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Based on review of medical records and interview with the Clinical Director it was determined the facility failed to provide the patient or a representative of the patient notice of their rights on admission and failed to document provision of the rights. This had the potential to affect all patients served by this facility.

Findings include:

A review of four medical records, # 1 ( 2 seperate admissions), 2, 3, and 4, revealed no documentation of patient rights being discussed or documented as being provided to the patient or their representative.

On 6/2/10 at 3:10 PM, the surveyor asked Employee Identifier (EI) # 1, the Clinical Director regarding the patient rights provided to the patients on admission. EI # 1 could not locate the rights in the medical record and stated that she would locate them.

On 6/3/10 at 7:30 AM, EI # 1 provided to the surveyor a patient handbook which the Liaison had been providing to the patient and attaching a sticker with the State hotline telephone number during the pre-assessment screening or on admission. EI # 1 stated that she would immediately have the registered nurses on the floor provide the information to the patients with the handbook. EI # 1 was asked how long it had been since the handbooks had been used and she stated that she did not know. EI # 1 went on to confirm that she had been auditing medical records and had not seen anything in the records to support patient rights being provided to the patients.

Based on review of medical records, facility policy and procedure and interview with the Clinical Director it was determined the facility failed to provide patient care in an environment that a reasonable person would consider safe. The facility failed to provide care to 1 of 1 patients who was restrained due to contractures of his legs without an order from a physician.

Findings include:

Facility Policy: HD-Nurse 418.03
Guideline Restraints; Assessment, Documentation and Application in Medical/Surgical Care

Guideline:
Restraint may be used as the least restrictive effective measure based on the current assessment by a registered nurse, of the patient, after other measures have been unsuccessful or determined to be inappropriate (clinical justification).

Procedure:
I. Assessment of patient need.
1. Assessment of a patient's baseline functioning is critical to establish patterns of behavior or needs...

II. Clinical Justification
Patients admitted to the hospital may require the use of mechanical restraints (soft limb) for the purpose of protecting medical devices...
1. Restraints used to maintain or deliver treatment associated with medical or surgical condition that if left untreated would compromise the patient.
2. Unable to follow directions to avoid unintentionally harming him/herself...

III. Initial Physician Order
If alternatives prove unsuccessful and the application of restraints are clinically justified, supervisor will notify the attending physician (or the covering physician) of the need to restrain...
A. A written or verbal order must be obtained from the attending physician within 12 hours.
B. A written order, based on the assessment of the patient by the attending physician must be documented within 24 hours...

Facility Policy: HD-AD 318.02
Restraints in General Population

Policy- It shall be the policy of Noland Health- Hospital Division that caregivers make every effort to provide a restraint-free environment. Reduction in the use of restraints will be accomplished through preventative alternatives that focus on the patient's well being while maintaining the patient's rights and dignity, and through on-going staff orientation and process improvement. Restraints will only be utilized when alternative, less restrictive measures have been attempted and failed.

Definition- Restraint:
Is any method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. The specific device used to restrain a patient does not in itself determine whether this policy applies. Rather, it is the device's intended use (such as physical restriction), its voluntary application and/or the identified patient need that determines whether the use of the device applies to this policy...

Staff Competency and Education:
All staff applying restraint devices shall receive instruction and demonstrate competency in the safe application of restraints and subsequent monitoring of restrained patients upon hire and annually thereafter...

1. Medical record # 1 was admitted 4/7/10 with a diagnosis of Acute Respiratory Failure. The patient was transferred to the long-term care hospital for continuation of treatment of his respiratory failure, pneumonia, IV (intravenous) antibiotics and followup care.
The past medical history include:
1. Respiratory Failure
2. Pneumonia
3. Chronic trach
4. PEG (percutaneous endoscopic gastrotomy) tube feeding
5. Bed-bound condition
6. UTI (urinary tract infection)
7. Alcohol abuse
8. Carotid stenosis.

The physical therapy evaluation dated 4/7/10 documented, " Bilateral lower extremity contracted." Pain scale on the evaluation documented, " patient grimace with range of motion."

The occupational therapy evaluation dated 4/7/10 documented, " Contracted bilateral lower extremity , right fingers stuck in/or contracted in/ cervical neck/ contracture."

The nurse documented 4/25/10 at 0700 on the narrative note addendum, " ... R (right) & L (left) legs contracted. Straightened out as much as possible, placed ankle restraints to keep legs from going into chest area, will monitor closely... 0900 ... replaced ankle restraints, done exercise with legs, tolerated well, seems like L leg hurts more than R leg...1300... checked feet in restraints no problems... 1600 sister at bedside explained ankle restraints to keep pt legs from getting pulled up to his chest."

The restraint flowsheet dated 4/25/10 time ordered 0600, time initiated 0600. Patient safety, education, rights, dignity, well being has documented under the other section, " Straighten out legs." Type of restraint right lower leg and right lower leg, patients behavior- calm.

There was no order for the restraints in the medical record from the physician or documented by the nurse as a verbal order from the physician.

On 6/2/10 at 1:00 PM the surveyor asked the Clinical Director, Employee Identifier (EI) # 1 about the use of the restraints on the patient to straighten out his contracted legs. The patient had documentation in the medical record of pain when his/her legs were moved due to the contractures.

On 6/3/10 at 7:30 AM, EI # 1 stated that she had spoken with the registered nurse, EI # 3 who had placed the patient in the restraint to straighten out his/her legs. EI # 1 stated that she had arranged to re-educate this nurse and conduct an inservice with facility staff regarding the use of restraints.

Based on review of medical records and interview the facility failed to ensure all of the patients served by this facility remained free of physical restraint. This affected medical record # 1 and had the potential to affect all patients.

Finding include:


1. Medical record # 1 was admitted 4/7/10 with a diagnosis of Acute Respiratory Failure. The patient was transferred to the long-term care hospital for continuation of treatment of his respiratory failure, pneumonia, IV (intravenous) antibiotics and followup care.

The nurse documented 4/25/10 at 0700 on the narrative note addendum, " ... R (right) & L (left) legs contracted. Straightened out as much as possible, placed ankle restraints to keep legs from going into chest area, will monitor closely... 0900 ... replaced ankle restraints, done exercise with legs, tolerated well, seems like L leg hurts more than R leg...1300... checked feet in restraints no problems... 1600 sister at bedside explained ankle restraints to keep pt legs from getting pulled up to his chest."

The restraint flowsheet dated 4/25/10 time ordered 0600, time initiated 0600. Patient safety, education, rights, dignity, well being has documented under the other section, " Straighten out legs." Type of restraint right lower leg and right lower leg, patients behavior- calm.

There was no order for the restraints in the medical record from the physician or documented by the nurse as a verbal order from the physician.

On 6/2/10 at 1:00 PM the surveyor asked the Clinical Director, Employee Identifier (EI) # 1 about the use of the restraints on the patient to straighten out his contracted legs. The patient had documentation in the medical record of pain when his/her legs were moved due to the contractures.

On 6/3/10 at 7:30 AM, EI # 1 stated that she had spoken with the registered nurse, EI # 3 who had placed the patient in the restraint to straighten out his/her legs. EI # 1 stated that she had arranged to re-educate this nurse and conduct an inservice with facility staff regarding the use of restraints.

Refer to G144 for Restraint Policy