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Based on interview and record review, the physician did not renew the bed enclosure restraint order on 10/08/10 for 1 of 2 patients (Patient #1) who were admitted to the facility for rehabilitation therapy.

Findings included:

Patient #1 was admitted on 10/04/10 for rehabilitation therapy after an acute episode of CVA (cerebrovascular accident). The physician ordered "bed enclosure" restraint on 10/05/10 at 12 midnight. This was renewed on 10/06/10 and 10/07/10. There was no physician order for the renewal of the bed enclosure restraint. On 10/07/10 at 11:30 PM, the nurse noted that she "aided" the patient to bed and "safely zipped" the Posey bed.

In an interview on 05/26/11 at approximately 11:30 AM, Personnel #4 was asked if the patient used the Posey bed on the night of 10/07/10 and the early morning of 10/08/10. She replied "yes."

In an interview on 05/26/11 at approximately 3:30 PM, Personnel #2 was informed that there was no physician order for the renewal of the bed enclosure restraint. After reviewing the patient's medical record, Personnel #2 stated that she could not find an order.

Risk Management 669 - "Use of Restraints in Non-Psychiatric Hospital or Unit" effective date 03/20/09 required "Order/ Renewal ...reorder every 24 hours ...Monitoring every 2 hours through observation ... Documentation monitoring results every 2 hours ..."

Based on interview and record review, the nursing staff did not monitor restraint use every 2 hours for 1 of 2 patients (Patient #1) who were admitted to the facility for rehabilitation therapy.

Findings included:

Patient #1 was admitted on 10/04/10 for rehabilitation therapy after an acute episode of CVA (cerebrovascular accident). The physician ordered "bed enclosure" restraint on 10/05/10 at 12 midnight. The nurse noted at 10:00 PM on 10/04/10 that the patient was put in the enclosure bed restraint. The patient was not monitored for restraint use for 10.5 hours from 10/04/10 at 10:00 PM to 10/05/10 at 8:45 AM. On 10/07/10, the patient was not monitored for restraint use approximately 2 hours in the afternoon from 3:30 PM to 5:30 PM.

In an interview on 05/26/11, Personnel #2 & #3 were informed of the above findings. Personnel #2 stated that looking at the daily flowsheet it showed that the patient was not monitored every 2 hours. Personnel #2 stated that the patient must have gone for therapy. The patient was not in therapy during these times.

Policy: Risk Management 669 - "Use of Restraints in Non-Psychiatric Hospital or Unit" effective date 03/20/09 required "Order/ Renewal ...reorder very 24 hours ...Monitoring every 2 hours through observation ... Documentation monitoring results every 2 hours ..."

Based on interview and record review, the registered nurse (RN) did not supervise and evaluate the nursing care of 1 of 2 patients (Patient #1) who were admitted to the facility for rehabilitation therapy.

Findings included:

Patient #1 was admitted on 10/04/10 for rehabilitation therapy after an acute episode of CVA (cerebrovascular accident). On the second shift of 10/07/10, the patient's blood pressure (BP) was 150/100. The "Daily Nursing Documentation/ Physical Assessment" and the narrative portion of the plan of care did not identify the patient's high blood pressure. The nurse did not perform an assessment and/ or provided any intervention, and the physician was not notified about the patient's increased BP.

In an interview on 06/08/11 at approximately 3:20 PM via phone, Personnel #3 was informed of the above findings. After reviewing the medical record, Personnel #3 confirmed the findings.

Policy 4.145 "Daily Nursing Documentation/ Physical Assessment Form" revised 05/2011 required "...to document nursing assessment and reassessment information on each patient...4. If any reassessment findings are abnormal, an assessment will be conducted and a narrative note will be written describing the problem area, abnormality, intervention, and follow-up..."