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The Hospital failed to adhere to their policy and procedure and documentation requirements related to restraint use for two of two patients requiring restraints.

The Surveyor reviewed the policy titled "Restraint/Seclusion" dated 9/2017. The Policy indicated that for a medical/surgical restraint the order is reviewed by the Licensed Independent Practitioner every calendar day. Also, when a restraint is discontinued if a patient requires re-restraining then a new order must be obtained. Further, all direct care staff providing care for the patient in restraints are to receive orientation and annual restraint training.

1.) Patient #10 was a ventilator (breathing machine) dependent patient who was reported as pulling at lines and tubings and required restraints to maintain safety and a treatment modality. The restraint order was written on 2/14/18 and was used for the seven days that followed.

The Surveyor reviewed the Safety Checks and Monitoring Sheet at 10:00 A.M. on 2/22/18. The Safety Checks and Monitoring sheet indicated that documentation was to be done every two hours during Patient #10's restraint period. On 2/21/18, Patient #10's monitoring sheet was completed nine of the twelve times required. On 2/21/18, Patient #10's monitoring sheet was completed two of the twelve times required. On 2/20/18, Patient #10's monitoring sheet was completed nine of the twelve times required. On 2/19/18, Patient #10's monitoring sheet was completed as required. On 2/18/18, Patient #10's monitoring sheet was completed ten of the twelve times required. On 2/17/18, Patient #10's monitoring sheet was completed eight of the twelve times required. On 2/16/18, Patient #10's monitoring sheet was completed six of the twelve times required. On 2/15/18, Patient #10's monitoring sheet was completed six of the twelve times required. On 2/14/18, Patient #10's monitoring sheet was completed one of the twelve times required.

2.) Patient #11 was a ventilator dependent patient who was reported as pulling at lines and tubings and required restraints to maintain safety and a treatment modality. The restraint order was written on 2/17/18 and was used for the five days that followed.

The Surveyor reviewed the Safety Checks and Monitoring Sheet at 10:00 A.M. on 2/22/18. The Safety Checks and Monitoring sheet indicated that documentation was to be done every two hours during Patient #11's restraint period. On 2/21/18, Patient #11's monitoring sheet indicated that Patient #11 was unrestrained for two hours between 4:00 P.M. and 6:00 P.M. and re-restrained at 8:00 P.M. No new order was generated for the second restraint of Patient #11 as required. On 2/20/18, Patient #11's monitoring sheet was completed seven of the twelve times required. On 2/19/18, Patient #11's monitoring sheet was completed six of the twelve times required. On 2/19/18 Patient #11's monitoring sheet indicated that Patient #11 was unrestrained for two hours between 10:00 PM and 12:00 A.M. and then re-restrained at 12:00 midnight without obtaining a new order to restrain Patient #11 as required.

The Hospital failed to conduct restraint training according to their policy and procedure for one of two nurses who participate in applying patient restraints.

The Surveyor reviewed the policy titled "Restraint/Seclusion" dated 9/2017. The Policy indicated that all staff providing direct patient care will receive annual education and training in the proper and safe use of restraints.

The Surveyor reviewed the Personnel file for the Nursing Supervisor on 2/22/18. The record did not indicate annual restraint training. According to the CPI Instructor's letter, the Nursing Supervisor was last trained in Non-Violent Crisis Intervention on 6/20/13 valid through 6/20/14.

The Nursing Supervisor was caring for Patient #10, a patient in constant medical/surgical restraints on 2/22/18.