9 minutes. Also, RN Staff #13 confirmed the release was in addition to the every 2-hour restraint assessment and ROM required by the facility policy.

A review of the daily progress notes by Physician #12 dated 2/23-2/27/2024 did not document Patient #5's continuous need for restraints. The physician failed to document the patient remained in restraints and that any less restrictive interventions were attempted. There was no documentation by Physician #12 that Patient #5 was in restraints or the need to continue the restraint after the daily physical assessments were completed for 5 of 5 days reviewed.

A review of the progress note dated 2/28/2024 at 11:18 AM revealed Physician #15 failed to document that the patient remained in a soft left wrist restraint and the need to continue the restraint.

A review of the facility policy titled, "Patient Restraints or Seclusion" with a reviewed date of 11/2023 was as follows:
" ...2.0 POLICY
2.1 All patients have the right to be free from restraints that are not medically necessary or are used for purposes other than patient benefit and safety. Restraints shall be used only where alternative methods are not sufficient to protect patients or others from injury and are not substituted for less restrictive forms of protective restraint. All patients will have an assessment performed by a competent and appropriate staff member to determine the safety and protective needs of the patient prior to the application of restraints or
medical protective device ....
4.0 Restraints or Seclusion Orders ...
4.2 ...
* When a patient is released from restraint or seclusion and exhibits behavior that can only be managed with reapplication of restraints or seclusion, a new order is required.
* A temporary, directly supervised release that occurs for the purpose of caring for a patient's needs is NOT considered a discontinuation, as long as the patient remains under direct staff supervision ..."

RN Staff #13 confirmed the release of the left wrist restraint on 2/29/2024 at 10:45 AM was not done to perform patient care and should have required a new order from the physician.


48749


A review of the electronic health record (EHR) for Patient #3 revealed the patient was admitted with a diagnosis of Sepsis (A life-threatening complication of an infection), Encephalopathy (a broad term for any brain disease that alters brain function or structure), and Decubitus Ulcer (the medical term for bedsore). The patient was placed in bilateral soft wrist restraints on 12/23/2023 for altered mental status and pulling at lines. Further review of the patient's electronic health record (EHR) revealed there was no documentation found supporting that the patient was released from restraints every two hours during the hours of 5:00 AM until 7:15 PM on 12/24/2023. The nurse failed to follow the facility's policy.

A review of the facility's policy and procedure "Patient Restraints or Seclusion" dated 11/2023 stated,

"8.9 The condition of the restrained patient will be continually assessed, monitored, and re-evaluated. This will be documented in the EMR.

8.10 Frequency of monitoring and assessment for NON-VIOLENT Restraints will be performed and documented every Two hours. Monitoring and assessment include performance and documentation of all appropriate patient care activities (E.g., circulation, range of motion, repositioning, hydration, nutrition, and/or elimination as well as neurological evaluations such as mental status and cognitive functioning.)"

On 02/29/2024 at 11:00 AM, an observation of the patient in room #408 was conducted with Staff# 3. Staff # 4 was observed performing a restraint release on Patient # 8 who was in bilateral upper extremity soft restraints that were secured to the side rails of the patient's bed. It was observed that Staff # 4 did not perform range of motion exercises on the patient's extremities. The nurse failed to follow the facility's policy " Patient Restraints or Seclusion" dated 11/2023.

An interview was conducted on 02/28/2024 at approximately 11:00 AM with Staff #3. When questioned if all patients are released from their restraints every two hours, Staff #3 Reported, "Yes, we release them, check their pulses and perform range of motion." Staff #3 was asked if any documentation on releasing patient #3 from restraints could be found during the time between 5:00 AM and 7:15 PM on 12/24/2023, Staff #3 reported "No."

Based on review and interviews the facility failed to ensure that chemical restraints that were given or may be administered Intramuscular (IM) or Intravenous (IV) for behavioral emergencies were identified and monitored as chemical restraints, ensure the policy and procedures instructed on the assessment and re-assessment of the patient after the administration of a chemical restraint, ensure all restraints were addressed in the patient plan of care, ensure staff was educated on the administration of chemical restraints and safe monitoring after administration, ensure chemical restraints were added to the restraint log and monitored through Risk and Quality in 1 of 1(#1) patient chart reviewed.

Patient #1

A review of patient #1's chart was conducted with staff # 2. Staff #2 stated that she was very familiar with the patient, his care, discharge, and family involvement during his stay at the facility.

A review of Staff #1's chart revealed he was admitted to the facility on 02/01/2024 at 1630 (4:30 p.m.) review of the patient's physician history and physical dated 2/1/24 stated,
"Chief Complaint:
Confusion
Fall
Vomiting
Altered mental status- improving
_____ (patient #1) is a 72 y.o. male presented to the ED with altered mental status for one day duration following a GLF (ground level fall)... Code stroke initiated, CT head negative...Infectious disease was consulted at Longview and recommended IV Vancomycin and Ceftazidime until March 6, 2024.Patient transferred to Tyler Continuity Care Hospital LTAC for IV antibiotics, and further care...Infectious disease was consulted at Longview and recommended IV Vancomycin and Ceftazidime until March 6, 2024...Patient transferred to Tyler Continuity Care Hospital LTAC for IV antibiotics, and further care."


A review of patient #1's chart revealed he had episodes of agitation being combative with staff and family. A review of the physician orders revealed a verbal telephone order was taken on 2/3/24 at 2306 (11:06 p.m.) for bilateral wrist restraints. The order stated the patient required restraints due to a "Lack of safety awareness. Climbing/getting OOB and Pulling out tubes/lines." The order stated, "Frequency: Routine Until Discontinued- Until Specified." The restraints were discontinued on 2/4/24 at 0310.

A review of patient #1's chart revealed a physician's note on 2/12/202. The note stated, "Patient agitated and combative this morning. Not cooperating for IV-line placement. He is refusing medications. Will put him back on restraints and low-dose Seroquel."

A physician order was noted on 2/12/24 for Mitten (secured)-BIL- Frequency: Routine Until Discontinued 02/12/24 0836 - Until Specified.

A review of patient #1's physician orders revealed there was an order for ziprasidone (Geodon- antipsychotic) injection 10mg on 12/12/24 at 2004 (8:04 p.m.). The physician (staff #18) wrote the order for once and for severe agitation. Staff #18 was not the patient's primary provider. There was no documentation that the provider assessed the patient, what behaviors the patient was exhibiting, or that the primary physician was notified. Staff #2 confirmed there was no documented physician note.

A review of patient #1's chart revealed the RN administered the Geodon IM 10 mg at 2037 (8:37 p.m.) There was no documentation by the nurse that this was given as a restraint. There was no documentation of the patient's behaviors except for "agitation and impulsive". There was no documentation if the Geodon was effective or if the nurse monitored the patient until 11:00 p.m. when the first vital signs were taken. There was no documentation that the Crisis Intervention Management Team was called, that any family was notified, that the primary physician was notified nor was there any documentation on the patient's care plan.

A review of a nursing progress note dated 2/13/24 at 3:45 PM by staff # 19 Licensed Vocational Nurse (LVN) stated, "____ (pt #1's daughter) whom is patients daughter was present for IDT team meeting. ________ (pt #1's daughter) verbalized that she is upset that patient was in restraints. We explained that we had to use restraints due to patient behaviors. We explained guidelines for restraints including nurse rounding and review by a MD every 24 hours. ____ (pt #1's daughter)had questions in regards to what happened last night. It was reported that the unit tech had been kicked in the face last night. ____ ____ (pt #1's daughter) questioned what provoked the kicking and why he was being disturbed in the night. We explained we have various reasons for checking on a patient throughout the night including assessment to see if patient needs to be changed, vitals, and circulation checks since patient was in restraints. ____ (pt #1's daughter) stated that patient should have been left alone to calm down, staff re-lnterated that per policy and regulation nursing has to assess patient, especially when restrained. _____ (staff #20) RT states that he and _____ (staff #21) PT were walking by yesterday when they noticed the patient was grabbing the nurse on the arm and verbally threatening the nurse. _____ (staff #20) informed ____ (Pt #1's daughter) that the patient attempted to kick him and used profanity for _____ (staff #20) to leave. ____ (Pt #1's daughter) asked why he did not get to walk with therapy yesterday, in which _____ (staff #21 PT) explained that the therapy student worked with patient for first attempt and did bed exercises and attempted to allow patient to rest to calm down or deescalate agitation, however, the patient was more agitated upon reassessment and therapist was unsuccessful due to agitation ..."

A review of the policy and procedure, "Patient Restraints or Seclusions"stated,

"5. 0 Violent or Self-Destructive Behavior.

5.1 When patients demonstrate violent or self-destructive behaviors, aggressive behaviors, assaultive behaviors, threatening behaviors, or are an immediate danger to themselves or others, the Crisis Intervention Management Team (Dr. Strong) may be called to de-escalate the patient ...

... The provider responsible for caring for the patient must evaluate the patient face-to-face within one hour of applying violent behavior restraints or seclusion. If a patient's violent or self-destructive behavior resolves and the restraint or seclusion intervention is discontinued before the practitioner arrives to perform the 1-hour face-to-face evaluation, the practitioner is still required to see the patient face-to-face and conduct the evaluation within 1 hour after the initiation of the intervention. This requirement also applies when a drug or medication is used as a restraint to manage violent or self-destructive behaviors.

5.2 The in-person provider evaluation includes the following:
o The patient's immediate situation (conditions or symptoms that warranted the use of emergent restraint or seclusion).

o The patient's reaction to the interventions used including alternatives attempted if applicable.

o The patient's medical and behavioral condition and the need to continue or terminate the restraint or seclusion. The provider may write an order to continue the use of restraints or seclusion after the in-person evaluation has been completed ...

4.2- The Registered Nurse is responsible to provide education and information regarding the use of the restraints and the patient's Plan of Care to the patient/family/caregiver.

The Registered Nurse is responsible to update the Plan of Care as the patient's status and need for restraint/seclusion changes."

An interview with staff #2 on 2/29/23 revealed that the patient had been having aggressive behaviors and was hitting staff, cursing, and kicked a staff member in the face. Staff #2 confirmed there was no incident report filed of the incident. Staff #2 confirmed this was a behavioral incident and the patient was at harm of hurting himself and/or someone else. Staff #2 confirmed there was no order or note to show this was medication given for violent behavior and was not addressed or treated as a chemical restraint. Staff #2 confirmed that she was not aware of any guidelines in the policy for how soon the nurse should assess the patient after the administration of a chemical restraint, how frequently, or how often.

An interview was conducted with Staff #5 RN, #22 RN, and #23 RN on 2/29/24 at 10:45 a.m. Staff #5, 22, and 23 were asked if a psychotropic medication was ordered for patient behaviors that were a threat to staff or the patient, would that be a chemical restraint/ emergency behavioral medication and what would be the procedure for that? Staff #22 and 23 stated they were not sure and staff #5 stated that they didn't give chemical restraints/ emergency behavioral medication and if one was ordered he would have to ask his charge nurse because he had never dealt with that issue. Staff #5, 22, and 23 were asked if they had any training on chemical restraints and how would the patient be assessed and reassessed. Staff #5, 22, and 23 stated they were not aware of any specific training and would have to ask the charge nurse.

An interview was conducted with Staff # 25 RN Educator on 2/28/24 at 9:45 a.m. Staff #25 was asked what a violent restraint was. Staff #25 stated, "I guess when they are in 4-point restraints." Staff #25 presented the survey team with a restraint log but there were no chemical restraints on the log. Staff #25 stated that she had just recently been assigned this task and was not aware she needed to be putting chemical restraints on the log. Staff #25 stated, "We have not been looking at chemical restraints. I didn't know I needed to." Staff #25 was asked how she monitored the restraint and if the restraint charts were being audited appropriately. Staff #25 stated that she just checks to make sure they have an order. There was no written process for her to follow. A review of employee charts (staff # 25, 13, 17, and 26) was conducted with staff #25. Staff # 25 stated that the staff had basic restraint training on health streams (a computer program that has general information on restraints and usage) and they have a health fair yearly, but it was geared more towards physical restraint use and not for chemical restraints. Staff #25 confirmed there was no chemical restraint information reported to quality.