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Based on a medical record review, a review of policies and procedures, and interviews with facility staff, it was determined that the facility failed to ensure that patient rights were protected for two patients (P) (P#1, P#3) out of four sampled patients. Specifically, P#1 was restrained on 7/13/22, 7/25/22, and 10/14/22 without a corresponding physician's order for restraints. P#3 was restrained on 7/23/22 and 7/25/22 without a physician order.

Cross-reference: A0168 Patient Rights: Restraint or Seclusion as it relates to the facility failing to ensure that P#1's rights were protected when P#1 was restrained without a corresponding physician order.

Based on a medical record review, a review of policies and procedures, and interviews with facility staff, it was determined that the facility failed to obtain a physcian order for restraints per the facility policy for two patients (P) (P#1, P#3) out of four sampled patients. Specifically, P#1 was restrained on 7/13/22, 7/25/22, and 10/14/22 without a corresponding physician's order for restraints. P#3 was restrained on 7/23/22 and 7/25/22 without a physician order.

Cross-reference: A0398 Supervision of contract staff as it relates to the facility failing to ensure that P#1'and P#3 were restrained by staff without a physcian order which is required by the facility policy.

Based on a medical record review, a review of policies and procedures, and interviews with facility staff, it was determined that the facility failed to ensure that patient rights were protected for two patients (P) (P#1, P#3) out of four sampled patients. Specifically, P#1 was restrained on 7/13/22, 7/25/22, and 10/14/22 without a corresponding physician's order for restraints. P#3 was restrained on 7/23/22 and 7/25/22 without a physician order.
Findings:

A medical record review revealed that Patient (P) #1 was a 59-year-old male admitted to the facility on 7/11/22 for acute respiratory failure (fluid buildup in the air sacs of the lungs).

Further review of the medical record revealed that on 7/13/22, P#1 was restrained (prevented from freedom of movement or action) with bilateral (two-sided) limb holders without a physician's order. Additionally, a review of P#1's restraint orders revealed there was not a renewed order for restraints by a physician on 7/13/22.

Continued review revealed that on 7/25/22, P#1 was restrained with bilateral limb holders without a physician's order. Additionally, a review of P#1's restraint orders revealed there was not a renewed order for restraints by a physician on 7/25/22.

Further review of the restraint orders for August 2022 revealed that restraint orders were in place daily until 8/23/22. On 8/23/22, P#1's physician ordered restraints to be discontinued. No additional orders for restraints were documented after 8/23/22.

A review of P#1's Physical Therapy (PT) note dated 10/14/22 revealed that P#1 was in a "roll-belt" restraint on 10/14/22. A review of P#1's restraint orders failed to reveal a physician's order for restraints on 10/14/22.

A review of P#3's medical record revealed that P#3 was restrained with mitts and a roll belt on 7/23/22 and 7/25/22, but there were no restraint orders for either of those dates.

A review of the facility's policy titled "Restraint," no policy #, last effective date 10/01/22, revealed the purpose of the policy was to provide guidelines for the use of restraint and/or seclusion and to promote the appropriate use and monitoring of restraint or seclusion. Alternative measures were to be considered prior to the application of restraint devices or the use of seclusion. The policy applied to all staff members who provided patient care, provided assistance with the application of restraints, and monitored patients in restraints and/or seclusion. The policy provided guidelines for the use of least restrictive interventions to avoid the use of restraint or seclusion and to protect the dignity and safety of patients. Restraint and seclusion of patients were utilized to ensure the immediate physical safety of the patient, staff, or others when preventive or alternative strategies were inadequate in providing a safe environment for all. In all cases, the use of restraints or seclusion required a physician's order. It would be in accordance with written facility policy, applicable law/regulation, and a written modification of the patient's plan of care. Futher review of the policy stated that patients restrained/secluded due to violent or self-destructive behavior would be assessed every 15 minutes. Additionally, the policy ststed that patients restrained due to unsafe or therapeutically disruptive behavior would be assessed every 2 hours or more frequently as needed.

A review of the facility's policy "Patient's Rights and Responsibilities," no policy #, last effective date 9/8/21, revealed the purpose was to establish guidelines for patient care that recognized each patient as an individual with unique healthcare needs, values, and cultural perspectives. All patients of the facility were entitled to be free from restraint/seclusion used as a means of coercion, discipline, convenience, or retaliation by staff.

An interview was conducted with Charge Nurse (CN) CC on 10/17/22 at 3:30 p.m. in the conference room. CN CC stated that she was familiar with P#1. CN CC said that P#1 had been combative and restless since admission to the facility and made several attempts to get out of his bed without assistance. She explained that this was the reason for initially ordering restraints. She continued to explain that it was the nursing staff's responsibility to round on their patients every two hours and that no patient would go longer than two hours without being checked on by a staff member. CN CC stated that P#1 was in restraints for a long time when he first arrived at the facility. She continued to explain that all restraints were required to be signed off on by the physician and must be reevaluated every 24 hours and prior to removing the order permanently.

An interview was conducted with Medical Doctor (MD) OO on 10/18/22 at 12:40 p.m. in the conference room. MD OO stated that he was familiar with P#1 and could recall that P#1 was initially admitted due to a brain bleed and substance abuse. MD OO continued to explain that P#1 was violent on admission and would not follow commands. MD OO stated due to P#1's non-compliance with medical advice and consistent confusion; it was difficult to calm P#1 down. MD OO said that P#1 had not required restraints as often as he did when he was initially admitted to the facility. He continued to explain that a nurse could place an order for restraints, but a physician was the only one who could approve the order. MD OO said the order for restraints must be reviewed every 24 hours to determine if the restraints could be removed or needed to be renewed.

Based on a medical record review, a review of policies and procedures, and interviews with facility staff, it was determined that the facility failed to obtain a physcian order for restraints per the facility policy for two patients (P) (P#1, P#3) out of four sampled patients. Specifically, P#1 was restrained on 7/13/22, 7/25/22, and 10/14/22 without a corresponding physician's order for restraints. P#3 was restrained on 7/23/22 and 7/25/22 without a physician order.

Findings:

A medical record review revealed that Patient (P) #1 was a 59-year-old male admitted to the facility on 7/11/22 for acute respiratory failure (fluid buildup in the air sacs of the lungs).

Further review of the medical record revealed that on 7/13/22, P#1 was restrained (prevented from freedom of movement or action) with bilateral (two-sided) limb holders without a physician's order. Additionally, a review of P#1's restraint orders revealed there was not a renewed order for restraints by a physician on 7/13/22.

Continued review revealed that on 7/25/22, P#1 was restrained with bilateral limb holders without a physician's order. Additionally, a review of P#1's restraint orders revealed there was not a renewed order for restraints by a physician on 7/25/22.

Further review of the restraint orders for August 2022 revealed that restraint orders were in place daily until 8/23/22. On 8/23/22, P#1's physician ordered restraints to be discontinued. No additional orders for restraints were documented after 8/23/22.

A review of P#1's Physical Therapy (PT) note dated 10/14/22 revealed that P#1 was in a "roll-belt" restraint on 10/14/22. A review of P#1's restraint orders failed to reveal a physician's order for restraints on 10/14/22.

A review of P#3's medical record revealed that P#3 was restrained with mitts and a roll belt on 7/23/22 and 7/25/22, but there were no restraint orders for either of those dates.

A review of the facility's policy titled "Restraint," no policy #, last effective date 10/01/22, revealed the purpose of the policy was to provide guidelines for the use of restraint and/or seclusion and to promote the appropriate use and monitoring of restraint or seclusion. Alternative measures were to be considered prior to the application of restraint devices or the use of seclusion. The policy applied to all staff members who provided patient care, provided assistance with the application of restraints, and monitored patients in restraints and/or seclusion. The policy provided guidelines for the use of least restrictive interventions to avoid the use of restraint or seclusion and to protect the dignity and safety of patients. Restraint and seclusion of patients were utilized to ensure the immediate physical safety of the patient, staff, or others when preventive or alternative strategies were inadequate in providing a safe environment for all. In all cases, the use of restraints or seclusion required a physician's order. It would be in accordance with written facility policy, applicable law/regulation, and a written modification of the patient's plan of care. "Patients restrained/secluded due to violent or self-destructive behavior would be assessed every 15 minutes. Patients restrained due to unsafe or therapeutically disruptive behavior would be assessed every 2 hours or more frequently as needed."

An interview was conducted with Charge Nurse (CN) CC on 10/17/22 at 3:30 p.m. in the conference room. CN CC stated that she was familiar with P#1. CN CC said that P#1 had been combative and restless since admission to the facility and made several attempts to get out of his bed without assistance. She explained that this was the reason for initially ordering restraints. She continued to explain that it was the nursing staff's responsibility to round on their patients every two hours and that no patient would go longer than two hours without being checked on by a staff member. CN CC stated that P#1 was in restraints for a long time when he first arrived at the facility. She continued to explain that all restraints were required to be signed off on by the physician and must be reevaluated every 24 hours and prior to removing the order permanently.

An interview was conducted with Medical Doctor (MD) OO on 10/18/22 at 12:40 p.m. in the conference room. MD OO stated that he was familiar with P#1 and could recall that P#1 was initially admitted due to a brain bleed and substance abuse. MD OO continued to explain that P#1 was violent on admission and would not follow commands. MD OO stated due to P#1's non-compliance with medical advice and consistent confusion; it was difficult to calm P#1 down. MD OO said that P#1 had not required restraints as often as he did when he was initially admitted to the facility. He continued to explain that a nurse could place an order for restraints, but a physician was the only one who could approve the order. MD OO said the order for restraints must be reviewed every 24 hours to determine if the restraints could be removed or needed to be renewed.