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Based on record review, interview and policy review, the facility failed to ensure restraint use was monitored every two hours. This affected two (Patients #2 and#3) of ten records reviewed. The facility census was 28.

Findings include:

1. Record review revealed Patient #2 was admitted to the facility on 09/11/23 at 2:02 PM. The internal medicine physician's history and physical stated the patient presented to a local emergency department following a fall from 15 feet off a ladder while cutting down trees. The initial evaluation at the emergency department revealed the patient had multiple facial fractures and was bradycardic. He ultimately required intubation. An extubation trial on 08/29/23 was attempted but the patient required re-intubation for inability to clear secretions and increased oxygen requirements. The patient was admitted to the facility with a diagnosis of acute hypoxic respiratory failure. A pulmonologist was consulted for ventilator weaning.

Nursing notes revealed the patient was pulling at his tracheostomy tube and indwelling urinary catheter. The physician ordered a soft left wrist restraint. The restraint was applied on 09/11/23 at 7:20 PM. The restraint flow sheet revealed that every two hour restraint monitoring was conducted as required from 09/11/23 at 8:00 PM through 09/22/23 at 2:00 PM. The flow sheet lacked documentation every two hour restraint monitoring occurred at 4:00 PM and 6:00 PM. The two hour checks resumed at 8:00 PM. On 09/25/23, the restraint flow sheet revealed restraint monitoring occurred at 6:00 AM. The medical record lacked documentation every two hour restraint monitoring occurred again until 8:00 PM, 12 hours later. On 10/01/23, the restraint flow sheet revealed restraint monitoring occurred at 6:00 AM, however, the medical record lacked documentation restraint monitoring occurred at 8:00 AM as required. The every two hour restraint monitoring continued at 10:00 AM on 10/01/23. The restraint flow sheet revealed the restraint monitoring occurred at 4:00 PM on 10/01/23. The medical record lacked documentation restraint monitoring occurred at 6:00 PM, 8:00 PM, or 10:00 PM.

2. Review of the medical record of Patient #3 revealed the patient was admitted on 09/29/23 at 2:35 PM. According to an internal medicine physician's history and physical, the patient had a past medical history of coronary artery disease, chronic diastolic and systolic heart failure with an ejection fraction of 20 to 25%, hypertension, diabetes, right cerebral infarction (stroke), extensive brain atrophy with symptoms consistent with vascular dementia resulting in dysphagia requiring PEG tube placement, sacral osteomyelitis, and thoracic aortic aneurysm. The patient presented to the emergency department of an outside hospital on 09/05/23 with lethargy, hypoxemia, and hypotension. The patient deteriorated on 09/10/23 with resulting coma and acute respiratory failure requiring intubation on 09/11/23. The patient was transferred to the facility for continued medical management.

The decision was made to apply non-violent soft right wrist restraint and the restraint was applied on 09/30/23 at 5:55 AM. Every two hour restraint monitoring occurred from 09/30/23 at 6:00 AM to 10/03/23 at 4:00 PM. The medical record lacked documentation restraint monitoring occurred at 6:00 PM. The restraint flow sheet revealed every two hour restraint monitoring occurred on 10/05/23 at 2:00 AM, however, the medical record lacked documentation restraint monitoring occurred again until 6:00 AM.

Staff B and Staff C were interviewed on 10/05/23 at 2:50 PM and confirmed documentation in the medical records of Patient #2 and Patient #3 lacked documentation of restraint monitoring every two hours.

The facility policy titled Restraints and Seclusion, revised on 04/01/23, documented restraints are a high-risk, potentially harmful procedure that is intended to be used only when a patient's behavior interferes with medical treatment and less restrictive methods have not succeeded. Restraints are to be applied for no longer than are clearly needed and any doubt about the need for restraints should be resolved in favor of using an alternative to restraints. Every use of restraints is to be documented in the patient's record. At a minimum, documentation must include the alternatives tried prior to restraint use, the justification for restraint, the patient assessment that demonstrates the need for restraint as part of the patient's treatment, a time-limited order by a physician, evidence of monitoring of the patient's condition during restraint, and demonstration of the need for continuing restraint beyond the initial order or of the satisfaction of criteria for release. Interdisciplinary team member documentation must state observations/interventions/findings from periodic observations, to include: safety, comfort, mobility skin integrity, food/hydration and toileting evert two hours for medical restraints.