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Based on policy review, medical record review, and staff interview, the facility failed to ensure the patient or patient representative participated in the development and implementation of the plan of care (A130). The facility failed to ensure restraints were only used when less restrictive interventions were determined to be ineffective (A164). The facility failed to ensure a physician order was obtained for non-violent restraints according to policy and procedure (A168). The facility failed to ensure restrained patients were monitored per their policy (A175).

Based on policy review, medical record review, and staff interview, the facility failed to ensure the patient or patient representative participated in the development and implementation of the plan of care for one of two medical records reviewed with restraints (Patient #1). A total of ten medical records were reviewed. The facility census was 13.

Findings include:

Review of the policy titled, Restraints/Protective Devices, revised 10/31/19, revealed restraints will be used only if less restrictive interventions have been considered or attempted and only imposed to ensure the immediate physical safety of the patient and must be discontinued at the earliest possible time. Alternatives to Restraints - Any mechanism that does not restrict a patient's movement or mobility, but may be effective in maintaining patient safety and well being. Use of alternatives is based on individual patient assessment. Alternatives to restraints may include: placing the patient by the nurses station; providing pleasurable distractions such as TV, music, conversation, reading to the patient, or engaging the patient in simple activities such as walking; any constructive hand motor activity (if not contraindicated); sitter.

Review of the medical record for Patient #1 revealed the patient was restrained on 09/19/21, and from 09/21/22 through 10/22/21. The Case Management note dated 10/11/21 noted the spouse complained that the patient remained in restraints and requested a sitter for the patient. The Internal Medicine progress note dated 10/14/22 noted the spouse was requesting a sitter. The medical record contained documentation the restraints were removed while family was at the bedside on 09/25/21 from 12:00 PM to 4:00 PM, on 09/27/21 from 10:30 AM to 2:00 PM, on 09/28/21 from 10:00 AM to 3:45 PM, on 10/10/21 from 10:34 AM to 4:25 PM, on 10/16/21 from 9:30 AM to 8:00 PM, and on 10/19/21 from 9:30 AM to 6:00 PM. The medical record lacked documentation of an order for a sitter or use of a sitter.

An order dated 09/19/21 at 5:00 PM noted post discharge follow up appointments for 10/04/21 at 8:10 AM for an annual well visit, a follow up appointment in two to four weeks with Neurosurgery with repeat CT Head, and a Neurosurgery Center follow up appointment on 10/06/21 at 2:30 PM. A CT of the brain was obtained on 10/05/21 at 10:23 AM; however, the medical record lacked documentation of any coordination of care with the Neurosurgery Center or Neurosurgeon. The medical record lacked documentation the patient was sent out to any of these follow up appointments or that any of these appointments were canceled.

The findings were verified in an interview with Staff A on 05/05/22 at 2:00 PM.

This deficiency substantiates Substantial Allegation OH00131317.

Based on policy review, medical record review, and staff interview, the facility failed to ensure restraints were only used when less restrictive interventions were determined to be ineffective for one of two medical records reviewed with restraints (Patient #1). A total of ten medical records were reviewed. The facility census was 13.

Findings include:

Review of the policy titled, Restraints/Protective Devices, revised 10/31/19, revealed restraints will be used only if less restrictive interventions have been considered or attempted and only imposed to ensure the immediate physical safety of the patient and must be discontinued at the earliest possible time. Alternatives to Restraints - Any mechanism that does not restrict a patient's movement or mobility, but may be effective in maintaining patient safety and well being. Use of alternatives is based on individual patient assessment. Alternatives to restraints may include: placing the patient by the nurses station; providing pleasurable distractions such as TV, music, conversation, reading to the patient, or engaging the patient in simple activities such as walking; any constructive hand motor activity (if not contraindicated); sitter.

Review of the medical record for Patient #1 revealed the patient was restrained on 09/19/21, and from 09/21/22 through 10/22/21. The Case Management note dated 10/11/21 noted the spouse complained that the patient remained in restraints and requested a sitter for the patient. The Internal Medicine progress note dated 10/14/21 noted the spouse was requesting a sitter. The medical record contained documentation the restraints were removed while family was at bedside on 09/25/21 from 12:00 PM to 4:00 PM, on 09/27/21 from 10:30 AM to 2:00 PM, on 09/28/21 from 10:00 AM to 3:45 PM, on 10/10/21 from 10:34 AM to 4:25 PM, on 10/16/21 from 9:30 AM to 8:00 PM, and on 10/19/21 from 9:30 AM to 6:00 PM. The medical record lacked documentation of an order for a sitter or use of a sitter.

The findings were verified in an interview with Staff A on 05/05/22 at 2:00 PM.

This deficiency substantiates Substantial Allegation OH00131317.

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 #1). A total of ten medical records were reviewed. The facility census was 13.

Findings include:

Review of the policy titled, Restraints/Protective Devices, revised 10/31/19, revealed an order was required prior to or immediately following application of all restraints. Orders for restraints must be renewed each calendar day. If restraints were discontinued and the same behavior became evident again, then a new order to re-apply the restraints must be obtained.

Review of the medical record for Patient #1 revealed the patient had a right soft wrist restraint from 09/20/21 at 8:00 PM through 09/22/21 at 2:00 AM. The medical record lacked an order for a right wrist restraint until 09/21/21 at 12:00 AM. The medical record also contained an order dated 09/21/21 at 7:00 AM for a left soft wrist restraint. No left wrist restraint was documented on 09/21/21 as the patient had left sided weakness.

The medical record contained documentation from 09/24/21 from 8:00 AM to 09/25/21 at 10:00 AM of wrist restraint in place with no mention as to which wrist or if both wrists were restrained. A note dated 09/24/21 at 6:00 PM noted left restraint reapplied, and at 8:00 PM noted bilateral wrist restraints remain on. The order dated 09/24/21 at 7:00 AM was for right soft wrist restraint. The medical record contained documentation from 09/25/21 at 4:00 PM through 09/27/21 at 8:00 AM of bilateral soft wrist restraints in place. The medical record lacked an order dated 09/25/21 for restraints. The medical record contained an order dated 09/27/21 at 6:00 AM for bilateral soft wrist restraints. The medical record contained documentation the restraints were removed on 09/27/21 at 10:00 AM and reapplied at 4:00 PM. The medical record lacked documentation of a new order for restraints on 09/27/21 when they were reapplied. The medical record contained documentation of bilateral soft wrist restraints on 09/27/21 at 4:00 PM through 09/28/21 at 8:00 AM. The medical record contained an order dated 09/28/21 at 6:00 AM for bilateral soft wrist restraints. The medical record contained documentation the restraints were removed on 09/28/21 at 10:00 AM and reapplied at 4:00 PM. The medical record lacked documentation of a new order for restraints on 09/28/21 when the restraints were reapplied. The medical record contained documentation of bilateral soft wrist restraints on 09/28/21 from 4:00 PM through 09/30/21 at 6:00 AM. The medical record contained an order for bilateral soft wrist restraints on 09/30/21 at 7:00 AM. The medical record lacked documentation of restraints on 09/30/21 from 8:00 AM through 6:00 PM, with no documentation of when or if the restraints were removed. The medical record contained documentation of bilateral soft wrist restraints on 09/30/21 from 8:00 PM through 10/01/21 at 8:00 PM. The medical record lacked documentation of a new order for restraints when the restraints were resumed on 09/30/21 at 8:00 PM.

The medical record contained an order dated 10/08/21 at 6:00 AM for bilateral soft wrist restraints. The medical record contained documentation of bilateral soft wrist restraints on 10/05/21 from 12:00 PM through 10/08/21 at 10:00 AM. The medical record contained documentation the restraints were removed at 10:00 AM and reapplied at 8:00 PM. The medical record lacked documentation of a new order when the restraints were reapplied on 10/08/21. The medical record contained documentation of bilateral soft wrist restraints on 10/08/21 from 8:00 PM through 10/09/21 at 10:00 AM. The medical record contained an order for bilateral soft wrist restraints on 10/09/21 at 6:00 AM. The medical record contained documentation the restraints were removed at 12:00 PM and reapplied at 8:00 PM on 10/09/21. The medical record lacked documentation of a new order on 10/09/21 when the restraints were reapplied. The medical record contained documentation of bilateral soft wrist restraints from 10/09/21 at 8:00 PM through 10/10/21 at 8:00 AM. The medical record contained documentation of an order dated 10/10/21 at 6:00 AM for bilateral soft wrist restraints. The medical record contained documentation the restraints were removed on 10/10/21 at 10:00 AM and reapplied at 4:25 PM. The medical record lacked documentation of a new order on 10/10/21 when the restraints were reapplied.

The medical record contained documentation of bilateral soft wrist restraints on 10/10/21 from 8:00 PM through 10/12/21 at 8:00 AM. The medical record contained documentation the restraints were removed on 10/12/21 at 10:00 AM and resumed at 4:00 PM. The medical record contained documentation of bilateral soft wrist restraints on 10/12/21 from 4:00 PM through 10/16/21 at 10:00 AM. The medical record lacked documentation of any restraint orders on 10/12/21 or 10/13/21. The medical record contained documentation the restraints were removed on 10/16/21 at 10:00 AM and reapplied at 9:40 PM. The medical record contained an order dated 10/15/21 at 6:00 AM for bilateral soft wrist restraints, but lacked an order for restraints dated 10/16/21 until 9:30 PM.

The medical record contained an order dated 10/18/21 at 6:00 AM for bilateral soft wrist restraints; however no restraints were documented on 10/18/21. The medical record contained an order for bilateral soft wrist restraints on 10/19/21 at 3:30 AM. The medical record contained documentation of bilateral soft wrist restraints on 10/19/21 from 3:45 AM to 10:00 AM. The medical record contained documentation the restraints were removed at 10:00 AM and reapplied at 7:20 PM. The medical record lacked documentation of a new order when the restraints were reapplied on 10/19/21. The medical record contained orders dated 10/20/21 at 4:00 AM and 10/21/21 at 4:00 AM for bilateral soft wrist restraints. The medical record contained documentation of bilateral soft wrist restraints on 10/19/21 at 7:20 PM to 10/20/21 at 6:00 PM. The restraints were removed on 10/20/21 at 8:00 PM and reapplied at 10:00 PM, with no new order documented. The medical record contained documentation of bilateral soft wrist restraints on 10/20/21 at 10:00 PM to 10/21/21 at 8:00 AM. The medical record contained documentation the restraints were removed on 10/21/21 at 9:30 AM and reapplied at 9:30 PM, with no new order documented. The medical record contained documentation the restraints were removed on 10/22/21 at 6:00 AM, with no further restraint use. The medical record contained an order for bilateral soft wrist restraints dated 10/22/21 with no time, signed by the physician on 10/22/21 at 6:35 PM, and marked physician and spouse notified on 10/21/21 at 10:15 PM.

The findings were verified in an interview with Staff A on 05/05/22 at 10:30 AM.

This deficiency substantiates Substantial Allegation OH00131317.

Based on policy review, medical record review, and staff interview, the facility failed to ensure restrained patients were monitored per their policy for one of two medical records reviewed with restraints (Patient #1). A total of ten medical records were reviewed. The facility census was 13.

Findings include:

Review of the policy titled, Restraints/Protective Devices, revised 10/31/19, revealed restrained patients are monitored every two hours. The patient's well-being must be observed by a staff member hourly and documented by the RN every two hours. Observation and assessment should include: the physical and emotional well-being of the patient, including nutrition, hydration, and toileting needs, range of motion, positioning, skin integrity, circulation status, respiratory status; alteration of skin integrity should be reported to physician and to wound care nurse for evaluation; maintaining the patient's rights, dignity, and safety; consideration of alternatives or less restrictive methods to restraints.

Review of the medical record for Patient #1 revealed the patient had a right soft wrist restraint on 09/22/21. The medical record lacked documentation of safety checks every two hours on 09/22/21 from 2:00 AM to 8:00 AM. Bilateral soft wrist restraints were ordered on 09/30/21. The medical record lacked documentation of restraint checks every two hours on 09/30/21 from 8:00 AM through 6:00 PM with no documentation that the restraints had been removed. Bilateral soft wrist restraints were ordered on 10/01/21 and 10/02/21. The medical record lacked documentation of restraint checks every two hours on 10/01/21 from 10:00 PM through 6:00 AM on 10/02/21. Bilateral soft wrist restraints were ordered on 10/04/21. The medical record lacked documentation of restraint checks every two hours on 10/04/21 from 2:00 PM to 10:00 PM. Bilateral soft wrist restraints were ordered on 10/05/21. The medical record lacked documentation of restraint checks every two hours on 10/05/21 from 4:00 AM to 8:00 AM. Bilateral soft wrist restraints were ordered on 10/07/21. The medical record documentation on 10/07/21 from 2:00 PM through 6:00 PM contained documentation of restraint type every two hours, but lacked documentation of all the safety checks. Bilateral soft wrist restraints were ordered on 10/08/21. The medical record lacked documentation of restraint checks every two hours on 10/08/21 from 4:00 PM to 8:00 PM. Bilateral soft wrist restraints were ordered on 10/09/21. The medical record lacked documentation of restraint checks every two hours on 10/09/21 from 4:00 PM to 8:00 PM. Bilateral soft wrist restraints were ordered on 10/10/21. The medical record lacked documentation of restraint checks every two hours on 10/10/21 from 2:00 PM to 8:00 PM. Bilateral soft wrist restraints were ordered on 10/16/21 at 9:30 PM. The medical record lacked documentation of restraint checks every two hours on 10/16/21 from 9:30 PM to 10/17/21 at 7:30 AM when the restraints were discontinued.

The findings were verified in an interview with Staff A on 05/05/22 at 10:30 AM.

This deficiency substantiates Substantial Allegation OH00131317.