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Based on observation, policy review, record review, staff interview and patient interview, it was determined the hospital staff failed to protect and promote patient's rights in the area of restraint and seclusion. The hospital failed to provide an ensure all staff were educated and trained on less restrictive interventions, assessing medical conditions, obtaining a correct medical order, properly applying a restraint, and re-assessing medical condition for the discontinuation of restraint and seclusion.
1. The side rails and Posey beds were used as a convenience to staff to keep the patients in bed to prevent falls. The side rails and Posey beds were not used according to the manufacturer's guidance or assessed to be discontinued at the earliest possible opportunity. See A154.
2. The facility used four side rails and a Posey bed as a restraint to prevent two patients from getting out of their beds. See A159.
3. The hospital staff failed to utilize the less restrictive interventions prior to initiating a restraint for two patients. See A164.
4. the hospital staff did not utilize a less restrictive restraint for two patients. See A165
5. The hospital staff failed to modify the care plan regarding the use of a restraint for two patients. See A166
6. The hospital staff failed to implement the Posey bed restraint appropriately for two patients. SeeA167
7. The hospital staff implemented restraint for two patients with out proper physician's orders. SeeA168
8. The hospital staff implemented a restraint without contacting the attending physician for two patients. SeeA170
9. The hospital staff failed to renew the restraint order every four hours up to a total of 24 hours for a self-destructive or violent behavior for two patients. SeeA171
10. The hospital staff failed to assess the restraint after 24 hours and before writing another restraint order for two patients. SeeA172
11. The hospital failed to ensure the restraint was discontinued at the earliest possible time for one patient. SeeA174
12. The physician failed to complete a face-to-face evalution of the medical and behavior condition regarding the need for a restraint for one patient. See A184
13. The hospital staff used side rails and a Posey bed as a restraint for 2 patients. One patient was not in immediate danger or a threat to themselves or others when the restraint was initiated. The side rails and Posey beds were used to keep the patients in bed to prevent falls. The side rails and Posey beds were not used correctly or assessed to be discontinued at the earliest possible time. See A185
14. The hospital staff failed to use less restrictive alternatives prior to the placement of a restraint for two patients. See A186
15. The hospital staff failed to document the condition or symptom which warranted the use of a restraint for one patient. See A187
16. The hospital staff failed to document the assessment of the patient's response to a restraint for two patients. See A188.
17. The hospital administration failed to train staff members on how to implement a restraint for two patients. See A194.
18. The hospital administration failed to provide documentation that the hospital staff were educated and trained on the use of a Posey bed for two patients. See A196
19. The hospital administration did not provide education or training to hospital staff on the proper use of a Posey bed. See A199
20. The hospital staff failed to demonstrate knowledge of choosing less restrictive interventions than restraints based on the assessment of the medical condition or behaviors for one patient. See A201
21. The hospital administration failed to educate, train, and demonstrate proper knowledge on how to recognize and respond to signs of distress in patients using Posey beds for two patients. The hospital staff failed to recognize the improper use of the Posey bed. The hospital staff failed to recognize signs of distress from the two patients. See A202
22. The hospital administration did not provide education or training to hospital staff regarding recognizing and responding to the clinical behavior changes with a use of a restraint for one patient. See A204

IMMEDIATE JEOPARDY
The surveyor team entered the facility at approximately 1:00 pm on 8/25/2014. During the facility tour, the surveyors noted the use of a Posey Bed Restraint System.
The surveyors established the risk of entrapment as an immediate jeopardy to patient safety two patients in Posey beds. The cummulatation of the effect of the findings and noncompliance of not following manufacturer's guidance of implementation of restraints at the facility identified significant failure. The surveyors notified the Facility Corporate Area Director of Compliance and Facility Corporate Quality Assurance, 8/25/2014 at 5:15 p.m. of the Immediate Jeopardy. The immediate jeopardy abatement plan was submitted by the facility on 8/27/14 at 8:00 a.m. and verified by the state agency at 10:30 a.m. and subsequently by the Centers for Medicare and Medicaid Services Regional Office on 8/27/14 at 11:30 a.m. The patients were removed from the beds, and less restrictive measures were put into place. The immediate jeparody was abated and the survey team exited the facility at 1:15 p.m.

Based on observation, policy review, record review and staff and patient interview, the hospital staff used side rails and a Posey bed as a restraint for 2 (#s 1 and 2) of 2 patients. The patients were not in immediate danger or a threat to themselves or others when placed in this restraint. The side rails and Posey beds were used as a convenience to staff to keep the patients in bed to prevent falls. The side rails and Posey beds were not used according to the manufacturer's guidance or assessed to be discontinued at the earliest possible opportunity. Findings include:

1. Patient #2 was admitted to the facility on 08/15/14 with diagnoses including acute respiratory failure, secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

Dictation in the progress notes by staff member O, MD (medical doctor), the medical record revealed:

a. On 08/15/14, "We will admit the patient and provide pulmonary toilet, close observation of his labs and his respiratory status. We will get Physical and Occupational Therapy involved. We will get Speech Therapy involved to assess his swallowing as well as his cognitive state. If there are any further problems, they will be handled as they arise." Staff member O., MD, noted in the progress note on the same date that patient #2 was "awake and alert" and "he seems somewhat confused."

b. On 8/16/14
....Plan: We will continue the same. The patient is actually doing quite well", and
..."we will watch him carefully and see how things go."

c. On 8/17/14
"Mr. (Pt name, patient 2) is doing better today. He is more alert and talkative. He says he is feeling really fairly well. He has had no nausea or vomiting, fevers or chills, He is quite impulsive and confused at times. However, when I was talking to him, he seemed to really be doing fairly well."

d. On 8/18/14
"He is much more alert than he had been. He is talkative and seems much more oriented."

e. On 8/19/14
"Mr (pt name, patient #2) is doing well from the aspect of his respiratory failure. This is pretty well resolved. He is still really pretty confused and impulsive. In fact in the last 24 hours, he has fallen three times. The patient has been told multiple times to use his call light and he will suddenly just get up and fall down. This morning, he actually pulled out his Foley catheter. We have made him a one-to-one sitter and we are trying to get a Vail (sic) bed. The patient states he feels fairly well other than pain in his right shoulder, which he has complained of since admission."
Plan: "We will continue to do the same."

f. On 8/20/14
"He is extremely weak and impulsive and confused. The patient actually fell four times in the course of 24 hours. He is belligerent and complaints (sic) that he wants to live (sic). We actually had him in a Vail (sic) bed yesterday and he manage (sic) to get his hand out through one small opening, get a hold of the zipper, unzip it and try to climb out of bed and he fell." Plan: We will continue with physical therapy and occupational therapy and nutritional therapy. ....."His behavior is so impulsive and erratic that I think we should at least have him on some thiamine. We will watch him carefully and see how things go. If there are any further problems, they will be handled as they arise."

g. On 8/21/14
"Patient name (#2) is doing fairly well today. I think he is more alert and aware of what is going on than what he has been. He is still exceptionally weak, however. When we do stand him up, he is completely off balance and it really takes two people to steady him to keep him from falling." Plan: "We will continue the same."
and;
...."We really need to get him back on his feet. We will watch him carefully, continue with therapy, and see how he does. He is extremely impulsive and is a very, very high fall risk. He actually has fallen four times in the last 48 hours despite trying to control him. We will watch him carefully and see how things go."

h. On 8/22/14
"Pt name (#2) is doing fairly well today. He is still very impulsive. He is awake and alert, but very unrealistic about his disease process. He just wants us to let him go and send him home. He clearly has nowhere to go, no clothing, no wallet, and he cannot really even walk at all without significant assistance."
and;
"PLAN: We will continue the same. If there are any further problems, they will be handled as they arise. His brother did come from (state name) and was planning on actually taking him home; however, when he saw (pt's name) status, they decided not to take him at this time as we had suggested they not take him. We will continue the same."

i. On 8/23/14
"Pt. name (#2) is doing fairly well. He still is quite confused at times and really is not showing good understanding of his disease process at all."
and;
"PLAN: We will continue to watch him carefully. We will use a sling on his shoulder whenever he is up if he will allow it. We will continue with physical therapy for his shoulder. If there are any further problems, they will be handled as they arise."

j. On 8/24/14
"Pt. name is doing well physiologically. Cognitively, however, he is still having difficulties. He still has very low understanding of his severity of illness. He is not exactly sure what happened to him. He feels like he is being held hostage here, but yet he cannot walk on his own. He is extremely impulsive. Physical therapy walked him a little bit on Friday and he takes huge steps and leans far forward. If the therapist had not been holding him, he would have fallen straight down. He really has no idea why he is even here, but it is clear that he is still certainly not able to go without continued care, Physiologically, he is doing much better. His vitals looked great. He has been afebrile and his abdomen seems to be healing up nicely." "PLAN: Continue same. The patient seems to be doing reasonably well. If there are any further problems, they will be handled as they arise."

k. On 8/25/14
"Pt. name (#2) is doing fairly well. He still is extremely impulsive and shows a very low understanding of his disease. He really cannot walk on his own without falling down. He is off balance and is very impulsive and tries to hurry. I have absolutely no doubt he would fall almost immediately if we allowed him to walk on his own. In addition, he complains bitterly that we will not allow him to get up out of bed by himself. As soon as we turn our backs on him, he will try to get up. He has been in a Vail bed that he does not like, but it is certainly keeping him safe."....
Physical Examination: "The patient is awake, alert and cooperative." PLAN: Continue the same. If there are any further problems, they will be handled as they arise."

l. On 8/26/14
...."I think at this point, the patient is still requiring the Vail bed for his safety." PLAN: "We will continue same. We will check CBC and BMP in the morning. If there are any further problems, it will be handled as they arise."

m. The physician's progress notes from 8/15/14 to 8/26/14, lacked documentation for a clinical rationale, and a medical condition as to why patient #2 was placed in a Posey bed, other than to keep him from falling while attempting to climb out of bed. The physician's notes lacked documentation as to when the Posey bed would be discontinued.

On 8/27/14 at 10:40 a.m., during an interview with resident #2, he stated he felt like, "I am in lock-down," when in the Posey bed. He stated he feels like he can't move or go to the bathroom and it makes his back hurt. "I feel closed in, in [sic] that bed and I don't like it."


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2. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, stage II ulcer, COPD, functional quadriplegic, and hypertension.

a. On 8/25/14 at 1:00 p.m., Staff member A, Area Director of Compliance and B, Quality Assurance Manager provided the initial tour. Patient #1 was observed to be lying flat in a Posey bed. All four side rails were in the upright position. The headboard and foot board were intact. The Posey bed netting was sagging, and the posey bed was not fitted tightly to the bed.

b. During the tour, Staff member B, the Quality Assurance manager, stated Posey beds were used to keep patients from falling. "We own one Posey bed and rent more when we need them."

c. On 8/25/14 at 3:30 p.m., patient #1 stated she hated the Posey bed. She felt entrapped. She could not reach her water or go to the bathroom. The bedside table was observed to be in the room with a container of water sitting on the table. The patient could not unzip the netting to reach her water container. The patient stated she had to use the call light and wait for staff. At this time, the warning label observed on the mattress included directions that the side rails were to be in the down position, which included a picture of a human figure entailed in a bed rail.

d. Review of the physician's daily progress notes dated 8/9/14, through 8/18/14, lacked documentation that patient #1 exhibited negative behaviors which were harmful to herself or others.

e. On 8/18/14 the physician's progress note showed patient #1 "was agitated and tried to climb out of bed. The patient is alert, awake and cooperative this morning."

f. On 8/19/14 the physician's progress noted showed "She is still very impulsive and confused at times, and crying out;...She is so impulsive that for her own safety we have put her in a Veil bed. This will hopefully keep her from falling on to the floor." The documentation lacked what the impulsive behavior was other than the patient attempting to get out of bed. The medical record lacked documentation of the patient's negative reaction to the restraint and a reassessment was not completed.

g. The physician's progress notes dated 8/20/14-8/25/14 lacked documentation that a re-assessment was completed on the patient's response to the restraint. The medical chart lacked documentation an assessment was completed to determine the earliest discontinuation of the restraint.

h. The daily nursing notes from 8/09/14- 8/25/14 showed four side rails were used to prevent the patient from exiting the bed. The medical chart lacked documentation of a physician's order for the use of four side rails. The medical record lacked the medical condition, negative behaviors that were a threat to the patient or others, the effect the side rails had on the patient, and the date the siderails restraint would be discontinued.

i. On 8/25/14 at 1:00 p.m., the four side rails were observed in the upright position with the Posey bed. The medical record included documentation that the four side rails of the Posey bed were in the up position from 8/18/14 to 8/25/14.

j. The medical surgical nurses flow sheets showed:
-8/18/14 patient was attempting to crawl out of the "veil bed" at 0545. At 1900 (7:00 p.m.) the patient was found on the floor laying next to the Posey bed. At 0200 patient continues to scream out. Patient states "she does not like being treated like a child."
-8/20/14 all four side rails up on the Posey bed. Use of "Veil bed for pt (patient) safety." The daily notes further showed a wound developed on the patients right buttock, and the Posey bed was a barrier to the healing process.
-8/21/14 a red area was documented on the right buttock.
-8/22/14 a small open area was documented on the right buttock.
-8/25/14 open wound on right buttock.

k. The Interdisciplinary Physician's Led Plan of Care lacked documentation of a treatment plan or a time frame for the use of the Posey bed. On 8/19/14 the skin integrity care plan showed the "vail [sic] bed" was a barrier to healing of the skin.

l. The physician's progress notes from 8/9/14-8/25/14 lacked documentation of a clinical rationale, a medical condition, negative behaviors, least restrictive measures attempted and failed, or a safety concern as to why patient #1 was to be restrained. Four side rails were used as a restraint without a physician's order or medical condition to warrant the use of the side rails. The Posey bed was documented to be initiated to keep her from falling and/or attempting to climb out of bed. The patient fell from the Posey bed with the four side rails in the upright position. The patient had a stage II pressure ulcer and the Posey bed was documented as a barrier in the healing of the ulcer.

The Restraint Policy reflected the bed enclosure and four side rails were considered a physical restraint. The Basic Premises section of the restraint policy included:
-"Restraint is only to be used when clinically necessary and in an emergency (a serious, probable, imminent threat of bodily harm to self or others where there is a present ability to effect such bodily harm). The benefits must be assessed to be greater than the risks associated with the restraint;
-Restraint shall be a temporary measure to preserve the patient's well being as assessment deems it necessary, and other available techniques or less restrictive interventions have failed;
-Restraints are not to be used as a means of ...convenience..;
-Restraint must be discontinued at the earliest possible time, regardless of length of time identified in the physician's order;
-Restraint for the "convenience" of health providers is not acceptable; and
-Use of restraints for the prevention of falls is not a routine part of the fall prevention program."

The policy revealed, a "clinical assessment/justification must identify the patient had unsafe behaviors, was not cognitively intact, and was placing self and others at risk or interfered with essential medical treatment, for example intravenous therapy. Immediately after the application of a restraint, an assessment must occur that documents the patient's response to the restraint, and if negative, reassess for changes in the interventions. The use of a restraint must be documented in the care plan."

The section titled Alternative/Treatments showed "Only health care workers with documented current competencies in use of restraint may apply restraints under the guidance of the registered nurse."

The Section titled Order showed "Obtain a written order from the physician's who must contain [sic] the specific reason for the restraint, date, specific time limit, and the signature of the physician."

IMMEDIATE JEOPARDY
The surveyor team entered the facility at approximately 1:00 pm on 8/25/2014. During the facility tour, the surveyors noted the use of a Posey Bed Restraint System.
The surveyors established the risk of entrapment as an immediate jeopardy to patient safety two patients in Posey beds. The cummulatation of the effect of the findings and noncompliance of not following manufacturer's guidance of implementation of restraints at the facility identified significant failure. The surveyors notified the Facility Corporate Area Director of Compliance and Facility Corporate Quality Assurance, 8/25/2014 at 5:15 p.m. of the Immediate Jeopardy. The immediate jeopardy abatement plan was submitted by the facility on 8/27/14 at 8:00 a.m. and verified by the state agency at 10:30 a.m. and subsequently by the Centers for Medicare and Medicaid Services Regional Office on 8/27/14 at 11:30 a.m. The patients were removed from the beds, and less restrictive measures were put into place. The immediate jeparody was abated and the survey team exited the facility at 1:15 p.m.

Based on observation, record review, policy review, and patient interview, the hospital staff used four side rails and a Posey bed as a restraint to prevent 2 (#s 1 and 2) of 2 patients from getting out of their beds. Findings include:

1. Patient #2 was admitted to the hospital on 8/15/14 with diagnoses including acute respiratory failure, secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

a. The medical surgical nurses' flow sheets from 8/19/14 through 8/26/14 showed four side rails and a Posey bed were used for patient #2 after the patient fell trying to get up out of bed.

b. The nurse notes revealed:
-8/19/14, resident #2 found on the floor in his room. At 10:15 a.m. a PCT was assigned as a 1:1 with the patient until 3 p.m., when " Pt. in a Veil (sic) bed. (symbol for no) longer needs a sitter." At 6 p.m., staff member O found "pt out of veil (sic) bed on floor. Reassessed pt than had PCT observe pt while eating dinner. Veil (sic) bed then secured with velcro tape over zipper." At 10:05 p.m. ""Less angry (and symbol) aggressive than last night. Veil (sic) bed securely enclosed. Pt doesn't seem to mind Veil bed."
-8/20/14 - "Veil (sic) bed with 4 rails up, zipper secure. Up in wheelchair twice."
-8/21/14 - "up in wheelchair at nurses station with seatbelt on. Patient agitated (sic) about being in the hospital and being in the "vail" (sic)bed."
- 8/22/14, "patient in "veil" (sic) bed with rails up and bed alarm on. Patient is agitated (sic) and shouting out into the halls."
-8/23/14, "Ativan and OXY IR for pain and agitation. Patient refuses scheduled meds and meals in the evening."
-8/24/14 - "refusing to eat, taking fluids. Refusing meds. In vail bed, side rails in use."
-8/25/14 -"Veil (sic) bed in use. Side rails in use."

c. The physician's progress notes on 8/19/14 revealed:
"He is still really pretty confused and impulsive. In fact in the last 24 hours, he has fallen three times. The patient has been told multiple times to use his call light and he will suddenly just get up and fall down. This morning, he actually pulled out his Foley catheter. We have made him a one-to-one sitter and we are trying to get a Vail bed." Staff member O noted the patient complained of pain in his right shoulder and he aches all over. Plan: "We will continue to do the same."

d. The physician's progress notes on 8/20/14 revealed:
"He is extremely weak and impulsive and confused. The patient actually fell four times in the course of 24 hours. He is belligerent and complaints (sic) that he wants to live (sic). We actually had him in a Vail (sic) bed yesterday and he manage (sic) to get his hand out through one small opening, get a hold of the zipper, unzip it and try to climb out of bed and he fell." Plan: We will continue with physical therapy and occupational therapy and nutritional therapy. ....."His behavior is so impulsive and erratic that I think we should at least have hi on some thiamine. We will watch him carefully and see how things go. If there are any further problems, they will be handled as they arise."

On 8/27/14 at 10:40 a.m., patient #2 stated he felt like "I am in lock-down" when in the Posey bed and he feels like he can't move or go to the bathroom, and it makes his back hurt. "I feel closed in, in that bed and I don't like it."


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2. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, COPD, functional quadriplegic, and hypertension.

a. The medical surgical nurses' flow sheets from 8/09/14-8/25/14 showed four side rails were used to prevent the patient from exiting the bed. On 8/18/14, a Posey bed was put into place to prevent the patient from climbing out of bed. The four side rails remained in place with the Posey bed. The medical record showed:
-8/15/14 "patient attempted to climb out of bed."
-8/16/14 "patient attempted to "walk" climb out of bed over the side rails. Multiple attempts to get out of bed increased anxiety and climbing over the side rails."
-8/17/14 "patient was crawling out of bed with the side rails up."
-8/18/14 "patient was attempting to crawl out of the "veil bed" (sic) at 0545. At 1900 (7:00 p.m.) the patient was found on the floor laying next to the Poesy bed. At 0200 patient continues to scream out. Patient states "she does not like being treated like a child."
-8/20/14 "all four side rails up on the Poesy bed. Use of "Veil (sic) bed for pt (patient) safety."

b. On 8/19/14 the physician's progress noted revealed "..we have put her in a Veil (sic) bed. This will hopefully keep her from falling on to the floor."

c. On 8/24/14 the physician documented in the progress notes that the patient tried, "to climb out of bed."

d. On 8/25/14 at 3:30 p.m., patient #1 stated she hated the bed and felt entrapped.

e. According to the Restraint Policy, a bed enclosure, four side rails, and non-releasing w/c (wheel chair) restraint were considered physical restraints.

Based on record review, policy review, and staff interview it was determined the hospital staff failed to utilize the less restrictive interventions prior to initiating a restraint for 2 (#s 1 and 2) out of 2 patients. Findings include:

1. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, stage II pressure ulcer, urinary tract infection, COPD, functional quadriplegic, and hypertension.

a. The medical record lacked documentation of the following:
-The hospital staff members attempted less restrictive interventions;
-A complete physician's order; and
-The negative behaviors which were a threat to herself or others.

b. The physician's original order, on 8/18/14, was to "Place pt (patient) in veil (sic) bed." The order lacked a time as to when the order was written, a clinical justification for the bed, medical diagnosis, or a length of time for the restraint use.

c. The medical surgical nurses' flow sheets from 8/09/14 through 8/25/14 showed "four side rails were used to prevent the patient from exiting the bed." The medical record lacked documentation for less restrictive interventions attempted prior to the four side rails or Posey bed.

d. The Restraint Order Form, dated 8/18, 8/19/ 8/20, 8/21, 8/22, 8/23, 8/24, 8/25, and 8/26/14, included "documented falls, impulsive, getting oob (out of bed) and being confused" were the reasons for the restraint. The medical record lacked specific behaviors to justify the four side rails, Posey bed and non-self-releasing seat belt. The physician's order lacked a time limit, a reassessment of the restraint, or an update of the care plan.

e. On 8/25/14 at 5:45 p.m., staff member C, Director of Nursing (DON) stated it was his job to review the physician's orders for completeness and he (staff C) did not review this order.

f. On 8/26/14 at 4:30 p.m., staff member D, Chief Executive Officer, (CEO) stated physician's orders were to be completed for restraints, which included the four side rails and the Posey bed.

g. Review of the Restraint Policy, on 8/25/14 at 3:00 p.m., lacked documentation "less restrictive interventions were required prior to placement of a restraint."


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2. Patient #2 was admitted to the facility on 08/15/14 with diagnoses including acute respiratory failure, secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

Review of patient #2's medical record revealed:

a. The physician's original order lacked a specific reason for the Posey bed's use, the side rails, non-releasing seat belt or the duration of the restraints.
b. Documented on the Restraint Policy under the section Order:
-Obtain a written order form the physician that must contain the specific reason for restrain, the date, specific time limit, and the signature of the physician.
c. Staff member O, MD, stated in a progress note on 8/19/14: "Mr (Pt #2's name) is doing well from the aspect of his respiratory failure. This is pretty well resolved. He is still really pretty confused and impulsive. In fact in the last 24 hours, he has fallen three times. The patient has been told multiple time to use his call light and he will suddenly just get up and fall down. This morning, he actually pulled out his Foley catheter. We have made him a one-to-one sitter and we are trying to get a Vail (sic) bed. The patient states he feels fairly well other than pain in his right shoulder, which he has complained of since admission."
d. A telephone order taken by an Registered Nurse (RN), from staff member O, MD, on 8/19/14 at 12:45 p.m., was written as: "Place pt (patient) in Veil (sic) bed please." The medical record lacked an order for use for the four side rails.
e. An initial occupational therapy assessment, dated 8/20/14 at 9:45 a.m., contained documentation of "seat belt provided." The medical record lacked a physician's order for a seat belt until 8/24/14 at 7:00 a.m. On the facility's "Restraint Orders" form, signed by staff member O, MD, the wheelchair belt, (not self-releasing) box was checked. A reason for the seat belt was not specified in the doctor's order, and there was not a mention of the duration of use. The medical record lacked documentation of least restrictive interventions attempted prior to the placement of the seatbelt.
f. On 8/27/14 at 10:40 a.m., resident #2 was observed to be in a wheelchair with a non-self-releasing seat belt around his waist, attached to the wheelchair.
g. Staff member O stated on 8/26/14 at 5 p.m. that resident#2 had the seatbelt on while up in the wheelchair to prevent him from getting up and falling.
h. The medical record lacked specific behaviors to justify the four side rails, and non-self-releasing seat belt.

Based on policy review, record review and patient interview it was determined the hospital staff did not utilize a less restrictive restraint for 2 (#s 1 and 2) of 2 patients. Findings include:

1. Patient #2 was admitted to the facility on 08/15/14 with diagnoses including acute respiratory failure, secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

a. Resident #2 was placed in a Posey bed on 8/19/14 after falling four times while attempting to get up out of bed without assistance. A one-on-one intervention was used while the hospital located a Posey bed.

b. The medical record lacked documentation of attempts to discontinue the use of the Posey bed for 8/19/14 through 8/25/14. The medical record lacked assessments to justify the need for continued use of the seat belt in the wheelchair and that the four side rails were the least restrictive interventions to protect patient #2's safety.

c. Review of the medical record revealed on 8/26/14 at 11:30 p.m., staff member O, M.D. wrote: "Patient had failed trial of mattress on the floor with very close supervision and is increasingly agitated with 1:1 staff in room. Place patient in Posey Enclosure Bed for self destructive behaviors that jeopardize the immediate physical safety of the patient. Less restrictive alternatives, including placing pt in a low stimulation environment, verbal cues & 1:1 sitter have been insufficient due to patient's orientation and physical abilities at present. This order is for 24 (sign for hours)."

d. The medical surgical flow sheets from "8/19/14 through 8/25/14 showed on the hourly checks, that the bedrails were used. A bed alarm was also used during these times."

e. On 8/27/14 at 10:40 a.m., patient #2 stated he felt like "I am in lock-down" when in the Posey bed and he feels like he can't move or go to the bathroom and it makes his back hurt. "I feel closed in, in that bed and I don't like it."


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2. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, stage II pressure ulcer, COPD, functional quadriplegic, and hypertension.

a. Review of the medical record lack documentation of the least restrictive intervention used prior to the implementation of the four side rails and Poesy bed.

b. Documented on the Restraint Policy bed enclosure and four side rails were considered physical restraints.

c. The medical surgical nurses flow sheets from "8/09/14 through 8/25/14 showed four side rails were used to prevent the patient from exiting the bed. A Posey bed on 8/18/14 was put into place to prevent the patient from climbing out of bed. The four side rails were still in place with the Posey bed. The documentation regarding the clinical needs for the use of the restraints were not in the medical record."

d. On 8/25/14 at 3:30 p.m., patient #1 stated she hated the bed. She felt entrapped.

Based on policy review and record review the hospital staff failed to modify the care plan regarding the use of a restraint for 2 (#s 1 and 2) of 2 patients. Findings include:

1. Patient #2 was admitted to the facility on 08/15/14 with diagnoses including acute respiratory failure, secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

a. Review of resident #2's care plan showed Alteration in Safety and Behavior; the use of a Posey bed as a restraint was not documented on the care plan prior to 8/25/14 . An assessment and goal of the intervention for the use of the non-self-releasing seat belt while in the wheelchair or use of four bedrails were not documented in the patient's care plan.

b. The medical record lacked a physician's order indicating the time limit for the use of the non-self-releasing seat belt while in the wheelchair, side rails or for the use of the Posey bed.


26492

2. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, stage II pressure ulcer, COPD, functional quadriplegic, and hypertension.

a. The Interdisciplinary Physician Led Plan of Care lacked documentation of the use of the side rails and a Posey bed. On 8/19/14 the care plan showed that the "vail [sic] bed" was a barrier to healing of the skin.

b. Documented on the Restraint Policy under the section Plan:
- "Upon completion of the assessment, written modification will be made to the patient's plan of care...
-The problem must be included on the patient plan of care with the determination of appropriate interventions/alternatives and goals.
-Additional intervention(s) and or goals should be added or deleted as the patient's condition and response to treatments changes.
-Plan changes occur at the time of:
a. Initial identification of safety risk
b. Need for additional intervention of alternatives and/or restraints
c. Discontinuation of interventions."

Based on observation, record review and staff interview the hospital staff failed to implement the Posey bed restraint appropriately for 2 (#s 1 and 2) of 2 patients. Findings include:

1. Patient #2 was admitted to the facility on 08/15/14 with diagnoses including acute respiratory failure, secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

a. On 8/26/14 at 8:05 a.m., resident #2 was observed to be sleeping in a Posey bed. The headboard and footboard were intact on the bed. The netting on the Posey bed was not taut.

b. On 8/26/14 at 10:30 a.m., staff member I, Maintenance Manager, measured Patient #2's Posey bed. The Stryker frame was 13.75 inches from the floor. Manufacturer's instructions for the Posey bed showed the bed should be no lower than 16-17 inches from the floor.

c. Review of resident #2's medical record lacked evidence an immediate assessment of the Posey bed was completed. The notes lacked evidence an immediate assessment was completed, to ensure the proper use of the non self-releasing seat belt, used to prevent patient #2 from getting up while in the wheelchair, was properly applied.

d. Review of physician's progress notes for 8/20/14 revealed the following entry by staff member O, M.D.:
"He is extremely weak and impulsive and confused. The patient actually fell four times in the course of 24 hours. He is belligerent and complaints (sic) that he wants to live (sic). We actually had him in a Vail (sic) bed yesterday and he manage (sic) to get his hand out through one small opening, get a hold of the zipper, unzip it and try to climb out of bed and he fell."

e. The medical surgical nurses flow sheets from "8/19/14 through 8/26/14 indicated patient #2 was in a Posey bed with four side rails in the up position. The Posey bed was put into use after the patient fell trying to get up out of bed. "

f. Review of the nurse notes revealed:
-"8/19/14, resident #2 found on the floor in his room at 10:15 a.m. and a PCT was assigned as a 1:1 with the patient until 3 p.m., when Pt. in a Veil (sic) bed. (symbol for no) longer needs a sitter." At 6 p.m., staff member O, M.D., found "pt out of veil (sic) bed on floor. Reassessed pt than had PCT observe pt while eating dinner. Veil (sic) bed then secured with velcro tape over zipper." At 10:05 p.m. ""Less angry (sign for and) aggressive than last night. Veil (sic) bed securely enclosed. Pt doesn't seem to mind Veil bed."
-8/20/14 - Veil (sic) bed within 4 rails up, zipper secure. Up in wheelchair twice.
-8/21/14 - up in wheelchair at nurses station with seatbelt on. Patient agitated (sic) about being in the hospital and being in the "vail" (sic)bed.
- 8/22/14, "patient in "veil" (sic) bed with rails up and bed alarm on. ......Patient is agitated (sic) and shouting out into the halls."
-8/24/14 - "Refusing to eat, taking fluids. Refusing meds. In vail (sic)bed, side rails in use."
-8/25/14 -"Veil (sic) bed in use. Side rails in use."

g. The Restraint Policy lacked documentation of how to appropriately use the Posey bed.



26492

2. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, stage II pressure ulcer, COPD, functional quadriplegic, and hypertension.

a. On 8/25/14 at 1:00 p.m., patient #1 was observed to be lying flat in a Posey bed. All four side rails were in the upright position. The headboard and foot board were intact. The Posey bed was observed not to be tight fitting to the bed. This created the Posey bed netting to sag.

b. On 8/26/14 at 10:30 a.m., staff member I, Maintenance Manager, measured Patient #1's Posey bed. The Stryker frame was 14 inches from the ground. The bed was raised to 28 inches in height. Manufacturer's instructions for the Posey bed showed the bed should be no lower than 16-17 inches from the floor and no higher than 25 inches.

c. The medical surgical nurses flow sheets from "8/09/14 through 8/25/14 showed four side rails were used to prevent the patient from exiting the bed. A Posey bed on 8/18/14 was put into place to prevent the patient from climbing out of bed. The four side rails were used in the upright position with the Posey bed." The medical record showed:
-8/18/14 patient was attempting to crawl out of the "veil bed" at 0545. At 1900 (7:00 p.m.) the patient was found on the floor laying next to the Posey bed. At 0200 patient continues to screams out. Patient states "she does not like being treated like a child."
-8/20/14 all four side rails up on the Posey bed. Use of "Veil bed for pt (patient) safety."

d. On 8/25/14 at 3:30 p.m., observed on the mattress of the Posey bed was a warning label. The label displayed a photo of a human entangled in a side rail. The label clearly showed do not use side rails. At this time patient #1 stated she hated the bed. She felt entrapped. She could not reach her water or go to the bathroom. She had to use her call light and wait.

e. Documented on the Quick-Guide for the Posey bed "ALWAYS make sure all side rails are in the fully DOWN position. This will reduce the risk of serious injury or death form ENTRAPMENT or patient injury from contact with side rails."

f. On 8/26/14 at 10:00 a.m., staff member H, Central Supply Manager stated he "only orders the Posey bed." He had not been trained on the proper use of the Posey bed. After this statement the CEO stated "we all assumed training was completed. It was not."

g. The Restraint Policy lacked documentation of how to appropriately use the Posey bed.

Based on record review, policy review and staff interview, it was determined the hospital staff implemented restraint for 2 (#s 1 and 2) of 2 patients without proper physician's orders. Findings include:

Documented on the Restraint Policy under the section Order:
-"Obtain a written order form the physician who must contain the specific reason for restraint, the date, specific time limit, and the signature of the physician."

1. Patient #2 was admitted to the facility on 08/15/14 with diagnoses including acute respiratory failure, secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

Review of Resident #2's medical record revealed:
a. A telephone order taken by an Registered Nurse (RN), from staff member O, MD, on 8/19/14 at 12:45 p.m., written as: "Place pt (patient) in Veil (sic) bed please." The medical record did not contain an order for use of four side rails. The order was incomplete. The order did not have a clinical rationale, medical reason, date, or time frame.
b. The medical record did not contain a physician's order for use of four side rails used on the Stryker frame with the Posey bed.
c. An initial occupational therapy assessment dated 8/20/14 at 9:45 a.m. contained documentation of "seat belt provided." The medical record did not contain a physician's order for a seat belt until 8/24/14 at 7:00 a.m. A reason for the seat belt was not specified in the doctor's order, nor was there a mention of the duration of use. The medical record lacked a physician's order for the use of four side rails.

d. Patient #2 was observed in the hall in his wheelchair on 8/26/14 at 4:03 p.m., with a non self-releasing seat belt around his waist.

e. On 8/27/14 at 10:40 a.m., resident #2 was observed to be in a wheelchair with a non self-releasing seat belt around his waist, attached to the wheelchair.

f. During an interview with staff member O, on 8/26/14 at 5 p.m., he stated resident#2 had the seatbelt on while up in the wheelchair to prevent him from getting up and falling.

g. On 8/26/14 at 10:00 a.m., the CEO stated all medical orders needed to be complete. This included the medical reason as to why the restraint was being used and the length of time for the restraint.


26492

2. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, stage II pressure ulcer, COPD, functional quadriplegic, and hypertension.

a. Review of the medical record revealed from 8/9/14 to 8/25/14 four side rails were implemented and used the entire 17 days without a physician's order.

b. On 8/18/14 a physician's order "place pt (patient) in veil (sic) bed." The order was incomplete. The order did not have a clinical rationale, medical reason, date, or time frame. The patient was in the Posey bed for seven days without a correct physician's order.

c. On 8/26/14 at 10:00 a.m., the CEO stated all medical orders needed to be complete. This included the medical reason as to why the restraint was being used and the length of time for the restraint.

Based on record review, policy review and staff interview the hospital staff implemented a restraint without contacting the attending physician for 2 (#s 1 and 2) of 2 patients. Findings include:

1. Patient #2 was admitted to the facility on 08/15/14 with diagnoses including acute respiratory failure, secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

a. Review of Resident #2's medical record revealed:
-"An initial occupational therapy assessment dated 8/20/14 at 9:45 a.m. contained documentation of seat belt provided."

b. The medical record lacked documentation of an order for the non-self-releasing seat belt use from 8/20/14 until 7:00 a.m. on 8/24/14. A reason for the seat belt was not specified in the doctor's order, and there was no order for the duration of use.

c. The medical record lacked documentation that the physician was notified of the use of the non-self-releasing seat belt use from 8/20/14 through 8/24/14.

d. Staff member O stated on 8/26/14 at 5 p.m., resident#2 "had the seatbelt on while up in the wheelchair to prevent him from getting up and falling."

e. There was not a physician's order for the use of four side rails on the Stryker frame with use of the Posey bed or documentation for the notification to the physician before initiating the use of the side rails on the Stryker frame of the Posey bed.


26492


2. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, stage II pressure ulcer, COPD, functional quadriplegic, and hypertension.

a. The medical record review revealed the physician was not notified of the implementation of the four side rails from 8/9/14 thru 8/25/14.

b. Review of the Restraint Policy revealed under the section Assessment "The physician/LIP must be notified of the use of restraint as soon as possible after the application, but within 30 minutes of its application."

c. The hospital staff failed to notify the physician within 30 minutes, for both patients, after implementing a restraint.

Based on record and policy review, the hospital staff failed to renew the restraint every four hours up to a total of 24 hours for a self-destructive or violent behavior for 2 (#s 1 and 2) of 2 patients. Findings include:

1. Patient #2 was admitted to the facility on 08/15/14 with diagnoses including acute respiratory failure, secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

a. Review of Resident #2's medical record revealed:
-An initial occupational therapy assessment dated 8/20/14 at 9:45 a.m. contained documentation of "seat belt provided."
-The medical record did not contain a physician's order for a seat belt until 8/24/14 at 7:00 a.m., when it was documented on the facility's 24 Hour Physician Restraint Order form.

c. The medical record did not include mention of the non-self-releasing seat belt use in the physician's progress notes from 8/20/14 through 8/26/14.

d. There was not an order for the implementation of four side rails used with the Posey bed. Use of a Posey bed was implemented on 8/19/14, to prevent patient #2 from falling out of bed. The four side rails were still in use on 8/25/14 with the Posey bed.

e. On 8/26/14, staff member O, stated resident#2 has the seatbelt on while up in the wheelchair to prevent him from getting up and falling.

f. On 8/26/14 at 11:30 p.m., staff member O, M.D. wrote: "Patient had failed trial of mattress on the floor with very close supervision and is increasingly agitated with 1:1 staff in room. Place patient in Posey Enclosure Bed for self destructive behaviors that jeopardize the immediate physical safety of the patient. Less restrictive alternatives, including placing pt in a low stimulation environment, verbal cues & 1:1 sitter have been insufficient due to patient's orientation and physical abilities at present. This order is for 24 (sign for hours)."


26492

2. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, COPD, functional quadriplegic, and hypertension.

a. The medical surgical nurses flow sheets from "8/09/14 through 8/25/14 showed four side rails were used to prevent the patient from exiting the bed. A Posey bed on 8/18/14 was put into place to prevent the patient from climbing out of bed. The four side rails were still in place with the Posey bed."

b. The medical record lacked documentation patient #1 had self-destructive behaviors to herself or others. The medical record lacked renewal orders every 4 hours for the first 24 hours of initiating the restraint.

c. The Restraint Policy lacked documentation on a definition and procedure for a self-destructive or violent patient and what the guidelines are for initiation the restraint or renewing the restraint orders.

Based on record review, the hospital staff failed to assess the restraint after 24 hours and before writing another restraint order for 2 (#s 1 and 2) of 2 patients. Findings include:

1. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, COPD, functional quadriplegic, and hypertension.

a. The medical surgical nurses flow sheets from 8/09/14 through 8/25/14 showed four side rails were used to prevent the patient from exiting the bed. A Posey bed on 8/18/14 was put into place to prevent the patient from falling.

b. The medical record lacked documentation that the physician completed an assessment after 24 hours prior to the renewal order for patient #1.

c. The Restraint Policy lacked documentation on a definition and procedure for a self-destructive or violent patient and what the guidelines are for initiation the restraint or renewing the restraint orders.


31093

2. Patient #2 was admitted to the facility on 08/15/14 with diagnoses including acute respiratory failure, secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

a. Review of Resident #2's medical record revealed:
- A telephone order taken by an Registered Nurse (RN), from staff member O, MD, on 8/19/14 at 12:45 p.m., written as: "Place pt (patient) in Veil (sic) bed please." The medical record did not contain an order for use of four side rails. The order was incomplete. The order did not have a clinical rationale, medical reason, date, or time frame.
On 8/19/14 the physician's progress notes reveal: "Mr (Pt name, patient #2) is doing well from the aspect of his respiratory failure. This is pretty well resolved. He is still really pretty confused and impulsive. In fact in the last 24 hours, he has fallen three times. The patient has been told multiple time to use his call light and he will suddenly just get up and fall down. This morning, he actually pulled out his Foley catheter. We have made him a one-to-one sitter and we are trying to get a Vail bed. The patient states he feels fairly well other than pain in his right shoulder, which he has complained of since admission."
Plan: "We will continue to do the same."

On 8/20/14 the physician's progress notes reveal: "He is extremely weak and impulsive and confused. The patient actually fell four times in the course of 24 hours. He is belligerent and complaints (sic) that he wants to live (sic). We actually had him in a Vail bed yesterday and he manage (sic) to get his hand out through one small opening, get a hold of the zipper, unzip it and try to climb out of bed and he fell." Plan: We will continue with physical therapy and occupational therapy and nutritional therapy. ....."His behavior is so impulsive and erratic that I think we should at least have him on some thiamine. We will watch him carefully and see how things go. If there are any further problems, they will be handled as they arise."
b. The medical record lacked documentation by the physician of patient #2's clinical response to the Posey bed within the first 24 hours of use.

Based on record and policy review, the hospital failed to ensure the restraint was discontinued at the earliest possible time for 1 (#1) of 2 patients. Findings include:

1. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, stage II pressure ulcer, COPD, functional quadriplegic, and hypertension.

a. The physician ordered a Posey bed on "8/18/14 to keep the patient in bed." The medical record lacked documentation of an unsafe situation warranting the use of the restraint. The original order, and the renewal orders for the restraint, lacked a time frame for discontinuing the restraint. The restraint was in place from 8/18/14 to 8/26/14.

b. The physician's progress notes, dated from 8/19/14 to 8/26/14, revealed patient #1 was alert, oriented, calm, cooperative, and confused at times. The progress notes lacked documentation that the restraint was to be discontinued in the future.


31093

2. Patient #2 was admitted to the facility on 08/15/14 with diagnoses including acute respiratory failure, secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

a. The physician ordered a Posey bed on 8/19/14 to keep the patient from falling. The original order and the renewal orders for the restraint lacked a time frame for discontinuing the restraint. The restraint was initiated on 8/19/14 and was still in place on 8/26/14, at the time of exit.

b. The physician's progress notes, dated from 8/19/14 through 8/25/14, lacked documentation of discontinuing the use of the restraint in the future.

c. Review of the Restraint Policy, under Reassessment/Monitoring, revealed, "Restraint use will be discontinued as soon as less restrictive methods can be safely employed."

Based on record and policy review, the physician failed to complete a face-to-face evalution of the medical and behavior condition regarding the need for a restraint for 1 (#2) of 2 patients. Findings include:

1. Patient #2 was admitted to the facility on 08/15/14 with diagnoses including acute respiratory failure, secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

Review of Resident #2's medical record revealed:

a. An initial occupational therapy assessment dated 8/20/14 at 9:45 a.m. included the documentation, "seat belt provided."

b. The medical record lacked the documentation of a face-to-face behavioral and physical evaluation within one hour by the attending physician for the non self-releasing seat belt use.

c. The hospital did not have a policy or procedure for a face-to-face evaluation.

Based on observation, record review, staff and patient interview, the hospital staff used side rails and a Posey bed as a restraint for 2 (#s 1 and 2) of 2 patients. Patient #1 was not in immediate danger or a threat to themselves or others when the restraint was initiated. The side rails and Posey beds were used to keep patients #1 and #2 in bed to prevent falls. The side rails and Posey beds were not used correctly or assessed to be discontinued at the earliest possible time. Findings include:

1. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, COPD, functional quadriplegic, and hypertension.

a. The Medical Surggical Flow Sheets from 8/09/14 through 8/24/14 showed four side rails were used to prevent the patient from exiting the bed.

b. On 8/18/14 the physician's progress noted revealed patient #1 was agitated and tried "to climb out of bed."

c. On 8/19/14 the physician's progress noted revealed "She is still very impulsive and confused at times, and crying out;...She is so impulsive that for her own safety we have put her in a Veil bed. This will hopefully keep her from falling on to the floor." There was no documentation of what the impulsive behaviors were, other than attempting to get out of bed.

d. A Posey bed on 8/18/14 was put into place to prevent the patient from climbing out of bed. The four side rails were still in the upright position with the Posey bed. The medical record showed:
-"8/15/14 patient attempted to climb out of bed.
-8/16/14 patient attempted to "walk" climb out of bed over the side rails. Multiple attempts to get out of bed increased anxiety and climbing over the side rails.
-8/17/14 patient was crawling out of bed with the side rails up."
-8/18/14 patient was attempting to crawl out of the "veil (sic) bed" at 0545. "At 1900 (7:00 p.m.) the patient was found on the floor laying next to the Posey bed. At 0200 patient continues to screams out. Patient states "she does not like being treated like a child."
-8/20/14 all four side rails up on the Posey bed. Use of "Veil (sic) bed for pt (patient) safety."

e. On 8/25/14 at 3:30 p.m., during an interview, patient #1 stated she hated the bed. She felt entrapped. She could not reach her water or go to the bathroom.

f. The medical record lacked documentation of behaviors and prior interventions used for patient #1. The medical record did not show patient #1 was displaying negative behaviors to justify the use of a restraint.


31093

2. Patient #2 was admitted to the facility on 08/15/14 with diagnoses including acute respiratory failure, secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

Progress note dictation by staff member O, MD (medical doctor) in the medical record revealed:

a. On 08/15/14, "We will admit the patient and provide pulmonary toilet, close observation of his labs and his respiratory status. We will get Physical and Occupational Therapy involved. We will get Speech Therapy involved to assess his swallowing as well as his cognitive state. If there are any further problems, they will be handled as they arise." Staff member O., MD noted in the progress note on the same date patient #2 was "awake and alert" and "he seems somewhat confused."

b. On 8/16/14
....Plan: We will continue the same. The patient is actually doing quite well", and
..."we will watch him carefully and see how things go."

c. On 8/17/14
"Mr. (Pt name, patient 2) is doing better today. He is more alert and talkative. He says he is feeling really fairly well. He has had no nausea or vomiting, fevers or chills, He is quite impulsive and confused at times. However, when I was talking to him, he seemed to really be doing fairly well."

d. On 8/18/14
"He is much more alert than he had been. He is talkative and seems much more oriented."

e. On 8/19/14
"He is still really pretty confused and impulsive. In fact in the last 24 hours, he has fallen three times. The patient has been told multiple times to use his call light and he will suddenly just get up and fall down. This morning, he actually pulled out his Foley catheter. We have made him a one-to-one sitter and we are trying to get a Vail bed." Staff member O noted the patient complained of pain in his right shoulder and he aches al over.
Plan: "We will continue to do the same."

f. On 8/20/14
"He is extremely weak and impulsive and confused. The patient actually fell four times in the course of 24 hours. He is belligerent and complaints (sic) that he wants to live (sic). We actually had him in a Vail bed yesterday and he manage (sic) to get his hand out through one small opening, get a hold of the zipper, unzip it and try to climb out of bed and he fell." Plan: We will continue with physical therapy and occupational therapy and nutritional therapy. ....."His behavior is so impulsive and erratic that I think we should at least have him on some thiamine. We will watch him carefully and see how things go. If there are any further problems, they will be handled as they arise."

g. On 8/21/14
"Patient (PT) name (#2) is doing fairly well today. I think he is more alert and aware of what is going on than what he has been. He is still exceptionally weak, however. When we do stand him up, he is completely off balance and it really takes two people to steady him to keep him from falling." Plan: "We will continue the same.
and;
....We really need to get him back on his feet. We will watch him carefully, continue with therapy, and see how he does. He is extremely impulsive and is a very, very high fall risk. He actually has fallen four times in the last 48 hours despite trying to control him. We will watch him carefully and see how things go."

h. On 8/22/14
" Pt name (#2) is doing fairly well today. He is still very impulsive. He is awake and alert, but very unrealistic about his disease process. He just wants us to let him go and send him home. He clearly has nowhere to go, no clothing, no wallet, and he cannot really even walk at all without significant assistance."
and;"PLAN: We will continue the same. If there are any further problems, they will be handled as they arise. His brother did come from Iowa and was planning on actually taking him home; however, when he saw (pt's name) status, they decided not to take him at this time as we had suggested they not take him. We will continue the same."

i. On 8/23/14
"Pt. name is doing fairly well. He still is quite confused at times and really is not showing good understanding of his disease process at all."
and;
"PLAN: We will continue to watch him carefully. We will use a sling on his shoulder whenever he is up if he will allow it. We will continue with physical therapy for his shoulder. If there are any further problems, they will be handled as they arise."

j. On 8/24/14
"Pt. name is doing well physiologically. Cognitively, however, he is still having difficulties. He still has very low understanding of his severity of illness. He is not exactly sure what happened to him. He feels like he is being held hostage here, but yet he cannot walk on his own. He is extremely impulsive. Physical therapy walked him a little bit on Friday and he takes huge steps and leans far forward. If the therapist had not been holding him, he would have fallen straight down. He really has no idea why he is even here, but it is clear that he is still certainly not able to go without continued care, Physiologically, he is doing much better. His vitals looked great. He has been afebrile and his abdomen seems to be healing up nicely." PLAN: Continue same. The patient seems to be doing reasonably well. If there are any further problems, they will be handled as they arise."

k. On 8/25/14
"Pt. name is doing fairly well. He still is extremely impulsive and shows a very low understanding of his disease. He really cannot walk on his own without falling down. He is off balance and is very impulsive and tries to hurry. I have absolutely no doubt he would fall almost immediately if we allowed him to walk on his own. In addition, he complains bitterly that we will not allow him to get up out of bed by himself. As soon as we turn our backs on him, he will try to get up. He has been in a Vail bed that he does not like, but it is certainly keeping him safe."....
Physical Examination: The patient is awake, alert and cooperative." PLAN: Continue the same. If there are any further problems, they will be handled as they arise."

l. On 8/26/14
...."I think at this point, the patient is still requiring the Vail bed for his safety." PLAN: We will continue same. We will check CBC and BMP in the morning. If there are any further problems, it will be handled as they arise."

m. The physician's progress notes from 8/15/ to 8/26/14 lacked documentation for a clinical rationale and a medical condition as to why patient #2 was placed in a Posey bed, other than to keep him from falling and pulling out his Foley catheter.

n. The physician's notes lacked documentation of when the Posey bed, side rails and non-releasing seat belt would be discontinued.

o. On 8/27/14 at 10:40 a.m., during an interview with resident #2, he stated he felt like "I am in lock-down" when in the Posey bed. He feels like he can't move or go to the bathroom and it makes his back hurt. "I feel closed in, in [sic] that bed and I don't like it."

Review of the Restraint Policy indicated bed enclosures and four side rails were considered a physical restraint. Under the section "Basic premises":
-"Restraint is only to be used when clinically necessary and in an emergency (a serious, probable, imminent threat of bodily harm to self or others where there is a present ability to effect such bodily harm). The benefits must be assessed to be greater than the risks associated with the restraint;
-Restraint shall be a temporary measure to preserve the patient's well being as assessment deems it necessary, and other available techniques or less restrictive intervention have failed;
-Restraints are not to be used as a means of ...convenience..;
-Restraint must be discontinued at the earliest possible time, regardless of length of time identified in the physician's order;
-Restraint for the "convenience" of health providers is not acceptable; and
-Use of restraints for the prevention of falls is not a routine part of the fall prevention program."

The policy revealed a "clinical assessment/justification must identify the patient had unsafe behaviors, was not cognitively intact, and was placing self and others at risk or interfered with essential medical treatment for example intravenous therapy. Immediately after the application of a restraint, an assessment must occur that documents the patient's response to the restraint, and if negative, reassess for changes in the interventions. The use of a restraint must be documented in the care plan."

The section titled Alternative/Treatments showed "Only health care workers with documented current competencies in use of restraint may apply restraints under the guidance of the registered nurse."

The Section titled Order showed "Obtain a written order from the physician who must contain [sic] the specific reason for the restraint, date, specific time limit, and the signature of the physician."

Based on record review, the hospital staff failed to use less restrictive alternatives prior to the placement of a restraint for 2 (#s 1 and 2) of 2 patients. Findings include:

1. Patient #2 was admitted to the facility on 08/15/14 with diagnoses including acute respiratory failure, secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

a. The progress note, dated 8/19/14, dictated by staff member O, MD, revealed, "He is still really pretty confused and impulsive. In fact in the last 24 hours, he has fallen three times. The patient has been told multiple times to use his call light and he will suddenly just get up and fall down. This morning, he actually pulled out his Foley catheter. We have made him a one-to-one sitter and we are trying to get a Vail (sic) bed."

b. The resulting effects of the less restriction intervention before the Posey bed was used, 1:1 staff on 8/19/14, were not documented in the physician's progress note.

c. The medical record lacked documentation of less restrictive interventions implemented before implementation of the non-releasing seat belt and the use of four side rails on the Stryker frame of the Posey bed.


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2. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, stage II pressure ulcer, COPD, functional quadriplegic, and hypertension.

d. A physician ordered a Posey bed on 8/18/14 to prevent falling and to keep the patient in bed. The medical record lacked documentation of less restrictive alternatives prior to the order of the Posey bed. Patient #1 was in the Posey bed up to 8/26/14.

e. The Restraint Policy included documentation that a restraint may only be implemented, "if alternatives would be inappropriate or ineffective under the circumstances."

Based on record review, the hospital staff failed to document the condition or symptom which warranted the use of a restraint for 1 (#1) of 2 patients. Findings include:

1. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, stage II pressure ulcer, COPD, functional quadriplegic, and hypertension.

a. The medical surgical nurses flow sheets from 8/09/14 through 8/25/14 showed four side rails were used to prevent the patient from exiting the bed.

b. The physician ordered a Posey bed on 8/18/14 to prevent the patient from falling and to keep the patient in bed. The medical record lacked documentation of an unsafe situation warranting the use of the restraint and seclusion. A patient attempting to get up out of bed and or the risk for falling is not an appropriate clinical rationale or justification for a restraint. The restraint was in place from 8/18/14 to 8/26/14.

c. The medical record lacked documentation the patient's medical condition warranted the use of four side rails and a Posey bed.

Based on record review, policy review and patient interview, the hospital staff failed to document the assessment of the patient's response to a restraint for 2 (#s 1 and 2) of 2 patients. Findings include:

1. Patient #2 was admitted to the facility on 08/15/14 with diagnoses including acute respiratory failure, secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

Review of the medical record showed a lack of a detailed assessment regarding the patient's response to the interventions, and a well reasoned plan, in the physician's progress notes and the patient's Interdisciplinary Physician Led Plan of Care, from 8/19/14 to 8/26/14.

a. On 8/20/14 the physician's progress note stated:
"He is extremely weak and impulsive and confused. The patient actually fell four times in the course of 24 hours. He is belligerent and complaints (sic) that he wants to live (sic). We actually had him in a Vail (sic) bed yesterday and he manage (sic) to get his hand out through one small opening, get a hold of the zipper, unzip it and try to climb out of bed and he fell." Plan: We will continue with physical therapy and occupational therapy and nutritional therapy. ....."His behavior is so impulsive and erratic that I think we should at least have him on some thiamine. We will watch him carefully and see how things go. If there are any further problems, they will be handled as they arise."

b. On 8/27/14 at 10:40 a.m., patient #2 stated he felt like "I am in lock-down" when in the Posey bed and he feels like he can't move or go to the bathroom and it makes his back hurt. "I feel closed in, in that bed and I don't like it."


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2. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, stage II pressure ulcer, COPD, functional quadriplegic, and hypertension.

a. The physician ordered a Posey bed on 8/18/14 to prevent falling. Documented on 8/18/14 patient "At 0200 patient continues to screams out. Patient stated "she does not like being treated like a child."

b. On 8/25/14 at 3:30 p.m., patient #1 stated she "hated the bed. She felt entrapped. She could not reach her water or go to the bathroom."

c. The medical record lacked any documentation the physician's responded to patient#1's negative reaction to the Posey bed, seclusion, or side rails. The hospital did not reassess the negative response to the restraint and seclusion from patient #1.

d. The Restraint Policy:
-Under Assessment "Immediately after application of a restraint, an assessment must occur that documents the patient's response to the restraint, and if negative, reassess for changes in the interventions."

Based on observation, record review, staff and patient interview the hospital administration failed to train staff members on how to implement a restraint for 2 (#s 1 and 2) of 2 patients. Findings include:

1. Patient #2 was admitted to the facility on 08/15/14 with diagnoses including acute respiratory failure, secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

a. On 8/25/14 at 3:20 p.m., staff member C, DON was observed in patient #1's room. He stated all four side rails were in the up position and demonstrated how they would look when they were in the down position. The staff member C returned the side rails to the up position, with staff member A, Area Director of Compliance watching the demonstration. Both staff members left the room with the side rails in the up position, the netting of the Posey bed was not taut, and the head and foot boards were intact on the bed.

b. On 8/25/14 at 5:45 p.m., staff member C, DON, presented an all-staff training on the correct and safe use of the Posy bed. The training did not include information on the necessity of the bed to be within 17 inches from the ground, to have the netting pulled taut, to have removed the head board and foot board, to have assured the netting was without rips or tears, and to check the placement of the zippers on the Posey bed.

c. On 8/26/14 at 8:05 a.m., resident #2 was observed sleeping in a Posey bed with the headboard and footboard intact. The netting on the Posey bed was not taut.

d. On 8/26/14 at 10:30 a.m., staff member I, Maintenance Manager, measured patient #2's Posey bed. The Stryker frame was 13.75 inches from the floor. Manufacturer's instructions for the Posey bed showed the bed should be no lower than 16-17 inches from the floor.


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2. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, COPD, functional quadriplegic, and hypertension.

a. On 8/25/14 at 3:30 p.m., patient #1 stated she hated the bed. She felt entrapped. She could not reach her water or go to the bathroom. The bedside table was observed to be in the room, and drinking water was on the table. The Posey bed was observed with loose netting. The four side rails were observed to be in the upright position. A picture of a human body entangled in a side rail was visible on the mattress. The phrase under the picture was "make sure all side rails are down."

b. The Posey 8060 "Quick-Check 10" illustrated that the netting and canopy must be secure. Side rails were to be "ALWAYS" in the down position. The bed was not to exceed 17 inches from the floor in the lowest position.

c. On 8/26/14 at 10:30 a.m., staff member I, Maintenance Manager, measured patient #1's Posey bed. The Stryker frame was 14 inches from the ground. Manufacturer's instructions for the Posey bed state the bed should be no lower than 16-17 inches from the floor. The netting and canopy was not tight on the Posey bed.

d. Restraint Policy:
Definition:
"Physical restraints are defined as any method or physical/mechanical devices that restrict freedom of movement or normal access to one's body, material, or equipment. It may be attached or adjacent to the patient's body that cannot be easily removed by the patient. Identified types of Physical restraints: Bed Enclosures, W/C Restraint (non-releasing),...Side Rails-full or 4."

e. Staff education:
-"Staff members who have direct patient care contact will have education and training regarding the use of restraints at orientation and yearly..."
-Direct care staff will receive training on "techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that requires the use of a restraint.
-The use of a nonphysical intervention skills...
-Signs and symptoms of physical distress in restrained patients."

f. Staff applying the restraint:
-"Safe use of restraint including application and removal of all types of restraint used in the hospital..."

g. On 8/26/14 at 10:00 a.m., the CEO stated there was an "assumption that training was provided on proper use of a Posey bed." "It was not."

h. On 8/25/14 at 6:00 p.m., staff member A provided the restraint training completed in 2013 for all staff at the hospital. The training provided not include the proper use of a Posey bed.

Based on observation, record and policy review, and staff and patient interview, the hospital administration failed to provide documentation that the hospital staff were educated and trained on the use of a Posey bed for 2 (#s 1 and 2) of 2 patients. Findings include:

1. Patient #2 was admitted to the facility on 08/15/14 with diagnoses including acute respiratory failure secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

a. On 8/25/14 at 1 p.m., during the initial tour Patient #1 was observed in a Posey bed with the side rails in the up position, the netting was not taut and the head and foot boards were on the Stryker frame.

b. On 8/25/14 at 3:20 p.m., staff member C, DON, was observed in patient #1's room. He stated the side rails were in the up position and demonstrated how they would look when they were in the down position. The staff member C returned the side rails to the up position, with staff member A, Area Director of Compliance watching the demonstration. Both staff members left the room with the side rails in the up position, the netting of the Posey bed blousing, and the head and foot boards intact on the bed.

c. On 8/26/14, at 8:05 a.m., Patient #2 was observed sleeping in a Posey bed with the head and foot boards on the Stryker frame, the netting was not taut.

d. On 8/26/14 at 10:30 a.m., staff member I, maintenance manager measured the height of patient #1's bed from the floor. It was 28.25 inches from the floor. The recommendation on the Posey bed instructions was for the bed not to exceed more than 25 inches from the floor.

e. On 8/26/14 at 10:45 a.m., staff member I, maintenance manager and Staff member H, central supply manager measured the distance of patient #2's bed from the floor. It was 13.75 inches from the floor. The recommendation on the Posey bed instructions for the lowest height of the bed from the floor was no more than 17 inches.


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2. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, COPD, functional quadriplegic, and hypertension.

a. On 8/25/14 at 3:30 p.m., patient #1 stated she hated the bed. She felt entrapped. She could not reach her water or go to the bathroom. The bedside table was observed and drinking water was on the table. The Posey bed netting was not tight. The four side rails were observed to be in the upright position. The headboard and footboard were on the bed. At this time observed on the mattress was a picture of a human body entangled in a side rail. The phrase under the picture was make sure all side rails are down.

b. The Posey 8060 "Quick-Check 10" illustrated that the netting and canopy must be secure. Side rails were to be "ALWAYS" in the down position. The lowest height of the bed was not to exceed 17 inches.

c. On 8/26/14 at 10:30 a.m., staff member I, Maintenance Manager, measured patient #1's Posey bed. The Stryker frame was 14 inches from the ground. The netting and canopy was not tight on the Posey bed.

d. On 8/26/14 at 10:00 a.m., staff member H, central supply manager, and I maintenance manager, both stated they had not been trained on the setup of a Posey bed. Staff member H state he only orders the beds.

e. On 8/26/14 at 10:00 a.m., the CEO stated there was an assumption that training was provided on proper use of a Posey bed. "It was not."

f. On 8/26/14 at 11:45 a.m., in an interview with Staff member J, the Posey bed vendor representative, he stated he has never provided training to the hospital staff.

g. On 8/26/14 at 12:00 p.m., Staff member J, the vendor representative for the Posey bed, provided training to the current hospital staff members. Staff member J stated in his training at no time are side rails to be used with a Posey bed. The netting and canopy must be tight and contain no rips, tears, or holes. He further stated that lowest height of the bed was not to be less than 16 inches from the floor and no higher than 25 inches from the floor. The footboard and headboard are not be on the bed with a Posey. "This type of bed should be the last resort."

Based on policy review and staff interview the hospital administration did not provide education or training to hospital staff on the proper use of a Posey bed for 2 of 2 patients. Findings include:

1. On 8/25/14 at 6:00 p.m., staff member A provided the restraint training completed in 2013. Review of the restraint training packet lacked information regarding the use of enclosed beds.

Definition:
"Physical restraints are defined as any method or physical/mechanical devices that restrict freedom of movement or normal access to one's body, material, or equipment. It may be attached or adjacent to the patient's body that cannot be easily removed by the patient. Identified types of Physical restraints: Bed Enclosures, W/C Restraint (non-releasing),...Side Rails-full or 4."

Staff education:
-"Staff members who have direct patient care contact will have education and training regarding the use of restraints at orientation and yearly..."
-Direct care staff will receive training on "techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that requires the use of a restraint.
-The use of a nonphysical intervention skills...
-Signs and symptoms of physical distress in restrained patients."

Staff applying the restraint:
-"Safe use of restraint including application and removal of all types of restraint used in the hospital..." The training provided to the hospital staff did not include the proper use of a Posey bed.

On 8/26/14 at 10:00 a.m., the CEO stated there was an "assumption that training was provided on proper use of a Posey bed." "It was not."

Based on record review the hospital staff failed to demonstrate knowledge of choosing less restrictive interventions than restraints based on the assessment of the medical condition, or behaviors for 1 (#1) of 2 patients. Findings include:

Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, COPD, functional quadriplegic, and hypertension.

The medical record lacked documentation of a medical condition, behaviors, and less restrictive interventions attempted prior to the use of the restraint. Review of the physician progress notes dated 8/9, 8/10, 8/11, 8/12, 8/13, 8/14, 8/15, 8/16, and 8/17/14 lacked documentation of less restrictive measures attempted prior to the placement of the restraint.

Based on observation, record and policy review, and staff and patient interview, the hospital administration failed to educate, train, and demonstrate proper knowledge on how to recognize and respond to signs of distress in patients using Posey beds for 2(#s 1 and 2 )of 2 patients. The hospital staff failed to recognize the improper use of the Posey bed. The hospital staff failed to recognize signs of distress from the patients. Findings include:

1. Patient #2 was admitted to the facility on 08/15/14 with diagnoses including acute respiratory failure, secondary to multiple trauma, blunt abdominal trauma with multiple points of bleeding, splenic laceration, status post splenectomy, recent hemorrhagic shock, generalized debility and poly drug abuse.

a. On 8/25/14 at 1 p.m., during the initial tour, Patient #1 was observed in a Posey bed with the side rails in the up position, the netting was not taut and the head and foot boards were on the Stryker frame.

b. On 8/25/14 at 3:20 p.m., staff member C, DON was observed in patient #1's room. He stated the side rails were in the up position and demonstrated how they would look when they were in the down position. The staff member returned the side rails to the up position, with staff member A, Area Director of Compliance watching the demonstration. Both staff members left the room with the side rails in the up position, the netting of the Posey bed blousing and the head and foot boards intact on the bed.

c. On 8/26/14, at 8:05 a.m., patient #2 was observed sleeping in a Posey bed with the head and foot boards on the Stryker frame, the netting was not taut.

d. On 8/26/14 at 10:30 a.m., staff member I, maintenance manager measured the distance of patient #1's bed from the floor. It was 28.25 inches from the floor. The Posey bed instructions recommend at a height no more than 25 inches. Staff member I stated he was not aware of this.

e. On 8/26/14 at 10:45 a.m., staff member I, maintenance manager measured the distance of patient #2's bed from the floor. It was 13.75 inches from the floor. The Posey bed instructions recommend the lowest position of the bed was to be no less than 16 inches from the floor. Staff member I stated he was not aware of this.




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2. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, COPD, functional quadriplegic, and hypertension.

a. On 8/25/14 at 3:30 p.m., patient #1 stated she "hated the bed." "She felt entrapped." "She could not reach her water or go to the bathroom." The patients' water was on the bedside table. The patient could not unzip the netting to reach her water. The patient stated she had to "use the call light and wait." At this time the warning label observed on the mattress stating side rails were to be in the down position. The mattress displayed a picture of a human figure entailed in a bed rail with a warning.

b. Review of the physician's daily progress notes dated "8/9/14 through 8/18/14 lacked documentation patient #1 exhibited negative behaviors which were harmful to herself or others."

c. On 8/18/14 the physician's progress note showed patient #1 "was agitated and tried to climb out of bed."

d. The medical surgical nurses flow sheets showed:
-8/18/14 patient was attempting to crawl out of the "veil bed" at 0545. At 1900 (7:00 p.m.) the patient was found on the floor laying next to the Posey bed. At 0200 patient continues to screams out. Patient states "she does not like being treated like a child."

e. The Posey 8060 "Quick-Check 10" illustrated that the netting and canopy must be secure. Side rails were to be "ALWAYS" in the down position. The lowest height of the bed was not to exceed 16 inches. Observed on the mattress was a picture of a human body entangled in a side rail. The phrase under the picture was make sure all side rails are down.

f. On 8/26/14 at 10:30 a.m., staff member I, Maintenance Manager, measured Patient #1's Posey bed. The Stryker frame was 14 inches from the ground. Manufacturer's instructions for the Posey bed state the bed should be no lower than 16-17 inches from the floor. The netting and canopy was not tight on the Posey bed. Staff member I stated he was not aware of this.

g. On 8/26/14 at 10:00 a.m., staff member H, central supply manager, and I maintenance manager, both stated they had not been trained on the setup of a Posey bed. Staff member H state he only orders the beds.

h. On 8/26/14 at 10:00 a.m., the CEO stated there was an" assumption that training was provided on proper use of a Posey bed." "It was not."

i. On 8/26/14 at 11:45 a.m., in an interview with Staff member J, the vendor representative for the Posey bed, stated he "has never provided training to the hospital staff."

j. On 8/26/14 at 12:00 p.m., Staff member J, the vendor representative for the Posey bed, stated "at no time are side rails to be used with a Posey bed. The netting and canopy must be tight and contain no rips, tears, or holes. He further stated that lowest height of the bed was not to be less than 16 inches from the floor and no higher than 25 inches. The footboard and headboard should not be on the bed with a Posey."

k. On 8/25/14 at 6:00 p.m., staff member A provided the restraint training completed in 2013 for all staff at the hospital.
Staff applying the restraint:
-"Safe use of restraint including application and removal of all types of restraint used in the hospital..." The training provided to the hospital staff did not include the proper use of a Posey bed. The training did not go over signs of distress.

Based on record review and staff interview the hospital administration did not provide education or training to hospital staff regarding recognizing and responding to the clinical behavior changes with a use of a restraint for 1 (#1) of 2 patients. Findings include:

1. Patient #1 was admitted to the hospital on 8/8/14 with diagnoses including bacterial meningitis with septic emboli, CVA, encephalopathy, acute pelvic pain, MRSA, atelectasis, acute respiratory failure, diabetes type II, urinary tract infection, COPD, functional quadriplegic, and hypertension.

a. Patient #1 was in a restraint from 8/09/14 to 8/26/14. The patient was in four side rail restraint from 8/9/14 thru 8/25/14. Patient #1 was in a Posey restraint and seclusion for 7 days. The medical chart lacked documentation of the clinical medical condition or behavior which precipitated the restraint. The medical provider documented the restraint was to keep the patient from falling and prevent her from getting out of the bed.

b. The medical record lacked documentation that the hospital staff assessed the patient's response to the restraint. The patient stated she did not like being treated like a "child" on 8/19/14. The medical chart lacked documentation as to what the patient's clinical condition was and when the restraint would be discontinued.

c. On 8/25/14 at 6:00 p.m., staff member A provided the restraint training completed in 2013 for all staff employed at the hospital. The training did not include assess and re-assessing the patients behavior prior to implementing a restraint and seclusion. The training lacked information on Posey beds.

d. On 8/26/14 at 10:00 a.m., the CEO stated there was an "assumption that training was provided on proper use of a Posey bed." "It was not."