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Based on policy review, medical record review, and staff interview, the facility failed to ensure restraints were used with a written modification to the patient's plan of care for two of two medical records reviewed with restraints (Patient #2 and #3). A total of ten medical records were reviewed. The facility census was 29.

Findings include:

Review of the policy titled, "Restraints and Seclusion," revised 07/01/21, revealed a modification of the patient's treatment plan related to restraint use, patient's response to restraint, and plan for reduction/elimination would be included in the patient's medical record.

1. Review of the medical record for Patient #2 revealed the patient had restraint orders dated 03/08/22, 03/11/22, and 03/13/22. The patient had bilateral mittens applied on 03/08/22 at 10:58 AM and had them removed on 03/08/22 at 11:01 PM. On 03/11/22 at 6:34 PM, the patient had bilateral soft wrist restraints applied. The restraints were discontinued on 03/14/22 at 11:05 AM. The care plan had restraints for non-violent behavior added with a start date of 03/11/22 and a resolved date of 04/01/22.

The findings were verified in an interview with Staff A on 04/06/22 at 10:30 AM.

2. Review of the medical record for Patient #3 revealed the patient had restraints ordered on 03/29/22 and 03/30/22. The patient had bilateral soft wrist restraints applied on 03/29/22 at 7:41 PM and discontinued on 03/30/22 at 4:00 PM. The care plan had restraints for non-violent behavior added 03/30/22 at 8:42 PM. The "Plan of Care - Encounter Notes" included restraints on 03/31/22 at 12:50 PM and 04/01/22 at 8:31 AM. The care plan also lacked documentation of a resolved date.

The findings were verified in an interview with Staff A on 04/07/22 at 9:50 AM.

Based on policy review, medical record review, and staff interview, the facility failed to ensure a physician order was obtained for non-violent restraints according to policy and procedure for one of two medical records reviewed with restraints (Patient #2). A total of ten medical records were reviewed. The facility census was 29.

Findings include:

Review of the policy titled, "Restraints and Seclusion," revised 07/01/21, revealed a written order was required for restraint use. Orders for restraints must be renewed on a daily basis.

Review of the medical record for Patient #2 revealed the patient had bilateral soft wrist restraints applied on 03/11/22 at 6:34 PM. The restraints were discontinued on 03/14/22 at 11:05 AM. The initial order for soft wrist restraints was dated 03/11/22 at 6:33 AM. The second order for soft wrist restraints was dated 03/13/22 at 3:35 AM and was noted to be canceled on 03/13/22 at 1:43 PM. The medical record lacked an order dated 03/12/22 or 03/14/22 for restraints. The findings were verified in an interview with Staff A on 04/06/22 at 10:30 AM.

Based on policy review, medical record review, and staff interview, the facility failed to ensure restrained patients were monitored per their policy for two of two medical records reviewed with restraints (Patients #2 and #3). A total of ten medical records were reviewed. The facility census was 29.

Findings include:

Review of the policy titled, "Restraints and Seclusion," revised 07/01/21, revealed observations would be completed every two hours for medical restraints.

1. Review of the medical record for Patient #2 revealed the patient had bilateral soft wrist restraints applied on 03/11/22 at 6:34 PM. The restraints were discontinued on 03/14/22 at 11:05 AM. The medical record lacked documentation of restraint monitoring every two hours on 03/12/22 from 5:32 AM to 8:00 AM, on 03/12/22 from 6:00 PM to 03/13/22 at 3:36 AM, on 03/13/22 from 5:34 AM to 8:00 AM, and on 03/13/22 from 12:00 PM to 03/14/22 at 11:05 AM when the restraints were noted to be discontinued. The findings were verified in an interview with Staff A on 04/06/22 at 10:30 AM.

2. Review of the medical record for Patient #3 revealed the patient had bilateral soft wrist restraints applied on 03/29/22 at 7:41 PM and discontinued on 03/30/22 at 4:00 PM. The medical record lacked documentation of monitoring every two hours on 03/30/22 from 4:00 AM to 8:00 AM. The findings were verified in an interview with Staff A on 04/07/22 at 9:50 AM.

Based on medical record review and staff interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient for eight of ten medical records reviewed (Patient #1, #2, #3, #4, #6, #7, #9, and #10). The facility census was 29.

Findings include:

1. Review of the medical record for Patient #1 revealed an order dated 01/19/22 for Aquacel AG with foam dressing to be applied to the sacral wound daily and when no longer intact. The medical record lacked documentation of a dressing change on 01/21/22, 01/24/22, 01/25/22, and 01/26/22.

2. Review of the medical record for Patient #2 revealed an order for a Dakins dressing twice a day to the sacrum. The medical record lacked documentation of a second dressing change on 03/09/22, 03/12/22, and 03/14/22. The medical record contained an order dated 04/01/22 for Aquacel AG daily to the sacrum. The medical record lacked documentation of a dressing change on 04/02/22.

3. Review of the medical record for Patient #3 revealed an order dated 03/02/22 to swab with Betadine and leave open to the air daily for both feet and both heels. The medical record lacked documentation of Betadine application to the right foot on 03/07/22, 03/10/22, 03/11/22, 03/12/22, 03/14/22, 03/24/22, and 03/25/22. The medical record lacked documentation of Betadine application to the left foot on 03/10/22, 03/11/22, and 03/14/22. The medical record lacked documentation of Betadine application to both heels on 03/07/22. The medical record contained an order dated 03/08/22 for an alginate dressing with tegaderm to be applied to the right heel every Tuesday and Friday. The medical record lacked documentation of a dressing change to the right heel on 03/11/22. The medical record contained an order dated 03/02/22 to apply Calmoseptine to the right gluteus/gluteal fold and leave open to air twice a day. The medical record lacked documentation of a second application of Calmoseptine to the right gluteus/gluteal fold on 03/10/22, 03/11/22, 03/12/22, 03/13/22, and 03/14/22. The medical record contained an order dated 03/09/22 to apply a composite dressing to the left axilla every Tuesday and Friday. The medical record lacked documentation of a dressing to the left axilla on 03/11/22 and 03/14/22.

4. Review of the medical record for Patient #4 revealed an order dated 02/17/22 for Aquacel AG daily to the left leg wound. The medical record lacked documentation on 02/19/22 of a dressing change to the left leg. The medical record contained an order dated 03/03/22 for honey alginate and an abdominal pad to be placed on the left leg wound every Tuesday, Thursday, and Saturday. The medical record lacked documentation of a dressing change to the left leg on 03/30/22.

5. Review of the medical record for Patient #6 revealed an order dated 03/24/22 for drawtex to be placed under the bumper of the peg tube twice a day. The medical record lacked documentation of wound care to the peg tube insertion site on 03/25/22 and contained only one dressing change on 03/26/22. The medical record contained an order dated 03/29/22 for drawtex to be applied to the peg tube insertion site daily. The medical record lacked documentation of wound care to the peg tube site on 04/04/22.

6. Review of the medical record for Patient #7 revealed an order dated 02/15/22 for Aquacel AG foam to be applied daily to the sacral wound. The medical record lacked documentation of wound care to the sacral wound on 02/17/22, 03/04/22, 03/05/22, 03/09/22, 03/12/22, 03/13/22, and 03/14/22. The medical record contained an order dated 02/22/22 for Aquacel AG to be applied daily to the left arm wound. The medical record lacked documentation of wound care to the left arm on 02/27/22, 03/03/22, 03/05/22, and 03/14/22.

7. Review of the medical record for Patient #9 revealed an order dated 02/13/22 for a wound vac to the lumbar spine wound to be changed every Monday, Wednesday, and Friday. The medical record lacked documentation of the wound vac being changed on 02/14/22.

8. Review of the medical record for Patient #10 revealed an order dated 02/01/22 for routine trach and stoma care twice a day. The medical record contained documentation of trach and stoma care only once on 02/14/22.

These findings were verified in an interview with Staff C on 04/07/22 at 12:15 PM.