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Based on review of hospital policies and interviews with hospital staff, the hospital failed to identify the steps the hospital would take to protect the patient and staff during abuse allegations. The hospital's abuse policy was requested and reviewed on the morning of 11/20/14. The policy did not instruct staff what steps are needed to immediately protect the patient and the staff, against whom the allegation was made, while the allegation is investigated. This was confirmed by Staff A.

Based on review of medical records, policies and procedures and hospital documents and interviews with hospital staff, the facility failed to ensure patient restraints were applied according to specific/complete orders for the restraints. This occurred in two of three medical records (Patients #1 and 3) reviewed for patients identified as having restraints applied.

Findings:

1. Record #1 - The record did not contain orders for specific restraints - the orders for restraints on 11/13, 11/14, 11/16 and 11/17/14 were for the use of soft wrist restraints. Nursing documentation for the above dates, documented mittens were also used on the patient. There were no orders for the mittens.

On 11/5 and 11/6/14, Patient #1 restraints were removed and reapplied. The medical record did not contain orders for the reapplication of the restraints.

2. Record #3 -The medical record documented the patient was restrained from 10/30-11/14/14. Restraints were removed and reapplied on 10/31 and 11/12/14. The medical record did not contain orders for the reapplication of the restraints.


3. The above findings were reviewed and verified with Staff A at the time of medical record review on 11/20/14.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure the clinical record documented a clear and detailed description of the patient's condition and symptoms that warranted the use of physical restraint and seclusion. This occurred in two of three medical records (Patients #2 and 3) reviewed for patients identified as having restraints applied.


Findings:

A hospital policy titled, "Restraint Reduction Plan," documented, "... The use of restraints is limited to those situations for which there is adequate and appropriate justification. The use of restraints for the following reasons is prohibited: the routine use of restraints for the prevention of falls...."

Patient #2 - had a endotracheal tube (ET) used for ventilation. The patient was in soft wrist restraints from 08/28 through 9/9/14. Nursing documented the patients behavior as "sedated", "non-arousable", "lethargic" and "non-responsive".

Patient #3- was restrained from 10/30 through 11/14. The patient was on a continuous intravenous Versed drip. Nursing documented the patients behavior as "sedated", "unresponsive", "lethargic", and "trying to get out of bed".

The above information was confirmed by Staff A during medical record review.