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Based on medical record review, policy review and staff interview the hospital failed to have time-limited a order when a restraint was utilized for 14 days on one of four patients in the survey sample. (Patient #2)

The findings include:

Review of Patient #2's medical record revealed the patient was a 75 year old admitted to the long term hospital on 09/09/2010. Patient #2's diagnoses included: acute/chronic respiratory failure, anoxic brain damage post cerebral air embolus, end stage renal disease (ESRD) with dialysis, tracheostomy, gastrostomy, Methicillin Resistant Staphylococcus aureus septicemia (MRSA), and MRSA pneumonia.

Review of the physician's orders revealed an order, which read: "10/8/10 apply glove mitten to (R) [right] hand to prevent pt [patient] from pulling trache (sic) tube, TDC (thigh dialysis catheter) and other tubes out. Release Q (every) 2 hrs (hours) for skin checks & (and) ROM (range of motion) then reapply." Patient #2's medical record did not reveal additional physician orders for the restraint of Patient #2's right hand. The restraint order dated 10/08/2010 was written as a standing order for the ongoing restraint of Patient #2's right hand without a time limit. The restraint order dated 10/08/2010 did not provide for a trial of lesser restrictive measures or assessment to determine if Patient #2 had a continued need for the glove mitten restraint.

Review of nursing notation from 10/08/2010 through 10/22/2010 for Patient #2 provided daily documentation Patient #2's right hand was restrained within the glove mitten.

Review of the hospital's policy titled "Use of Restraint/Safety Device" read: "Purpose A) To ensure all residents' individual needs are taken into consideration and are only utilized when a resident's (sic) has demonstrated a threat to himself and alternatives have been unsuccessful." The hospital's policy did not designate that each order for a restraint needed to be time limited. The hospital's policy did not prevent an order for restraint use to be written as a standing order.

An interview was conducted on 11/24/2010 at 8:06 a.m. with Staff #2, the Vice President of Patient Services. Staff #2 reviewed the Conditions of Participation for Patient Rights and the use of restraints; Staff #2 stated "Hand mitts are not a restraint" and pointed out, in the 2008 version of the hospital regulations, the first line of a paragraph. The surveyor directed the attention to the last line in the paragraph, within both the 2008 and 2009 hospital regulations, which read: "Likewise, if the mitts are so bulky that the patient's ability to use their hands is significantly reduced, this would be considered restraint and the requirements would apply." Staff #2 verbally agreed the purpose of Patient #2's hand mitten was to restrict her ability to grasp and pull out her tracheal tube, dialysis catheter and "other lines". Staff #2 verbally agreed the glove mitten placed on Patient #2's right hand functioned as a restraint and met the requirements for a restraint. Staff #2 reviewed the hospital's policy for restraint use and reported the policy did not document a time limit for the use of restraints or contained the requirements as specified within the conditions of participation for hospitals.