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Based on observation, record review, review of hospital policy, and staff interview, the Hospital failed to ensure 1 of 1 active patients (Patient #12) remained free from physical restraints [side rails]. Failure to adequately assess the patient, determine the least restrictive intervention to prevent falls, and obtain a physician's order for the use of the restraint, violated the rights of Patient #12 and has the potential to result in injuries.

Findings include:

Review of the Hospital policy titled "Restraint Use" occurred on 07/08/14. This policy, dated November 2012, stated,
". . . GENERAL PROVISIONS:
Indications: Restraints are only used when less restrictive interventions have been determined to be ineffective in protecting the patient, staff or others from harm . . .
b) The assessment must determine that the risks associated with the use of the restraint are outweighed by the risk of not using it. Alternative interventions do not always need to be tried, but should be considered prior to use of a restraint . . .
f) A physician's order is required to initiate, change, continue, and discontinue restraint . . ."

Review of the Hospital policy titled "Patient Safety Plan (Fall Risk)" occurred on 07/08/14. This policy, dated 2010, stated,
". . . Use of Side Rails:
1. Use of four side rails with the intent to prevent the patient from leaving the bed is considered a restraint, and as such, is prohibited . . .
2. In most instances, it is safer to leave the bottom side rail closest to the bathroom down. Injuries may occur if the patient attempts to climb over the side rails to exit the bed. . . ."

Review of Patient #12's medical record occurred on July 07-08, 2014 and identified the Hospital admitted the patient on 06/06/14 for antibiotic therapy and wound care. A nurse's note, dated 07/06/14 at 4:30 a.m., stated, "pt [patient] found on floor by CNA [certified nursing assistant] pt stated 'I slid out of bed' . . . pt back to bed, no apparent injuries . . ."

Observation on 07/08/14 at 1:10 p.m. showed Patient #12 laying sideways on the bed, his feet hanging over the edge, four side rails (two at the head of the bed and two at the foot of the bed) in the upright position, a fall mat on each side of the bed, and a bed alarm. Two nurses (#1 and #2) entered the room and repositioned the patient. The nurses exited the room and all four side rails remained in the upright position.

Patient #12's medical record failed to show an individualized assessment to determine the least restrictive interventions to prevent falls and failed to show a physician's order for the use of side rail restraints.

During an interview on the afternoon of 07/08/14, an administrative nurse (#1) agreed the use of four side rails is a restraint and required a physician's order.

Based on observation, record review, and staff interview, the Hospital failed to ensure nursing staff developed and kept nursing care plans current for 8 of 16 active patient (Patient #1, #2, #3, #6, #7, #9, #12, and #14) records reviewed. Failure to establish a care plan limited the Hospital's ability to manage patient needs, communicate treatment approaches, and ensure continuity of care.

Findings include:

- Review of Patient #1's active medical record occurred on July 07-08, 2014 and identified the Hospital admitted the patient on 06/21/14 for ventilator weaning due to respiratory failure status post extensive thoracic surgery for lung cancer. The patient's current medical condition included a tracheostomy, feeding tube, bilateral axillary DVT [deep vein thrombosis], and tachycardia. Review of Patient #1's progress notes indicated the patient experienced depression due to her current medical condition.

Review of Patient #1's "Interdisciplinary Care Plan" (a pre-printed form) showed staff identified various diagnoses/problems, but failed to date, time, and initial the plan and failed to include the specific outcomes and actions for the diagnoses/problems identified. The patient's care plan lacked inclusion of all nursing and medical care needs, including appropriate and individualized interventions as a response to those needs.

- Review of Patient #2's active medical record occurred on July 07-08, 2014 and identified the Hospital admitted the patient on 06/30/14 for intravenous (IV) antibiotics due to an infection in the left knee. The patient's current medical condition included left knee wound care, chronic poorly controlled diabetes, dialysis three days a week, and a colostomy. Patient #2's history and physical (H&P) identified a history of severe peripheral vascular disease and a right below the knee amputation, and progress notes revealed left heel, left foot, right thumb, and coccyx wounds. Review of physician orders showed bedrest and wound care to all areas mentioned above.

Review of Patient #2's "Interdisciplinary Care Plan" showed staff identified various diagnoses/problems, but failed to date, time, initial, and include the specific outcomes and actions for them. The care plan lacked inclusion of all nursing and medical care needs, including appropriate and individualized interventions as a response to those needs.

- Review of Patient #3's active medical record occurred on July 07-08, 2014 and identified the Hospital admitted the patient on 06/12/14 for ventilator weaning due to a decreased level of consciousness and respiratory failure. The patient's current medical condition included confusion, tracheostomy, feeding tube, foley catheter, and rectal tube. Review of physician orders showed bedrest and at times, wrist restraints. Nurse notes identified the patient as very hard of hearing, confused and calling out.

Review of Patient #3's "Interdisciplinary Care Plan" showed staff identified various diagnoses/problems, but failed to include the specific outcomes and actions for the diagnoses/problems identified. The patient's care plan lacked inclusion of all nursing and medical care needs, including appropriate and individualized interventions as a response to those needs.


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- Review of Patient #6's active medical record occurred on July 07-08, 2014 and identified the Hospital admitted the patient on 05/30/14 for ventilator weaning and antibiotic therapy.

Observation on 07/07/14 at 10:40 a.m. showed Patient #6 in a bed with three side rails in the upright position, a blue heel boot on the patient's left foot, and a foley catheter. Patient #6's care plan failed to identify the specific problem and address and include these interventions.

The care plan indicated Patient #6's alteration in comfort and altered neurological and/or vascular perfusion. The care plan failed to specifically identify the problems and failed to identify specific actions (interventions) for the problems.

- Review of Patient #7's active medical record occurred on July 07-08, 2014 and identified the Hospital admitted the patient on 05/28/14 for ventilator weaning, wound care and antibiotic therapy.

Observation on 07/07/14 at 2:05 p.m. showed two certified nursing assistants (CNAs) (#4 and #5) turned and repositioned Patient #7. Observation showed the patient on a ventilator, a foley catheter present, and her arms and hands contracted.

During an interview on 07/07/14 at 3:15 p.m., a family member stated Patient #7 has frequent seizures and appears to be in pain.

Patient #7's care plan (found mixed in with physician's progress notes) failed to identify any problems except acute pain (no location of pain identified or how the patient would show pain), and altered neurological and/or vascular perfusion (no onset date or time identified). The care plan failed to identify other problems and specific interventions observed, including the family member's concerns.

- Review of Patient #12's medical record occurred on July 07-08, 2014 and identified the Hospital admitted the patient on 06/06/14 for antibiotic therapy and wound care. A nurse's note, dated 07/06/14 at 4:30 a.m., identified Patient #12 slid out of bed.

Observation on 07/08/14 at 1:10 p.m. showed Patient #12 in bed with a bed alarm, a fall mat on each side of the bed, and four side rails (two at the head of the bed and two at the foot of the bed) in the upright position.

Patient #12's care plan failed to identify any problems related to falls, the use of side rail restraints, or any other indications as to why the facility implemented these interventions.

- Review of Patient #9's medical record occurred on July 07-08, 2014 and identified the Hospital admitted the patient on 06/05/14 for wound care and antibiotic therapy.

Patient #9's care plan failed to indicate the date of initiation for eight problem focus areas and failed to identify specific intervention related to all of the problems.


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- Review of Patient #14's active medical record occurred on July 08, 2014 and identified the Hospital admitted the patient on 07/01/14 for IV antibiotic treatment for osteomyelitis.

During interview on 07/08/14 at 8 a.m., Patient #14 indicated he had a "sore" on his bottom and every two hours the facility staff cleaned it and put "stuff"on.

Review of Patient #14's record occurred on 07/08/14. The record contained a physician's order, dated 07/03/14, for "Calmospetine apply to bottom BID [twice daily] & PRN [as needed] to bottom [sic]." Review of Nursing Flow Sheets identified a "reddened area" to his coccyx. The undated/unsigned Interdisciplinary Plan of Care under "DIAGNOSIS/PROBLEM" of "Alteration in skin integrity. . ." identified various problems for Patient #14. The plan of care did not indicate where, on Patient 14's body, these problems existed or the use of Calmoseptine.

During an interview on 07/08/14 at 3:35 p.m., an administrative nurse (#1) stated she expected staff to develop a care plan for each patient upon admission, include all nursing and medical care needs, and revise and update the care plan as patient needs change. The nurse (#1) stated she expected staff to develop or update the care plan in response to falls, restraints, and skin issues.