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Based on a review of documentation and staff interviews, the facility failed to ensure that each order for restraint used for the management of violent or self destructive behavior that jeopardized the immediate physical safety of the patient, a staff member, or others was discontinued at the earliest possible time.

Findings were:

Review of the medical records of Patient #1 and #9 revealed ongoing documented incidents of aggressive behavior toward staff and other patients that jeopardized the immediate physical safety of staff members, the patients themselves, and other patients. However, the orders for the patients' restraints were inappropriately maintained as ongoing orders for medical restraints- nonviolent and attributed to patient fall risks, rather than obtaining orders for behavioral restraints for these incidents. Patient behavioral restraints require ongoing assessment by an RN or licensed independent practitioner to determine the earliest time when the patient may be released as well as more frequent physician orders to maintain the restraint.

Facility policy #PC 200, entitled Restraint Use, effective date 9/15, included the following:
"Restraint is only to be used when clinically necessary and an emergency ...Restraint shall be a temporary measure to preserve the patient's well being as assessment deems necessary ...Restraint must be discontinued at the earliest possible time, regardless of the length of time identified in the physician order ...Use of restraints for the prevention of falls is not a routine part of the fall prevention program ...
The following is prohibited from use at any time within the organization: ...
2. Behavioral restraints ...
F. Reassessment/Monitoring ...
3. Restraint must be ended at the earliest possible time. A competent RN or LIP, after assessment of the patient, may discontinue the patient's restraints ...
4. Daily reassessment includes assessment of current condition, behavior of patient, interventions and success of alternatives, patient's response to intervention with alternatives and re-intervention as necessary ...
9. Restraint use will be discontinued as soon as less restrictive methods can be safely employed ...
G. Discontinuation
1. Patients in restraints will be continually assessed for the readiness to discontinue restraints..."

The medical record of Patient #1 included the following:

A physician order for a rear-fastening seat belt, a patient restraint which is a seat belt that fastens in back of the patient making it difficult for them to release him/herself, on 10/21/15 at 2:56 p.m. read as follows:
"CONTINUOUS SEAT BELT REAR FASTENING ...
Restraints initiated due to risk of injury related to patient's risk to self or others.
Restraint type(s) utilized on patient include rear fasten seatbelt ..."

The rear fastening seat belt restraint was ordered by the physician on the following dates:
o 10/21/15 at 2:56 p.m.
o 10/22/15 at 4:42 a.m.
o 10/23/15 - 11/4/15 at 6:00 a.m. each day
From 10/22/15 through 11/4/15, the frequency of the seat belt order was noted as "Daily 0600."

A physician order for an enclosed net bed, a patient restraint, on 10/27/15 at 6:00 p.m. read as follows:
"CONTINUOUS ENCLOSED BED NET BED ...
Restraints initiated due to risk of injury related to patient's risk to self or others.
Restraint type(s) utilized on patient include side rails x4 in addition to rear fasten seatbelt ..."

Subsequent orders for the enclosed net bed restraint included the phrase, "Further explanation of reason restraints initiated: Extremely High Fall Risk ..."

The enclosed net bed restraint was ordered by the physician on the following dates:
o 10/27/15 at 6:00 p.m.
o 10/28/15 - 10/30/15 at 6:00 a.m. each day
From 10/28/15 through 10/30/15, the frequency of the net bed order was noted as "Daily 0600."

Physician progress notes for Patient #1 included the following:
· 10/21/2015 at 8:10 a.m.: "Subjective: Patient and wheelchair going to therapy. She is quite agitated and aggressive this morning. She is trying to hit and bite. Currently looking for placement for this young lady. She is incontinent of bowel and bladder. Making little if any progress with therapies. Continues to be aphasic. Nursing reports no other issues at this time ..." (Note: Initiation of a rear fastening seat belt is not mentioned.)
· 10/27/15 at 8:01 a.m.: "Subjective: Patient is awake alert and sitting up in bed eating breakfast. The CNA is helping her with that. This patient was aggressive with another patient's family member yesterday. She has learned how to unlock her wheelchair and propel it down the hallway on her own. Most likely will have to get her a net bed to keep her contained. She continues to be incontinent of bowel and bladder. Appetite is excellent. Nursing reports no other issues or concerns ..."
· 10/28/2015 at 7:59 a.m.: "Subjective: Patient is resting comfortably in her net bed. Appears to be in no acute distress or acute pain. This was required to keep her from roaming in the hall and being aggressive with other patients or family members of patient's. Her appetite continues to be very good. Incontinent of bowel and bladder. Sleeping well at night. Anticipating discharge next Tuesday..."

Relevant nursing notes for Patient #1 were as follows:

· 10/15/15 at 11:55 a.m.: "Patient set off the bed alarm for the 5th time in a row. Assisted CNA to check the patient and move her up in bed so that she can eat lunch. Patient swinging her arms and mouthing "no", but once her food tray was delivered, she kept grabbing at the tray and kicking at nurse and CNA..."
· 10/17/15 at 8:36 a.m. "0800 other therapist got pt dressed and up in w/c, with front seat belt in place, pt is getting combative with therapist and trying to bite her..."
· 10/21/15 at 2:26 p.m. "1420 pt is now unfastening her front seatbelt, also she is pulling chair alarm off."
· 10/21/15 at 3:33 p.m. "1500 put back to bed, sr (side rails) up x 3, bed low position, bed alarm is on."
· 10/22/15 at 2:51 p.m. "0800 has been fed breakfast, pt is some what combative when trying to get her dressed, dressed and then put in w/c with rear fastening seatbelt and chair alarms..."
· 10/22/15 at 5:07 p.m. "1630 was going to put pt back to bed, but pt became combative and hitting at nurses. Pt left in w/c (wheelchair) with rearfastening [sic] seatbelt. And chair alarm on..."
· 10/27/15 at 9:01 a.m. "Pt is lying in the bed and CNA is trying to change pt's brief. Pt is trying to bite, hit and scratch the CNA at this time. Gave am meds with PRN Ativan 1mg and OxyIR 5mg (Note: also ordered PRN). Pt appears to be in pain or discomfort at this time. Pt tried to hit, scratch and bite the nurse. Will continue to monitor. Pt is lying in the bed, side rails up x3 and bed alarm on ..."
· 10/27 15 at 2:43 p.m. "CNA staff and nurse changed pt's brief at this time due to urine. Pt was transferred in the net bed at this time. Nurse continues restraint log and monitors every hour. Pt was kicking, scratching and trying to bite the CNA staff and nurse during the process. No distress noted."
· 10/30/15 at 7:00 a.m. "Patient impulsive and a high fall risk with potential for injury, patient also has hx of combativeness and requires close supervision. Net bed in place to assist with patient's safety needs."

Restraint/seclusion assessment records for Patient #1 continued as above for the rear fastening seat belt through the date of her discharge on 11/5/15. The enclosed net bed was ordered only through 10/30/15. Assessments were required every two hours for the need to continue the restraints, and an LVN, contrary to facility policy, often performed the assessments which determined patient status and the need to continue the restraints.

Fall risk assessment scores were documented for Patient #1 on nursing shift assessments as follows:
"Fall Risk Assessment ...High risk fall interventions were implemented, based on a score of 45 or greater obtained using the Morse Fall scale. Fall Risk Score= 55. Patient does not have a history of falling during this admission or within the last 3 months. There is a secondary diagnosis noted which could increase the risk of a fall ..."

A review of the clinical record of Patient #9 revealed a nursing progress note on 3/14/16 at 5:20 p.m. included, "Pt in bed, family has left unit, Pt trying to get out of bed, when offered assistance to Pt to get OOB (out of bed), became combative, when redirected, became more combative. Pt does not seem to understand importance of not getting OOB without assistance ..." An enclosed net bed restraint documentation record was initiated at 6:00 p.m. on 3/14/16. Assessments were required every two hours for the need to continue the restraints, and an LVN, contrary to facility policy, often performed the assessments which determined patient status and the need to continue the restraints. A review of subsequent nurse progress notes for this patient reveal no further incidents of combative behavior.

Patient #9 had a restraint documentation record for each of the following dates:
Enclosed Net Bed: 3/14/16 - 3/23/16
Rear Fastening Seat Belt: 3/15/16 - 3/21/16, 3/26/16 - 3/29/16.

In an interview with the Staff #1, Chief Nursing Officer, on the morning of 5/3/16 in the facility conference room, he was asked whether he recalled Patient #1 and whether the patient had been restrained during transport to another facility. He stated, "I know the case you're talking about ...This patient wasn't restrained while she was here at any point or when she left ..."

In a subsequent interview with Staff #1, Chief Nursing Officer, on the morning of 5/4/16 in the facility conference room, he discussed the fall risk assessment rating given to patient at the facility. He stated, "Anything over a 50 we consider a high fall risk. Patient #1 was rated a 55. These were restraints we used because she was a high fall risk..." Staff #1 confirmed the above findings.

In an interview with Staff #7, the attending physician for Patient #1 at TrustPoint Hospital, on the morning of 5/4/16 in the facility conference room, in a discussion regarding this patient and her restraints while at the facility, he stated, "This patient was a fall risk ...Yes, this patient was restrained but it was because of falls." Discussion ensued regarding the lack of nursing documentation in the patient's record regarding staff concerns about her falling as compared to the ample documentation regarding her combativeness and aggression. Staff #7 stated, "I think you just don't get it. This was a patient who was real likely to fall. I'm just glad she didn't."

The above two incidents described violent behavior that jeopardized the immediate physical safety of the patient and staff members. These restraints were ordered and documented as non-violent restraints with orders lasting 24 hours. The appropriate order for violent behavior should be limited to 4 hours or less, before renewal. The above findings were discussed a final time in an interview with Staff #1 on the morning of 5/4/16 in the facility conference room.

Based on a review of facility documentation and staff interviews, the facility failed to ensure that the condition of each patient who was restrained was monitored by a physician, other licensed independent practitioner or trained staff at an interval as determined by the hospital policy for 2 of 2 patients (Patients #1 and #9) who were restrained.

Findings were:

Facility policy #PC 200, entitled Restraint Use, effective date 9/15, included the following:
"Restraint is only to be used when clinically necessary and an emergency ...Restraint shall be a temporary measure to preserve the patient's well being as assessment deems necessary ...Restraint must be discontinued at the earliest possible time, regardless of the length of time identified in the physician order ...Use of restraints for the prevention of falls is not a routine part of the fall prevention program...
III. Procedure
A. Assessment ...
2. Assessment of the patient's need for restraint and/or alternative measures is performed. Only a registered nurse with documented current competencies to assess the initial or ongoing need for restraints may assess/reassess the patient ...
F. Reassessment/Monitoring ...
3. Restraint must be ended at the earliest possible time. A competent RN or LIP, after assessment of the patient, may discontinue the patient's restraints ...
9. Restraint use will be discontinued as soon as less restrictive methods can be safely employed ...
G. Discontinuation
1. Patients in restraints will be continually assessed for the readiness to discontinue restraints...
J. Staff Education ...
b. For staff authorized to perform assessment (Registered Nurse, Physician)..."

The medical record of Patient #1 included the following:

A physician order for a rear-fastening seat belt, a patient restraint which is a seat belt that fastens in back of the patient making it difficult for them to release him/herself, on 10/21/15 at 2:56 p.m. read as follows:
"CONTINUOUS SEAT BELT REAR FASTENING ...
Restraints initiated due to risk of injury related to patient's risk to self or others.
Restraint type(s) utilized on patient include rear fasten seatbelt.
Patient monitored every 60 minutes..."

The rear fastening seat belt restraint was ordered by the physician on the following dates:
o 10/21/15 at 2:56 p.m.
o 10/22/15 at 4:42 a.m.
o 10/23/15 - 11/4/15 at 6:00 a.m. each day
From 10/22/15 through 11/4/15, the frequency of the seat belt order was noted as "Daily 0600."

A physician order for an enclosed net bed, a patient restraint, on 10/27/15 at 6:00 p.m. read as follows:
"CONTINUOUS ENCLOSED BED NET BED ...
Restraints initiated due to risk of injury related to patient's risk to self or others.
Restraint type(s) utilized on patient include side rails x4 in addition to rear fasten seatbelt.
Patient monitored every 60 minutes..."

The enclosed net bed restraint was ordered by the physician on the following dates:
o 10/27/15 at 6:00 p.m.
o 10/28/15 - 10/30/15 at 6:00 a.m. each day
From 10/28/15 through 10/30/15, the frequency of the net bed order was noted as "Daily 0600."

Restraint/Seclusion Care Documentation Records in the clinical record of Patient #1 included the following:

· 10/22/15 Rear Fastening Seat Belt: Patient assessments began at 6:00 a.m. and a notation was made each hour. The patient was "in bed" at 6:00 a.m. and 7:00 a.m. At 8:00 a.m. and each hour thereafter until 5:00 p.m., restraint assessments of the patient were completed by a staff LVN contrary to facility policy. The assessments included parameters for "criteria for use continues" and "managed safety/no injuries."
· 10/23/15 Rear Fastening Seat Belt: Patient assessments began at 6:00 a.m. and each hour included the notation "Pt in Bed" with the exception of 10:00 a.m. and 11:00 a.m. indicating Patient #1 was restrained at those times. The restraint assessments were made by a staff LVN.
· " 10/26/17 [sic]" Rear Fastening Seat Belt: At 8:00 p.m., patient restraint assessments were completed by a staff LVN. From 9:00 p.m. through 4:00 a.m., assessments were marked, but unsigned, thus there was no way to ascertain whether an appropriately trained and licensed individual had completed the assessments.
· 10/27/15 Rear Fastening Seat Belt: Restraint assessments were completed by an RN. At 2:00 p.m. and 4:00 p.m., it was noted that the patient was "In Bed/Side Rails x 3." No assessment was performed at 3:00 p.m. From 8:00 p.m. through the remainder of this date, an LVN had marked the assessment form "Not in Use."
· 10/27/15 Net Bed: Patient restraint assessments began at 6:00 p.m. for this restraint and were completed each hour. Each assessment was made by a staff LVN.
· 10/28/15 Rear Fastening Seat Belt: The patient is noted as being in bed for each hour throughout the 24 hour period. As an order for an enclosed net bed was in effect, it is assumed the patient was in the net bed.
· 10/28/15 Net Bed: Hourly patient restraint assessments were completed by an RN from 6:00 p.m. through 4:00 a.m. only. The remaining assessment check times are blank, yet the patient was documented to have been in bed the entire day. Thus the facility could provide no documentation the patient was assessed for continuation of restraints during the time period from 6:00 a.m. to 6:00 p.m.
· 10/29/15 Net Bed: Patient restraint assessments from 6:00 a.m. through 4:00 p.m. were completed by a staff LVN.

The medical record of Patient #9 included a nursing progress note on 3/14/16 at 5:20 p.m. included, " Pt in bed, family has left unit, Pt trying to get out of bed, when offered assistance to Pt to get OOB, became combative, when redirected, became more combative. Pt does not seem to understand importance of not getting OOB without assistance ... " An enclosed net bed restraint documentation record was initiated at 6:00 p.m. on 3/14/16. Assessments for the need to continue the restraint and patient response to restraint were completed by an LVN on 3/14/16 from 6:00 p.m. through 4:00 a.m. The hourly assessments evaluating the need to continue a rear fastening seat belt restraint documentation record was completed by an LVN from 5:00 p.m. to 5:00 a.m. on 3/19/16.

The above findings were confirmed in an interview with the Chief Nursing Officer on the morning of 5/4/16 in the facility conference room.