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Based on hospital policy review, medical record reviews, observations, and staff interviews, the hospital staff failed to protect the patient's right to personal privacy for 2 of 2 inpatient Medical/Surgical units observed during tour (Unit #3 and Unit #4).

The findings include:

Review on September 22, 2016 of the hospital's policy, "Confidentiality of Medical Records" last revised May 2016 revealed, Purpose: "Patients' medical records...and for this reason they must always be kept strictly confidential. ...patients have certain rights in these records including the right to expect that they will be maintained confidentially. ...1. Non-Confidential a) ...the follow is not generally confidential: Name' Room Number; Date of admission; and Date of discharge. b) There are exceptions in which all the patient information INCLUDING the above must be held as strictly confidential. ...2. Confidential a) All other information, whether clinical or otherwise, that is created and maintained as part of a patient's medical record is confidential and subject to this policy directive."

Observation on September 20, 2016 at 1045 during tour of Unit #4 revealed room 409 and on September 21, 2016 at 1400 during tour of the Unit #3 unit revealed room 310. Observations revealed both rooms were occupied by a patient. Further observation revealed both rooms had a 24-hour medical record (paper) stored on the wall outside the room. Review of the contents of the records revealed it contained the following 24-hour documents:

- Patient Care Flow Sheet with Neurological, Respiratory, Cardiac, Gastrointestinal, Renal, Skin, Pain, and Wound nursing assessment.
-Nursing progress notes
-Nursing Fall Assessment
-Medical Administration Record (MAR), including all ordered and administered medications for the next 24 hours.
-Vital Signs, Daily Intake and Output, Splints, Position, Bed Alarms, Provision of Activities of Daily Living (ADLs) to include bath and oral care.
-Medical-Surgical Restraint Care Plan/ Monitoring/Daily RN (registered nurse) Assessment
-Interdisciplinary Education Record
-Respiratory Care Record and Shift Summary
-Physical Therapy Progress Notes
-Speech Language Pathology Beside Dysphagia (difficulty swallowing) Evaluation
-Occupational Therapy Progress Notes

Continued observation during tours revealed 24-hour medical records outside the doors of all patient occupied rooms (30 of 40) on Unit #3 and #4. Observation revealed the medical record was not secure and was readily accessible. Further observation revealed visitors/family members and non-clinical hospital staff (housekeeping and dietary) walking on the hall in close proximity to the 24-hour medical records at various times throughout unit tours.

Interview on September 20, 2016 at 1045 with the hospital's Area Director of Quality Management (ADQM) revealed the patient's 24-hour medical record has routinely hung on the wall outside the patient care room. Interview revealed the "main record" was maintained and protected at the nursing station. Interview revealed the patient's 24-hour chart was, "Not as protected as we'd like, but typically someone (staff) is in the general area." Continued interview revealed 24-hour charts were developed as a means of "convenience for staff so that they aren't constantly running back and forth to the nursing station to document in the medical record." Further interview revealed the 24-hour medical record was closed and "typically" there was more staff rounding on the hall but since census was low, rounding was not as usual. Interview confirmed 24-hour medical records stored on the wall outside the occupied patient care rooms were not protected.

Interview on September 21, 2016 at 0925 with the hospital's Privacy Officer (PO) revealed two patient records are maintained on each unit. One record was kept in the nursing, which was considered protected, and contains physician orders, diagnostic studies, labs, etc., and the other 24-hour record was stored on the wall outside the occupied patient's room. Interview with the PO indicated charts outside the occupied patient's room contain documents for a 24-hour period, which are removed at the end of each day and replaced with new forms. Interview with the PO indicated the documents in the chart outside the patient's room are not secure. "I know in some cases they (staff) have taken charts (24-hour medical record) to the nurses' station because family get in it. We have thought about moving them but it's just easier that the information is on the bedside (24-hour) chart because all the disciplines aren't in the nursing station at one time." Interview confirmed 24-hour medical records stored on the wall outside occupied patient care rooms is not protected.

Based on hospital policy review, medical record reviews, and staff interviews, the hospital staff failed to update the interdisciplinary care plan for 2 of 10 patients requiring the use of non-violent restraints.

The findings include:

Review on September 22, 2016 of the hospital's policy, "Care Plan, Interdisciplinary" revised September 2015 revealed, "...At least weekly, the interdisciplinary team will meet to revise and update the established care plan and to discuss discharge options and needs. ...Goals are set and the team agrees upon target dates for accomplishment. ... 7. ...specific goals and target dates will be addressed and progress toward goals will be measured and documented. 8. New goals and target dates will be set as appropriate. ... 9. During weekly rounds, the case manager will document progress toward goals and barriers to discharge and each team member present will sign in to note collaboration ..."

1. Open medical record review on September 22, 2016 for Patient #3 revealed an 82 year old was transferred from another hospital and admitted on September 2, 2016 following a fall at home. Review of the History and Physical (H&P) dated September 03, 2016 by Medical Doctor (MD #1) revealed the reason for admission was Acute respiratory failure, requiring mechanical ventilation (breathing performed by a machine); Neck injury and fracture; Congestive Heart Failure (CHF); and History of alcohol abuse with withdrawal symptoms. Review of physician orders revealed a "Medical-Surgical Restraint Physician Assessment And Order" by Medical Doctor (MD) #2 for non-violent restraints (bilateral right and left upper extremities) daily for each day on September 17, 2016 through September 19, 2016. Review revealed check boxes beside each corresponding intervention with "Disruption of medical/surgical care" and "Engaging in unsafe behavior" marked. Continued review revealed check boxes for "specific behavior necessitating restraints" with "Pulling at invasive devices" and "Attempting to climb out of bed" marked. Review revealed, "Interventions previously attempted" with marked check boxes beside "Wrap/Cover tube insertion site, Tube secured, Bed alarm system, Verbal de-escalation, Redirection/reorientation". Further review of the order revealed, "... VII. Include in the Plan of Care... criteria for discontinuation." Further review of the orders revealed no documented "Duration/Time limitation" for restraint use per policy.

Nursing plan of care (POC) review revealed that a daily "Care Plan" was completed for each day on September 17, 2016 through September 19, 2016 (3 days) and the patient was in non-violent restraints during that time interval. Review of the "Care Plan" for September 17, 2016 revealed, "Restraints initiated R/T (related to) potential for injury: Date September 17, 2016: Goal: Patient will be without injury." Review revealed marked check boxes beside "Obtain order for least restrictive restraint, Type of restraint included on physician assessment, Notify family of need for restraints, Implement restraint monitoring, Educate patient/family on restraints, Provide auditory stimulation" and "Encourage family presence." Continued review of the care plan revealed a check box beside "Patient continues to be at risk for injury" that was marked as the "Daily RN (registered nurse) assessment for restraint usage" with "Pt (patient) continues to pull at invasive lines and disrupts therapy; attempted to get out of bed" noted by RN #4 with no documentation of the "criteria for discontinuation" noted. Further review of the nursing "Care Plan" for September 18, 2016 revealed no change in the plan or documented "criteria for discontinuation" of restraint use. Review revealed, "Pt continues to pull at invasive lines" noted by RN #4. Further review of the "Care Plan" for September 19, 2016 also revealed no change in the interventions or "criteria for discontinuation" of restraint use. Review revealed, "Pt continues to pull at invasive lines and tubing that are necessary for care" noted by RN #5. Review revealed no documented plan of care updates per policy or documented "criteria for discontinuation" per non-violent restraint orders and hospital policy.

Review of the multidisciplinary team meeting notes and POC dated September 20, 2016 revealed a note at 1700 by RN #6 indicating discussion with the patient's son and wife that included Case Manager (CM) #1. Review indicated consideration of making the patient a Do Not Resuscitate (DNR) after input from the neurologist about his prognosis. Review revealed no documentation regarding plans for the reduction in non-violent restraint use. Continued review of the multidisciplinary team meeting notes dated September 22, 2016 at 0941 by CM #1 revealed, "Patient continues with agitation and confusion. ...Barriers to Discharge: "...poor cognition...restraints..." Review revealed no documentation regarding "criteria for discontinuation" of non-violent restraint use or change in the patient's code status.
Interview on September 21, 2016 at 1130 with the nurse manager revealed the nursing "Care Plan" is a pre-printed form that is used for any patient in non-violent restraints. Nursing staff mark the check box corresponding with the least restrictive intervention(s) and the "Daily RN assessment for restraint usage". Continued interview indicated nursing staff document a short assessment of the continued need for restraint in the "Note" section of the "Care Plan". Interview revealed "criteria for discontinuation" was not on the pre-printed "Care Plan" and was not included on the "Care Plan" for Patient #3.
Interview on September 22, 2016 at 1120 with the Restorative Care (RC) nurse revealed patients are discussed with the physician each morning during "Grand Rounds". Interview indicated barriers to discharge, placement concerns, and patient condition and status are some of the topics discussed. Interview indicated Patient #3's status was changed to comfort care only on September 21, 2016 and served as the means to reduce non-violent restraint use for him. Interview revealed there was no documentation in the current "Care Plan" reflecting the change in patient care or goals, "It's not documented and it should be." Interview confirmed the plan of care was not updated when the patient's condition and status of care changed.
2. Closed medical record review on September 21, 2016 for Patient #6 revealed a 40 year old was transferred from another hospital and admitted on August 26, 2016 following a motor vehicle accident (MVA). Review of physician orders revealed a "Medical-Surgical Restraint Physician Assessment And Order" by Medical Doctor (MD) #2 for non-violent restraints (bilateral right and left upper extremities) daily for each day on September 16, 2016 through September 18, 2016. Review revealed check boxes beside each corresponding intervention and "Disruption of medical/surgical care" and "Engaging in unsafe behavior" indicated on the physician's order form. Continued review revealed check boxes for "specific behavior necessitating restraints" with "Pulling at invasive devices" and "Attempting to climb out of bed" marked. Continued review of the orders revealed, a marked check box beside "Interventions previously attempted" with "Wrap/Cover tube insertion site, Tube secured, Equipment placed out of visual field, Bed alarm system, Verbal de-escalation, Redirection/reorientation" check boxes marked. Review revealed, "VII. Include in the Plan of Care... criteria for discontinuation."
Nursing plan of care (POC) review revealed that a daily "Care Plan" was completed for each day on September 16, 2016 through September 18, 2016 revealed the patient was in non-violent restraints. Review of the "Care Plan" for September 16, 2016 revealed, "Restraints initiated R/T (related to) potential for injury: Date: September 16, 2016 Goal: Patient will be without injury." Review revealed marked check boxes beside "Obtain order for least restrictive restraint, Type of restraint included on physician assessment, Notify family of need for restraints, Implement restraint monitoring, Educate patient/family on restraints, Provide auditory stimulation" and "Encourage family presence." Continued review of the care plan revealed a check box beside "Patient continues to be at risk for injury" that was marked as the "Daily RN assessment for restraint usage" with "LUE (left upper extremity) mitten applied, unable to redirect pt (patient). Pt. trying to pull self over railing and pulling off TC (trachea collar), at risk for decannulation" noted by RN #7. Review revealed no documented "criteria for discontinuation" per the physician's order. Further review of the nursing "Care Plan" dated September 17, 2016 through September 18, 2016 revealed no change in the interventions. "Unable to redirect Pt." noted by RN #7 on September 17, 2016 and "Unable to redirect pt. Pt. trying to pull self OOB (out of bed), pulling on TC and invasive lines" noted by RN #7 on September 18, 2016. Review revealed no documented update or "criteria for discontinuation" per physician order.

Interview on September 21, 2016 at 1130 with the nurse manager revealed the nursing "Care Plan" is a pre-printed form that is used for any patient in non-violent restraints. Nursing staff mark the check box corresponding with the least restrictive intervention(s) and the "Daily RN assessment for restraint usage". Continued interview indicated nursing staff document a short assessment of the continued need for restraint in the "Note" section of the order. Interview revealed "criteria for discontinuation" was not included on the "Care Plan" for Patient #3 per policy.

Based on hospital policy review, medical record reviews, and staff interviews, the hospital staff failed to ensure non-violent restraint orders included the duration/time limitation for 2 of 2 patients in non-violent restraints (Patient #3 and #6).

The findings include:

Review on September 22, 2016 of the hospital's policy, "Restraints, Non Emergent and Emergent" revised October 2015 revealed, "...Restraints will only be used in accordance with the order of a physician. ...The physician's order must specify the following: i. Date and time ...iv. Duration/Time limitation..."

1. Open medical record review on September 22, 2016 for Patient #3 revealed an 82 year old was transferred from another hospital and admitted on September 2, 2016 following a fall at home. Review of the History and Physical (H&P) dated September 03, 2016 by Medical Doctor (MD #1) revealed the reason for admission was Acute respiratory failure, requiring mechanical ventilation (breathing performed by a machine); Neck injury and fracture; Congestive Heart Failure (CHF); and History of alcohol abuse with withdrawal symptoms. Review of physician orders revealed a "Medical-Surgical Restraint Physician Assessment And Order" by Medical Doctor (MD) #2 for non-violent restraints (bilateral right and left upper extremities) for each day on September 17, 2016 through September 19, 2016 (3 days). Further review of the three daily orders revealed no documented "Duration/Time limitation" for restraint use per policy.

Interview on September 21, 2016 at 1130 with the Nurse Manager revealed non-violent restraint orders are filled out by the third shift nursing staff for the oncoming shift. Interview revealed non-violent restraint orders should contain duration/time limitation. Interview confirmed the non-violent restraint orders on September 17, 2016 through September 19, 2016 did not include duration/time limitation per policy.

Concurrent interviews on September 22, 2016 at 0830 with the Chief Nursing Officer (CNO) and Area Director of Quality Management (ADQM) indicated that all restraint orders should be timed, dated, and include duration/time limitation per policy. Interview confirmed the non-violent restraint orders on September 17, 2016 through September 19, 2016 did not include duration/time limitation per policy.

2. Open medical record review on September 21, 2016 for Patient #6 revealed a 40 year old was transferred from another hospital and admitted on August 26, 2016 following a motor vehicle accident. Review of physician orders revealed a "Medical-Surgical Restraint Physician Assessment And Order" by Medical Doctor (MD) #2 for non-violent restraints (bilateral right and left upper extremities) for each day on September 16, 2016 through September 18, 2016 (3 days). Further review of the order revealed no documented "Duration/Time limitation" for restraint use per policy.
Interview on September 21, 2016 at 1130 with the Nurse Manager revealed non-violent restraint orders are filled out by the third shift nursing staff for the oncoming shift. Interview revealed non-violent restraint orders should contain duration/time limitation. Interview confirmed the non-violent restraint orders on September 16, 2016 through September 18, 2016 did not include duration/time limitation per policy.

Concurrent interviews on September 22, 2016 at 0830 with the Chief Nursing Officer (CNO) and Area Director of Quality Management (ADQM) indicated that all restraint orders should be timed, dated, and include duration/time limitation per policy. Interview confirmed the non-violent restraint orders on September 16, 2016 through September 18, 2016 did not include duration/time limitation per policy.

Based on policy review, medical record review, observation, and staff interviews, the hospital staff failed to ensure non-violent restraint orders were timed for 2 of 10 medical records sampled (Patient #3 and #6).

The findings include:

Review on September 22, 2016 of the hospital's policy, "Content of the Medical Record and Documentation Standards" revised August 2015 revealed, "... Procedure 1. General Requirements ...a. [as written] All entries must be ...timed, and date... 2. Verbal/Telephone Orders... c. All verbal/telephone orders shall be signed, dated and timed by the ordering physician..."

Review on September 22, 2016 of the hospital's policy, "Restraints, Non Emergent and Emergent" revised October 2015 revealed, "...Restraints will only be used in accordance with the order of a physician. ...The physician's order must specify the following: i. Date and time ..."

1. Closed medical record review on September 22, 2016 for Patient #3 revealed an 82 year old was transferred from another hospital and admitted on September 2, 2016 following a fall at home.

Physician order review revealed a "Medical-Surgical Restraint Physician Assessment And Order" dated September 17, 2016 by MD #2 for bilateral "soft limb" restraints to the right and left upper extremity due to "Disruption of medical/surgical care, Engaging in unsafe behavior ...Pulling at invasive lines, Attempting to climb out of bed. ..." Review of the physician order revealed the order was not timed by the Registered Nurse (RN #1) who initiated the order or by MD #1 when the ordered was authenticated per policy. Continued review of physician orders revealed "Medical-Surgical Restraint Physician Assessment And Order" dated September 18, 2016 and September 19, 2016 by MD #2, mirroring that of September 17, 2016. Review revealed neither order was timed by the nurse (RN #2) who initiated the order or by MD #2 when the order was authenticated. Further review revealed the orders were incomplete for the physician's time of signature.

Interview on September 21, 2016 at 1130 with the Nurse Manager revealed non-violent restraint orders are filled out by the third shift nursing staff for the oncoming shift. Interview indicated the order is signed by the primary nurse once it has been authenticated by the physician/Licensed Independent Practitioner. Continued interview revealed nursing staff do not currently indicate a time when noting the physician's order. Interview confirmed non-violent restraint orders were not timed by the nursing staff.

Concurrent interviews on September 22, 2016 at 0830 with the Chief Nursing Officer (CNO) and Area Director of Quality Management (ADQM) indicated that all orders should be timed and dated. Interview with the CNO and ADQM revealed "Medical-Surgical Restraint" physician orders are good for 24 hours.

2. Closed medical record review on September 21, 2016 for Patient #6 revealed a 40 year old was transferred from another hospital and admitted on August 26, 2016 following a motor vehicle accident (MVA).

Physician order review revealed a "Medical-Surgical Restraint Physician Assessment And Order" dated September 16, 2016 and September 17, 2016 by MD #2 for "Hand mitt, tied left upper extremity due to "Disruption of medical/surgical care, Engaging in unsafe behavior ... Pulling at invasive lines, Attempting to climb out of bed, Inability to follow simple directions / instructions." Review of the physician order revealed it was not timed by the Registered Nurse (RN #3) who initiated the order or by MD #2 who authenticated the order. Continued review of physician orders revealed a telephone order on September 17, 2016 at 2135 from MD #2 for "Bil. (bilateral) soft wrist restraints. Pt. (patient) at risk for falls and decannulation (removal of breathing tube)" by RN #3. Review revealed the order was not timed by MD #2 when the order was authenticated. Further review of "Medical-Surgical Restraint" orders revealed an order on September 18, 2016 by MD #2 for bilateral "soft limb" restraints to the right and left upper extremity due to "Disruption of medical/surgical care, Engaging in unsafe behavior ... Pulling at invasive lines, Attempting to climb out of bed. ..." Review of the physician's order revealed it was not timed by the nurse (RN #3) who initiated the order or by MD #2 who authenticated the order per policy. Review revealed neither order was timed by the nurse (RN #3) initiating the order or by MD #2 when the order was authenticated. Review revealed the orders were incomplete for the physician's time of signature.

Concurrent interviews on September 22, 2016 at 0830 with the Chief Nursing Officer (CNO) and Area Director of Quality Management (ADQM) indicated that all orders should be timed and dated. Interview with the CNO and ADQM revealed "Medical-Surgical Restraint" physician orders are good for 24 hours.

Interview on September 21, 2016 at 1130 with the Nurse Manager revealed non-violent restraint orders are filled out by the third shift nursing staff for the oncoming shift. Interview indicated the order is signed by the primary nurse once it has been authenticated by the physician/Licensed Independent Practitioner. Continued interview revealed nursing staff do not currently indicate a time when noting the physician's order. Interview confirmed non-violent restraint orders were not timed by the nursing staff.

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