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Based on clinical record review, policy and procedure review, and interview, it was determined the Facility failed to update the plan of care for one (#19) of three (#7, #19 and #20) Patients reviewed who were placed in restraints. Failure to include the use of restraints in the plan of care did not reflect a process of assessment, intervention and evaluation by the Interdisciplinary Team when restraints were used and had the likelihood to affect all patients who were restrained. The findings follow:

A. Review of Patient #19's clinical record on 06/29/17 revealed the Patient was in restraints from 05/22/17 to 05/26/17. There was no evidence the patient's plan of care was updated to reflect the use of restraints. The findings were confirmed in an interview with the Chief Nursing Officer on 06/29/17 at 0940.

B. Review of the policy "Use of Restraints in Rehabilitation Hospitals" on 06/29/17 revealed "Care Planning: Specific interventions guiding the application and use of restraints and monitoring of patients in restraints will be incorporated into the patient's Plan of Care. Updates to the Plan of Care specific to the use of restraints will be conducted a minimum of weekly or sooner when there is an application change in the patient's condition." The findings were confirmed in an interview with the Chief Nursing Officer on 06/29/17 at 0945.

Based on clinical record review, policy and procedure review and interview, it was determined one (#20) of three (#7, #19 and #20) Patients were not restrained in accordance with a Physician's order. Failure to obtain a Physician's order for restraints did not allow the physician to be knowledgeable regarding the patient's need for restraints. The failed practice affected Patient #20 and had the likelihood to affect all patients who were restrained. The findings follow:

A. Review of Patient #3's clinical record on 06/29/17 revealed the Patient was in restraints from 05/06/17 at 1300 to 05/18/17 at 1259. There was no evidence of a physician's order for restraints for 05/09/17 or 05/14/17. The findings were confirmed in an interview with the Chief Nursing Officer on 06/29/17 at 0940.

B. Review of the policy "Use of Restraints in Rehabilitation Hospitals" on 06/29/17 revealed "Order/Renewal: Requires LIP (Licensed Independent Practitioner) reorder every calendar day. Documentation of the subsequent verbal or written order as given is required." The findings were confirmed in an interview with the Chief Nursing Officer on 06/29/17 at 0945.

Based on clinical record review, policy and procedure review, and interview, it was determined the Facility failed to ensure restraint monitoring was conducted every two hours as per policy for one (#20) of three (#7, #19 and #20) patients reviewed who were placed in restraints. The failed practice did not ensure the patient's needs were assessed periodically, and created the likelihood the patient would remain in restraints longer than necessary. The failed practice had the potential to affect all patients who were restrained. The findings follow.

A. Review of Patient #20's clinical record on 06/29/17 revealed the Patient was in restraints from 05/06/17 at 1300 to 05/18/17 at 1259. There was no evidence of every two hour restraint monitoring from 05/07/17 at 0300 to 05/07/17 at 0659, from 05/10/17 at 1900 to 05/11/17 at 0659, from 05/11/17 at 1900 to 05/12/17 at 0659, from 05/12/17 at 1900 to 05/13/17 at 0659. The findings were confirmed in an interview with the Chief Nursing Officer on 06/29/17 at 0930.

B. Review of the policy "Use of Restraints in Rehabilitation Hospitals" on 06/29/17 revealed "Monitoring: Every 2 hour monitoring through observation, interaction, direct examination. Monitoring is to include: Level of distress/agitation, mental status, cognitive function, vital signs (as appropriate), hydration, nutrition, elimination needs, positioning needs/ROM (range of motion), circulation and skin condition. Documentation: Monitoring results every 2 hours." The findings were confirmed in an interview with the Chief Nursing Officer on 06/29/17 at 0945.