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Based on record review, policy and procedure review and interviews, the Hospital failed to ensure that for three patients, (Patient #6, #7 and #8), out of a total sample of 10 patients, the Plan of Care with regard to restraint use, was updated and evaluated in accordance with Hospital Policy.

Findings include:

The Hospital Policy titled Restraint Utilization, dated July of 2012, indicated that a care plan to reduce restraint use will be implemented on all patients in restraints to ensure that the physical safety of the non-violent or non-self-destructive patient will be reviewed and renewed daily.


The Medical Restraint Order and Flow Record indicated that every 24 hours: a) an evaluation of the least restrictive intervention used/considered that are ineffective will be documented, b) a reason for restraint use is documented and c) the nurse will assess the restrained patient every 2 hours while in restraints for patient safety and physical needs and document.


The Medical Restraint Order and Flow Record indicated that every 12 hours (once on the 7:00 A.M. to 7:00 P.M. shift and once on the 7:00 P.M. to 7:00 A.M. shift): a) a precipitating/continued reason for restraints will be documented, b) patient specific interventions will be documented and c) the Plan of Care with regard to continued or discontinued restraint use will be assessed and documented.


1) Review of Patient #6's Hospital Record indicated that he/she was admitted to the Long Term Acute Care facility (LTAC) on 1/17/14 at 7:26 A.M.


The Medical Restraint Order and Flow Record indicated that, on 1/17/14 at 8:00 P.M., Patient #6 was pulling at his/her intravenous (IV) tubing and dressings and was unable to follow safety instructions to prevent disruption of life sustaining interventions. The Medical Restraint Order and Flow Record indicated that soft limb restraints and mitts were applied to prevent Patient #6 from pulling out IV lines and his/her breathing tube.


The Medical Restraint Order and Flow Record indicated that, on 1/17/14 and 1/18/14, soft limb restraints were used to prevent Pt. #6 from pulling out his/her IV lines and breathing tube.


The Medical Restraint Order and Flow Record indicated that, on 1/19/14, the soft limb restraints were removed and hand mitts were applied from 1/19/14 to 1/23/14 to prevent Pt. #6 from pulling out his/her IV lines and breathing tube.


Review of the Medical Restraint Order and Flow Records, from 1/17/14 to 1/23/14 (7 days reviewed), for Patient #6 indicated that:


For 1 out of the 7 Medical Restraint Order and Flow Records reviewed the reason for restraint use was not documented as required.


For 4 out of the 7 Medical Restraint Order and Flow Records reviewed for the 7:00 A.M. to 7:00 P.M shift, the Plan of Care regarding the need for continued or discontinued use of restraint was not documented as required.


For 5 out of the 7 Medical Restraint Order and Flow Records reviewed for the 7:00 P.M. to 7:00 A.M shift, the Plan of Care regarding the need for continued or discontinued use of restraint was not documented as required.


2) Review of Patient #7's Hospital Record indicated that he/she was admitted to the LTAC on 4/2/14 at 7:22 P.M.


The Medical Restraint Order and Flow Record indicated that, on 4/4/14 at 7:00 A.M., Patient #7 was pulling at his/her intravenous (IV) tubing and dressings and was unable to follow safety instructions. The Medical Restraint Order and Flow Record indicated that soft limb restraints were applied to prevent Patient #6 from pulling out IV lines.


Review of the Medical Restraint Order and Flow Records, from 4/4/14 to 4/7/14 (3 days reviewed), for Patient #7 indicated that:

For 2 out of the 3 Medical Restraint Order and Flow Records reviewed the reason for restraint use was not documented as required.

For 2 out of the 3 Medical Restraint Order and Flow Records reviewed for the 7:00 A.M. to 7:00 P.M shift, the Plan of Care regarding the need for continued or discontinued use of restraint was not documented as required.


For 1 out of the 3 Medical Restraint Order and Flow Records reviewed for the 7:00 P.M. to 7:00 A.M shift, the Plan of Care regarding the need for continued or discontinued use of restraint was not documented as required.

3) Review of Patient #8's Hospital Record indicated that he/she was admitted to the LTAC on 3/8/14 at 5:20 P.M.


The Medical Restraint Order and Flow Record indicated that, on 3/8/14 at 7:00 P.M., Patient #8 was placed in restraints. The Medical Restraint Order and Flow Record for 3/8/14 did not indicate: a) the type of restraint used, b) the less restrictive interventions used/considered that were ineffective, or c) the reason for restraint use.

The Medical Restraint Order and Flow Record, dated 3/9/14, indicated that Patient #8 was pulling at his/her intravenous (IV) tubing and dressings and was unable to follow safety instructions to prevent disruption of life sustaining interventions. The Medical Restraint Order and Flow Record indicated that soft limb restraints were applied to prevent Patient #8 from pulling out IV lines and his/her breathing tube.


For 1 out of the 4 Medical Restraint Order and Flow Records reviewed, the every two hour Registered Nurse (RN) check for patient safety and need was not consistently documented as required.


For 1 out of the 4 Medical Restraint Order and Flow Records reviewed for the 7:00 P.M. to 7:00 A.M. shift, the patient specific interventions were not documented as required.

For 2 out of the 4 Medical Restraint Order and Flow Records reviewed for the 7:00 A.M. to 7:00 P.M shift, the Plan of Care regarding the need for continued or discontinued use of restraint was not documented as required.

For 1 out of the 4 Medical Restraint Order and Flow Records reviewed for the 7:00 P.M. to 7:00 A.M shift, the Plan of Care regarding the need for continued or discontinued use of restraint was not documented as required.

Based on observation, record review and interview, the Hospital failed to ensure for one patient, (Patient #1), out of a total sample of 10 patients, the Plan of Care with regard to: a) wound care, b) range of motion (ROM) exercises, c) application of orthotic devices (a brace or splint) to prevent foot drop (when the front lower leg muscles are too weak to lift the foot upward at the ankle), d) the administration of nutritional supplement and e) oral care was implemented, completed and/or evaluated according to Hospital Policy and Practitioner's Orders. The Hospital also failed to ensure that the Interdisciplinary Plan of Care was implemented and/or evaluated according to Hospital Policy for two patients, (Patient #1 & Patient #3), out of a total sample of 10 patients.


Findings include:

1) The Hospital Policy titled, Plan for the Provision of Care, revised date 4/2013, indicated that the care, treatment and planning processes are designed to ensure that appropriate care is delivered according to the patient's specific needs and the severity level of their disease, condition, impairment, and/or disability. Individualized care, treatment and therapy goals are identified, as well as the services required to meet these goals.

2) Review of Patient #1's Transfer Summary indicated that Patient #1 was transferred from an Acute Care Hospital to the Long Term Acute Care Hospital (LTAC) on 3/5/14 for the continued care and treatment of a Stage IV pressure ulcer (a deep pressure sore reaching into muscle and bone) of the left buttock. The Transfer Summary indicated that Patient #1 had a skin graft of the pressure ulcer at the Acute Care Hospital in an effort to promote healing.

The Surveyor interviewed the Family Member at 9:17 A.M. on 4/14/14. The Family Member said that Patient #1's pressure ulcer was not cared for properly at the LTAC.

Review of Patient #1's Care Plan, dated 3/6/14, indicated that Impaired Skin Integrity and Pressure Ulcer (Active) were identified as problems and appropriate interventions were documented. The Care Plan indicated that the pressure ulcer dressing changes would be done per order of the Practitioner and nursing would conduct a weekly assessment of the wound area.

Review of Patient Care Notes, dated 3/6/14 at 2: 43 A.M. to 4/18/14 at 6:19 A.M., did not indicate a nursing wound and skin assessment for the week of 4/6/14 or 4/13/14.

Review of the Daily Electronic Nursing Worklist, dated 3/12/14 to 4/17/14, indicated that, on 3/12/14 at 5:55 P.M., the Wound Care Physician ordered the pressure ulcer graft area to be washed every 12 hours with saline followed by a saline wet to dry dressing (placing a moist gauze dressing on a wound area and allowing it to dry so wound drainage and dead tissue can be removed when the old dressing is changed).

Review of the Daily Electronic Nursing Worklist, dated 3/12/14 to 4/17/14, did not indicate that any dressing changes were done on 3/18/14, 3/25/14, 3/27/14, 3/28/14, 3/29/14, 3/31/14, 4/2/14, 4/6/14 and 4/11/14.

Review of the Daily Electronic Nursing Worklist, dated 3/12/14 to 4/17/14, indicated that only one dressing change was done on 3/19/14, 3/20/14, 3/21/14, 3/22/14, 3/23/14, 3/24/14, 3/26/14, 3/30/14, 4/1/14, 4/3/14, 4/4/14, 4/5/14, 4/7/14, 4/8/14, 4/9/14, 4/10/14, 4/13/14 and 4/17/14.

The Surveyor interviewed the Family Member on 4/14/14 at 9:17 A.M. The Family Member said that the Hospital was not providing Patient #1 with any ROM exercises or doing anything about his/her foot drop.

Review of Patient #1's Care Plan, dated 3/6/14, indicated that orthotic devices (to prevent foot drop) would be applied per Practitioner's orders and ROM exercises would be initiated in order to maintain Patient #1's independent activities of daily living in as much as his/her condition allowed.

Review of the Daily Electronic Nursing Worklist, dated 3/26/14 to 4/17/14, indicated that, on 3/26/14 at 2:33 P.M., Nurse Practitioner #1 ordered bilateral L'Nard boots (an orthotic boot to prevent foot drop) to be on for 2 hours and to be off for 2 hours throughout the day.

Review of the Daily Electronic Nursing Worklist, dated 3/26/14 to 4/17/14, did not indicate that the L'Nard boots were applied per schedule on 3/27/14, 4/3/14, 4/4/14, 4/5/14, 4/7/14, 4/9/14, 4/12/14, 4/14/14, 4/15/14, 4/16/14 and 4/17/14.

Review of the Daily Electronic Nursing Worklist, dated 4/9/14 to 4/17/14, indicated that, on 4/9/14 at 12:04 P.M., the Wound Care Physician ordered ROM exercises to all extremities except the right shoulder (Patient #1 had a history of a chronic dislocation of the right shoulder) every shift (2 times every 24 hours because of 12 hour shifts).

Review of the Daily Electronic Nursing Worklist, dated 4/9/14 to 4/17/14, indicated that ROM exercises were conducted only one time on 4/10/14, 4/11/14, 4/12/14, 4/13/14, 4/14/14, 4/16/14 and 4/17/14.

The Surveyor interviewed the Family Member on 4/14/14 at 9:17 A.M. The Family Member said Pt. #1 did not always get his/her nutritional supplements (high protein drinks) which were ordered to optimize wound healing.

Review of Patient #1's Care Plan, dated 3/6/14, indicated that nutritional intake (protein) would be monitored in an effort to aid in the healing of the pressure ulcer.

Review of the Daily Electronic Nursing Worklist, dated 3/13/14 to 4/17/14, indicated that, on 3/13/14 at 11:47 A.M., Nurse Practitioner #2 ordered Ensure (a balanced nutritional supplement) three times a day with meals, and Healthy Shots (a high protein supplement) twice daily between meals for Patient #1.

Review of the Daily Electronic Nursing Worklist, dated 3/13/14 to 4/17/14, did not indicate that Patient #1 received any Ensure on 3/18/14, 3/25/14, 3/28/14, 3/30/14, 3/31/14, 4/2/14, and 4/11/14.

Review of the Daily Electronic Nursing Worklist, dated 3/13/14 to 4/17/14, indicated that Patient #1 received Ensure only one time on 4/13/14.

Review of the Daily Electronic Nursing Worklist, dated 3/13/14 to 4/17/14, indicated that Patient #1 received Ensure only 2 times on 3/15/14, 3/19/14, 3/20/14, 3/21/14, 3/23/14, 3/24/14, 3/26/14, 3/27/14, 3/29/14, 4/1/14, 4/4/14, 4/8/14, 4/9/14, 4/10/14, 4/12/14, 4/14/14, 4/15/14 and 4/16/14.

Review of the Daily Electronic Nursing Worklist, dated 3/13/14 to 4/17/14, did not indicate that Pt. #1 received any Healthy Shots on 3/23/14, 3/28/14, 3/29/14, 3/30/14, 3/31/14, 4/1/14, 4/2/14, 4/7/14 and 4/11/14.

Review of the Daily Electronic Nursing Worklist, dated 3/3/14 to 4/17/14, indicated that Pt. #1 received only one Healthy Shot on 3/15/14, 3/16/14, 3/19/14, 3/25/14, 3/26/14, 3/27/14, 4/3/14, 4/8/14, 4/9/14, 4/12/14, 4/13/14, 4/14/14, 4/15/14, and 4/16/14.

The Surveyor interviewed the Family Member on 4/14/14 at 9:17 A.M. The Family Member said that Pt. #1 developed oral thrush (a condition in which the fungus Candida albicans accumulates on the lining of the mouth) as a result of poor oral care.

Review of Pt. #1's Transfer Summary from the Acute Care Hospital indicated that Pt. #1 was being treated for oral thrush prior to discharge from the Acute Care Hospital and was on Nystatin Oral Suspension (an antifungal medication); however, the Daily Electronic Nursing Worklist did not indicate that oral care was provided to Pt. #1 on 3/11/14, 3/19/14, 3/21/14, 3/22/14, 3/28/14, 3/30/14, 4/6/14, 4/11/14, 4/14/14 and 4/15/14.

Review of Pt. #1's Admission History and Physical to the LTAC, dated 3/6/14 at 1:46 P.M., indicated that the Nystatin Oral Suspension would be continued three times a day and was noted as given on the Electronic Medication Administration Record.

The Surveyor noted on a tour of the LTAC Unit on 4/18/14 that Pt. #1 had a sign over his/her bed reminding staff to provide oral care after every meal.

3) The Hospital Policy titled, Interdisciplinary Team (IDT) Care Meeting, revised date 10/2013, indicated that the IDT team meets within 7 calendar days of a patient's admission and weekly thereafter. The IDT Policy indicated that team members have a role in participating in the IDT meeting to assure that patient care is delivered according to each patient's unique need. The IDT Policy indicated that team members include the following disciplines: Medical Staff, Nursing, Case Management, Rehabilitation Care, Respiratory Care, Nutrition Services, Pharmacy and Wound Care and that each discipline provides a summary of the patient's progress towards identified goals.

Review of Patient #1's IDT Care Conference Records did not indicate any wound care update/assessment for the week of 3/11/14, 3/18/14, 3/25/14, 4/1/14, or 4/8/14.

Review of Patient #1's IDT Care Conference Records did not indicate any nursing attendance/input for the week 3/18/14 or 4/1/14.

4) Review of Patient #3's Hospital Record indicated that Patient #3 was transferred from an Acute Care Hospital to the Long Term Acute Care Hospital (LTAC) on 3/1/14 for continued care and treatment after a traumatic brain injury from a motor vehicle accident. The Hospital Record indicated that Patient #3 had a tracheostomy (surgical opening into the windpipe) and was on a ventilator (breathing machine).

Review of Patient #3's IDT Care Conference Records did not indicate any nursing attendance/input for the week of 4/1/14.