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Based on policy review, observation, medical records review and staff interviews facility staff failed to obtain a physician order for non-violent restraint in 6 of 7 patients with restraints (Patients #9, #13, #14, #15, #16 and #6).

The findings include:

Review on 03/16/2017 of the policy and procedure "Physical Restraints (Violent and Non-Violent Behavior) and Seclusion" (release date 06/2016) revealed, "... e. 4 side rails up on a patient hospital bed are normally considered a restraint. 4 Side Rails - if a patient's condition requires all 4 side rails be raised and the situation does not meet an exception (post-procedure, etc.), the initial order is good for up to seven (7) calendar days..."

Observation on 03/14/2017 at 11:30 revealed RN #2 providing care in room 412 (patient #14). Observation revealed patient lying in bed with all 4 side rails up. Observation on 03/15/2017 at 1400 during tour on the 4th floor revealed patients lying in their beds with 4 side rails up in rooms 408, 409 and 412.

1. Review of open medical record on 03/15/2017 revealed patient #9 was assigned to room 408. Patient #9 was admitted on 02/25/2017 with acute and chronic respiratory failure, UNSP (unspecified) with hypoxia or hypercapnia. Review revealed no written order for the restraints observed during tour and no documented exceptions for the need of 4 side rails.

Interview on 03/15/2017 at 1400 and 03/16/2017 at 0900 with RN #1 revealed patients who are at high fall risk may have interventions that include: side pads and 4 side rails. Interview revealed the use of 4 side rails and the side pads had not been considered a restraint. Interview revealed facility leadership and core staff reassessed patients with 4 side rails up and obtained orders for patients appropriate for restraints who were currently on the nursing unit.

2. Review of open medical record on 03/15/2017 revealed patient #13 was assigned to room 214. Patient #13 was admitted on 11/17/2017 with severe sepsis without septic shock. Review revealed no written order for the restraints observed during tour and no documented exceptions for the need of 4 side rails.

Interview on 03/15/2017 at 1400 and 03/16/2017 at 0900 with RN #1 revealed patients who are at high fall risk may have interventions that include: side pads and 4 side rails. Interview revealed the use of 4 side rails and the side pads had not been considered a restraint. Interview revealed facility leadership and core staff reassessed patients with 4 side rails up and obtain orders for patients appropriate for restraints who were currently on the floor.

3. Review of open medical record on 03/15/2017 revealed patient #14 was assigned to room 412. Patient #14 was admitted on 02/16/2017 with respiratory failure (RF) UNSP with hypoxemia or hypercapnia. Review revealed no written order for the restraints observed during tour and no documented exceptions for the need of 4 side rails.

Interview on 03/14/2017 at 11:47 with RN #2 revealed 4 side rails was a restraint but 4 side rails were used with the side pads. Interview revealed there was no physician order obtained for restraints.

Interview on 03/15/2017 at 1400 and 03/16/2017 at 0900 with RN #1 revealed patients who are at high fall risk may have interventions that include: side pads and 4 side rails. Interview revealed the use of 4 side rails and the side pads had not been considered a restraint. Interview revealed facility leadership and core staff reassessed patients with 4 side rails up and obtained orders for patients appropriate for restraints who were currently on the nursing unit.

4. Review of open medical record on 03/15/2017 revealed patient #15 was assigned to room 409. Patient #15 was admitted on 02/22/2017 with respiratory failure (RF) UNSP with hypoxia or hypercapnia. Review revealed no written order for the restraints observed during tour and no documented exceptions for the need of 4 side rails.

Interview on 03/15/2017 at 1400 and 03/16/2017 at 0900 with RN #1 revealed patients who are at high fall risk may have interventions that include: side pads and 4 side rails. Interview revealed the use of 4 side rails and the side pads had not been considered a restraint. Interview revealed facility leadership and core staff reassessed patients with 4 side rails up and obtained orders for patients appropriate for restraints who were currently on the nursing unit.

5. Review of open medical record on 03/15/2017 revealed patient #16 was assigned to room 209. Patient #16 was admitted on 01/08/2017 with respiratory failure (RF) and UNSP with hypoxemia or hypercapnia. Review revealed no written order for the restraints observed during tour and no documented exceptions for the need of 4 side rails.

Interview on 03/15/2017 at 1400 and 03/16/2017 at 0900 with RN #1 revealed patients who are at high fall risk may have interventions that include: side pads and 4 side rails. Interview revealed the use of 4 side rails and the side pads had not been considered a restraint. Interview revealed facility leadership and core staff reassessed patients with 4 side rails up and obtained orders for patients appropriate for restraints who were currently on the nursing unit.

6. Review of closed medical record on 03/14/2017 revealed patient #6 was admitted on 02/01/2017 with acute respiratory failure (ARF) and pneumonia. Flow sheet review revealed on 02/13/2017 at 0800 and 2000; and 02/14/2017 at 0800 and 2000, "4 side rails up" was documented. Review revealed no written order for restraints and no documented exceptions for the need of 4 side rails.

Interview on 03/15/2017 at 1400 and 03/16/2017 at 0900 with RN #1 revealed patients who are at high fall risk may have interventions that include: side pads and 4 side rails. Interview revealed the use of 4 side rails and the side pads had not been considered a restraint. Interview revealed facility leadership and core staff reassessed patients with 4 side rails up and obtained orders for patients appropriate for restraints who were currently on the nursing units.

Based on policy and procedure review, facility observations, staff interviews, and medical records review, QAPI indicators for falls risk scoring, and restraint use were not incorporated into staff care routines and education for the development of improved quality patient care.

The findings include:

Policy and procedure review on 03/16/2017 of event reporting via the "Event Reporting System (ERS)" (release date 06/2016) revealed "An 'event' is defined as any occurrence or situation not consistent with routine operation of the facility and which may have caused or may have the potential for causing injury to patients ...All event reports are reviewed periodically by the Quality Council ..." Falls and restraints are included as aspects of event reporting.

1. Policy and procedure review on 03/16/2017 of falls risk assessment revealed "Falls Prevention, H-PC 03-008 and H-PC 03-008 PRO" (release date 06/2016). "Use of a multi-interventional Fall Prevention program that uses fall prevention and management practices ...may be effective in reducing the occurrence of patient falls during hospitalization ...History of Falls - Includes one or more falls (with or without injury) within the previous three (3) months prior to admission ...After a patient falls, a fall is investigated by completing the designated divisional investigation form ... A Score > 10 = At Risk. Those patients identified as being 'at risk' for falls will have additional interventions added to their plan of care...In the event that a patient fall occurs, regardless of the score of the Initial Fall Risk screen, he/she will be automatically considered at risk for falls ... and the Care Plan will be revised to reflect increased risk."

Medical record reviews on 03/15/2017 and 03/16/2017 revealed variation in daily fall risk scores for patients (The "fall history score" is determined as; score = 0 if no, score = 10 if yes). Patient #4 had a documented fall on 01/10 2017 at 18:45. The initial fall risk score had been 7 on admission, was 24 on the day of the fall, and 26 after the fall. Beginning three days after the event, the "fall history score" varied between 0-10 on assessments on 01/12/2017 through 02/1/2017, and except for 02/16/2017, remained zero through the survey date on 03/16/2017. The "total fall risk score" was documented as low as three after the fall at the facility occurred, and an accurate fall history score (10) was not entered as part of the daily assessment through 03/16/2017.

Staff interview on 03/15/2017 at 11:10 with AS #3 (Administrative Staff) revealed that once a patient had been identified as having a history of fall or had a fall during admission, he/she would always be a high fall risk. Continued interview revealed falls education was provided to all clinical staff during the annual skills fair in October and November. AS #3 indicated that falls and falls assessments had been identified as facility concerns, and no additional falls training for core staff beyond the annual skills fair in 2016 had been done prior to 03/14/2017

Staff interview on 03/15/2017 at 1330 with RN #1 revealed the system requires staff to physically record a "fall history score" with each assessment. Staff are expected to review the previous 24 hour assessment, make adjustments to the "total fall risk score" and " ...staff need to be mindful before they process assessments".

2. Policy and procedure review on 03/16/2017 of definition and use of physical restraints revealed "Physician Restraints (Violent and Non-Violent Behavior) and Seclusion" (release date 06/2016) revealed, "... e. 4 side rails up on a patient hospital bed are normally considered a restraint unless ..." specific conditions are met. "4 Side Rails - if a patient's condition requires all 4 side rails be raised and the situation does not meet an exception (post-procedure, etc.), the initial order is good for up to seven (7) calendar days following the day the order was obtained ...While side rails are up, document the restraint use using the required forms."

Observation on 03/14/2017 at 11:30 revealed RN #2 providing care in room 412, and the patient lying in bed with 4 side rails up. Continued observation on 03/15/2017 at 1400 during a tour on the 2nd and 4th floor revealed patients lying in beds with 4 side rails up in rooms 209 (Patient #16), 214 (Patient #13), 408 (Patient #9), 409 (Patient #15), and 412 (Patient #14).

Closed and open medical record review on 03/14/2017 and 03/15/2017 revealed no written orders, or documented restraint policy exceptions for; Patient #2, Patient #6, Patient #9, Patient #13, Patient #14, Patient #15, or Patient #16.

Staff interview on 03/15/2017 at 1400 with RN #1 revealed patients who are considered high fall risk, may have interventions that include: side pads and 4 side rails. Further interview revealed the use of 4 side rails and the side pads by staff had not been considered a restraint. Further interview on 03/16/2017 at 0830, revealed facility leadership and core staff reviewed facility restraint policy, and reassessed patients with 4 side rails up in the evening of 03/15/2017. New restraint orders were obtained for patients meeting policy guidelines and currently on the nursing units.

Based on policy and procedure review, observation, medical record review, and staff interview, the facility failed to prevent falls by not accurately documenting high falls risks during routine patient reassessment (Patients #5, #9 and #7).

The findings include:

Review on 03/16/2017 of the policy and procedure "Assessment/Re-assessment - Interdisciplinary Patient" (release date 10/2016) revealed "...6. The admitting RN will screen each patient during the initial assessment process to identify those patients requiring further specialized interventions ... iv. Falls risk. ... An RN reassessment of the patient shall occur, at a minimum of once every 12-hour shift..."

Review on 03/16/2017 of the policy and procedure "Falls Prevention" (release date 06/2016) revealed "...b. A score of > or equal 10 = At Risk ... f. In the event that a patient fall occurs, regardless of the score of the Initial Fall Risk screen, he/she will be automatically considered at risk for falls, additional interventions will be considered, and the Care Plan revised to reflect increased risk ..."

Observation during tour on the 4th floor on 03/14/2017 at 11:30 revealed patients identified as high fall risk had a yellow magnet on the door frame outside of their room and a fall "stop" sign over their beds.

1. Medical record review on 03/14/2017 revealed patient #5 was admitted on 11/30/2016 with severe metabolic encephalopathy (brain injury), hydrocephaly (fluid on the brain), acute renal failure (kidney disease) and dysphasia (difficulty swallowing). The patient had a prior history of a fall on admission. 12/01/2017 admission falls score was 21. Review of the flow sheet revealed patient fell on 01/01/2017. Review revealed patient #5 falls score on 12/31/2016 at 0900 and 01/01/2017 at 0800 was 7. Continued review revealed patient fell at 1540 at which time the patient fall score was increased to 21.

Interview on 03/15/2017 at 11:10 with AS #3 revealed once a patient had been identified as having a history of fall or had a fall during admission, he/she would always be a high fall risk. Continued interview revealed falls education was provided to all clinical staff at the annual skills fair in October and November. Falls and falls assessments had been identified as a problem, but there had been no additional training for core staff outside of the annual skills fair.

Interview on 03/15/2017 at 1330 with RN #1 revealed the system requires staff to physically check a previous history of fall with each assessment. Staff should have reviewed the previous 24 hour assessment. Interview revealed "staff need to be mindful before they process assessments".

2. Medical record review on 03/14/2017 revealed patient #9 was admitted on 02/25/207 with myotonic dystrophy (muscle weakness), ventilator dependent (breathing machine) with metabolic encephalopathy and acute and chronic respiratory failure. Patient #9 was identified as a falls risk on admission 02/25/2017. On 03/10/2017 at 22:01 patient #9 had documented fall score of 9. Continued review revealed patient #9's falls score was increased to 18 after she had a fall on 03/11/2017 at 0030. Further review revealed on 03/14/2017 at 10:57, patient #9's falls score documented as 9 (three days after the fall).

Interview on 03/15/2017 at 11:10 with AS #3 revealed once a patient had been identified as having a history of fall or had a fall during admission, he/she would always be a high fall risk. Continued interview revealed falls education was provided to all clinical staff at the annual skills fair in October and November. Falls and falls assessments had been identified as a problem, but there had been no additional training for core staff outside of the annual skills fair.

Interview on 03/15/2017 at 1330 assessment. Staff should have reviewed the previous 24 hour assessment. Continued interview revealed "staff need to be mindful before they process assessments."




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3. Medical record review on 03/14/2017 of the "HISTORY AND PHYSICAL" dated 02/09/2017 at 1738 revealed a 73 year old Patient #7 was admitted on 02/08/2017 for rehabilitation due to a status post surgical procedure. Review revealed patient #7 had a open reduction internal fixation (hip replacement) to her left hip after a fall. Review of the "...chronological retrieval for fall risk screening data...Nursing admission...Fall risk screening:..." by RN#2 dated 02/09/2017 at 0051 revealed the patient had a history of a previous fall and a total fall risk score of 17. Review revealed the routine reassessment documentation for "...Fall risk screening..." noted Patient #7 did not have a history of a previous fall and the "...Total fall risk score..." equaled less than ten. Review revealed the following nursing reassessment entries had a no previous fall history and a fall risk score less than ten: 02/09/2017 at 1236, 02/09/2017 at 2309, 02/10/2017 at 1426, 02/10/2017 at 2154, 02/11/2017 at 1628, 02/12/2017 at 2343, 02/13/2017 at 1126. Continued review dated 02/14/2017 at 0102 and 02/14/2017 at 0417 revealed no previous fall history with a fall risk score below ten was documented by RN #3 (RN assigned to care for Patient #7 the evening she fell). Review revealed on 02/14/2017 at 2130 Patient #7 fell while trying to get up to use the bedside commode.

Interview on 03/15/2017 at 0934 with RN #3 revealed fall risk patients are identified during shift change handoff and the fall risk score is noted in the computerized patient' s chart. Review revealed RN #3 did not remember the fall risk score per policy but indicated the fall risk score "over seven for me."

Interview on 03/14/2017 at 1225 by RN #4 revealed fall risk is assessed upon admission. The fall risk precautions are implemented when the fall risk score is five and greater. Interview revealed the fall risk score is documented in the computer. Interview revealed once the fall risk precautions are implemented reassessments are done every shift and PRN (as needed).

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