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Based on observation, record review and interview the facility failed to offer other alternatives to reduce the need for restraints for two patients (ID#2,4) of four patients.

Finding Included:

The facility policy dated 2/2016 "Patient Restraint/Seclusion" stated:
Restraint or seclusion use will be limited to clinically justified situations, and the least restrictive restrain will used with the goal of reducing and ultimatley eliminating, the use of restraints.

Record review of the nurses noted documented on 08/25/2019 revealed Patient, (ID#2) was admitted for altered mental status and had a nasogastric tube inserted. It is also documented that the patient was stretching, moving and thrashing the arms around, and was high risk of pulling the tube. Patient (ID#2) was observed to be restrained on 08/27/2019 at 10:35 a.m.

Record review of the census dated 08/27/2019 revealed Patient, (ID #4) was admitted on 08/26/2019 for altered mental status. Interview with the staff (ID #57) on 08/27/2019 at 10:30 a.m. revealed Patient (ID#4) had Breast Cancer with metastasis to the brain and had been combative. Observation on 08/27/2019 at 10:30 a.m. noted Patient (ID#4) trying to get out of bed, while her wrist were restrained bilaterally and her feet and body were hanging out of the bed.

Interview 08/27/2019 at 11:00 a.m. with the nurse manager, (ID#56) stated they had not considered other alternatives.

Based on record review and interview the facility did not ensure nursing care plans hospital were kept current, for two (ID#2, 8) out of five patients did not reflect the patient's current needs.

Findings Included:

Record review of facility policy, dated 5/2019, "Clinical Documentation Charting Guidelines within the Electronic Health Record", stated:

CAREPLAN DOCUMENTATION
Select the Care Plan based on information collected during the Admission History, initial assessment, and diagnoses. Your patient might also have suggested care plans based on documentation, problems, and diagnoses

1. Care plans should be related to the patient's current diagnosis and the interventions and outcomes.

Record review of Patient (ID#2) a 79-year-old female was in the admitted for hypoxia, sepsis, and pneumonia. The care plan did not address potential for skin breakdown

Record review revealed Patient (ID#8) a 22-year old-female was admitted for shortness of breath, worsening leg edema, and was six days post cesarean section. The care plan did not address the physical or the emotional care of a patient post cesarean section.

Interview on 08/27/2019 with the charge nurse (ID #58) stated yes, something should be documented.