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Based on medical record review, staff interview, and facility policy and procedure review, it was determined the facility failed to ensure patients' rights were protected and promoted. This directly impacted the safety of 3 of 6 patients (Patient #2, #4, and #6) whose medical records were reviewed. This resulted in patients not being kept safe and had the potential to affect all patients receiving care at the facility. Findings include:

Refer to A-0154 as it refers to the facility's failure to ensure patients' right to be free from the use of restraints as a means of convenience.

Refer to A-0165 as it refers to the facility's failure to ensure the least restrictive intervention was used before placing patients in restraints.

Refer to A-0167 as it refers to the facility's failure to ensure restraints were implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by facility policy.

Refer to A-0168 as it refers to the facility's failure to ensure the use of restraints was in accordance with the order of a physician.

Refer to A-0169 as it refers to the facility's failure to ensure orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN).

Refer to A-0175 as it refers to the facility's failure to ensure the condition of the patient who was restrained was monitored by a physician at an interval determined by hospital policy.

Refer to A-0176 as it refers to the facility's failure to ensure the physician or other licensed practitioners had a working knowledge of the facility policy regarding the use of restraints.

The cumulative effect of these negative systemic practices impacted patient's rights and had the ability to affect all patients receiving services at the facility.

Based on medical record review, staff interview, and facility policy review, it was determined the facility failed to ensure patients were free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. This directly affected 1 of 6 patients (Patient #4) who were restrained and whose medical records were reviewed. This resulted in the potential for patients to be restrained unnecessarily and had the potential to affect patient safety for any patients receiving care at the facility. The findings include:

A facility policy titled "Restraint Use" revised February 2022 was reviewed. The policy stated, "Restraint shall be a temporary measure to preserve the patient's well being as assessment deems it necessary, and other available techniques or less restrictive interventions have failed. Restraints are not to be used as a means of coercion, discipline, convenience, or retaliation." This policy was not followed. An example included:

Patient #4 was a 53 year old male who was admitted to the facility on 3/21/25 with a diagnosis of "Traumatic subarachnoid hemorrhage with loss of consciousness status unknown."

Patient #4's medical record included an initiate restraint order on 3/21/25 at 3:10 PM by Staff A, the provider. It stated "BSW restraints needed to ensure pt safety and to prevent self removal of medicallyu [sic] necessary and life sustaining treatment devices. Pt attempting to open wounds and climb out of bed repeated;y. [sic]" However, there was no restraint monitoring on 3/21/25. The restraint order was not initiated.

A provider note dated 3/22/25 at 11:08 AM signed by staff A noted in the subjective section "requiring sitter and intermittent restraints." The medical record did not contain any documentation the patient was placed in restraints. It was unclear why Patient #4's provider documented that Patient #4 was requiring intermittent restraints considering there was no documentation Patient #4 was being restrained or assessed in restraints.

The Director of Licensure and Accreditation, Nurse Manager, and Clinical Compliance Specialist were interviewed together on 4/22/25 beginning at 10:34 AM and Patient #4's medical record was reviewed in their presence. They confirmed there was no documentation of Patient #4 being placed in restraints on 3/21/25.

Staff A was interviewed by phone on 4/22/25 beginning on 1:57 PM and Patient #4's medical record was reviewed in his presence. Staff A stated, "in the lack of a sitter, he needs to be restrained." When asked if the order on 3/21/25 was placed in anticipation of needing restraints he stated, "Yes -if he wasn't going to have a sitter immediately." Staff A also stated, "if sitter wasn't available put in restraints, only until sitter was available."

The provider note dated 3/22/25 at 11:08 AM was reviewed with Staff A. He was asked why he would note that that patient was "requiring sitter and intermittent restraints." He stated, "I must have gotten in report that he was requiring sitter and intermittent restraints." He stated that he looks at a report called the house supervisor report to write the subjective section.

The house supervisor report was requested from the Director of Licensure and Accreditation, Nurse Manager, and Clinical Compliance Specialist, and the surveyors were told that it was not kept.

Staff B was interviewed on 4/23/25. She was asked if she was aware of providers putting in restraint orders before the patient needed to be restrained. She confirmed providers do put restraint orders in for patients just in case they might be needed. She mentioned an example of a provider placing a restraint order before a patient needs to be restrained could be due to, "coming from a different facility and they were in restraints in the past."

Staff C was interviewed on 4/23/25. She was asked if she was aware of providers putting in restraint orders before the patient needed to be restrained. She stated, "Yes." She stated she will mark the order complete after her assessment if the patient did not need to be restrained.

Staff E was interviewed on 4/23/25. She was asked if restraints were ever used in place of sitters and she answered, "probably on occasion if a sitter was running late and not shown up ..."

The facility failed to ensure patients were free from the use of restraints for convenience.

Based on policy review, staff interview, and medical record review, it was determined the facility failed to ensure the least restrictive intervention was used for 1 of 6 patients (Patient #4) who were placed in restraints and whose medical record was reviewed. This resulted in the potential for patients to be restrained unnecessarily and had the potential to affect the patient safety for all patients who receive care at the facility. Findings include:

A facility policy titled "Restraint Use," revised February 2022, was reviewed. This policy stated, "Preserving patient rights and dignity during treatment in the least restrictive manner." This policy was not followed. An example included:

Patient #4 was a 53 year old male who was admitted on 3/21/25 with a diagnosis of "Traumatic subarachnoid hemorrhage with loss of consciousness status unknown."

An order was entered on 3/21/25 at 3:10 PM for the initiation of restraints noting, "BSW restraints needed to ensure pt safety and to prevent self removal of medicallyu [sic] necessary and life sustaining treatment devices. Pt attempting to open wounds and climb out of bed repeated;y [sic]."

Patient #4's chart did not include he was placed in restraints or that he was monitored while in restraints. Additionaly, there was no documentation of least restrictive interventions or de-escalation to be performed before restraints were ordered or initiated.

The Director of Licensure and Accreditation, Nurse Manager, and Clinical Compliance Specialist were interviewed on 4/22/25 beginning at 10:34 AM and Patient #4's medical record was reviewed in their presence. They confirmed no documentation of the patient being placed in restraints on 3/21/25 was in the medical record.

Staff A was interviewed by phone on 4/22/25 beginning on 1:57 PM and Patient #4's medical record was reviewed in his presence. Staff A stated, "in the lack of a sitter, he needs to be restrained." When asked if the order on 3/21/25 was placed in anticipation of needing restraints he stated, "Yes -if he wasn't going to have a sitter immediately." Staff A also stated, "if sitter wasn't available put in restraints, only until sitter was available."

Staff F was interviewed on 4/23/25 beginning at 11:26 AM. She was asked if restraints were ever used in place of sitters and she answered, "probably on occasion if a sitter was running late and not shown up ..."

The facility failed to ensure least restrictive measures were utilized before the order and use of restraints.

Based on policy review and staff interview, it was determined the facility failed to ensure restraints were initiated with safe restraint techniques in accordance with hospital policy for 2 of 6 patients (Patients #4 and #6) whose records were reviewed. Failure to implement safe restraint techniques caused restraints to be used as needed, and restraints to be used without an immediate order by the provider. Findings included:

A facility policy titled, "Restraint Use," revised February 2022 stated, "Restraint is only to be used when clinically necessary and an [sic] emergency ... A restraint order may NEVER be written as a PRN order." The policy also stated, "A registered nurse may assess the immediate need for restraint and apply restraints without an order. The LIP/LP must be notified of the use of restraint as being applied as soon as possible after application. If the initiation of the restraint is based on a significant change in the patient's condition, the LIP/LP will be notified immediately." This policy was not followed. Examples included:

1. Restraints were used as needed.

Patient #4 was a 53 year old male admitted to the agency on 3/21/25 with a diagnosis of subarachnoid hemorrhage.

Patient #4's medical record included an initiate restraint order on 3/21/25 at 3:10 PM by Staff A, the provider. It stated "BSW restraints needed to ensure pt safety and to prevent self removal of medicallyu [sic] necessary and life sustaining treatment devices. Pt attempting to open wounds and climb out of bed repeated;y. [sic]" However, there was no restraint monitoring on 3/21/25. The restraint order was not initiated.

Staff A was interviewed on 4/22/25 and Patient #4's medical record was reviewed. He confirmed he remembered Patient #4. He stated, "in the lack of a sitter, he needs to be restrained." When asked if the order on 3/21/25 was placed in anticipation of needing restraints he stated, "Yes - if he wasn't going to have a sitter immediately."

Staff B was interviewed on 4/23/25. When asked if providers placed restraint orders as needed, Staff B stated, "Yes they will sometimes put it in as needed, say if they came from another facility in restraints - they might put it in as an as needed."

Staff C was interviewed on 4/23/25. When asked if providers order restraints just in case they would be needed, Staff C said "yeah."

2. Restraints were initiated without a provider order.

Patient #6 was an 18 year old female admitted to the facility on 12/27/24 with a diagnosis of polytrauma.

Patient #6's medical record included a restraint flowsheet showing she was placed in 4 point restraints beginning at 7:00 PM on 12/17/24.

Patient #6's medical record included a restraint order dated 12/17/24 at 9:46 PM. The order stated "Followed up with [physician name] at 2145. Ok'd 4 point restraints." It was unclear why 2 hours and 46 minutes passed before a physician ordered the restraints.

Staff D was interviewed during Patient #6's medical record review on 4/23/25 at 2:40 PM. She confirmed the order went 2 hours and 46 minutes without a provider order. She stated it needed to be immediate.

The facility failed to ensure restraints were initiated with safe restraint techniques in accordance with hospital policy

Based on policy review, medical record review, and staff interview, it was determined the facility failed to ensure restraints were used in accordance with the order of a licensed practitioner for 1 of 6 patients (Patient #6) whose records were reviewed. This caused a restraint to be initiated without a provider order for over 2 hours. Findings included:

A facility policy titled, "Restraint Use," revised February 2022 stated, "A registered nurse may assess the immediate need for restraint and apply restraints without an order. The LIP/LP must be notified of the use of restraint as being applied as soon as possible after application. If the initiation of the restraint is based on a significant change in the patient's condition, the LIP/LP will be notified immediately." This policy was not followed. An example includes:

Patient #6 was an 18 year old female admitted to the facility on 12/27/24 with a diagnosis of polytrauma.

Patient #6's medical record included a restraint flowsheet showing she was placed in 4 point restraints beginning at 7:00 PM on 12/17/24.

Patient #6's medical record included a restraint order dated 12/17/24 at 9:46 PM. The order stated "Followed up with [physician name] at 2145. Ok'd 4 point restraints." It was unclear why 2 hours and 46 minutes passed before a physician ordered the restraints.

Staff D was interviewed during Patient #6's medical record review on 4/23/25 at 2:40 PM. She confirmed the order went 2 hours and 46 minutes without a provider order. She stated it needed to be immediate.

The facility failed to ensure restraints were initiated with a provider order.

Based on policy review, medical record review, and staff interview, it was determined the facility used restraint orders on an as needed basis for 1 of 6 Patients (Patient #4) whose records were reviewed. Using restraints on an as needed basis created the potential for restraint implementation without immediate provider involvement and had the potential to cause patient harm. Findings included:

A facility policy titled, "Restraint Use," revised February 2022 stated, "Restraint is only to be used when clinically necessary and an [sic] emergency ... A restraint order may NEVER be written as a PRN order." This policy was not followed. An example included:

Patient #4 was a 53 year old male admitted to the agency on 3/21/25 with a diagnosis of subarachnoid hemorrhage.

Patient #4's medical record included an initiate restraint order on 3/21/25 at 3:10 PM by Staff A, the provider. It stated "BSW restraints needed to ensure pt safety and to prevent self removal of medicallyu [sic] necessary and life sustaining treatment devices. Pt attempting to open wounds and climb out of bed repeated;y. [sic]" However, there was no restraint monitoring on 3/21/25. The restraint order was not initiated.

Staff A was interviewed on 4/22/25 and Patient #4's medical record was reviewed. He confirmed he remembered Patient #4. He stated, "in the lack of a sitter, he needs to be restrained." When asked if the order on 3/21/25 was placed in anticipation of needing restraints he stated, "Yes - if he wasn't going to have a sitter immediately."

The provider's order constituted a PRN order for a physical restraint.

Staff B was interviewed on 4/23/25. When asked if providers placed restraint orders as needed, Staff B stated, "Yes they will sometimes put it in as needed, say if they came from another facility in restraints - they might put it in as an as needed."

Staff C was interviewed on 4/23/25. She was asked if she was aware of providers putting in restraint orders before the patient needed to be restrained. She stated, "Yes." She stated she will mark the order complete after her assessment if the patient did not need to be restrained.

Staff E was interviewed on 4/23/25. She was asked if she was aware of providers putting in restraint orders before the patient needed to be restrained. She confirmed providers do put restraint orders in for patients just in case they might be needed. She mentioned an example of a provider placing a restraint order before a patient needs to be restrained could be due to, "coming from a different facility and they were in restraints in the past." She was asked if restraints were ever used in place of sitters and she answered, "probably on occasion if a sitter was running late and not shown up."

The facility failed to ensure restraints were never used on an as needed basis.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure patients in restraints were assessed and reassessed based on the individual needs of the patient and in accordance with facility policy for 1 of 6 patients (Patient #2) whose records were reviewed. This had the potential to negatively impact the safety of patients requiring restraints in the facility. Findings include:

A facility policy titled, "Restraint Use", revised February 2022, stated "Clinical assessment/justification must identify that the patient presents with unsafe behavior, is not cognitively intact, is placing self and others at risk and/or the patient may disrupt essential medical interventions." It also stated, "Daily reassessment includes the assessment of current condition, behavior of patient, interventions, and success of alternatives." The policy outlined expected documentation for patients requiring the use of restraints which included identification of unsafe behavior, clinical justification, and restraint type. This policy was not followed. An example includes:

Patient #2 was a 47 year old male, admitted to the facility on 11/15/24 for acute hypoxic respiratory failure and multitrauma.

Patient #2 had an order for restraints and documentation of restraints beginning 11/15/24 at 4:00 PM. The admission assessment for Patient #2 was signed by the provider on 11/15/24 at 4:06 PM. The provider did not document signs or symptoms that would support the clinical necessity for restraints. It was documented in the admission assessment "Neuro: Will continue to minimize sedation to not worsen any delirium issues" but provided no additional clinical justification or assessment for restraint use.

Patient #2's record included a provider note dated 11/18/24 at 12:46 PM. The note included the provider's first assessment of restraints since they were initiated on 11/15/24 at 4:00 PM, over 68 hours before. It stated, "remove restraints as able." There was no additional restraint assessment by the provider in the note.

Staff D was interviewed on 4/22/25 beginning at 8:37 AM, and Patient #2's record was reviewed in her presence. She confirmed Patient #2's provider documentation did not follow facility policy for provider assessment of restraint use.

The facility failed to ensure restraint assessments were documented by providers.

Based on personnel file review, policy review, review of competencies, and staff interview, it was determined the facility failed to ensure its providers had a working knowledge of the hospital's policy regarding the use of restraints. This impacted 2 of 2 providers (Staff A and F) whose personnel records were reviewed. Failure to ensure providers had a working knowledge of restraint policy had the potential to interfere with quality and safety of patient care. Findings include:

A facility policy titled, "Restraint Use", revised February 2022, stated "a restraint order may NEVER be written as a PRN order." Included in the policy was, "Daily reassessment includes assessment of current condition, behavior of patient, interventions, and success of alternatives." This policy was not followed. Examples include:

1. Restraint assessment documentation was incomplete.

Patient #4 was a 53 year old male, admitted to the facility on 3/21/25 for traumatic subarachnoid hemorrhage.

Patient #4's medical record included an initiate restraint order on 3/21/25 at 3:10 PM by Staff A, the provider. A continue restraint order was placed for Patient #4 on 3/23/25 at 8:43 AM. The first documentation of Patient #4 in restraints began 3/23/25 at 7:00 AM.

Staff A was interviewed by phone on 4/22/25 beginning at 1:57 PM, and Patient #4's record was reviewed. Staff A confirmed Patient #4 was not placed in restraints till 3/23/25. When asked if the order on 3/21/25 was placed in anticipation of needing restraints he stated, "Yes - if he wasn't going to have a sitter immediately."

2. Restraint documentation was incomplete.

Patient #2 was a 47 year old male admitted to the facility on 11/15/24 for acute hypoxic respiratory failure and multitrauma.

Patient #2 had an order for restraints and documentation of restraints beginning 11/15/24 at 4:00 PM. The admission assessment for Patient #2 was signed by the provider on 11/15/24 at 4:06 PM. The provider did not document signs or symptoms that would support the clinical necessity for restraints. It was documented in the admission assessment "Neuro: Will continue to minimize sedation to not worsen any delirium issues" but provided no additional clinical justification or assessment for restraint use.

Staff D was interviewed on 4/22/25 beginning at 8:37 AM, and Patient #2's record was reviewed in her presence. She confirmed Patient #2's physician documentation did not follow facility policy.

The facility failed to ensure staff had a working knowledge of restraint policy.