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Based on observation, interview and record review, the facility failed to ensure licensed staff, Registered Nurses and Licensed Vocational Nurses (RNs and LVNs) updated the physical restraint care plans for one patient (Patient 2) to reflect current orders and restraint use.

This failure had to potential for negative outcomes like deteriorating health and increased complications and reduced quality of care.

Findings:

Review of a facility provided nursing policy titled: "Restraint Use", last reviewed 10/2025 and in effect, indicated restraint use was to keep patients safe, clinical indicators (behaviors) would be documented, and the least restrictive restraint would be used. The policy outlined that a Licensed Independent Practitioner (LIP)'s order was required to initiate, change, continue, or discontinue a restraint, and each order would include the restraint type, instructions and duration of use. And the policy indicated that documentation of alternative treatment, patient behaviors and patient response was required at least every two hours. Additionally, the policy indicated if a restraint was discontinued documentation would indicate when and why it was discontinued; and the care plan would be updated to reflect the current restraint ordered and used.

Review of a facility provided nursing policy titled: "Care Planning", last reviewed 10/2025 and in effect, indicated that care, treatment and services would be planned for each patient's individual care needs and goals. And the care plan would be updated regularly based on assessment findings.

Review of a facility job description titled Registered Nurse (RN), last revised 2/1/2017, indicated that the RN would follow all hospital policies, ensure physicians orders were followed. Additionally, the RN duties included assessment and implementation of individualized care plans to meet the needs of each patient.

Review of a document titled; core competencies RN, last reviewed 5/1/25, indicated all RNs in the facility would demonstrate competency to obtain orders for restraints, and discontinue restraints when less restrictive measures are sufficient, monitor if the restraint is clinically indicated, and document all findings and actions into the medical record.

Review of a facility job description titled Licensed Practical/LVN, last revised 2/1/2017, indicated that the LVN comply with hospital policies.

Review of a document titled; core competencies LPN/LVN, last reviewed 5/1/25, indicated all LPN/LVNs would demonstrate competency of the facility restraint policy and obtain LIP orders appropriately, monitor the need for continuation of the restraint and document all restraint assessments and actions into the medical record.

During a facility tour on, 11/24/25, at 11:00 AM a patient Patient 2 was observed cooperating with Physical Therapy (PT) transferring to a wheelchair. There was no restraint observed.

Review of Patient 2's medical record indicated Patient 2 was admitted to the facility on 10/14/25 with a history of severe weakness, contractures, acute renal failure (sudden loss of kidney function), and mechanical ventilation (a machine that helps with breathing).

Review of facility provided documents titled: "LTAC Restraint Physician Order", dated 11/21/25, at 8:30 AM, indicated Patient 2 had an order for bed rails x4 and wrist restraints to right and left wrist.

On 11/21/25, from 7:00 AM to 5:00 PM, RN 4 documented bed rails x4 and bilateral wrist restraints. RN 4 continued the care plan.

On 11/21/25, from 7:00 PM, to 11/22/25, at 4:40 AM, RN 5 documented restraint checks, but did not indicate the type of restraint used. RN 5 continued the restraint care without indicating the type of restraint therapy provided to Patient 2.

Review of facility provided documents titled: "LTAC Restraint Physician Order", dated 11/22/25, at 8:00 AM, Patient 2 had an order for bed rails x4 and wrist restraints to right and left wrist.

On 11/22/25, from 7:15 AM to 5:15 PM, RN 6 documented bed rails x4 only. RN 6 did not update the care plan to reflect only bed rails. And RN 6 continued the restraint care plan indicating bed rails x4 and bilateral wrist restraints were in use.

On 11/22/25, from 7:17 PM, to 11/23/25, at 6:36 AM, RN 7 documented bed rails x4 and wrist restraint to left arm. RN 7 continued the care plan.

Review of facility provided documents titled: "LTAC Restraint Physician Order", dated 11/23/25, at 8:00, Patient 2 had an order for bed rails x4 and wrist restraints to left wrist only.

On 11/23/25, from 7:00 AM to 5:00 PM, RN 6 documented bed rails x4 and bilateral wrist restraints were used in the care plan. And documented bed rails x4 was the only restraint used under restraint checks. RN 6 continued the care plan without updating to reflect the current treatment provided to Patient 2.

During an interview with concurrent medical record review on 11/24/25, at 11:10 AM, the Director of Nursing (DON) indicated that Patient 2's care plan should have been updated to reflect the current treatment plan that was in use. DON confirmed it had not been updated.

Based on observation, interview and record review, the facility failed to implement restraint policies that were intended to promote dignity and keep patients safe when restraints were removed and re-applied without a physician order, and when clinical assessment of patient behaviors that would identify appropriate use of restraints was not consistently documented for two patients (Patient 1 and Patient 2).

This failed practice had the potential to cause negative outcomes including physical and psychological harm to Patients 1 and 2 and to other patients with physical restraints.

Findings:

Review of a facility provided nursing policy titled: "Restraint Use", last reviewed 10/1/2025 and in effect, indicated the use of restraint was or patient safety. And indicated clinical indicators (behaviors) would be documented to indicate why the restraint was needed, and the least restrictive restraint would be used. The policy outlined that a Licensed Independent Practitioner (LIP) order that included the restraint type, instructions for use, and duration of use was required to initiate, change, continue, or discontinue a restraint. The policy indicated that documentation of alternative treatment, patient behaviors and patient response was required at least every two hours, and if a restraint was discontinued documentation would indicate when and why it was discontinued; and the care plan would be updated to reflect the order and current treatment. Additionally, the policy indicated when a restraint was discontinued a new order would be obtained if a restraint was needed again. And that a restraint should never be ordered or used "as needed" (PRN).

Review of a facility provided nursing policy titled: "Care Planning", last reviewed 10/1/2025 and in effect, indicated that care, treatment and services would be planned for each patient's individual care needs and goals. And the care plan would reflect current orders and be updated regularly based on assessment findings.

Review of a facility job description titled, "Registered Nurse (RN)," last revised 2/1/2017, indicated that the RN would follow all hospital policies, ensure physicians orders were followed. Additionally, the RN duties included assessment and implementation of individualized care plans to meet the needs of each patient.

Review of a document titled; "Core Competencies RN," last reviewed 5/1/25, indicated all RNs in the facility would demonstrate competency to obtain orders for restraints, and discontinue restraints when less restrictive measures are sufficient, monitor if the restraint is clinically indicated, and document all findings and actions into the medical record.

Review of a facility job description titled Licensed Practical/Vocational Nurse (LVN), last revised 2/1/2017, indicated that the LVN comply with hospital policies.

Review of a document titled; "Core Competencies LPN/LVN, last reviewed 5/1/25, indicated all LPN/LVNs would demonstrate competency of the facility restraint policy and obtain LIP orders appropriately, monitor the need for continuation of the restraint and document all restraint assessments and actions into the medical record.

During an interview on 11/24/25, at 10:30 AM, the Director of Quality and Risk Management (DQRM) indicated that a LIP would assess the patient face to face to order or renew a restraint, and indicated the LIP was available in the facility until 7:00 PM or later, and with Tele Health (a computer screen with assistance from a bedside nurse) after hours. And DQRM indicated that the LIP signed the order after completing the face-to-face assessment of the patient.

1. During a facility tour on, 11/24/25, at 10:40 AM a Patient 1 was observed in bed with side rails up x4. And there was a soft wrist restraint attached to Patient 1's left bed rail but not attached to Patient 1's wrist. DQRM confirmed this finding.

Review of Patient 1's record indicated Patient 1 was admitted to the facility on 9/13/25 with a history of cancer and recent stroke.

Review of facility provided orders sets titled: "LTAC Restraint Physician Order", dated between 11/20 and 11/25/25, indicated that:

On 11/20/25, at 8:00 AM, Patient 1 had an order for a left wrist restraint, and side rails x4. The order had been renewed from the previous day.

On 11/21/25, at 8:00 AM, Patient 1 had an order for a left wrist restraint, and side rails x4. The order had been renewed from the previous day.

On 11/22/25, at 8:00 AM, Patient 1 had an order for a left wrist restraint, and side rails x4. The order had been renewed from the previous day.

On 11/23/25, at 8:00 AM, Ptient 1 had an order for a left wrist restraint, and side rails x4. The order had been renewed from the previous day.

On 11/24/25, at 8:00 AM, Patient 1 had an order for a left wrist restraint, and side rails x4. The order had been renewed from the previous day.

On 11/25/25, at 8:00 AM, it indicated that Patient 1 had an order for a left wrist restraint, and side rails x4. The order had been renewed from the previous day.

A review of the orders sets were preprinted on paper with check boxes to fill in. And included a box to check if the order was a new order, or a renewal of the previous order. Five of five restraint orders reviewed in Patient 1's record indicated the order was a renewal of orders (continuation of the last order).

Review of restraint care plan documentation in Patient 1's record from 11/20/25 to 11/25/25 indicated Patient 1 had restraints documented:

On 11/20/25, from 7:00 AM to 7:00 PM, LVN 1 documented left wrist restraint. The restraint care plan was continued. The restraint care plan was continued.

On 11/20/25, from 7:00 PM to 11/21/25, 5:00 AM, RN 1 documented left wrist restraint and bed rails x4. The restraint care plan was continued.

On 11/21/25, from 7:30 AM to 10:30 AM, LVN 2 documented left wrist restraint and bed rails x4. The restraint care plan was continued.

On 11/21/25, from 12:30 PM to 11/22/25, 5:00 AM, LVN 3 documented left wrist restraint and bed rails x4. The restraint care plan was continued.

On 11/22/25, unsigned documentation indicated that the care plan was continued with left wrist restraint, and bed rails x4. No restraint checks had been documented for Patient 1 between 5:01 AM to 7:00 PM. The restraint care plan was continued.

On 11/22/25, from 7:00 PM to 11/23/25, 5:00 AM, LVN 3 documented left wrist restraint and bed rails x4. The restraint care plan was continued.

On 11/23/25, from 7:30 AM to 11:15 PM, LVN 4 documented left wrist restraint and bed rails x4. The restraint care plan was continued.

On 11/24/25, at 1:10 AM, LVN 5 documented assumed care of Patient 1. There was no restraint checks documented from 1 AM to 6:59 AM. There was no documentation to indicate the restraints had been discontinued, and the restraint care plan was continued with left wrist restraint and bed rails x4.

On 11/24/25, from 1:00 AM to 5:00 AM LVN 5 documented side rails x4 and soft wrist restraint to left wrist. The care plan was continued.

On 11/24/25, from 7:00 AM to 5:00 PM, LVN 6 documented bed rails x4. And at 5:30 PM LVN 6 documented that the left wrist restraint had been removed with Patient 1 was tolerating safely with no attempts to remove oxygen. The restraint care plan was continued.

On 11/24/25, at 6:44 PM, LVN 7 documented a left wrist restraint was applied to Patient 1. And documented an hour later Patient 1 had removed the restraint. LVN 7 indicated a deal was made with Patient 1 to keep the restraint off.

On 11/25/25, at 6:05 AM, LVN 7 documented that Patient 1 remained safe without a restraint to the left wrist through the shift, and the restraint was still off with no safety issues. An order to renew a restraint to Patient 1s left wrist was signed on 11/24/25 at 8:00 AM despite the documented change in Patient 1's condition and documentation that indicated removal of Patient 1's wrist restraint the shift prior had been tolerated safely.

2. During a facility tour on, 11/24/25, at 11:00 AM Patient 2 was observed cooperating with PT transferring to a wheelchair. There was no restraint observed.

Review of Patient 2's record indicated Patient 2 was admitted to the facility on 10/14/25 with a history of severe weakness, contractures, acute renal failure (sudden loss of kidney function), and mechanical ventilation (a machine that helps with breathing).

Review of facility provided documents titled: "LTAC Restraint Physician Order", dated between 11/20/25 and 11/25/25, indicated that:

On 11/20/25, at 9:00 AM, Patient 2 had an order for bed rails x4. The order had been renewed from the previous day.

On 11/21/25, at 8:30 AM, Patient 2 had an order for bed rails x4 and wrist restraints to right and left wrist. The order had been renewed from the previous day.

On 11/22/25, at 8:00 AM, Patient 2 had an order for bed rails x4 and wrist restraints to right and left wrist (bilateral). The order had been renewed from the previous day.

On 11/23/25, at 8:00 AM, Patient 2 had an order for bed rails x4 and wrist restraints to left wrist only. The order had been renewed from the previous day.

On 11/24/25, at 8:00 AM, Patient 2 had an order for bed rails x4 only. The order had been renewed from the previous day.

A revew of the orders sets were preprinted on paper with check boxes to indicate if the order was a new order, or a renewal of the previous order. Five of five restraint orders reviewed in Patient 2's record were renewal orders (continuation of the last order), five of five restraint orders included side rails x4, two of five orders included bilateral wrist restraint that had not been ordered previously to be renewed, and one of five orders included a left wrist only.

Review of restraint care plan documentation in Patient 2's record from 11/20/25 to 11/25/25 indicated Patient 2 had restraints documented:

On 11/20/25, from 7:00 AM to 5:00 PM, RN 2 documented bed rails x4, and bilateral wrist restraints. The restraint care plan was continued by RN 2 with the addition of bilateral wrist restraints.

On 11/20/25, at 4:40 PM RN 2 documented, "soft wrist restraints placed on BIL (bilateral) wrist". The facility was unable to provide an order signed by any LIP for bilateral wrist restraints on 11/20/25.

On 11/20/25, from 7:05 PM to 11/21/25, at 5:06 AM, RN 3 documented bed rails x4 and bilateral wrist restraints. RN 3 continued the care plan.

On 11/21/25, from 7:00 AM to 5:00 PM, RN 4 documented bed rails x4 and bilateral wrist restraints. RN 4 continued the care plan.

On 11/21/25, from 7:00 PM, to 11/22/25, at 4:40 AM, RN 5 documented restraint checks, but did not indicate the type of restraint used. RN 5 continued the restraint care plan.

On 11/22/25, from 7:15 AM to 5:15 PM, RN 6 documented bed rails x4 only. RN 6 did not update the care plan to reflect only bed rails. And RN 6 continued the restraint care plan. The facility could not provide an order to discontinue bilateral wrist restraints.

On 11/22/25, from 7:17 PM, to 11/23/25, at 6:36 AM, RN 7 documented bed rails x4 and wrist restraint to left arm. RN 7 continued the care plan. The facility could not provide an order to discontinue the right wrist restraint.

On 11/23/25, at 9:30 AM, RN 6 documented bed rails x4 and indicated Patient 2 was unable to follow commands.

On 11/23/25, from 7:00 AM to 5:00 PM, RN 6 documented bed rails x4 and bilateral wrist restraints were used in the care plan. And documented bed rails x4 was the only restraint used under restraint checks. RN 6 continued the care plan without updating to reflect the current treatment provided to Patient 2. The documentation was inconsistent, and the facility could not provide an order to discontinue either the right or left wrist restraint.

On 11/23/25, from 7:00 PM, to 11/24, at 5:00 AM, RN 5 documented bed rails x4 and continued the care plan. The facility was unable to provide an order to remove the left wrist restraint that was ordered.

On 11/24/25, at 10:32 AM, RN 8 indicated restraints with an "x". RN 8 did not document in the restraint flow sheet or the restraint care plan. The facility was unable to provide documentation to clearly indicate if Patient 2 had restraints in use from 7AM to 7PM on 11/25/25.

On 11/24/25, at 7:00 PM, to 11/25, at 5:00 AM, RN5 documented bed rails x4 were used. RN5 continued the care plan. The facility could not provide an order to discontinue restraints for Patient 2.

During an interview and concurrent record review on 11/24/25, at 11:10 AM, the Director of Nursing (DON) and DQRM confirmed that restraint documentation observed in Patient 1's record did not reflect the current restraint orders. The DON agreed that the documentation did not always clearly indicate if Patient 1 and Patient 2 had restraints on or off. The DON indicated that restraint documentation was expected to be completed each shift, at a minimum of every two hours, and documentation should include the type of restraint on the patient, the patient behaviors, the patient response to the restraint and ongoing assessments of the need for the restraint. Additionally, the DON indicated that if the restraint was removed there should be a note that described the patient's status change, and the care plan should have been updated to reflect the current treatment plan that was in use. The DON and DQRM indicated they were unsure if an order was needed to discontinue restraints. And the DON indicated that when an order included two different restraint types (bed rails x4 and wrist restraints) the nurse had discretion to use the least restrictive option or both at any time until the order was discontinued. DQRM and DON indicated the restraint order was good for 24 hours and provided the nurses with removal criteria and indicated the nurse did not need to notify the doctor if the restraint was discontinued because it was included in the order.

Based on observation, interview and record review, the facility did not ensure that nursing staff obtained an order for wrist restraints for one patient (Patient 2), when Registered Nurse (RN) 2 applied bilateral wrist restraints to Patient 2.

This failed practice had the potential the potential to lead to serious consequences such physical and psychological harm.

Findings:

Review of a facility provided nursing policy titled: "Restraint Use", last reviewed 10/2025 and in effect, indicated the use of restraint was for patient safety. And indicated clinical indicators (behaviors) would be documented to indicate why the restraint was needed, and the least restrictive restraint would be used. The policy outlined that a Licensed Independent Practitioner (LIP) order was required to initiate, change, continue, or discontinue a restraint, and each order would include the restraint type, instructions and duration of use. And the policy indicated that if a restraint was ordered emergently a signed order would be obtained within a few minutes of restraint application. Additionally, the policy indicated when a restraint was discontinued (not used) a new order would be obtained by the LIP if the restraint was needed again.

Review of a facility job description titled, Registered Nurse, last revised 2/1/2017, indicated that the RN would follow all hospital policies, ensure physicians orders were followed.

Review of Patient 2's record indicated Patient 2 was admitted to the facility on 10/14/25 with a history of severe weakness, contractures, acute renal failure (sudden loss of kidney function), and mechanical ventilation (a machine that helps with breathing).

Review of facility provided documents titled: "LTAC Restraint Physician Order", dated between 11/20/25 and 11/21/25, indicated that:

On 11/20/25, at 9:00 AM, Patient2 had an order for bed rails x4. The order had been renewed from the previous day.

On 11/21/25, at 8:30, Patient 2 had an order for bed rails x4 and wrist restraints to right and left wrist. The order had been renewed from the previous day.

On 11/20/25, from 7:00 AM to 5:00 PM, RN 2 documented bed rails x4, and bilateral wrist restraints. The restraint care plan was continued by RN 2 with the addition of bilateral wrist restraints.

On 11/20/25, at 4:40 PM RN 2 documented, "soft wrist restraints placed on BIL (bilateral) wrist". The facility was unable to provide an order signed by any LIP for bilateral wrist restraints on 11/20/25.

During an interview on11/24/25, at 10:30 AM, the Director of Quality and Risk Management (DQRM) indicated that a LIP order was needed to use a restraint on patients, and the LIP must assess the patient face to face to order or renew a restraint. DQRM indicated the LIP was available in the facility until 7:00 PM or later, and with Tele Health (a computer screen with assistance from a bedside nurse) after hours. Additionally, the DQRM indicated that the LIP would sign the order after completing the face-to-face assessment of the patient. DQRM confirmed there was not an order for bilateral wrist restraints on 11/20/25.