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Based on clinical record review, interview and review of manufacturer's guidelines, it was determined 2 (#1 and #2) patients of 11 (#1-#11) patients were not afforded safe implementation and monitoring of restraints by trained staff. Nursing staff were not knowledgeable in the safe and recommended use of a safety enclosure bed. Failure to provide patients with effectively trained, knowledge staff to initiate, monitor and affect safe restraint use had the potential to allow patient injury. The failed practice affected Patients #1 and #2 and had the potential to affect any patient placed in a safety enclosure bed. Findings follow:

A. Review of manufacturer's guidelines, Safe-T Care Manufacturing, Inc., Product Operation Manual )(Model LTC) received from the Chief Nursing Officer (CNO) at 1200 on 09/28/12 revealed the following on page 2, under "PRECAUTIONS (continued), " "#4. Always leave side rails in the "up" position except when moving the patient from the bed." The CNO stated these manufacturer's guidelines were placed on each safety enclosure bed by the rental company and were there for the nurses to use as a reverence guide.

B. Review of the nursing note of Patient #1 revealed documentation of less than four side rails up while Patient #1 was in an enclosure bed from 09/14/12 through 09/19/12. The above was verified by the CNO at 1115 on 10-01-12.

C. Review of the nursing note of Patient #2 revealed documentation of less than four side rails while Patient #2 was in an enclosure bed from 07/25/12 through 07/28/12/. The above was verified by the CNO at 115 on 10/01/12.

D. During an interview with Registered Nurse (RN) #4 at 1150 on 09/28/12, she was asked how many side rails were placed in the up position on a safety enclosure bed when a patient was placed in it and she stated "no more than three up because four would be a double restraint".

E. During an interview with Registered Nurse (RN) #5 at 1155 on 09/28/12, she was asked how many side rails were placed in the up position on a safety enclosure bed when a patient was placed in it and she stated "The top two rails at the head only."

F. During an interview with Registered Nurse (RN) #6 at 1200 on 09/28/12, she was asked how many side rails were placed in the up position on a safety enclosure bed when a patient was place in it and she stated "Three side rails would be placed up."

G. During an interview with Registered Nurse #7 at 1030 on 10-01-12, she was asked how many side rails were placed in the up position on a safety enclosure bed when a patient was placed in it and she stated "Three side rails up, but only one up if a mat was on the floor."

H. During an interview with Registered Nurse #8 at 1040 on 10-01-12. She was asked how many side rails were placed in the up position on a safety enclosure bed when a patient was placed in it and she stated "Two side rails up for an enclosure bed."

J. During an interview with Registered Nurse #9 at 1040 on 10-01-12, she was asked how many side rails were placed in the up position on a safety enclosure bed when a patient was placed in it and she stated "Two side rails up."

Based on observations during a tour of the Facility on 09/27/12 beginning at 0935, it was determined the Facility failed to maintain furnishings in a state of good repair and cleanliness. Failure of the Facility to maintain furnishings in a state of good repair and cleanliness did not ensure patients received care in a clean and sanitary environment. Findings follow:

A. During the tour of Room 6020 at 0940 on 09/27/12, a thick, swirled accumulation of dust and trash (medication cup, bits and pieces of paper) were visible from the doorway. The above was verified by the CNO at 0940.

B. During the tour of Room 6017 at 1005 on 09/27/12, a thick swirled accumulation of dust and trash ( needle cover, bits and pieces of paper) were visible from the doorway. The window ledge, the head wall and the fan were coated with thick layers of dust. The above was verified by the CNO at 0941.

C. During the tour of Room 6015 at 0943 on 09/27/12, a thick, swirled accumulation of dust and trash (bits and pieces of paper) were visible under the bed. The above was verified by the CNO at 0943.

D. During the tour of 6013 at 1000 on 09/27/12, a swirled accumulation of dust and trash (medication cup, bits and pieces of paper) were noted under the bed and on the mats next to the bed. The window ledge was covered with a thick accumulation of dust as was the head wall and the tops of picture frames. The bedside/visitor's chair had an extremely thick coat of dust, food particles and other trash on the wooden support on either side of the seat and on the bottom rails. The base of the bed was dusty and several small, rust and yellowish spots were noted on the base. The visitor in Room 6012 stated the room had been "that way since we came". The top of the over bed table was noted to have a sticky substance on it as well. The blades of the fan blowing on the patient were coated with thick dust and the motor housing was noted to have thick layers of dust and strands of hair coating it. The above was verified by the CNO at 1000.

E. During the tour of Room 6009 at 1005 on 09/27/12, a thick layer of heavy dust was noted on the head wall and swirling dust was noted under the bed. The overbed table legs and the base of the Intravenous (IV) pole were covered with brown, reddish brown and off white spots. A urinal containing 200 milliliters of urine was noted sitting on the window ledge. The patient occupying Room 6013 was a tracheostomy patient. The above was verified by the CNO at 1005 on 09/27/12.

F. During the tour of Room 6001 at 1010 on 09/27/12, a thick layer of dust was noted on the head wall.

G. During the tour of Room 6085 at 1020 on 09/27/12, a candy wrapper, a gum wrapper and a medication cup under the bed were visible from the doorway.

H. During a tour of Room 6088 at 1030 on 09/27/12, a thick layer of dust was noted on the window ledge and the bed base was covered with multiple colors (brown, reddish brown) spots. The corners of the bed were coated with multiple colors (brown, reddish brown) of spots as well as flecks of sand. The above was verified by the CNO at 1040 on 09/27/12.