HospitalInspections.org

Based on interview and document review, the acute care hospital failed to ensure patients were free from unnecessary restraints for 4 of 6 patients (P1, P4, P5, and P6) reviewed who used an enclosure bed restraint and 3 of 3 patients (P1, P2, P3) who had a soft wrist restraint. The enclosed bed restraints were placed without an individualized comprehensive assessment for least restrictive measures or device, and without signed physician orders.

Due to the serious nature of this systemic system failure the hospital is unable to ensure adequate Patient Rights.

Therefore the hospital is unable to meet the Conditions of Participation of Patient Rights at 42 CFR 482.13.

Findings include:
See A154:

Based on interview and document review, the hospital failed to ensure comphrensive individualized assessments were conducted to ensure least restrictive restraint measures were implemented, and failed to ensure orders for restraints were signed by a physician for 7 of 7 patients (P1, P2, P3, P4, P5, P6, and P7) reviewed for restraint use; the hospital also failed to identify appropriate indications and/or justification for use of enclosure beds for 4 of 4 patients (P1, P4, P5, & P6) who had enclosure beds. In addition, the hospital failed to ensure an effective quality assurance restraint program was implemented.

Findings include:

P1 was admitted to the hospital on 4/2/19, with diagnoses which included acute respiratory failure due to influenza A, acute disseminated encephalomyelitis, dysphagia, hypertension, hypothyroidism, liver cirrhosis, and atrial fibrillation.

P1's Record of Death form dated 6/5/19, indicated P1 died on 6/5/19, at 12:30 a.m. The form indicated P1 was in restraints within 24 hours of death, P1 was restrained within 1 week of death, and death was unexpected.

P1's physician visit notes reviewed indicated P1 had left sided weakness and was able to make intentional movements with right extremities.

P1's record lacked an individualized care plan with goals for the use of restraints.

P1's medical record was reviewed and revealed the medical record lacked a comprehensive individualized assessment for the least restrictive measures upon initiation and ongoing use of soft wrist restraints, mittens tied, mittens untied, and enclosure (net) bed.

P1's restraint order dated 4/25/19, included restraint type soft wrist restraints; restraint reason interference with medical treatment. Duration of order was one day. The order was not signed by the physician until 4/27/19.

P1's signed physician order dated 4/27/19, included restraint type mittens tied (both mittens): restraint reason interference with medical treatment. Duration of order was one day. P1's restraint order for bilateral mittens was renewed daily:
-The order bilateral mitten order on 4/30/19, was not signed by the physician until 5/20/19.
-The orders dated 5/1/19 to 5/5/19, did not identify which hand- mittens should be applied to, and were not signed by the physician until 5/20/19.

P1's signed physician order dated 5/6/19, included restraint type mittens untied (right hand): restraint reason interference with medical treatment. Duration of order was one day. P1's restraint order for right hand mitten untied was renewed daily. Orders for the untied right mitten for 5/7/19 to 5/9/19, were not signed by the physician until 5/20/19. Order dated 5/10/19, was not signed by the physician until 5/13/19, and order dated 5/11 and 5/12/19, were not signed by the physician until 5/20/19.

P1's order dated 5/13/19, included restraint type soft wrist restraints, did not identify which side, and restraint reason interference with medical treatment. Duration of order was one day. This order was not signed by the physician until 5/20/19.

P1's order dated 5/18/19, included restraint type mittens untied to right hand, restraint reason was interference with medical treatment. Duration was one day. This order was not signed by the physician until 5/24/19.

P1's nurse progress note dated 6/1/19, at 7:13 p.m. indicated P1 was found on the floor mat by her right side at 6:55 p.m. by night shift nursing assistant. The note further indicated the bed pad alarm was correctly placed however, did not go off.

P1's order dated 6/1/19, at 10:11 p.m. included restraint type enclosure bed, and restraint reason interference with medical treatment. Duration was one day. This order was not signed by the physician until 6/3/19.

P1's nursing progress note dated 6/2/19, at 6:13 a.m. indicated P1 was alert but confused. "Pt placed in a net bed after fall on 6/1. Pt remained restless all night and had little sleep." Subsequent nursing progress note at 7:52 p.m. included, "Pt is a [sic] net bed for fall safety and unable to comprehend or benefit from education."

P1's record lacked evidence of a physician order for renewal of the net bed order on 6/2/19. A nursing progress note dated 6/3/19, at 1:36 a.m. included, "Patient continues on enclosed net bed for fall prevention." Subsequent progress note at 6:48 p.m. included, "continues to be in a net bed for fall safety."

P1's physician order dated 6/3/19, included restraint type enclosure bed, and restraint reason interference with medical treatment. Duration was one day. This order was not signed by the physician until 6/9/19, 4 days after P1 had died. The record included an order for the enclosure bed on 6/4/19, signed by the physician 7:14 a.m.

P1's nursing progress note dated 6/4/19, at 6:16 p.m. included, "Continues to be in the net bed for fall safety and is still trying to get out of the bed during assessment. Unable to benefit from education."

P1's physician daily progress notes were reviewed from admission on 4/25/19, through 6/5/19. The use of restraints was not addressed or identified with the exception of a physician note dated 6/2/19. That note included, "Patient is lying in bed comfortably. She is in a net bed. RN (registered nurse) noted a fall last night. No associated head injuries."

During an initial interview on 6/7/19, at 10:00 a.m. the chief nursing officer (CNO) stated P1 was in a net bed because of huge fall risk, P1 was very impulsive, restless, and rolled around in bed.

P1's record was reviewed with the CNO on 6/7/19, at 11:00 a.m. The CNO stated the nurses chart by exception, and the nursing flowsheets were considered individualized comprehensive assessments, even though general terms were used. The CNO stated the record did not specifically indentify why the net bed was ordered for P1, and the record did not identify a least restrictive measure was attempted. When questioned about the physician order reason for the restraint "Interference with medical treatment," the CNO was not able to artculate how the net bed would prevent P1 from interferring with medical treatment; the net bed would not have prevented P1 from removing her PICC line (a central line access for intravenous medications) and/or her PEG tube (feeding tube). The CNO confirmed there was not a physician order in the record for the net bed on 6/2/19.

During an interview on 6/8/19, at 5:30 p.m. P1's family member (FM)-A stated on 6/1/19, they were notified P1 had a fall from bed. Upon arrival to the hospital between 7:30-8:00 p.m. staff were bringing in the net bed. FM-A stated staff did not explain what the net bed was for, but it was obvious, "To prevent her from falling out of bed." FM-A stated to his knowledge no other interventions had been attempted prior to the implementation of the net bed, and in his (FM-A's) opinion, when P1 was admitted to the hospital the bed enclosure was for staff convenience so they would not have to do 1:1's.

During an interview on 6/8/19, at 4:00 p.m. RN-A stated enclosed beds were not used as a fall intervention. RN-A stated appropriate fall interventions included 1:1, moving the bed up against the wall, and use of a low bed with fall mats in place. RN-A stated net beds were used with traumatic brain injury (TBI) patients for calming effects or if they had uncontrolled gross body movements. RN-A stated least restrictive measures were always supposed to be attempted and documented in the record with the effectiveness of that intervention. RN-A stated once a restraint was applied every 2 hours, the patient was released and assessed for ongoing use of the restraint however, the EPIC (electronic health record) system flowsheets only allowed for very general terms (or words) that were not individualized to that patient. RN-A stated nurses would have to document in a progress note for that. RN-A stated although they (RNs) wrote progress notes to give a clear picture, some nurses did not and it was difficult to determine what interventions were effective, which ones were not, and how long the interventions were effective.

During an interview on 6/10/19, at 8:35 a.m. the medical director (MD) stated the net bed was prescribed for P1 because she was confused, agitated, moved around in bed, didn't like to be touched, and tried to reach objects. The MD indicated after the net bed was placed, P1 had increased agitation from unknown etiology; medication regimen versus worsening of the encephalopathy. MD indicated the net bed was not removed in order to determine if the bed was causing the increase in agitation.

During an interview on 6/10/19, at 12:00 p.m. RN-B stated she cared for P1 from 6/1- 6/4/19, and was the nurse who responded to P1's fall on 6/1/19. RN-B stated P1 had left side weakness however, could roll to the right side. RN-B stated on 6/1/19, prior to the fall, P1 was cooperative with cares, confused, and grabbing at things in the air. RN-B stated P1 was also asking for a cigarette, rolled back and forth trying to get out of bed, so a bed alarm was placed, and shortly after that P1 rolled out of bed. RN-B stated she was alerted of the fall by a nursing assistant, P1 was tranferred back to bed, and RN-B left for the evening. RN-B stated the next morning when she arrived, P1 had been placed in a net bed, continued to grab at things in the air, and was agitated. RN-B stated the net bed was placed to prevent falls, but the main use was to see if it would help decrease stimulation. However, the net bed hadn't really helped with providing a calming effect for P1.


P2 was admitted to the hospital on 5/24/19, with diagnoses acute hypoxic respiratory failure due to multilobar pneumonia, status post bilateral below-knee amputations, dysphagia, and acute ischemic stroke.

P2's medical record was reviewed and revealed the medical record lacked a comprehensive individualized assessment for the least restrictive measures upon initiation and ongoing for soft wrist restraints, mittens tied and mittens untied.

P2's restraint order dated 5/24/19, included restraint type soft wrist restraints; restraint reason interference with medical treatment, bilateral writs. Duration of the order was one day. The physician signed the order on 5/24/19.

P2's nurse progress note dated 5/24/19 included, " ...Bilateral wrist restraints on and tied down as pt. [patient] is confused, impulsive and reaches for trach when released ..."

P2's nurse progress note dated 5/25/19 included, " ...changed right wrist restraint to a mitt tied down, as pt. [patient] is able to wiggle out of tied down wrist restraint and dislodges her trach ..."

P2's nurse progress note dated 5/25/19 included, " ...Pt. [patient] is impulsive. Has left wrist tied down, and right mitt tied down to prevent dislodgement of trach. Pt [patient] will attempt to pull at it ..."

P2's nurse progress note dated 6/8/19 included, " ...Patient continues on bilateral wrist restraints for pulling on tubes order in place ..."

P2's restraint orders for the continued use of the soft wrist restraints were reviewed, and lacked a signed order renewal by the physician for the use of the soft wrist restraints on 5/25/19, 5/26/19, 5/27/19, 6/3/19, 6/4/19.
-The renewal order placed 6/2/19/19, was signed 6/4/19.
-No renewal orders were found for 6/5/19.

P2's restraint order dated 5/28/19, included restraint type soft wrist restraints mittens tied; restraint reason interference with medical treatment, bilateral wrists. Duration of the order was one day. The physician signed the order on 5/28/19.

P2's nurse progress notes dated 5/28/19 did not identify or address the use of restraints.

P2's physician progress notes were reviewed, and indicated the restraint use was not consistently addressed or identified.

On 6/7/19, at 4:23 p.m. the director of quality management (DQM)-A verified a daily signed physician order was needed for restraints. The DQM-A stated when signing the physician order, it indicated the physician has assessed the patient to carry on the order for the restraints.

P3 was admitted to the facility on 5/22/19, with diagnoses that included acute metabolic encephalopathy/delirium and dysphagia.

P3's medical record was reviewed and lacked documentation of a comprehensive individualized assessment for the least restrictive measures upon initiation, and ongoing use of mittens untied, and soft wrist restraints.

P3's restraint order dated 5/22/19, included restraint type mittens untied, and with the reason: Interference with medical treatment, bilateral hands. Duration of the order was one day. The physician signed the order on 5/23/19.

P3's nurse progress note dated 5/22/19 included, " ...Pt [patient] continues to touch nose and is redirectable at times. Bilateral mitts untied placed. Family educated on leaving the restraints on, even when they are present ..."

P3's nurse progress note dated 5/23/19, indicated " ...patient continues with soft wrist restraints bilaterally." There was no order for the discontinuation of the untied mittens or the implementation of the soft wrist restraints on 5/23/19.

P3's restraint order dated 5/24/19, included restraint type soft wrist restraints; restraint reason interference with medical treatment, bilateral hands. Duration of the order was one day. The physician did not sign the order.

P3's nurse progress note dated 5/24/19, included, "Patient is stable. He is alert and confused. Impulsive and pulling at his Foley and NG tube. He tries to get out of bed stating he want to go home..."

P3's nurse progress note dated 5/25/19, included, "Patient is stable, no new changes. He remains confused but no agitation noted. No overnight concerns. He remains in bilateral soft wrist restraints to protect his NG tube ..."

P3's restraint orders for the continued use of the soft wrist restraints were reviewed and there was no signed order renewal by the physician for the use of the soft wrist restraints on 5/23/19, 5/27/19, 5/29/19, 5/30/19, and 5/31/19.

P3's physician progress notes provided were reviewed and revealed the restraint use was not consistently addressed or identified.

On 6/7/19, at 5:53 p.m. DQM-A verified the information identified for P3 regarding the physician orders for the restraints. TheDQM-A again confirmed a daily signed physician order was needed for restraints.

P4 was admitted to the facility on 3/8/19, with diagnoses that included acute encephalopathy, chronic kidney disease stage five on hemodialysis, and intermittent focal seizures.

P4's medical record was reviewed and lacked a comprehensive individualized assessment for the least restrictive measures upon initiation and ongoing use of mittens untied, and enclosure (net) bed.

P4's restraint order dated 3/12/19, included restraint type mittens untied, and the reason: Interference with medical treatment, keeps pulling on his NG tube. Duration of the order was one day.

P4's nurse progress note dated 3/12/19, included, " ...kept pulling on his NG tubing; even removed the orange cap and chewed on it until it was flat. Writer saw him chewing and asked him to open his mouth; it was the orange cap from the NG tube. Frequent education on him pulling the tubing did not work. Bilateral mitts initiated to protect his tubes ..."

P4's restraint order dated 3/20/19, included restraint type enclosure bed and the reason: Interference with medical treatment, high fall risk/altered mental status. Duration of the order was one day. The physician signed the order on 3/21/19.

P4's nurse progress note dated 3/20/19, included, " ...Pt [patient] attempted to climb out of bed himself this morning. NAR [nursing assistant registered] assisted writer to get pt [patient] into his chair with tray locked in blace [sic]. Net bed requested and ordered. MD [medical doctor] ordered IV Ativan PRN [as needed] ..."

P4's nurse progress note dated 3/27/19, included, "The pt [patient] is alert with some confusion. He remained in the net bed all shift but it was open. He was not restless he slept well ..."

P4's progress note dated 3/28/19, included, "Patient was found laying on the floor; attempting to crawl out of bed to get to the commode at 0830. Pt [patient] stated he did not hit his head and was not in any pain ...Previously taken out of the net bed, a new net bed was ordered for patient and will placed in his room tonight ..." Review of the physician orders provided revealed there was no physician order for the reimplementation of the net bed on 3/28/19.

P4's nurse progress note dated 4/1/19, included, " ...Continues is a net bed for safety as pt [patient] is impulsive and confused ..."

P4's nurse progress note dated 4/19/19, included, "Alert, confused, and fall risk. Unaware of his own safety. Therefore, he is currently on enclosed bed for fall precaution ..."

P4's restraint order dated 5/14/19, included restraint type mittens untied, and the reason: Interference with medical treatment. Duration of the order was one day. The physician signed the order on 5/15/19.

P4's nurse progress note dated 5/14/19, included, " ...NG tube applied to allow intake of meds. Bilateral mittens applied to prevent pulling at tubes."

P4's physician note dated 3/20/19, included, "Patient is lying in bed comfortably with no acute distress."

P4's physician progress notes provided were reviewed, and revealed the restraint use was not consistently addressed or identified.

P4's restraint orders for the continued use of the enclosure bed were reviewed and indicated not all physician orders were signed within twenty-four hours, there were days when there was not a renewal order obtained, and days when the order was placed and not signed by a physician. Some examples include but are not limited to the following:
-The renewal order placed on 3/25/19, was signed 4/15/19.
-The renewal order placed 3/30/19, was signed 4/4/19.
-The renewal order placed 3/31/19, was signed 4/12/19.
-The renewal order placed 4/1/19, was signed 4/12/19.
-The renewal order placed 4/2/19, was signed 4/12/19.
-The renewal order placed 4/3/19, was signed 4/7/19.
-The renewal order placed 4/5/19, was signed 4/12/19.
-The renewal order placed 4/6/19, was signed 4/12/19.
-The renewal order placed 4/7/19, was signed 4/12/19.
-No renewal orders were found for 4/8/19, 4/9/19, and 4/10/19.
-A physician did not sign the renewal order dated 4/11/19.
-No renewal order was found for 4/12/19.
-The renewal order placed 4/15/19, was signed 4/22/19.
-The renewal order placed 4/17/19, was signed 4/21/19.
-The renewal order placed 4/18/19, was signed 5/21/19.
-The renewal order placed 4/22/19, was signed 5/21/19.

On 6/10/19, at 3:01 p.m. the CNO stated P4 was in a net bed because of body movements, he very impulsive, and was rolling back and forth in the bed continuously. The CNO stated the net bed gives the patient the flexibility to be mobile without staff constantly hovering, and providing stimulation to the patient on a continuous basis. The CNO stated net beds were not used for fall prevention.

P5 was admitted to the facility on 3/4/19, with diagnoses that included acute metabolic encephalopathy, acute respiratory failure, and seizure disorder.

P5's medical record was reviewed and revealed the medical record lacked a comprehensive individualized assessment for the least restrictive measures upon initiation and ongoing use of mittens untied, soft wrist restraints, and enclosure (net) bed.

P5's restraint order dated 3/4/19, included restraint type soft wrist restraints with the reason: Interference with medical treatment. Duration of the order was one day. The physician signed the order on 4/25/19.

P5's nurse progress notes dated 3/5/19, included, " ...Bilateral wrist restraints in place to prevent the pulling of tubes and lines ..."

P5's nurse progress note dated 3/8/19, included, " ...Patient continues in bilateral wrist restraints to prevent tube dislodgement, patient continues to be impulsive with wild involuntary movement."

P5's restraint orders for the continued use of the soft wrist restraints were reviewed and indicated not all physician orders were signed within twenty-four hours, and there were days when there was not a renewal order obtained. Some examples include but are not limited to the following:
-The renewal order placed on 3/5/19, was signed 4/25/19.
-The renewal order placed 3/6/19, was signed 4/25/19.
-The renewal order placed 3/7/19, was signed 4/25/19.
-The renewal order placed 3/8/19, was signed 4/25/19.
-The renewal order placed 3/9/19, was signed 4/25/19.
-The renewal order placed 3/10/19, was signed 4/25/19.
-The renewal order placed 3/11/19, was signed 4/25/19.
-The renewal order placed 3/13/19, was signed 4/25/19.

P5's restraint order dated 3/15/19, included restraint type enclosure bed restraint with the reason: Interference with medical treatment. Duration of the order was one day. The physician signed the order on 3/16/19.

P5's restraint order dated 3/15/19, included restraint type mittens untied with the reason: Interference with medical treatment. Comments included, "Even with the patient being in the net bed, she is able to pull at her trach tube and her NG tubing. At this time, it is necessary to initiate right hand mitt." Duration of the order was one day. The physician signed the order on 3/16/19.

P5's nurse progress note dated 4/3/19, included, "Pt [patient] in nonverbal; and unable to follow commands per baseline. Continues to be in a net bed for fall safety and unable to benefit from education ..."

P5's nurse progress note dated 4/5/19, included, "She is less agitated the pasttwo [sic] night, but may still need the Net Bed for safety as she spontaneously tries to get out of bed ..."

P5's nurse progress note dated 4/15/19, included, " ...She remains in net bed due to impulsiveness and safety concerns ..."

P5's nurse progress note dated 4/16/19, included, " ...She continues in Net Bed for safety reasons. She spontaneously tries to get out of bed and puts legs over when net bed is opened ..."

P5's nurse progress note dated 4/18/19, included, " ...She remains in Net Bed for safety as there is no sense of orientation and she is impulsive; tries to jump out of bed ..."

P5's nurse progress note dated 4/25/19, included, "Patient continues in net bed for safety, patient is impulsive and unable to follow direction, patient is at significant risk for falls ..."

P5's nurse progress note dated 4/26/19, included, " ...Pt [patient] continues in a net bed due to safety concerns/fall risk ..."

P5's nurse progress note dated 5/11/19, included, "Pt [patient] code status changed to comfort care ...Net bed restraint discontinued as pt [patient] has not been trying to get out of bed ..."

P5's restraint orders for the continued use of the enclosure bed were reviewed and indicated not all physician orders were signed within twenty-four hours, there were days when there was not a renewal order obtained, and days when the order was placed and not signed by a physician. Some examples include but are not limited to the following:
-The renewal order placed on 3/16/19, was signed 4/25/19.
-No renewal orders were found for 3/17/19.
-The renewal order placed 3/18/19, was signed 4/25/19.
-The renewal order placed 3/20/19, was signed 4/25/19.
-The renewal order placed 3/21/19, was signed 4/25/19.
-The renewal order placed 3/22/19, was signed 4/25/19.
-The renewal order placed 3/23/19, was signed 4/25/19.
-A physician did not sign the renewal order dated 3/24/19.
-No renewal orders were found for 3/25/19.
-The renewal order placed 3/26/19, was signed 4/25/19.
-The renewal order placed 3/27/19, was signed 4/25/19.
-The renewal order placed 3/28/19, was signed 4/25/19.
-The renewal order placed 3/29/19, was signed 4/25/19.
-The renewal order placed 3/30/19, was signed 4/25/19.
-The renewal order placed 3/31/19, was signed 4/14/19.
-The renewal order placed 4/1/19, was signed 4/25/19.
-The renewal order placed 4/2/19, was signed 4/25/19.
-The renewal order placed 4/3/19, was signed 4/25/19.
-The renewal order placed 4/4/19, was signed 4/25/19.
-The renewal order placed 4/5/19, was signed 4/25/19.
-The renewal order placed 4/6/19, was signed 4/25/19.
-The renewal order placed 4/7/19, was signed 4/25/19.
-No renewal orders were found for 4/8/19.
-The renewal order placed 4/9/19, was signed 4/14/19.
-No renewal orders were found for 4/10/19.
-The renewal order placed 4/11/19, was signed 4/25/19.
-The renewal order placed 4/12/19, was signed 4/25/19.
-No renewal orders were found for 4/13/19.
-The renewal order placed 4/14/19, was signed 4/25/19.
-The renewal order placed 4/15/19, was signed 4/25/19.
-The renewal order placed 4/16/19, was signed 4/25/19.
-The renewal order placed 4/17/19, was signed 4/25/19.
-The renewal order placed 4/18/19, was signed 4/25/19.
-No renewal orders were found for 4/19/19.
-The renewal order placed 4/20/19, was signed 4/25/19.
-No renewal orders were found for 4/21/19, 4/24/19, 4/25/19, and 4/27/19.
-A physician did not sign the renewal order dated 4/28/19.
-No renewal orders were found for 4/29/19.
-A physician did not sign the renewal order dated 4/30/19.
-No renewal orders were found for 5/1/19.
-A physician did not sign the renewal order dated 5/3/19.
-A physician did not sign the renewal order dated 5/4/19.
-A physician did not sign the renewal order dated 5/5/19.
-No renewal orders were found for 5/6/19.
-A physician did not sign the renewal order dated 5/7/19.
-A physician did not sign the renewal order dated 5/8/19.
-No renewal orders were found for 5/9/19, and 5/10/19.

P5's physician progress notes provided were reviewed and revealed the restraint use was not consistently addressed or identified.

On 6/10/19, at 3:03 p.m. the CNO stated P5 was in a net bed because of body movements, rolling up and down and back and forth. The CNO stated P5 did not like to be touched. The CNO stated the enclosed bed was the least restrictive restraint for her. The CNO verified the net beds were not used for fall prevention by the hospital.

P6 was admitted to the facility on 3/23/19, with diagnoses that included encephalopathy, physical deconditioning secondary to intracranial hemorrhage with left sided hemiplegia and hemiparesis.

P6's medical record was reviewed and revealed the medical record lacked a comprehensive individualized assessment for the least restrictive measures upon initiation and ongoing use of mittens untied, mittens tied and enclosure (net) bed.

P6's restraint order dated 3/23/19 included restraint type enclosure bed; restraint reason interference with medical treatment. Duration of the order was one day.

P6's nurse progress note dated 3/26/19 included, " ...Pt [patient] has enclosure bed to prevent falls and ensure safety ..."

P6's nurse progress note dated 3/27/19 included, " ...Continues in net bed for physical safety ...Has been calm/sleeping thus far ..."

P6's nurse progress note dated 4/7/19/19 included, "Patient continues in a net bed, patient is confused and impulsive and makes attempts to roll out of bed ..."

P6's nurse progress note dated 4/8/19 included, " ...Patient in net bed for safety, moves a lot and rolls a lot in bed ..."

P6's nurse progress note dated 4/9/19 included, "Pt [patient] continues with net bed restraint and has therapeutic mitt on right hand. Was calm throughout the shift and slept all night ..."

P6's nurse progress note dated 4/10/19 included, "Pt [patient] still remains in net bed due to excessive moving around ..."

P6's nurse progress note dated 4/10/19 included, " ...Net bed in place and secure as pt [patient] likes to roll self with force into netting ..."

P6's nurse progress note dated 4/19/19 included, " ...Patient continues in a net bed due to agitation and continual attempts at getting out of bed ..."

P6's nurse progress note dated 4/22/19 included, "Patient continues to be in enclosed bed for fall prevention ..."

P6's nurse progress note dated 4/24//19 included, " ...Patient was restless overnight. Vitals stable. He kept pulling on his peg tube even with the abdominal binder on. Very hard to keep him settled down in bed. Right hand mitt applied to protect peg tubing was caught several times holding the tube in his hand and pulling on it. He still needs the net bed because of safety reasons ..."

P6's nurse progress note dated 4/25/19 included, " ...He still needs the net bed to prevent falls ..."

P6's nurse progress note dated 5/1/19 included, " ...Pt [patient] continues in a net bed and a right mitt restraint for safety/potential of pulling out lines ..."

P6's nurse progress note dated 5/3/19 included, " ...Pt has 2:1 sitter for fall safety, right mitten for potential tube dislodgement and unable to benefit from education.

P6's nurse progress note dated 5/21/19 included, " ...Mitt untied placed on right hand due to pulling at lines, scratching himself and trying to hit staff ..."

P6's nurse progress note dated 5/21/19 included, "Pt [patient] is up in chair, calm and cooperative. Removed restraint at this time ..."

P6's physician visit dated 4/12/19 included, " ...still requiring a net bed due to impulsivity and risk of falls ..."

P6's physician visit dated 4/13/19 included, " ...still requiring a net bed due to impulsivity and risk of falls ..."

P6's physician visit dated 4/19/19 included, " ...still requiring a net-bed due to impulsivity and risk of falls ..."

P6's physician visit dated 4/27/19 included, " ...still requiring a net bed due to impulsivity and risk of fall ..."

P6's physician progress notes provided were reviewed and revealed the restraint use was not consistently addressed or identified.

P6's restraint orders for the continued use of the enclosure bed were reviewed and revealed not all physician orders were signed within twenty-four hours, there were days when there was not a renewal order obtained and days when the order was placed and not signed by a physician. Some examples include but are not limited to the following:
-The renewal order placed on 3/26/19 was signed 4/12/19.
-The renewal order placed 3/31/19 was signed 3/29/19.
-The renewal order placed 4/1/19 was signed 4/12/19.
-No renewal orders were found for 4/2/19.
-The renewal order placed 4/3/19 was signed 4/12/19.
-The renewal order placed 4/4/19 was signed 4/12/19.
-The renewal order placed 4/5/19 was signed 4/12/19.
-The renewal order placed 4/6/19 was signed 4/12/19.
-The renewal order placed 4/7/19 was signed 4/12/19.
-No renewal orders were found for 4/8/19, 4/9/19 and 4/10/19.
-A physician did not sign the renewal order dated 4/11/19.
-No renewal orders were found for 4/12/19, 4/13/19, 4/14/19.
-The renewal order placed 4/17/19 was signed 5/22/19.
-No renewal orders were found for 4/19/19.
-A physician did not sign the renewal order dated 4/20/19.
-The renewal order placed 4/23/19 was signed 4/26/19.
-A physician did not sign the renewal order dated 4/28/19.
-No renewal orders were found for 4/29/19.

P6's restraint order dated 5/4/19 included restraint type untied mittens; restraint reason interference with medical treatment. Duration of the order was one day.

-The renewal order placed 5/4/19 was signed 5/6/19.

On 6/10/19, at 3:06 p.m. the chief nursing officer (CNO) stated P6 was in a net bed as he kept rolling back and forth in bed. The CNO stated every bed was a low bed and we put mats on the floor. The CNO stated, "All we would be doing would be picking up patients up off the floor." The CNO verified the hospital did not consider using net bed as a fall prevention.

P7 was admitted to the hospital on 5/16/19, with diagnoses of multiple fractures and tramatic head injuries as a result of a motor vehichle accident.

P7's medical record was reviewed and revealed the medical record lacked a comprehensive individualized assessment for the least restrictive measures upon initiation and ongoing for mittens.

P7's order dated 5/17/18, at 9:06 p.m. included restraint of mittens, with reason interference with medical treatment. The order was signed by the physician on 5/18/19, at 7:03 a.m. Physician progress note dated 5/18/19, indicated P7 had pulled out nasal gastric tube (NG).

P7's restraint orders for mittens dated 5/19, 5/20, 5/21 5/22, 5/23, and 5/24/19, were not ever signed by a physician.

P7's physician visit progress notes from 5/19 and 5/20/19, did not address and/or identify P7's restraint use.

P7's physician visit note dated 5/21/19, included "Frustrated about the mittens, but cooperative. Unnderstands it is to protect her from pulling her NG tube and PICC line" and "more calm and pleasant today, resting comfortably"

P7's physician visit notes dated 5/22, 5/23