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Based on policy and procedure review, medical record review, and staff interview, hospital staff failed to complete an assessment immediately after restraint application to ensure restraints were safely and properly applied and no patient injury occurred for 2 of 6 restrained patients reviewed [Pts # 3, 8].

The findings include:

Review of Hospital Policy, "RESTRAINTS AND SECLUSION",dated 06/2012, revealed "... PURPOSE: To ensure the patient's right to be free from restraints of any form that are not medically necessary. To ensure that restraints are never used as a means of coercion, discipline, convenience, or retaliation by staff....MEDICAL RECORD DOCUMENTATION AND PLAN OF CARE: Every use of restraint is to be documented in the patient's record. At a minimum documentation must include....Evidence of monitoring of the patient's condition during restraint.... patient's response to restraint.....is included in the patient's medical record. Interdisciplinary Team Member documentation must: ....State type of device applied and patient response (shift and prn) (Restraint Record and Plan of Care). ..."

1. Medical record review of Pt # 3, a patient admitted on 06/01/2016 for Myasthenia Gravis (disease that leads to abnormal muscle weakness and fatigue) and ventilator dependent respiratory failure (machine is needed to move air in and out of the lungs to get enough oxygen in the blood) revealed a Restraint Order/ Assessment Sheet dated 06/08/2016 at 0200. Review revealed the type of restraint was mittens, right and left. Review revealed Pt # 3 was "pulling @ [at] vent [ventilator] tubing and DHT [dobhoff tube - type of feeding tube inserted through the nasal passage]. Record review failed to reveal the time the mittens were applied, who applied them, any assessment of patient condition after application, the time the restraints were discontinued, or whether any patient injury occurred during restraint.

Interview with Charge Nurse [CN] # 3, on 06/22/2016 at 0845, revealed a Respiratoy Therapist (RT # 1) requested restraints after Pt # 3 disconnected self from the ventilator. Interview revealed mitten restraints (soft padded restraints that cover the hand and fingers) were pulled and RT # 1 and CN # 3 applied them. Interview revealed the restraints were only on a few minutes. The assigned nurse, interview revealed, discontinued the restraints almost immediately and by the time CN # 3 "sat down to write, the event was over." Interview revealed CN # 3 was not present when the restraints were discontinued.

Interview with RN # 4, the assigned nurse, revealed RN # 4 discontinued the restraints. Interview revealed RN # 4 came into the patient's room as the mittens were being applied, and afterwards RN # 4 stated she talked with the patient and calmed her down, and because she had not had any issues with the patient pulling at tubes and lines earlier, RN # 4 removed the restraints. "The CN said I needed to sign for restraints, but I had no problems and was not going to leave them on. ..." RN # 4 said.

Interview with RT # 1, on 06/23/2016 at 0945, revealed RT # 1 and CN # 3 applied the mitten restraints. Interview revealed RT # 1 did not document anything about the restraint. "That's a nursing detail" RT # 1 said, "...because the nurse has to assess the patient before a restraint is applied."

Interview with the Chief Nursing Officer [CNO], on 06/23/2016 at 1540, revealed there was no additional information in Pt # 3's medical record related to the application or removal of the restraint or the condition of the patient after application. Interview revealed hospital policy was not clear on those requirements. Further interview revealed information in the record did not meet expectations.

2. Open medical record review of Pt # 8 revealed the patient was admitted on 06/16/2016 with ventilator dependent respiratory failure. Record review revealed a restraint order, dated 06/16/2016 at 1540. Review revealed the first evidence of monitoring was at 2000 (4 hours 40 minutes after the order). Review did not reveal any notation to indicate time of restraint application or patient condition after application. .

Interview with the CNO, on 06/23/2016 at 1540, revealed policy was not followed.

Based on policy and procedure review, medical record review, and staff interview the hospital failed to ensure a written's physician order for restraints for 2 of 6 restraint records reviewed ( Pts # 3, 8)

The findings include:

Review of Hospital Policy, "RESTRAINTS AND SECLUSION",dated 06/2012, revealed "... PURPOSE: To ensure the patient's right to be free from restraints of any form that are not medically necessary. To ensure that restraints are never used as a means of coercion, discipline, convenience, or retaliation by staff....DEFINITIONS:....Medical Restraint: Use of restraints in medical and post-surgical care to protect medical lines and tubes....PROCEDURE:....The initial assessment must be performed by physician, Licensed Independent Practitioner [LIP]or Registered Nurse. An initial assessment performed by the RN shall be reviewed by the physician and a physician's order is issued as indicated. The physician's order indicates agreement with assessment and the plan of care to use restraints. If a physician or LIP is not available to issue such an order, a registered nurse initiates restraint use based on an appropriate assessment of the patient. In that case, the MD/DO [Medical Doctor/ Doctor of Osteopathy] or LIP is notified immediately as clinically possible, of the initiation of restraint, and a telephone order is obtained from that practitioner and entered in to the patient's medical record....A written order, based on an examination of the patient by the MD/DO or LIP is entered into the patient's medical record on a daily basis when restraint use is clinically appropriate..... ORDERS TO INITIATE RESTRAINT Any physician of the active medical staff, or licensed practitioner....may issue an order for restraint. Orders for restraints must be renewed on a daily basis.... MEDICAL RECORD DOCUMENTATION AND PLAN OF CARE: Every use of restraint is to be documented in the patient's record. At a minimum documentation must include....a time-limited order by a physician, or licensed independent practitioner. ..."

1. Open medical record review, on 06/22/2016, of Pt # 3, a patient admitted on 06/01/2016 for Myasthenia Gravis (disease that leads to abnormal muscle weakness and fatigue) and ventilator dependent respiratory failure (machine is needed to move air in and out of the lungs to get enough oxygen in the blood) revealed a Restraint Order/ Assessment Sheet dated 06/08/2016 at 0200, signed by a Registered Nurse [CN # 3]. Review revealed the form indicated the type of restraint was mittens, right and left [soft padded restraint that covers a hand and fingers]. Review revealed Pt # 3 was "pulling @ [at] vent [ventilator] tubing and DHT [dobhoff tube - type of feeding tube inserted through the nasal passage]. Review of the form did not reveal a physician signed the order until 06/14/2016 [6 days later].

Staff interview, on 06/22/2016 at 0845, with the Charge Nurse who signed the order [CN # 3] revealed the policy allows the Registered Nurse to assess the patient and apply a restraint when a physician is not present. Interview revealed CN # 3 did not call the physician on call to notify of the restraint because "the nurse came and almost immediately said the restraint was off." Interview revealed the form listed TO/VO (telephone order/verbal order), but physicians are not typically called at night for restraint orders.

Interview with MD # 1, on 06/22/2016 at 1525, revealed "it's unfortunate" the restraint order was not signed. Interview revealed it was highly irregular to find an order not signed days later, the routine was for the physician to sign the order the next morning. Interview revealed "I was here, I did not see the order."

Interview with the Chief Nursing Officer [CNO], on 06/23/2016 at 1540 revealed policy was not met.

2. Open medical record review of Pt # 8, on 06/23/2016, revealed the patient was admitted on 06/16/2016 with ventilator dependent respiratory failure. Record review physician orders for restraints on 06/16/2016 and 06/18/2016-06/22/2015. Review did not reveal a written physician order for restratints on 06/17/2016. Record review revealed documentation of restraint monitoring on 06/17/2016.

Interview with Administrative Staff (AS) # 1 on 06/23/2016 revealed there was evidence Pt # 8 was restrained on 06/17/2016, but no evidence of a physician order that day.

Interview with the CNO, on 06/23/2016 at 1540, revealed policy was not followed.

Based on policy and procedure review, medical record reviews, and staff interviews, the hospital failed to prevent prn (as needed) restraint orders for 2 of 6 restraints reviewed (Pts # 3, 9).

The findings include:

Review of Hospital Policy, "RESTRAINTS AND SECLUSION",dated 06/2012, revealed "... PURPOSE: To ensure the patient's right to be free from restraints of any form that are not medically necessary. To ensure that restraints are never used as a means of coercion, discipline, convenience, or retaliation by staff....ORDERS TO INITIATE RESTRAINT....The order for a restraint may never be written as a standing order or on an as needed bases [sic] (PRN) . ... "

1. Open medical record review, on 06/22/2016, of Pt # 3, a patient admitted on 06/01/2016 for Myasthenia Gravis (disease that leads to abnormal muscle weakness and fatigue) and ventilator dependent respiratory failure (machine is needed to move air in and out of the lungs to get enough oxygen in the blood) revealed a Restraint Order/ Assessment Sheet dated 06/17/2016 at 0700, signed by a Registered Nurse [RN # 7]. The type of restraint, review revealed, was wrist restraints, left and right. Review revealed the order was signed by a physician on 06/17/2016, no time documented. Record review did not reveal any other notation to indicate a restraint was applied or needed on 06/17/2016.

Staff interview, on 06/23/2016 at 0935, with RN # 7 revealed RN # 7 wrote the restraint order on 06/17/2016 for Pt # 3. Interview revealed Pt # 3 was not in restraints on 06/17/2016. Interview revealed RN # 7 was helping another nurse and made a mistake and placed the "wrong sticker" on the order sheet making the order on the incorrect patient.

Interview with the Chief Nursing Officer [CNO], on 06/23/2016 at 1540, revealed it was an error but did not meet policy.

2. Open medical record review for Pt # 9, on 06/23/2016, revealed the patient was admitted 06/20/2016 at for respiratory failure and rehabilition. Record review revealed the patient was ordered and on restraints from 06/20/2016 until 0140 on 06/23/2016. Review revealed the restraints were removed at 0140 and did not reveal they were reapplied. Review of a physician order revealed a restraint order was placed by a RN on 06/23/2016 at 0700 and signed by the MD at 0820.

Staff Interview with AS # 1, on 06/23/2016, revealed Pt # 9 did not have restraints reapplied after 0140 on 06/23/2016.

Interview the the CNO, on 06/23/2016 at 1540, revealed policy was not followed.

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