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Based on staff interview and a review of facility documents, it was determined facility staff failed to ensure that there were ongoing assessments which demonstrated that continued restraint was needed for one (1) of two (2) patients sampled (Patient #1).

Findings included:

Patient #1 was admitted to the facility on 10/18/18. A review of Patient #1's medical record revealed a physician order for right and left upper extremity restraints (RUE/LUE) for safety due to agitation/delirium.

A nursing progress note on 10/21/18 from 1520-1605 (3:20 p.m. - 4:05 p.m.) by Staff Member (SM) #12 a registered nurse (RN), documented the following related to Patient #1: "Patient observed trying to climb out of bed; agitated, chewing on hand mitts, turning self-attempts to calm were unsuccessful. MD paged to bedside, restraints, medical orders implemented".

The record review also revealed a physician order for IV (intravenous) Haldol 2 milligrams (an antipsychotic medication used for agitation), IV Lorazepam 0.5 mg, (an anti-anxiety medication), and Toradol 15 mg IV (non-steroidal anti-inflammatory pain medication), which were documented as administered between 4:25 p.m. and
4:29 p.m. on 10/21/18.

After the initial RN assessment noted above, there were three nursing assessments documented on the restraint flow sheet for Patient #1 by registered nurses SM 's # 16 and 13 between 6:28 p.m. and 8:00 p.m. on 10/21/18.

The restraints were documented to be in use by SM #15, a patient care assistant (PCA), at 4:37 p.m., 5:02 p.m., and 7:00 p.m. on 10/21/18. SM #14, a patient care technician (PCT), documented continued restraint use at 7:46 p.m., 9:00 p.m., 9:07 p.m., 10:07 p.m., 10:09 p.m., and 11:09 p.m. on 10/21/18. SM #14's flow sheet notes at 10:07 p.m., 10:09 p.m., and 11:09 p.m. on 10/21/18 documented that Patient #1 was "sleeping".

Documentation was not available which evidenced that a nursing assessment was performed after the time period of 7:01 p.m. - 8:00 p.m. on 10/21/18, or that a nurse re-assessed the patient after SM #14, a PCT, noted that
Patient #1 remained in soft RUE and LUE restraints, and was sleeping for the time frame between 10:01 p.m. on 10/21/18 -12:00 a.m. on 10/22/18.

The record lacked restraint related documentation by any licensed or unlicensed staff members after SM #14's 11:09 p.m. flowsheet entry on 10/21/18, which evidenced that Patient #1 was sleeping.

Patient #1 was transferred to (hospital name) on 10/21/18 at 11:54 p.m. The record lacked documentation which evidenced whether restraints were continued or discontinued prior to the time of transfer.

SM #1, the Director of the facility's Quality program was interviewed on 11/13/18 at 3:00 p.m. and stated "There's information that's missing. It does not appear that (SM #13) did a shift assessment that day for that patient, I agree, there is missing documentation".

The facility's policy entitled "Restraint and Seclusion of Patients" was reviewed, and revealed in part the following information: "...7. Monitoring Frequency and Parameters...c. The registered nurse is responsible for reassessing and monitoring the patient in restraints. i. The registered nurse may delegate components of monitoring to other competent staff members within the scope of their practice or licensure. ii. The registered nurse is responsible for supervising all delegated monitoring components. iii. When the Patient Care Assistant (PCA) or Patient Care Technician (PCT) notices a change from the previous monitoring, the registered nurse shall be notified immediately...f. A restrained patient who travels off the nursing unit (e.g., for diagnostic procedures) shall be accompanied by staff trained in the management of restraints. h. Frequencies for assessment, monitoring and care are based on minimum requirements for all restrained patients and are outlined in Attachment B...8. Discontinuation: a. Restraint shall be discontinued by a registered nurse once the behavior(s) or situation(s) that prompted the determined need for restraint are assessed to no longer be harmful to the physical safety of the patient, staff members, or others and medical treatment may be accomplished through less restrictive means. The RN will document the date and time the restraint was discontinued...Attachment B/ Restraint Documentation and Monitoring Requirements...(Non-Violent Restraint); Monitoring: RN/PCA/PCT every hour Care Needs: RN/PCA/PCT every 2 hours; Assessment: RN Every 2 hours; Discontinuation: RN with each restraint removal unless removed for therapy, hygiene, etc.".

Concerns were discussed as above with SM #1, and again on 11/14/18 between 6:00 p.m. and 6:30 p.m. with members of administration.

Based on staff interview and a review of facility documents, it was determined facility staff failed to ensure that an attending physician for one (1) of two (2) patients sampled (Patient #1) was notified of the application of restraints as soon as possible.

Findings included:

Patient #1 was admitted to the facility on 10/18/18. A review of Patient #1's medical record revealed that
Staff Member (SM) #17, a physician, wrote an order for right and left upper extremity restraints (RUE/LUE) for safety due to agitation/delirium on 10/21/18 at 4:30 p.m.

A nursing progress note on 10/21/18 from 1520-1605 (3:20 p.m. - 4:05 p.m.) by SM #12 a registered nurse (RN), documented the following regarding Patient #1: "Patient observed trying to climb out of bed; agitated, chewing on hand mitts, turning self-attempts to calm were unsuccessful. MD paged to bedside, restraints, medical orders implemented".

The record review also revealed that SM #17 wrote orders for IV (intravenous) Haldol 2 milligrams (an antipsychotic medication used for agitation), IV Lorazepam 0.5 mg, (an anti-anxiety medication), and Toradol 15 mg IV (non-steroidal anti-inflammatory pain medication), which were documented as administered between 4:25 p.m. and 4:29 p.m. on 10/21/18.

Patient #1 was transferred to (name of hospital) on 10/21/18 at 11:54 p.m. SM #18, an Internal Medicine physician, wrote a Hospitalist transfer note/critical care note dated 10/21/18 at 10:57 p.m., which stated in part "...Today (patient) continued to be febrile for the entire day and intermittently agitated and lethargic. This afternoon (patient) was increasingly agitated for which IV Haldol 2 mg and Lorazepam 0.5 mg IV were given. (Patient) also received 1L earlier today...". There was no documentation of restraint use in the transfer note.

SM #7, Patient #1's attending physician wrote a discharge summary note dated 10/22/18 at 12:40 a.m. and stated the following in part: "Patient was transferred to (hospital name) on the night of 10/21/18. I did not physically see the patient. Below is an overview of the events leading to the transfer to (hospital name) ({per SM #18's name} documentation on 10/21/19)...Today (he/she) continued to be febrile for the entire day and intermittently agitated and lethargic. This afternoon (he/she) was increasingly agitated for which IV Haldol 2 mg and Lorazepam 0.5 mg IV were given. (He/she) also received 1L earlier today...".
There was no documentation of restraint use in the discharge summary note by the attending physician.

The facility's policy entitled "Restraint and Seclusion of Patients" was reviewed, and included the following information in part: "...If the restraint is ordered by a LIP other than the attending physician, that LIP shall consult the attending physician as soon as possible and the consultation shall be documented within 24 hours of the restraint order...".

SM #1, the facility's Director of Quality was interviewed on 11/13/18 at 3:00 p.m., and stated "There's holes in the chart that don't tell the story. The doctor's note isn't there related to restraints. The physician that ordered the restraints never wrote a note".
SM #1 also stated "There's information that's missing. It does not appear that (SM #13) did a shift assessment that day for that patient, I agree, there is missing documentation".

Concerns were discussed as above with SM #1, and again on 11/14/18 between 6:00 p.m. and 6:30 p.m. with members of administration.