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Based on observations, document review, and interview the facility failed to modify the plan of care to include restraints for two of four restrained patients included in the survey sample. (Patients #5 and #6)

The findings included:

1. Patient #5 was observed in hand mitt restrains during the initial tour 11:30 a.m. through 12:45 p.m., on March 4, 2013. Review of Patient #5's electronic medical record (EMR) revealed the patient was placed in bilateral hand mitt restraints on March 1, 2013. Review of Patient #5's plan of care did not include a modification for his/her bilateral hand mitt restraints.

2. Review of Patient #6's EMR revealed the patient had been placed in hand mitt restraints on January 6, 7, 15, and 16, 2013. Review of Patient #6's plan of care did not include a modification for either of his/her bilateral hand mitt restraint episodes.

An interview was conducted on March 4, 2012 at approximately 3:16 p.m. with Staff #1. Staff #1 discussed the facility's quality indicators related to restraints. Staff #1 was asked to review the EMRs for Patient #5 and Patient #6 related to plan of care modifications regarding restraints. Staff #1 reviewed both EMRs and reported the staff had failed to modify the plan of care for Patients #5 and #6 to include restraints. Staff #1 reported the patients' plan of care was part of their EMR.

Review of the facility's policy titled "Use of Physical or Chemical Restraints: General Requirements" read in part "Modify the care plan electronically ..."

An interview was conducted on March 4, 2013 at 4:33 p.m., with Staffs #1, #2, and #4. Staff #4 stated, "We reviewed the charts. The staff did not tie the use of restraints back into the care plans for [name of Patients #5 and #6.]"

Based on observation and interview, the hospital staff failed to ensure a safe environment. The door to three patient rooms were tied or propped open.

Findings:

On 3/4/13 at 1:15 p.m. room number 301 was observed to have the door tied open. A rope was tied to an ante room-adjoining the patient's room and then tied to the exit door. The door would not close. The Director of Nursing (DON) removed the rope and allowed the door to close. The DON stated that room 301 was a "negative pressure room" and there for did not have a magnetic latch to keep the door open. The magnetic latch would disengage in the event of a fire/safety hazard to allow the door to close. Two other negative pressure rooms were observed and the doors were propped open with trash cans, preventing the door from closing in the event of a fire/safety hazard. Room number 301 was again observed at approximately 3:00 p.m., again tied open. The DON inquired of the staff members at the nursing station-none of which reported as having tied the door open.

On 3/4/13 at approximately 4:00 p.m. the Director of Quality was interviewed and a policy regarding negative pressure room doors, or preventing the doors from automatically closing was requested. No policy was presented during the survey.

The Administrator, Director of Quality and the Director of Nursing were interviewed on 3/4/13 at 5:45 p.m. and no further information regarding was presented.