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Based on document review and interview the facility failed to meet the Condition of Patient Rights by inappropriate use of restraints and failure to report a patient death in a restraint, placing all patients at risk for loss of their rights. Findings include:

--- (see A-154) Restraints were utilized as a convenience to prevent falls for 2 (# 4 and #9) of 3 inpatients and 4 (#5, #7, #10, and #14) of 6 discharge patients with a total universe and review of 9 medical records where restraints were utilized as a part of the patient's care.

--- (see A-159) The use of "Net Bed" as a form of fall prevention for 1 ( #4) of 1 inpatients and 2 (#7, and #10) of 2 discharged patients with a total universe and review of 3 medical records where the "Net Bed" was utilized as a part of the patient's care.

--- (see A-174) Failure to discontinue restraints at the earliest possible time for 3 (#4, #9 and #10) of 8 patients with a total universe of 8 patients reviewed where restraints were utilized as part of the patient's care.

--- (see A-213) Failure to meet restraint death reporting requirements for 1 (#7) of 1 patients that expired while restrained in a "Net Bed."

Based on document review and interview, it was determined that the facility was using or had used restraints as a form of convenience (to prevent patients from either getting out of bed or falling out of bed and per family request) for 2 of 3 open records (#4, #9) and 4 of 6 closed records (#5, #7, #10, #14 ). The review consisted of a total universe of 9 restraint records reviewed. The facilities actions resulted in a loss of the patient's right to be free from restraints. Findings include:

Patient #4:
On 02/18/2014 at approximately 1030 during the initial tour of the medical unit with staff A, it was noted that patient #4 was in a "net bed". (Net beds are a form of restraint restricting patient movement to get out of bed). When staff A was queried about the reason for the net bed he stated that, "it is to prevent him from falling." A review of the medical record on 02/18/2014 at 1230 revealed the following:

On 02/05/2014 documentation in the medical reads as follows:
At 1920 "Patient attempting to get out of bed again, repositioned patient once again, reminded him that he could fall, told patient that if he continues to get out of bed that he would have to get restraints put on him so he wouldn't fall, call bell within reach, bed in lowest locked position, will continue to monitor."
At 2105 "Patient continued to get out of bed. Soft wrist restraints applied after order received."

On 02/07/2014 documentation in the medical reads as follows:
At 0832 the nursing documentation reads "Patient found on floor, lying on the mats next to his bed, restraint in place. Helping hands and HO (house officer) were called. Patient was placed back in bed and assessed by HO. No signs of injury, patient able to follow simple commands. Patient was transferred to 501 and a net bed was obtained."
At 1400 the "Restraint Order and Flow Record, Medical ", order for the "soft limb restraint x 1 to the left arm" was discontinued.
At 1900 the "Restraint Order and Flow Record, Medical for the "Net Bed" was written (five hours after discontinuation of the soft wrist restraint). The "Restraint Order and Flow Record, Medical ", states that "reason for restraint use, unable to follow safety instructions."
Review of a physician progress note for 02/07/2014 in the section titled "Plan" reads "1. We will obtain a 'net bed' for further fall precautions."
On 02/13/2014 staff Z documented at 3:10 "Patient found sitting up in a cage (net bed) restraint..."

Patient #9:
On 02/19/2014 at 0830 a review of the medical record for patient #9 revealed the following:
Patient was admitted to the facility on 02/07/2014 at 1933.
On 02/09/2014 at 1545 the nursing documentation reads "Restraints d/c'd (discontinued), unable to lift arms."
At 1637 the documentation reads "Family request right wrist be restrained for safety. Order written by HO (house officer) and restraint applied."
On 02/12/2014 at 0330, the nursing documentation supports the continued use of the soft wrist restraint.
On 02/13/2014 at 0821 nursing documentation reads "Patient alert x 2-3, no complaints of pain or distress at this time, patient right hand restraint x 1, in place."
On 02/16/2014 at 0621 nursing documentation reads "Right soft wrist restraint remains in place to prevent patient from decannulation self." At 1730 the nursing documents "Resting in bed right wrist restraint remains intact still attempts to pull at neck, reminded of restraint on right wrist and follows directions not to try to pull at neck..."
On 02/18/2014 at 1645 "Patient in bed alert and orientated x 1-2, no signs or symptoms of pain noted, no distress, patient continues to be on wrist restraints right wrist, restraints released as time I (nurse) am in room, monitor patient, relaxed, no agitated, checked skin intact, no skin tear noted, before leaving room put restraint in place at right wrist, patient continues to be calm, no agitation..."
On 02/18/2014 at 1645, it was confirmed by staff A that the patient was still currently in restraints.

Patient #10:
On 02/19/2014 at 1100 a review of the medical record for patient # 10 revealed the following:
Patient was admitted on 11/26/2013 at 1815 in 4-point restraints with a central line IV(intravenous) line and abdominal wound with dressing.
On 12/04/2013 at 1401 nursing documentation reads "Patient remains restrained with bilat (bilateral) soft wrist restraints for safety to prevent patient from pulling at abdominal wound dressing and to prevent patient from getting out of bed as he attempted to throw his right leg out of bed early this afternoon."
On 12/15/2013 at 1331 staff heard a noise and found that the patient had slipped out of the bilateral soft wrist restraints and was on the floor. No documentation of the patient making any attempts to remove abdominal dressing.
On 12/19/2013 at 2010 the nursing documentation reads that "RN was passing patient 's room when she saw patient ambulating, right wrist restraint was off, she immediately went into the room to assist him but he fell on the floor on his buttocks, house officer notified, he came and checked patient, he ordered UA (urine analysis) C&S(culture & sensitivity) as patient is confused, no injury noted, vital signs stable, left message to the guardian, will continue to monitor." There was no documentation of the patient attempting to remove the abdominal dressing.
On 12/20/2013 at 0700 on the Restraint Order and Flow Record, Medical an order was obtained for medical restraints- "soft limb x 3"; they were then discontinued on 12/21/2013 at 0100.
On 12/20/2013 at 1245 a telephone order was written for "Net Bed." Per the documentation the patient was placed into the "net Bed" on 12/21/2013 at 0130.
On 12/21/2013 at 0700 a restraint order was written for "Net Bed , Mitts x 2."
The medical record documentation then revealed that the patient stayed in the "net bed" until 0700 on 12/26/2013 the day of discharge.

Patient #14:
On 02/19/2014 at 1300 a review of the incident log was conducted that revealed that patient #14 had a fall on 12/23/2014 at 1200, with "no injuries." Documentation of the incident in the area titled "Brief Description" reads "Patient found on floor within 15 minutes of restraints being removed due to being alert and fully orientated, without aggressive behavior." In the next section titled "Outcome" contained the following documentation "No apparent injury to patient. Patient denies any complaint of pain. Restraints were re-started and reapplied."

On 02/19/2014 at 1500 during an interview with staff C when queried are restraints being used to prevent patients from getting out of bed and falling staff C stated "yes." When asked if patients are restrained because the family wants them to be staff C stated "No, we tell them that all the time." Staff C did at this time confirm the documentation of the findings in the medical records for patients #4, #9, #10 and the incident log for patient #14. Staff C stated "It is pretty obvious that restraints are being used to keep patients in bed to prevent falls."

On 02/18/2014 at 1500 a review was conducted of Vibra of Southeastern Michigan policies titled "Restraint Use- policy # PC-NUR-05-010- Revised date Mar 2012, Patient Safety Plan (Fall Risk-policy #PC-NUR-05-013-revision date 12/2012 and Fall Prevention & Management Program-policy # PC 11.00- revise date 2/13." Results of the policy review revealed a lack of any mention of restraints being used to to keep patients in bed or as a part of the fall prevention program.

Staff C provided a document on 02/18/2014 at 1545 titled " Vibra Healthcare Therapeutic Surface Decision Tree, dated June 1, 2008" the document reads "Fall Risk------Yes-------High Low Bed" "Fall Risk --------Yes----requires constant supervision-----RC Safe Enclosure Bed." When queried if the RC Safe Enclosure Bed was the "Net Bed" staff C replied "yes."


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Patient #5
Review of patient #5's medical record 'Clinical Notes' with Staff #A, on 2/19/14 at approximately 1000, revealed that the patient had fallen twice on 11/19/13 while attempting to get out of bed at 0456 and 1500. A restraint order was documented for "soft limb (restraints) X 2" at 0500 with specified reason documented as, "Unable to follow safety instructions." Staff #A verified at that time that the restraints were initially applied to prevent falls. Interview with the Attending Physician #G, on 2/19/14 at approximately 1030, revealed that he didn't know that restraints were not to be used to prevent falls. The Physician stated at that time, "I know we can't use them (restraints) like that in the Nursing Homes, but didn't know we couldn't use them (to prevent falls) in the hospitals."

Patient #7
Additionally, review of Patient #7's medical record with Staff #A, on 2/19/14 at approximately 1300, revealed that the patient was placed in a "Net Bed" from 11/13/13 - 11/17/13. Further review of the 'Restraint Order and Flow Records' revealed the 'Reason for Restraint Use' was "Unable to follow safety instructions". Staff #A verified that the "Net Bed" was used to prevent falls during that time period.

Based on document review and interview, the facility failed to ensure that the "Net Bed" type restraint was not used as a part of the fall prevention program for 1 of 1 inpatients (#4) and 2 of 2 discharged patients (#7, #10). The review consisted of a total universe of 3 patients that the facility had utilized a "Net Bed" restraint for; resulting in a loss of the patient's right to be free from restraints. Findings include:

On 02/18/2014 at approximately 1030 during the initial tour of the medical unit with staff A, it was noted that patient #4 was in a "net bed". When staff A was queried about the reason for the bed he stated that "it is to prevent him from falling."

Patient #4:
A review of the medical record for patient #4 on 02/18/2014 at 1230 revealed the following:
Patient admitted to the facility on 01/17/2014 at 1740 from another facility for continued care and rehabilitation. At time of admission, a physician's order was written for a "soft mitt restraint to the left upper extremity," documented reason for the restraint was to "prevent pulling at tubing, prevent disruption of life sustaining interventions, unable to follow safety instructions."
Medical record documentation then supports that the soft mitt to the left extremity was on until 01/31/2014 at 1939 when the nursing documentation reads "restraints discontinued."
On 02/01/2014 at 0027, the nursing documentation again confirms the discontinuation of the restraint and reads "patient is not agitated or attempting to pull at tubings. IV (intravenous) patent and flushes well, will continue to monitor."
From 02/01/2014 0027 thru 02/05/2014 1012, the nursing documentation revealed that the patient was frequently monitored and safety was maintained. The documentation also supports that the bed was placed in the lowest locked position and call bell within reach.

On 02/05/2014 the medical record for patient #4 contained the following nursing documentation:
At 1428 nursing documentation reads "patient found on floor by patient care technician. placed back into bed with helping hands. patient has no signs or symptoms of pain or distress noted at this time. patient denies pain by mouthing words. house doctor called to come assess patient for injury. safety maintained and will continue to monitor."
At 1439 nursing documentation reads "patient was placed in a low boy bed for safety... placed mats for safety... house doctor said patient was free from injuries. patient vitals good..... safety maintained."
At 1850 "Patient legs hanging over side of bed. Placed patients legs into bed and reminded him that he needed to stay in bed."
At 1901 "Patient attempting to get out of bed, repositioned patient in bed and reminded him that he needed to stay in bed and that he could hurt himself if he got out of bed and fell."
At 1920 "Patient attempting to get out of bed again, repositioned patient once again, reminded him that he could fall, told patient that if he continues to get out of bed that he would have to get restraints put on him so he wouldn't fall, call bell within reach, bed in lowest locked position, will continue to monitor."
At 2105 "Patient continued to get out of bed. Soft wrist restraints applied after order received."
Physician order for the restraints reads "type of restraint-soft limb x 2, placement- right arm left arm, reason for restraint use-unable to follow safety instructions." The nursing documentation on the "Restraint Order and Flow Record, Medical" in the section titled "Night Shift," "Precipitating/Continued Reason for restraints' boxes are checked for pulling at tubing/dressing and unable to follow safety instructions."

On 02/06/2014 the nursing documentation reads:
At 0522 "Soft wrist restraints remain in place bilaterally."
At 0700 an order was obtained to continue the soft limb restraints x 2 , the order does not state the reason for restraints use, the day shift nursing section titled "Precipitating/Continued Reason for restraints" has boxes checked for "unable to follow safety instructions, prevent disruption of life sustaining interventions (e.g., mechanically ventilated)." No boxes stating the reason for continued use were checked on the flow record for night shift.
At 1026 nursing documentation reads"Patient is in BSWR (bilateral soft wrist restraints) at this time to prevent patient from falling out of bed."

On 02/07/2014 the medical record for patient #4 contained the following:
At 0700 an order was written for "soft limb restraint x 1 to the left arm."
At 0832 the nursing documentation reads "Patient found on floor, lying on the mats next to his bed, restraint in place. Helping hands and HO (house officer) were called. Patient was placed back in bed and assessed by HO. No signs of injury, patient able to follow simple commands. Patient was transferred to 501 and a net bed was obtained."
At 1400 the "Restraint Order and Flow Record, Medical ", for the "soft limb restraint x 1 to the left arm" was discontinued.
At 1900 the "Restraint Order and Flow Record, Medical for the "Net Bed" was written (five hours after discontinuation of the soft wrist restraint). The "Restraint Order and Flow Record, Medical ", states that "reason for restraint use, unable to follow safety instructions."
Review of a physician progress note for 02/07/2014 in the section titled "Plan" reads "1. We will obtain a 'net bed' for further fall precautions."

The medical record for patient #4 revealed that he remained in the "net bed" up until the time of discharge.
The medical record review also supported that as of 02/12/2014 at 1400 staff were getting the patient out of bed and up into a geri-chair.
A review of the discharge instructions for the patient to a skilled nursing facility on 02/18/2014, revealed that in the section titled "Nursing Assessment and Recommendations it reads "Able to follow simple commands at times-Poor safety awareness 1:1 sitter."

On 02/18/2014 at 1530, during an interview with staff C, when queried about the "Net Bed" being used to prevent falls she stated "it is part of our fall risk program." When asked if the facility utilizes sitters and/or bed alarms as a part of the fall prevention program she stated "yes." She then went on to say that they "do not always have sitters available to sit with patients." When asked if she could locate an order for a bed alarm or a 1:1 sitter for patient #4 prior to the use of the net bed she stated that she "could not."

Patient #10:
On 02/19/2014 at 1000 a review of the medical record for patient #10 was conducted and revealed the following:
Patient #10 was admitted to the facility on 11/26/2013 at 1804 for "rehabilitation, as well as wound management and management of other medical problems."
Nursing documentation at 1815 reads "Patient arrived via ambulance in 4-point restraints, left chest wall double lumen central line, abdominal dressing, Foley (urinary) catheter."
At 1845 the nursing documentation reads "Patient standing in the doorway of his room, staff escorted patient back to bed and restraints reapplied. Supervisor aware, Will continue to monitor."
At 1957 the nursing documentation reads "PCT (patient care technician) reported patient had his hand in his abdominal wound. Writer checked abdominal incision. Cleaned and covered with dressing. Restraints reapplied and tightened."

On 11/27/2013 at 0631 the nursing documentation reads BSWR (bilateral soft wrist restraints), use caution...patient is very strong and can maneuver out of them unless tight. Sitter is currently at bedside."
At 0800 the nursing documentation reads bed in low position with head of bed elevated. Bilateral soft wrist restraints intact."
The nursing documentation supports that the patient remained in either bilateral soft wrist restraints or bilateral soft wrist restraints and bilateral mitts from 11/26/2013 thru 12/19/2013.

On 12/19/2013 at 2010 the nursing documentation reads that, "(RN) was passing patient 's room when she saw patient ambulating, right wrist restraint was off, she immediately went into the room to assist him but he fell on the floor on his buttocks, house officer notified, he came and checked patient, he ordered UA (urine analysis) C&S(culture & sensitivity) as patient is confused, no injury noted, vital signs stable, left message to the guardian, will continue to monitor."

On 12/20/2014 at 0700 on the "Restraint Order and Flow Record, Medical" an order was obtained for "medical restraints-soft limb x 3"; they were then discontinued on 12/21/2013 at 0100. On the document where the RN's documented the every two hour checks it was noted the last documentation was for "12/21/2013 at 0100."
On 12/20/2013 at 1245 a telephone order was written for "Net Bed." The order was noted by the RN at 1300. Per the documentation the patient was placed into the "Net Bed" on 12/21/2013 at 0130.
On 12/21/2013 at 0619 the nursing documentation reads "Patient placed in 'net bed' for safety at 0130 with mitt restraints."
The medical record documentation then revealed that the patient stayed in the "net bed" until 12/26/2013 the day of discharge.

On 02/18/2014 at 1600, during an interview with staff C, when queried about the "Net Bed" being used to prevent falls she stated "it is part of our fall risk program." When asked if the facility utilizes sitters and/or bed alarms as a part of the fall prevention program she stated, "yes, we do." She then went on to say that, "we do not always have sitters available to sit with patients." When asked if she could locate an order for a bed alarm or a 1:1 sitter for patient #4 prior to the use of the net bed she stated that she, "could not."

Staff C provided a document on 02/18/2014 at 1545 titled " Vibra Healthcare Therapeutic Surface Decision Tree June 1, 2008" the document reads "Fall Risk------Yes-------High Low Bed" "Fall Risk --------Yes----requires constant supervision-----RC Safe Enclosure Bed." When queried if the RC Safe Enclosure Bed was the "Net Bed" staff C replied "yes."

On 02/18/2014 at 1500 a review was conducted of facility policies titled "Restraint Use- policy # PC-NUR-05-010- Revised date Mar 2012, Patient Safety Plan (Fall Risk-policy #PC-NUR-05-013-revision date 12/2012 and Fall Prevention & Management Program-policy # PC 11.00- revise date 2/13." Results of the policy review revealed a lack of any mention of the "bed net" being used as a restraint or as a part of the fall prevention program.


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Patient #7
Additionally, review of Patient #7's medical record with Staff #A, on 2/19/14 at approximately 1300, revealed that the patient was placed in a "Net Bed" from 11/13/13 - 11/17/13. Further review of the 'Restraint Order and Flow Records' revealed the 'Reason for Restraint Use' was "Unable to follow safety instructions." Staff #A verified that the "Net Bed" was used to prevent falls during that time period.

Based on document review and interview, the facility failed to release 3 of 9 (#4, #9, #10) patients from restraints at the earliest possible time resulting in the loss of the patient's right to be free from restraint. The total universe of restraint records reviewed were 9. Findings include:

On 02/18/2014 at approximately 1030 during the initial tour of the medical unit with staff A, it was noted that patient #4 was in a "net bed". When staff A was queried about the reason for the bed he stated that "it is to prevent him from falling." A review of the medical record on 02/18/2014 at 1230 revealed the following:

Patient #4:
On 02/05/2014 documentation in the medical reads as follows:
At 1920 "Patient attempting to get out of bed again, repositioned patient once again, reminded him that he could fall, told patient that if he continues to get out of bed that he would have to get restraints put on him so he wouldn't fall, call bell within reach, bed in lowest locked position, will continue to monitor."
At 2105 "Patient continued to get out of bed. Soft wrist restraints applied after order received."

On 02/07/2014 documentation in the medical reads as follows:
At 0832 the nursing documentation reads "Patient found on floor, lying on the mats next to his bed, restraint in place. Helping hands and HO (house officer) were called. Patient was placed back in bed and assessed by HO. No signs of injury, patient able to follow simple commands. Patient was transferred to 501 and a net bed was obtained."
At 1400 the "Restraint Order and Flow Record, Medical ", for the "soft limb restraint x 1 to the left arm" was discontinued.
At 1900 the "Restraint Order and Flow Record, Medical" for the "Net Bed" was written (five hours after discontinuation of the soft wrist restraint). The "Restraint Order and Flow Record, Medical ", states that "reason for restraint use, unable to follow safety instructions."
Review of a physician progress note for 02/07/2014 in the section titled "Plan" reads "1. We will obtain a 'net bed' for further fall precautions."
On 02/05/2014 documentation in the medical reads as follows:
At 1920 "Patient attempting to get out of bed again, repositioned patient once again, reminded him that he could fall, told patient that if he continues to get out of bed that he would have to get restraints put on him so he wouldn't fall, call bell within reach, bed in lowest locked position, will continue to monitor."
At 2105 "Patient continued to get out of bed. Soft wrist restraints applied after order received."

Patient #9:
On 02/19/2014 at 0830 a review of the medical record for patient #9 revealed the following:
Patient was admitted to the facility on 02/07/2014 at 1933.
On 02/09/2014 at 1545 the nursing documentation reads "Restraints d/c'd (discontinued), unable to lift arms."
At 1637 the documentation reads "Family request right wrist be restrained for safety. Order written by HO (house officer) and restraint applied."
On 02/12/2014 at 0330, the nursing documentation supports the continued use of the soft wrist restraint.
On 02/13/2014 at 0821 nursing documentation reads "Patient alert x 2-3 (person, place time), no complaints of pain or distress at this time, patient right hand restraint x 1, in place.."
On 02/16/2014 at 0621 nursing documentation reads "Right soft wrist restraint remains in place to prevent patient from decannulation self." At 1730 the nursing documents "Resting in bed right wrist restraint remains intact still attempts to pull at neck, reminded of restraint on right wrist and follows directions not to try to pull at neck..."
On 02/18/2014 at 1645 "Patient in bed alert and orientated x 1-2 (person and place), no signs or symptoms of pain noted, no distress, patient continues to be on wrist restraints right wrist, restraints released as time I am in room, monitor patient, relaxed, no agitated, checked skin intact, no skin tear noted, before leaving room put restraint in place at right wrist, patient continues to be calm, no agitation..."
On 02/18/2014 at 1645, it was confirmed by staff A that the patient was still currently in restraints.

Patient #10:
On 02/19/2014 at 1100 a review of the medical record for patient # 10 revealed the following:
Patient was admitted on 11/26/2013 at 1815 in 4-point restraints with a central line IV (intravenous) and abdominal wound with dressing.
On 12/04/2013 at 1401 nursing documentation reads "Patient remains restrained with bilat (bilateral) soft wrist restraints for safety to prevent patient from pulling at abdominal wound dressing and to prevent patient from getting out of bed as he attempted to throw his right leg out of bed early this afternoon."
On 12/15/2013 at 1331 staff heard a noise and found that the patient had slipped out of the bilateral soft wrist restraints and was on the floor. No documentation was found of the patient making any attempts to remove abdominal dressing.
On 12/19/2013 at 2010 the nursing documentation reads that "a RN was passing patient 's room when she saw patient ambulating, right wrist restraint was off, she immediately went into the room to assist him but he fell on the floor on his buttocks, house officer notified, he came and checked patient, he ordered UA (urine analysis) C&S(culture & sensitivity) as patient is confused, no injury noted, vital signs stable, left message to the guardian, will continue to monitor." There was no documentation of the patient attempting to remove the abdominal dressing.

On 02/19/2014 at 1500 during an interview with staff C when queried are restraints being used to prevent patients from getting out of bed and falling staff C stated, "yes." When asked if patients are restrained because the family wants them to be staff C stated, "No, we tell them that all the time." When queried about discontinuing restraints at the earliest possible time staff C stated, "Since we are using them as a part of fall prevention we are not stopping them (discontinuing at the earliest possible time) ." Staff C did at this time confirm the documentation and the findings in the medical records for patients #4, #9, #10.

On 02/19/2014 at 1600 a further review was conducted of the facility policy titled "Restraint Use, policy # PC-NUR05-010, revised date Mar 2012." The policy reads in the section titled "General Provisions: 3. Restraints will be discontinued at the earliest possible time. a) Every attempt is made to remove the patient from the restraint as soon as possible...."
An additional review of a documents provided by staff C titled "Instructions for Completion of the Restraint Order and Flow Record (Medical)", undated, discusses the "Guidelines for Applying Restraints" the documentation makes no mention of the use of a "net bed" as a form of restraint. Document titled "Restraint Use Attachment D, policy # PC-NUR 05-010 Guidelines for Restraint Selection and Application Types of Restraints" lists mitts, soft limb restraints, freedom splints and lap belts.

On 02/20/2014 at 0800 during further interview with staff C, she confirmed that the policies reviewed do not speak to the use of the "net bed."

Based on document review and interview, the facility failed to report one of one (#7) patient death in a restraint while the patient was in a "Net Bed" restraint to CMS as required. Findings include:

On 2/18/14 at approximately 1400, review of the fall log dated November 2013 revealed that patient #7 fell on 11/12/13 and was placed in a "Net Bed". Review of the medical record with Staff #A on 2/19/14 at approximately 1300 revealed that the patient was in a "Net Bed" between 11/13/13 - 11/17/13. Review of the 'Clinical Notes' documented that the patient expired on 11/17/13. Interview with the Staff #A and the CEO on 2/20/14 at approximately 1000 revealed that the restraint/death reporting to CMS had not been done. The facility had an internal restraint/death log for 2013 which listed patient #7's death on the log.