HospitalInspections.org

Based on document review, staff interview and observation, the facility failed to ensure patient could participate in the development and implementation of their plan of care due to lack of provision of information in language and terms the patient could understand (see tag A 130), the facility failed to ensure patient or his or her representative had the right to make informed decisions (see tag A131), the facility failed to ensure patient had the right to receive care in a safe setting (see tag A144), the facility failed to ensure patient had the right to be free from all forms of abuse (see tag A145), the facility failed to ensure patient rights to be free from physical or mental abuse and/or restraint (see tag A154), the facility failed to ensure the modification of the patient's plan of care with use of restraint (see tag A166), the facility failed to ensure an order was written by a physician or other licensed independent practitioner prior to the use of restraints (see tag A168), the facility failed to ensure the attending physician was notified of restraint use (see tag A170), the facility failed to ensure a time limit for use of restraint and that a new order for restraint was written after 24 hours (see tag A171), the facility failed to ensure after 24 hours that a face-to-face assessment by the physician or licensed independent practitioner was done before writing a new order for restraint (see tag A 172), the facility failed to ensure alternatives or less restrictive interventions were documented prior to use of restraint (see tag A186), the facility failed to document rationale for continued use for restraints (see tag A188).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that Patients Rights were promoted.

Based on document review, staff interview and observation, the facility failed to ensure patient could participate in the development and implementation of their plan of care due to lack of provision of information in language and terms the patient could understand for 1 of 10 (#1) patient medical records reviewed (MR).

Findings:

1. Policy titled, "Suspected Patient Abuse/Neglect", revised/reapproved 12/16, indicated on pg. 2, point 5.M., "Neglect includes but is not limited to...Failure to accommodate the specialized needs of the disabled or elderly patient".

2. Policy titled, "Cultural Competency Diversity", revised/reapproved 11/17, indicated on pg. 2, under Procedure section, bulleted point, "Modify communication approaches to meet cultural needs. See leadership policy on Translation Communication".

3. Facility lacked a policy/procedure related to translation communication.

4. Review of patient medical records on 2/14/18 at approximately 1201 hours indicated, patient 1 was a 61-year old who presented to the facility on 12/29/17 at 1954 hours for complex medical status, including end-stage renal disease, diabetes mellitus type 1, and encephalopathy. History & Physical indicated patient does not speak English. Review of systems and family history were unable to be obtained due to patient being non-English speaking. Physician Order dated 1/30/18 at 1030 hours indicated Speech Therapy was to be done daily with Spanish language assistance and rehab swallow study was okay to be done if okay with Speech Language Therapist and Primary Care Physician with instructions to be provided in Spanish. A bedside dysphagia swallow study was done by staff 7 (Speech Language Therapist) on 1/31/18 at 1906 hours and again on 1/3/18 at 1828 hours. MR lacked documentation of instructions being provided in Spanish. Physician Progress Note dated 2/3/18 indicated patient "will follow commands in Spanish". MR lacks documentation that staff provided translation services to this patient. This patient is currently an inpatient at this facility.

5. Staff 7 (Speech Language Therapist) was interviewed on 2/14/18 at approximately 1618 hours and confirmed:
A. Daily speech therapy was not being done with Spanish language assistance. A bedside dysphagia swallow study was done by this staff member on 1/31/18 at 1906 hours and again on 1/3/18 at 1828 hours and instructions were not provided to patient in Spanish.
B. a barium swallow study is going to be done 2/21/18, but there is no process in place for instructions to be provided in Spanish.
C. this staff member speaks Spanish, but has no documentation supporting this and has not attended any education courses related to Spanish for medical professionals.

6. Staff 8 (R.N.) was interviewed on 2/14/18 at approximately 1705 hours, and confirmed when asked how he/she communicated with patient 1 he/she stated "with facial cues and hand gestures". When asked to utilize the Cyracom language translation services so surveyor could speak with the patient who spoke only Spanish, staff 8 stated they had just learned about the services a few hours ago and did not know how to use it.

7. Staff 9 (Telemetry Technician), staff 10 (Unit Secretary), staff 11 (Patient Care Technician) and staff 12 (R.N.) were interviewed together on 2/14/18 at approximately 1710 hours, at the nurses station. When asked how they communicated with patient 1, they looked puzzled and said they didn't know. When asked about the Cyracom language translation services, they all stated they had just learned about the services a few hours ago and did not know how to use it. When asked if they had spoken about it in daily safety huddles since 2/7/18, they all stated they had no knowledge of the language translation services.

8. Staff 2 (Chief Clinical Officer) was interviewed on 2/14/18 at approximately 1150, 1239, 1426 and 1700 hours, and confirmed when Patient 1 had a swallow study done on 1/31/18 at 1906 hours and again on 1/3/18 at 1828 hours there was no translation service available for staff to communicate with the patient. This staff member is not sure how staff communicated with Patient 1.

9. On 2/14/18 at approximately 1700 hours, the Inpatient Care Unit, 5th Floor, was toured accompanied by staff 2 (Chief Clinical Officer) and patient 1 was in room 510. He/She was alert and making eye contact, but could not speak English and had a NG tube (nasogastric) in place.

Based on document review, staff interview and observation the facility failed to ensure patient or his or her representative had the right to make informed decisions due to lack of provision of information in language and terms the patient could understand for 1 of 10 (#1) patient medical records reviewed.

Findings:

1. Policy titled, "Suspected Patient Abuse/Neglect", revised/reapproved 12/16, indicated on pg. 2, point 5.M., "Neglect includes but is not limited to...Failure to accommodate the specialized needs of the disabled or elderly patient".

2. Policy titled, "Cultural Competency Diversity", revised/reapproved 11/17, indicated on pg. 2, under Procedure section, bulleted point, "Modify communication approaches to meet cultural needs. See leadership policy on Translation Communication".

3. Facility lacked a policy/procedure related to translation communication.

4. Review of patient medical records on 2/14/18 at approximately 1201 hours indicated, patient 1 was a 61-year old who presented to the facility on 12/29/17 at 1954 hours for complex medical status, including end-stage renal disease, diabetes mellitus type 1, and encephalopathy. History & Physical indicated patient does not speak English. Review of systems and family history were unable to be obtained due to patient being non-English speaking. Physician Order dated 1/30/18 at 1030 hours indicated Speech Therapy was to be done daily with Spanish language assistance and rehab swallow study was okay to be done if okay with Speech Language Therapist and Primary Care Physician with instructions to be provided in Spanish. A bedside dysphagia swallow study was done by staff 7 (Speech Language Therapist) on 1/31/18 at 1906 hours and again on 1/3/18 at 1828 hours. MR lacked documentation of instructions being provided in Spanish. Physician Progress Note dated 2/3/18 indicated patient "will follow commands in Spanish". MR lacks documentation that staff provided translation services to this patient. This patient is currently an inpatient at this facility.

5. Staff 7 (Speech Language Therapist) was interviewed on 2/14/18 at approximately 1618 hours and confirmed:
A. Daily speech therapy was not being done with Spanish language assistance. A bedside dysphagia swallow study was done by this staff member on 1/31/18 at 1906 hours and again on 1/3/18 at 1828 hours and instructions were not provided to patient in Spanish.
B. a barium swallow study is going to be done 2/21/18, but there is no process in place for instructions to be provided in Spanish.
C. this staff member speaks Spanish, but has no documentation supporting this and has not attended any education courses related to Spanish for medical professionals.

6. Staff 8 (R.N.) was interviewed on 2/14/18 at approximately 1705 hours, and confirmed when asked how he/she communicated with patient 1 he/she stated "with facial cues and hand gestures". When asked to utilize the Cyracom language translation services so surveyor could speak with the patient who spoke only Spanish, staff 8 stated they had just learned about the services a few hours ago and did not know how to use it.

7. Staff 9 (Telemetry Technician), staff 10 (Unit Secretary), staff 11 (Patient Care Technician) and staff 12 (R.N.) were interviewed together on 2/14/18 at approximately 1710 hours, at the nurses station. When asked how they communicated with patient 1, they looked puzzled and said they didn't know. When asked about the Cyracom language translation services, they all stated they had just learned about the services a few hours ago and did not know how to use it. When asked if they had spoken about it in daily safety huddles since 2/7/18, they all stated they had no knowledge of the language translation services.

8. Staff 2 (Chief Clinical Officer) was interviewed on 2/14/18 at approximately 1150, 1239, 1426 and 1700 hours, and confirmed when Patient 1 had a swallow study done on 1/31/18 at 1906 hours and again on 1/3/18 at 1828 hours there was no translation service available for staff to communicate with the patient. This staff member is not sure how staff communicated with Patient 1.

9. On 2/14/18 at approximately 1700 hours, the Inpatient Care Unit, 5th Floor, was toured accompanied by staff 2 (Chief Clinical Officer) and patient 1 was in room 510. He/She was alert and making eye contact, but could not speak English and had a NG tube in place.

Based on document review, staff interview and observation the facility failed to ensure patient had the right to receive care in a safe setting due to lack of provision of information in language and terms the patient could understand for 1 of 10 (#1) patient medical records reviewed.

Findings:

1. Policy titled, "Suspected Patient Abuse/Neglect", revised/reapproved 12/16, indicated on pg. 2, point 5.M., "Neglect includes but is not limited to...Failure to accommodate the specialized needs of the disabled or elderly patient".

2. Policy titled, "Cultural Competency Diversity", revised/reapproved 11/17, indicated on pg. 2, under Procedure section, bulleted point, "Modify communication approaches to meet cultural needs. See leadership policy on Translation Communication".

3. Facility lacked a policy/procedure related to translation communication.

4. Review of patient medical records on 2/14/18 at approximately 1201 hours indicated, patient 1 was a 61-year old who presented to the facility on 12/29/17 at 1954 hours for complex medical status, including end-stage renal disease, diabetes mellitus type 1, and encephalopathy. History & Physical indicated patient does not speak English. Review of systems and family history were unable to be obtained due to patient being non-English speaking. Physician Order dated 1/30/18 at 1030 hours indicated Speech Therapy was to be done daily with Spanish language assistance and rehab swallow study was okay to be done if okay with Speech Language Therapist and Primary Care Physician with instructions to be provided in Spanish. A bedside dysphagia swallow study was done by staff 7 (Speech Language Therapist) on 1/31/18 at 1906 hours and again on 1/3/18 at 1828 hours. MR lacked documentation of instructions being provided in Spanish. Physician Progress Note dated 2/3/18 indicated patient "will follow commands in Spanish". MR lacks documentation that staff provided translation services to this patient. This patient is currently an inpatient at this facility.

5. Staff 7 (Speech Language Therapist) was interviewed on 2/14/18 at approximately 1618 hours and confirmed:
A. Daily speech therapy was not being done with Spanish language assistance. A bedside dysphagia swallow study was done by this staff member on 1/31/18 at 1906 hours and again on 1/3/18 at 1828 hours and instructions were not provided to patient in Spanish.
B. a barium swallow study is going to be done 2/21/18, but there is no process in place for instructions to be provided in Spanish.
C. this staff member speaks Spanish, but has no documentation supporting this and has not attended any education courses related to Spanish for medical professionals.

6. Staff 8 (R.N.) was interviewed on 2/14/18 at approximately 1705 hours, and confirmed when asked how he/she communicated with patient 1 he/she stated "with facial cues and hand gestures". When asked to utilize the Cyracom language translation services so surveyor could speak with the patient who spoke only Spanish, staff 8 stated they had just learned about the services a few hours ago and did not know how to use it.

7. Staff 9 (Telemetry Technician), staff 10 (Unit Secretary), staff 11 (Patient Care Technician) and staff 12 (R.N.) were interviewed together on 2/14/18 at approximately 1710 hours, at the nurses station. When asked how they communicated with patient 1, they looked puzzled and said they didn't know. When asked about the Cyracom language translation services, they all stated they had just learned about the services a few hours ago and did not know how to use it. When asked if they had spoken about it in daily safety huddles since 2/7/18, they all stated they had no knowledge of the language translation services.

8. Staff 2 (Chief Clinical Officer) was interviewed on 2/14/18 at approximately 1150, 1239, 1426 and 1700 hours, and confirmed when Patient 1 had a swallow study done on 1/31/18 at 1906 hours and again on 1/3/18 at 1828 hours there was no translation service available for staff to communicate with the patient. This staff member is not sure how staff communicated with Patient 1.

9. On 2/14/18 at approximately 1700 hours, the Inpatient Care Unit, 5th Floor, was toured accompanied by staff 2 (Chief Clinical Officer) and patient 1 was in room 510. He/She was alert and making eye contact, but could not speak English and had a NG tube in place.

Based on document review, staff interview and observation, the facility failed to ensure patient had the right to be free from all forms of abuse due to lack of provision of information in language and terms the patient could understand for 1 of 10 (#1) patient medical records reviewed.

Findings:

1. Policy titled, "Suspected Patient Abuse/Neglect", revised/reapproved 12/16, indicated on pg. 2, point 5.M., "Neglect includes but is not limited to...Failure to accommodate the specialized needs of the disabled or elderly patient".

2. Policy titled, "Cultural Competency Diversity", revised/reapproved 11/17, indicated on pg. 2, under Procedure section, bulleted point, "Modify communication approaches to meet cultural needs. See leadership policy on Translation Communication".

3. Facility lacked a policy/procedure related to translation communication.

4. Review of patient medical records on 2/14/18 at approximately 1201 hours indicated, patient 1 was a 61-year old who presented to the facility on 12/29/17 at 1954 hours for complex medical status, including end-stage renal disease, diabetes mellitus type 1, and encephalopathy. History & Physical indicated patient does not speak English. Review of systems and family history were unable to be obtained due to patient being non-English speaking. Physician Order dated 1/30/18 at 1030 hours indicated Speech Therapy was to be done daily with Spanish language assistance and rehab swallow study was okay to be done if okay with Speech Language Therapist and Primary Care Physician with instructions to be provided in Spanish. A bedside dysphagia swallow study was done by staff 7 (Speech Language Therapist) on 1/31/18 at 1906 hours and again on 1/3/18 at 1828 hours. MR lacked documentation of instructions being provided in Spanish. Physician Progress Note dated 2/3/18 indicated patient "will follow commands in Spanish". MR lacks documentation that staff provided translation services to this patient. This patient is currently an inpatient at this facility.

5. Staff 7 (Speech Language Therapist) was interviewed on 2/14/18 at approximately 1618 hours and confirmed:
A. Daily speech therapy was not being done with Spanish language assistance. A bedside dysphagia swallow study was done by this staff member on 1/31/18 at 1906 hours and again on 1/3/18 at 1828 hours and instructions were not provided to patient in Spanish.
B. a barium swallow study is going to be done 2/21/18, but there is no process in place for instructions to be provided in Spanish.
C. this staff member speaks Spanish, but has no documentation supporting this and has not attended any education courses related to Spanish for medical professionals.

6. Staff 8 (R.N.) was interviewed on 2/14/18 at approximately 1705 hours, and confirmed when asked how he/she communicated with patient 1 he/she stated "with facial cues and hand gestures". When asked to utilize the Cyracom language translation services so surveyor could speak with the patient who spoke only Spanish, staff 8 stated they had just learned about the services a few hours ago and did not know how to use it.

7. Staff 9 (Telemetry Technician), staff 10 (Unit Secretary), staff 11 (Patient Care Technician) and staff 12 (R.N.) were interviewed together on 2/14/18 at approximately 1710 hours, at the nurses station. When asked how they communicated with patient 1, they looked puzzled and said they didn't know. When asked about the Cyracom language translation services, they all stated they had just learned about the services a few hours ago and did not know how to use it. When asked if they had spoken about it in daily safety huddles since 2/7/18, they all stated they had no knowledge of the language translation services.

8. Staff 2 (Chief Clinical Officer) was interviewed on 2/14/18 at approximately 1150, 1239, 1426 and 1700 hours, and confirmed when Patient 1 had a swallow study done on 1/31/18 at 1906 hours and again on 1/3/18 at 1828 hours there was no translation service available for staff to communicate with the patient. This staff member is not sure how staff communicated with Patient 1.

9. On 2/14/18 at approximately 1700 hours, the Inpatient Care Unit, 5th Floor, was toured accompanied by staff 2 (Chief Clinical Officer) and patient 1 was in room 510. He/She was alert and making eye contact, but could not speak English and had a NG tube in place.

Based on document review, staff interview, and observation the facility failed to ensure patient rights to be free from physical or mental abuse and/or restraint due to lack of provision of information in language and terms the patient could understand in order to communicate needs or participate in health care decisions for 1 of 10 (#1) patient medical records reviewed.

Findings:

1. Policy titled, "Suspected Patient Abuse/Neglect", revised/reapproved 12/16, indicated on pg. 2, point 5.M., "Neglect includes but is not limited to...Failure to accommodate the specialized needs of the disabled or elderly patient".

2. Policy titled, "Cultural Competency Diversity", revised/reapproved 11/17, indicated on pg. 2, under Procedure section, bulleted point, "Modify communication approaches to meet cultural needs. See leadership policy on Translation Communication".

3. Facility lacked a policy/procedure related to translation communication.

4. Policy titled, "Restraint Use", revised/reapproved 6/16, indicated on pg. 3, point 3., "Every attempt is made to remove the patient from restraint as soon as possible...Appropriateness of removal of restraint should include an evaluation of the patient's ability to appreciate the potential outcome of his/her behavior...".

5. Review of patient medical records on 2/14/18 at approximately 1201 hours indicated, patient 1:
A. was a 61-year old who presented to the facility on 12/29/17 at 1954 hours for complex medical status, including end-stage renal disease, diabetes mellitus type 1, and encephalopathy. History & Physical indicated patient does not speak English. Review of systems and family history were unable to be obtained due to patient being non-English speaking. Physician Order dated 1/30/18 at 1030 hours indicated Speech Therapy was to be done daily with Spanish language assistance and rehab swallow study was okay to be done if okay with Speech Language Therapist and Primary Care Physician with instructions to be provided in Spanish. A bedside dysphagia swallow study was done by staff 7 (Speech Language Therapist) on 1/31/18 at 1906 hours and again on 1/3/18 at 1828 hours. MR lacked documentation of instructions being provided in Spanish. Physician Progress Note dated 2/3/18 indicated patient "will follow commands in Spanish". MR lacks documentation that staff provided translation services to this patient. This patient is currently an inpatient at this facility.
B. Restraint Order and Flow Records, Medical, indicated patient was in restraints of either bilateral soft wrist restraints and/or bilateral mitts daily from 12/29/17 at 2000 hours through 2/14/18 at 1808 hours to prevent pulling at tubing/dressing, unable to follow safety instructions, sedation/confusion and/or to prevent disruption of life sustaining interventions.

6. Staff 7 (Speech Language Therapist) was interviewed on 2/14/18 at approximately 1618 hours and confirmed:
A. Daily speech therapy was not being done with Spanish language assistance. A bedside dysphagia swallow study was done by this staff member on 1/31/18 at 1906 hours and again on 1/3/18 at 1828 hours and instructions were not provided to patient in Spanish.
B. a barium swallow study is going to be done 2/21/18, but there is no process in place for instructions to be provided in Spanish.
C. this staff member speaks Spanish, but has no documentation supporting this and has not attended any education courses related to Spanish for medical professionals.

7. Staff 8 (R.N.) was interviewed on 2/14/18 at approximately 1705 hours, and confirmed when asked how he/she communicated with patient 1 he/she stated "with facial cues and hand gestures". When asked to utilize the Cyracom language translation services so surveyor could speak with the patient who spoke only Spanish, staff 8 stated they had just learned about the services a few hours ago and did not know how to use it.

8. Staff 9 (Telemetry Technician), staff 10 (Unit Secretary), staff 11 (Patient Care Technician) and staff 12 (R.N.) were interviewed together on 2/14/18 at approximately 1710 hours, at the nurses station. When asked how they communicated with patient 1, they looked puzzled and said they didn't know. When asked about the Cyracom language translation services, they all stated they had just learned about the services a few hours ago and did not know how to use it. When asked if they had spoken about it in daily safety huddles since 2/7/18, they all stated they had no knowledge of the language translation services.

9. Staff 2 (Chief Clinical Officer) was interviewed on 2/14/18 at approximately 1150, 1239, 1426 and 1700 hours, and confirmed when Patient 1 had a swallow study done on 1/31/18 at 1906 hours and again on 1/3/18 at 1828 hours there was no translation service available for staff to communicate with the patient. This staff member is not sure how staff communicated with Patient 1.

10. On 2/14/18 at approximately 1700 hours, the Inpatient Care Unit, 5th Floor, was toured accompanied by staff 2 (Chief Clinical Officer) and patient 1 was in room 510. He/She was alert and making eye contact, but could not speak English and had a NG tube in place.

Based on document review and staff interview, the facility failed to ensure the modification of the patient's plan of care with use of restraint for 2 of 10 (#1 and 2) patient medical records reviewed.

Findings:

1. Policy titled, "Restraint Use", revised/reapproved 6/16, indicated on pg. 4, point 8., "Documentation is required when restraints are initiated, and throughout the episode of restraint use and will initiate or update the Nursing Care Plan: Risk for Injury".

2. Review of patient medical records on 2/14/18 at approximately 1201 hours indicated:
A. patient 1 Restraint Order and Flow Records, Medical, indicated patient was in restraints of either bilateral soft wrist restraints and/or bilateral mitts daily from 12/29/17 at 2000 hours through 2/14/18 at 1808 hours to prevent pulling at tubing/dressing, unable to follow safety instructions, sedation/confusion and/or to prevent disruption of life sustaining interventions and lacked documentation of modification of the plan of care on the p.m. shift on 1/4/18, 1/8/18 and 1/11/18.
B. patient 2 Restraint Order and Flow Records, Medical, indicated patient was in bilateral soft wrist restraints daily from 1/29/18 at 0700 hours through 2/1/18 at 0640 hours and lacked documentation of modification of the plan of care on the p.m. shift on 1/29/18.

3. Staff 2 (Chief Clinical Officer) was interviewed on 2/14/18 at approximately 1150, 1239, 1426 and 1700 hours, and confirmed Restraint Order and Flow Record documentation for the above-mentioned patients lacked an update of the care plan after restraints were used as required per policy and procedure.

Based on document review and staff interview, the facility failed to ensure an order was written by a physician or other licensed independent practitioner prior to the use of restraints for 1 of 10 (#1) patient medical records reviewed.

Findings:

1. Policy titled, "Medical Record Documentation Requirements", revised/reapproved 12/16, indicated on pg. 2, point 7.b., "Restraint orders must be authenticated within 24 hours by the prescribing physician".

2. Review of patient medical records on 2/14/18 at approximately 1201 hours indicated patient 1 Restraint Order and Flow Records, Medical, indicated patient was in restraints of either bilateral soft wrist restraints and/or bilateral mitts daily from 12/29/17 at 2000 hours through 2/14/18 at 1808 hours to prevent pulling at tubing/dressing, unable to follow safety instructions, sedation/confusion and/or to prevent disruption of life sustaining interventions and restraint order is not signed or dated by the physician on 1/27/18.

3. Staff 2 (Chief Clinical Officer) was interviewed on 2/14/18 at approximately 1150, 1239, 1426 and 1700 hours, and confirmed Restraint Order and Flow Record documentation for the above-mentioned patient lacked documentation of physician signature and date as required per policy and procedure.

Based on document review and staff interview, the facility failed to ensure the attending physician was notified of restraint use for 1 of 10 (#1) patient medical records reviewed.

Findings:

1. Policy titled, "Restraint Use", revised/reapproved 6/16, indicated on pg. 3, bulleted points, "A physician must be contacted following application of the restraint...Use of restraints must be in accordance with the order of a physician who is responsible for the care of the patient and authorized by facility to order restraints".

2. Review of patient medical records on 2/14/18 at approximately 1201 hours indicated patient 1 Restraint Order and Flow Records, Medical, indicated patient was in restraints of either bilateral soft wrist restraints and/or bilateral mitts daily from 12/29/17 at 2000 hours through 2/14/18 at 1808 hours to prevent pulling at tubing/dressing, unable to follow safety instructions, sedation/confusion and/or to prevent disruption of life sustaining interventions and restraint order on 1/27/18 and lacked documentation the attending physician was notified of restraint use on 1/27/18.

3. Staff 2 (Chief Clinical Officer) was interviewed on 2/14/18 at approximately 1150, 1239, 1426 and 1700 hours, and confirmed Restraint Order and Flow Record documentation for the above mentioned patient documentation lacked that the attending physician was notified of restraint use on 1/27/18 as required per policy and procedure.

Based on document review and staff interview, the facility failed to ensure a time limit for use of restraint and that a new order for restraint was written after 24 hours for 2 of 10 (#1 and 2) patient medical records reviewed.

Findings:

1. Policy titled, "Restraint Use", revised/reapproved 6/16, indicated on pg. 5, point 1.b)., "A Physician's Order is required every 24 hours for continuation of a medical restraint".

2. Review of patient medical records on 2/14/18 at approximately 1201 hours indicated:
A. patient 1 Restraint Order and Flow Records, Medical, indicated patient was in restraints of either bilateral soft wrist restraints and/or bilateral mitts daily from 12/29/17 at 2000 hours through 2/14/18 at 1808 hours to prevent pulling at tubing/dressing, unable to follow safety instructions, sedation/confusion and/or to prevent disruption of life sustaining interventions and:
a. the time between orders was greater than 24 hours on 1/2/18, 1/8/18, 1/10/18 and 1/11/18. The time order started on 1/1/18 was 0700 hours and reordered at 0830 hours on 1/2/18. The time order started on 1/7/18 was 0700 hours and reordered at 1100 hours on 1/8/18. The time order started on 1/9/18 was 0700 hours and reordered at 1400 hours on 1/10/18. The time order started on 1/10/18 was 1400 hours and reordered at 1700 hours on 1/11/18.
b. restraint order time limit is not documented from 12/29/17 through 2/14/18.
B. patient 2 Restraint Order and Flow Records, Medical, indicated patient was in bilateral soft wrist restraints daily from 1/29/18 at 0700 hours through 2/1/18 at 0640 hours and restraint order time limit is not documented from 1/29/18 through 1/31/18.

3. Staff 2 (Chief Clinical Officer) was interviewed on 2/14/18 at approximately 1150, 1239, 1426 and 1700 hours, and confirmed Restraint Order and Flow Record documentation for the above-mentioned patients lacked a time limit for use of restraint and/or that a new order for restraint was written after 24 hours as required per policy and procedure.

Based on document review and staff interview, the facility failed to ensure after 24 hours that a face-to-face assessment by the physician or licensed independent practitioner was done before writing a new order for restraint for 2 of 10 (#1 and 2) patient medical records reviewed.

Findings:

1. Policy titled, "Restraint Use", revised/reapproved 6/16, indicated on pg. 5, point 1.b)., "A face-to-face assessment of the patient by the attending physician is documented daily folllowing initiation of restraint and before renewal of restraint orders".

2. Review of patient medical records on 2/14/18 at approximately 1201 hours indicated:
A. patient 1 Restraint Order and Flow Records, Medical, indicated patient was in restraints of either bilateral soft wrist restraints and/or bilateral mitts daily from 12/29/17 at 2000 hours through 2/14/18 at 1808 hours to prevent pulling at tubing/dressing, unable to follow safety instructions, sedation/confusion and/or to prevent disruption of life sustaining interventions and lacked documentation after 24 hours of a face-to-face assessment by the physician or licensed independent practitioner before writing a new order for restraint from 12/29/17 through 2/14/18.
B. patient 2 Restraint Order and Flow Records, Medical, indicated patient was in bilateral soft wrist restraints daily from 1/29/18 at 0700 hours through 2/1/18 at 0640 hours and lacked documentation after 24 hours of a face-to-face assessment by the physician or licensed independent practitioner before writing a new order for restraint from 1/29/18 through 1/31/18.

3. Staff 2 (Chief Clinical Officer) was interviewed on 2/14/18 at approximately 1150, 1239, 1426 and 1700 hours, and confirmed Restraint Order and Flow Record documentation for the above-mentioned patients lacked after 24 hours that a face-to-face assessment by the physician or licensed independent practitioner was done before writing a new order for restraint as required per policy and procedure.

Based on document review and staff interview, the facility failed to ensure alternatives or less restrictive interventions were documented prior to use of restraint for 2 of 10 (#1 and 2) patient medical records reviewed.

Findings:

1. Policy titled, "Restraint Use", revised/reapproved 6/16, indicated on pg. 2, under General Provisions section, "Restraints are only used when less restrictive interventions have been determined to be ineffective in protecting the patient, staff or others from harm".

2. Review of patient medical records on 2/14/18 at approximately 1201 hours indicated:
A. patient 1 Restraint Order and Flow Records, Medical, indicated patient was in restraints of either bilateral soft wrist restraints and/or bilateral mitts daily from 12/29/17 at 2000 hours through 2/14/18 at 1808 hours to prevent pulling at tubing/dressing, unable to follow safety instructions, sedation/confusion and/or to prevent disruption of life sustaining interventions and lacked documentation of patient specific interventions on 1/11/18.
B. patient 2 Restraint Order and Flow Records, Medical, indicated patient was in bilateral soft wrist restraints daily from 1/29/18 at 0700 hours through 2/1/18 at 0640 hours and lacked documentation of patient specific interventions on the p.m. shift on 1/29/18.

3. Staff 2 (Chief Clinical Officer) was interviewed on 2/14/18 at approximately 1150, 1239, 1426 and 1700 hours, and confirmed Restraint Order and Flow Record documentation for the above-mentioned patients lacked documentation of patient specific interventions prior to use of restraints as required per policy and procedure.

Based on document review and staff interview, the facility failed to document rationale for continued use for restraints for 2 of 10 (#1 and 2) patient medical records reviewed.

Findings:

1. Policy titled, "Restraint Use", revised/reapproved 6/16, indicated on pg. 4, point 8., "Documentation is required when restraints are initiated, and throughout the episode of restraint use...".

2. Review of patient medical records on 2/14/18 at approximately 1201 hours indicated:
A. patient 1 Restraint Order and Flow Records, Medical, indicated patient was in restraints of either bilateral soft wrist restraints and/or bilateral mitts daily from 12/29/17 at 2000 hours through 2/14/18 at 1808 hours to prevent pulling at tubing/dressing, unable to follow safety instructions, sedation/confusion and/or to prevent disruption of life sustaining interventions and lacked documentation of the precipitating/continued reason for restraints on the a.m. shift on 12/30/17, 1/8/18 and 1/10/18; and on the p.m. shift on 12/29/17-1/3/18, 1/6/18-1/11/18 and 1/27/18..
B. patient 2 Restraint Order and Flow Records, Medical, indicated patient was in bilateral soft wrist restraints daily from 1/29/18 at 0700 hours through 2/1/18 at 0640 hours and lacked documentation of the precipitating/continued reason for restraints on the p.m. shift on 1/29/18 and 1/30/18.

3. Staff 2 (Chief Clinical Officer) was interviewed on 2/14/18 at approximately 1150, 1239, 1426 and 1700 hours, and confirmed Restraint Order and Flow Record documentation for the above-mentioned patients lacked documentation of the precipitating/continued reason for restraints as required per policy and procedure.

Based on document review and staff interview, the facility failed to ensure legible and complete entries including date, time, and authentication for 1 of 10 (#1) patient medical records reviewed.

Findings:

1. Policy titled, "Medical Record Documentation Requirements", revised/reapproved 12/16, indicated on pg. 2, point 7., "All entries into the medical record must be legible, signed, dated, and timed".

2. Review of patient medical records on 2/14/18 at approximately 1201 hours indicated:
A. patient 1 Restraint Order and Flow Records, Medical, indicated patient was in restraints of either bilateral soft wrist restraints and/or bilateral mitts daily from 12/29/17 at 2000 hours through 2/14/18 at 1808 hours to prevent pulling at tubing/dressing, unable to follow safety instructions, sedation/confusion and/or to prevent disruption of life sustaining interventions and:
1. restraint order time is blank on 1/4/18, not legible on 1/5/18 and not signed or dated by the physician or Registered Nurse (R.N.) on 1/27/18.
2. lacked documentation of R.N. initials on the a.m. shift on 12/30/17 and 1/5/18; on the p.m. shift on 12/30/17-1/5/18, 1/8/18-1/11/18 and 1/27/18.

2. Staff 2 (Chief Clinical Officer) was interviewed on 2/14/18 at approximately 1150, 1239, 1426 and 1700 hours, and confirmed for the above-mentioned patients MR documentation lacked legible and complete entries including date, time, and/or authentication.