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Based on observations, interviews and documents review, it was determined the Governing Body failed to to provide a safe setting for patients (A168), failed to provide monitoring of restrained patients (A175) and failed to maintain trained staff (A194). The failed practice affected the four restrained patients on the Gero-Psych Unit at the time of the survey and had the potential to affect all patients admitted to the facility that required restraints.

Based on observations, interviews, clinical record reviews and policy and procedure review it was determined the facility failed to protect the rights of patients and provide care in a safe setting in that the facility failed to obtain physician's orders for restraints, failed to monitor restrained patients every two hours per facility restraint policy and procedures and failed to ensure staff were trained and knowledgeable regarding the manufacturer's guidelines of equipment used on four (#2, #4, #13 and #14) of four (#2, #4, #13, and #14) patients.
Observations and interviews revealed four (#2, #4, #13 and #14) of four (#2, #4, #13 and #14) current patients, ages 82 - 94, with diagnoses of Dementia, were secured in chairs with lap belts and were unable to self-release. Failure to obtain physician's orders, monitor restrained patients per facility policy and procedure and train staff in the use of patient equipment had the potential to allow non-cognitively functioning patients to be at risk for entrapment, entanglement and suffocation. Findings follow:
A. Observations, interviews and clinical record review revealed four (#2, #4, #13 and #14) of four (#2, #4, #13 and #14) currently restrained patients did not receive care in a safe setting in that the facility failed to obtain physician's orders for restraints per facility policy and procedure numbered I 14.0 and titled Restraints/Seclusion. See A168.

B. Observations, interviews and clinical record review revealed four (#2, #4, #13 and #14) of four (#2, #4, #13 and #14) currently restrained patients did not receive care in a safe setting in that the facility failed to monitor the restrained patients every two hours per facility policy and procedure numbered I 14.0 and titled Restraints/Seclusion. See 175.

C. Observations, interviews and clinical record review revealed four (#2, #4, #13 and #14) of four (#2, #4, #13 and #14) currently restrained patients were not afforded safe implementation of restraints by trained staff. Nursing staff were not knowledgeable in the safe and recommended use of lap belts. See A194.

Based on observations, interviews and review of Manufacturer's Guidelines, it was determined that four (Patient #2, #4, #13 and #14) of four (#2, #4, #13 - #14) currently restrained patients in the Gero Psych Unit did not receive care in a safe setting in that the facility failed to ensure restraint orders were obtained per facility policy for restrained patients. Failure to obtain physician's orders for restraints did not allow the physician to be knowledgeable of the patient's need for restraints and prohibited the Facility from following its policy. The failed practice affected Patients #2, #4, #13 and #14 on 04/04/13 and 04/05/13. Findings follow.

A. Review of manufacturer's guidelines Review of the Self-Releasing Padded Belts received from the CNO (Chief Nursing Officer) at 0900 on 04/05/13 revealed the following:

INDICATIONS FOR USE:
Patients needing a reminder to call for assistance before exiting a chair or bed, and are able to follow instructions...
.
CAUTION This product is designed for self-release. If the patient is not able to easily self-release, it is considered a restraint and must be prescribed by a physician.

CONTRAINDICATIONS:
Do Not use on a patient who is or becomes highly aggressive, combative, agitated, or suicidal...
...DO NOT use on a patient who is unwilling or unable to follow instructions, and is at risk of a fall or re-injury from self-release ...

WARNING
...There is a risk of chest compression or suffocation if the patient's body weight is suspended off the mattress or chair seat. Use extreme cautions with chair cushions. If a cushion dislodges, straps may loosen and allow the patient to slide off the seat. Monitor per facility policy to ensure that the patient cannot slide down, or fall off the chair seat or mattress and become suspended or entrapped.

B. During a tour of the Gero Psych Unit at 1000 on 04/04/13, three patients (#2, #4 and #14) were observed secured in chairs by lap belts while in the Activity Room. Further Surveyor observations at this time included:

Patient #2, a 84 year old with admitting diagnoses of Delirium, SDAT (Senila Dementia Alztheimer Type) with Behavior Disturbances, unable to follow directions issued by staff.

Patient #4, a 82 year old with diagnoses of Delirium, Bipolar, Dementia with Behavior Disorders, did not respond to the actions, noises or general activity of the activity (bowling with an inflatable beach ball and plastic bowling pins.)

Patient #14, a 94 year old with admitting diagnoses of Dementia and Behavior Disturbance,
did not respond to the actions and noises from the activity and did not respond to verbal statements from this surveyor.

C. During a tour of the Gero-Psych Unit conducted at 0940 on 04/05/13 Patients #4, #13 and #14 were observed in the Activity Room. The following observations were made:
0945 Patient #14 was observed to be in a recliner, lap belt in use. Patient #14 would not respond to verbal stimulation from this Surveyor. The CNO agreed Patient #14 could not self-release at 0945.

0953 Patient #13, a 85 year old with admitting diagnoses of Dementia with Depression, was noted to be seated in a wheelchair, lap belt in use. The CNO tried to get Patient #13 to release the lap belt buckle. Patient #13 was unable to follow instructions and could not self-release. Patient #13 was noted to lean forward, grab wheelchair arms and get up.

0955 Patient #4 was noted to be in a blue recliner, lap belt in use. The CNO tried to get Patient #4 to release the lap belt buckle. Patient #4 was unable to do so and kept repeating "I can't see it." Patient #4 did become agitated during this attempt to get her to unbuckle the lap belt.

D. During an interview with the CNO, the Gero-Psych Program Manager and the Gero-Psych Nurse Manager at 1005 on 04/05/13, stated they were unaware of the Manufacturer's Guidelines for lap belt use. The CNO, the Gero-Psych Program Manager and the Gero-Psych Nurse Manager were asked if the Facility required a physician's order for the lap belt use and all three stated no because the Facility never considered the lap belt to be a restraint. The CNO, the Gero-Psych Program Manager and the Gero-Psych Nurse Manager were asked if there was a policy and procedure, protocol or any criteria for the lap belt use and all three stated no because the Facility never considered the lap belt to be a restraint.

Based on observations, interviews, review of clinical records and policies and procedures, it was determined the Facility restrained four (#2, #4, #13 and #14) of four (#2, #4, #13 and #14) current patients without physician's orders. Failure to obtain physician's orders for restraints did not allow the physician to be knowledgeable of the patient's need for restraints and prohibited the Facility from following its policy. The failed practice affected Patients #2, #4, #13 and #14 on 04/04/13 and 04/05/13. Findings follow:

A. Review of the clinical record of Patient #2 revealed no orders for restraints.

B. Review of the clinical record of Patient #4 revealed no orders for restraints.

C. Review of the clinical record of Patient #13 revealed there were no orders for restraints.

D. Review of the clinical record of Patient #14 revealed there were no orders for restraints.

E. The above findings were confirmed by the Chief Nursing Officer at 1135 on 04/05/13.

Based on clinical record review and interview, it was determined the facility failed to ensure renewal orders for restraints were obtained from the physician every 24 hours for four of four ICU patients. Failure to ensure current restraint orders were in place allowed Patients #7 through #10 to be restrained without orders. Findings follow.

A. Review of ICU policy titled "ICU Ventilator Restraint Protocol" stated: " A. Secure a initial physician order to implement the protocol (Refer to Physician Order #255) ... A daily physician order is not necessary if the protocol is being followed and the patient still meets the approved criteria."

B. Review of Patient #7's ICU closed clinical record revealed orders for bilateral soft wrist restraints at 1400 on 02/26/13. Review of ICU Alternative Restraint Forms revealed Patient #7 was in bilateral soft wrist restraints and restraint monitoring was documented from 2000 on 02/27/13 through 0600 on 03/01/13. Findings were confirmed by the Chief Nursing Officer (CNO) on 04/05/13 at 1145.

C. Review of Patient #8's ICU closed clinical record revealed no orders for restraints. Review of ICU Alternative Restraint Forms revealed Patient #8 was in bilateral wrist restraints and restraint monitoring was documented from 1930 on 2/23/13 through 1600 on 02/24/13, 2000 on 02/24/13 through 0359 on 02/27/13, and 0800 through 1000 on 02/27/13. Findings were confirmed by the CNO on 04/05/13 at 1430.

D. Review of Patient #9's ICU closed clinical record revealed orders for bilateral soft wrist restraints at 1900 on 02/27/13 and 1900 on 02/28/13. Review of ICU Alternative Restraint Forms revealed Patient #9 was in bilateral wrist restraints and restraint monitoring was documented from 2000 on 02/26/13 through 0000 on 02/27/13 and 0800 through 1600 on 02/27/13. Findings were confirmed by the CNO on 04/05/13 at 1430.

E. Review of Patient #10's ICU closed clinical record revealed orders for bilateral soft wrist restraints at 0245 on 03/02/13, at 0245 on 03/03/13, at 0230 on 03/04/13,, at 0200 on 03/07/13, at 0900 on 03/09/13, and at 0200 on 03/11/13, and orders for chest restraint on 03/02/13 and 03/03/13. Review of ICU Alternative Restraint Forms revealed Patient #10 was in bilateral wrist restraints and restraint monitoring was documented from 0800 through 1400 on 03/05/13, from 2000 on 03/05/13 through 0604 on 03/06/13, from 2000 on 03/06/13 through 0014 on 03/07/13, and from 2000 on 03/08/13 through 0000 on 03/09/13.

F. Findings were confirmed for Patients (#7-#10) by the CNO on 04/05/13 at 1430.

Based on observations, interviews and clinical record and policies and procedures review, it was determined the Facility failed to monitor restrained patients as required by Facility policy and procedure numbered I 14.0 and titled Restraints/Seclusion, for four (#2, #4, #13 and #14) of four (#2, #4, #13 and #14) current patients. Failure to monitor and assess restrained patients every two hours per Facility policy and procedure had the potential to allow patient injury or death and did not allow the patient to be assessed and released from restraints as early as safely possible. The failed practice affected four current patients, #2, #4, #13 and #14 on 04/04/13 through 04/05/13. Findings follow:

A. Review of the clinical record of Patient #2 revealed no monitoring of restraints.

B. Review of the clinical record of Patient #4 revealed no monitoring of restraints.

C. Review of the clinical record of Patient #13 revealed no monitoring of restraints.

D. Review of the clinical record of Patient #14 revealed no monitoring of restraints.

E. The above findings were confirmed by the Chief Nursing Officer at 1135 on 04/05/13.



Based on reviews of policy and procedures, interviews and clinical record review, it was determined the facility failed to monitor restrained patients as required by facility policy and procedure titled "ICU Ventilator Restraint Protocol" for three (#7, #9 and #10) of four (#7-10) restrained ICU patients. Failure to monitor and assess every two hours did not allow for the patient to be released from restraints as early as safely possible. The failed practice had the potential to affect three (#7, #9, and #10) of four (#7 - #10) restrained ICU patients. Findings follow.

A. Review of ICU policy titled "ICU Ventilator Restraint Protocol" stated "Assesses the patient at least every two (2) hours to determine if the patient still meets the protocol criteria."

B) Review of Patient #7's ICU closed clinical record revealed orders for bilateral soft wrist restraints at 1400 on 02/26/13. Restraint monitoring was not documented from 1400 through 2000 on 02/26/13, and from 0200 through 2000 on 02//27/13. Findings were confirmed by the CNO on 04/05/13 at 1145.

C) Review of Patient #9's ICU closed clinical record revealed orders for bilateral soft wrist restraints on 02/27/13 at 1900 and 02/28/13 at 1900. Restraint documentation began at 2000 on 02/26/13. Monitoring was not documented from 0000 through 0800 and 1600 through 2200 on 02/27/13, and from 0600 on 02/28/13 through 0200 on 02/29/13. Findings were confirmed by the CNO on 04/05/13 at 1430.

D) Review of Patient #10's ICU closed clinical record revealed orders for bilateral soft wrist restraints on 03/02/13 through 03/04/13, 03/07/13, 03/09/13, and 03/11/13 and orders for chest restraint on 03/02/13 and 03/03/13. Restraint monitoring was not documented from 0400 through 0800 and 1600 through 2000 on 03/03/13, from 0800 through 2000 on 03/04/13, from 0412 through 0800 and from 1400 through 2000 on 05/05/13, from 0604 through 2000 on 03/06/13, from 0400 through 2000 on 03/08/13 and no monitoring was documented at all on 03/11/13. Findings were confirmed by the Chief Nursing Officer (CNO) on 04/05/13 at 1145.

Based on interviews, observations, review of Manufacturer's Guidelines, policies and procedures, and clinical record review, it was determined four (#2, #4, #13 and #14) of four (#2, #4, #13-14) current patients were not afforded safe implementation and monitoring of restraints by trained staff. Nursing staff of all levels at the Facility were not knowledgeable in the safe and recommended use of lap belts. Failure to provide patients with effectively trained, knowledgeable staff to initiate, monitor and affect safe restraint use had the potential to allow patient injury. The failed practice affected Patients #2, #4, #13 and
#14 on 04/04/13 and 04/05/13. Findings follow:

A. During an interview with Staff Registered Nurse (RN) #1 at 1430 on 04/04/13 she stated lap belts are not considered restraints because the lap belts are self-releasing. Staff RN #1 was asked what type of patients the lap belts were utilized on. Staff RN #1 stated the lap belts were primarily utilized on patients who were at high risk of falling.

B. During an interview with the CNO, the Gero-Psych Program Manager and the Gero-Psych Nurse Manager at 1005 on 04/05/13, they stated they were unaware of the Manufacturer's Guidelines for lap belt use.