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Based on review of facility documentation, medical records (MR), and employee interviews (EMP), it was determined the facility failed to ensure the physician's order for the use of a bed enclosure was initiated safely for one of two medical records reviewed for the use of a restraint (MR29).

Findings include:

Review on October 29, 2019, at 11:00 AM of the facility's "Patient Rights and Responsibilities," dated 2018 revealed "As a patient of this hospital, or as a family member or guardian of a patient at this hospital, we want you to know the rights you have under federal and Pennsylvania state law as soon as possible in your hospital stay. We are committed to honoring your rights, and want you to know that by taking an active role in your health care, you can help your hospital caregivers meet your needs as a patient or family member. That is why we ask that you and your family share with us certain responsibilities. ... You have the right to: ... Receive kind, respectful, safe, quality care delivered with the highest quality of service; ... Receive care free from restraint or seclusion unless necessary to provide medical, surgical or behavioral health care; ..."

Review on October 30, 2019, at 9:30 AM of the facility's "Bed User Manual 8060 A-Frame Canopy Enclosure," no date noted, revealed "... DOCTOR'S ORDERS: You must carefully follow doctor's orders, and the CAREPLAN written by the medical team attending the patient when using the Posey Bed. ..."

Review on October 30, 2019, at 9:39 AM of the facility ' s "Policy #10 "Use of Restraints," review dated August 13, 2019, revealed "Purpose The hospital is dedicated to promoting individualized care and treatment to support independence. The hospital utilizes measures to decrease or eliminate restraint use through least restrictive strategies. ... Guidelines: ... Non-violent, non-self-destructive: ... Content of Order/Renewal: Orders will contain the Type of restraint Reason for Restraint Time limitation for restraint - NO PRN or Standing restraint or trial release orders are allowed ..."

Review of MR29 on October 30, 2019, from 1:00 to 2:00 PM revealed the physician ordered a bed enclosure restraint on March 23, 2019 at 1:41 AM. The reason for the restraint was documented as the patient was unaware of their physical limitations and was confused.

The Posey Bed Enclosure was initiated by staff on March 23, 2019, at 8:17 AM. The Posey Bed Enclosure continued until April 1, 2019, at 8:29 AM.

Interview with EMP1 on October 30, 2019, at 1:55 PM revealed the facility had one Posey Bed Enclosure, and when a bed enclosure was not available, staff were to call the company and rent one. EMP1 stated the facility's Posey Bed Enclosure must have been in use or they were unable to get one on March 23, 2019 at 1:41 AM. EMP1 stated there was no written policy for staff to follow. EMP1 also noted the facility would have used a one-on-one [sitter] for MR29 until the Posey Bed Enclosure was available.

Interview with EMP5 on November 1, 2019, 8:53 AM confirmed there was no documentation in MR29 that a one-to-one [sitter] was provided for the patient, who the physician documented as confused and unaware of their physical limitations, from 1:41 AM to 8:17 AM when the bed enclosure was initiated.

Based on review of facility documentation, medical records (MR), and employee interviews (EMP), it was determined the facility failed to ensure patients restrained in a bed enclosure were observed and monitored every two hours for two of two medical records reviewed for restraint utilization with a bed enclosure (MR29 and MR30).

Findings include:

Review on October 29, 2019, at 11:00 AM of the facility's "Patient Rights and Responsibilities," dated 2018 revealed "As a patient of this hospital, or as a family member or guardian of a patient at this hospital, we want you to know the rights you have under federal and Pennsylvania state law as soon as possible in your hospital stay. We are committed to honoring your rights, and want you to know that by taking an active role in your health care, you can help your hospital caregivers meet your needs as a patient or family member. That is why we ask that you and your family share with us certain responsibilities. ... You have the right to: ... Receive kind, respectful, safe, quality care delivered with the highest quality of service; ... Receive care free from restraint or seclusion unless necessary to provide medical, surgical or behavioral health care; ..."

Review on October 30, 2019, at 9:30 AM of "Bed User Manual 8060 A-Frame Canopy Enclosure," no date, revealed "... Risks: Improper use of the Posey Bed may lead to serious injury or death. Patient monitoring should be established by hospital protocol and the patient's CARE PLAN. ... Adverse Events: ... Skin irritation from contact with the bed fabric, or from excessive rubbing behavior; Breathing problems due to ENTRAPMENT or contact with canopy material or bedding; ... Warning: Failure to comply with physician's order, the patient's CAREPLAN and all instructions, Warnings and Cautions in this manual, the In-Service DVD, and on all labels on the Posey Bed, could result in patient death or serious injury. ... NEVER leave the patient unattended without proper monitoring. Failure to monitor per your facility's policy, the physician's orders, or the CAREPLAN could result in serious injury or death. ... Follow the CAREPLAN for daily patient release. Be sure to consider patient needs for: Nourishment; ... Toileting; and Restorative Nursing. ..."

Review on October 30, 2019, at 9:39 AM of the facility's "Policy #10 Use of Restraints," review dated August 13, 2019, revealed "Purpose The hospital is dedicated to promoting individualized care and treatment to support independence. The hospital utilizes measures to decrease or eliminate restraint use through least restrictive strategies. ... Guidelines: ... Non-violent, non-self-destructive: ... Monitoring: Every 2 hour monitoring through observation, interaction, direct examination; Monitoring is to include: Level of distress/agitation; Mental status; Cognitive Function; Vital Signs (as appropriate); Hydration, nutrition, elimination needs; Positioning needs/ROM; and Circulation and skin condition. ... Documentation: Monitoring results every 2 hours; Clinical justification for use; ... Discontinuation: When risks identified during the assessment no longer exist, the restraint is to be removed. ... All staff that has direct patient contact must have orientation as well as annual education, training, and competency assessment in: ... 6. Monitoring the physical and psychological well-being of the patient including but not limited to respiratory and circulation status, skin integrity, vital signs, and any other applicable indicators. ..."

Review of the restraint education provided to clinical staff, no date, revealed "Medical Restraints ... 1) Observed in Record Review at Encompass Health Rehabilitation Hospital of Sewickley, LLC ... In two out of two patient records who had medical restraints utilized, there were nursing assessments that were not completed in accordance with the organizations policy that required every two hour monitoring for patients in non-violent restraints. ... Every two hour monitoring through observation, interaction, direct examination; Monitoring is to include: ... Vital signs (as appropriate); Hydration, nutrition, elimination needs; ... Circulation and skin condition. ..."

Review on October 30, 2019, of MR29, at 1:00 PM to 2:00 PM revealed the patient was in a bed enclosure on March 23, 2019, starting at 8:17 AM through April 1, 2019, at 8:29 AM.

There was no documentation the patient was assessed every two hours as follows:
March 23, 2019 between 6:00 PM and 10:18 PM.
March 24, 2019 between 4:00 AM and 8:00 AM, between 6:00 PM and 10:20 PM.
March 25, 2019 between 4:00 PM and 6:14 PM, and 9:00 PM and 12:33 AM March 26, 2019.
March 26, 2019 between 1:52 AM and 6:03 AM, 10:00 AM and 2:29 PM, 2:29 PM and 7:15 PM, and 7:15 PM and 8:14 AM on March 27, 2019.
March 27, 2019 between 8:14 AM and 10:23 AM, 10:23 AM and 6:00 PM, 6:00 PM and 11:38 PM.
March 28, 2019 between 1:50 AM and 4:05 AM, 8:00 AM and 12:00 PM, 4:00 PM and 6:21 PM, and 10:03 PM and 12:45 AM on March 29, 2019.
March 29, 2019 between 12:00 PM and 2:51 PM, 5:24 PM and 8:10 PM, and 10:03 PM and 12:35 AM on March 30, 2019.
March 30, 2019 between 4:19 AM and 8:22 AM, 8:22 AM and 10:36 PM, and 11:49 PM and 1:51 AM on March 31, 2019.
March 31, 2019 between 1:51 AM and 12:37 PM, 4:00 PM and 6:25 PM, 6:25 PM and 9:54 PM, and 10:55 PM and 1:59 AM on April 1, 2019.
April 1, 2019 between 1:59 AM and 8:25 AM.

Interview on November 5, 2019, at 1:13 PM with EMP5 confirmed the above findings for MR29.

Review on October 30, 2019, at 2:00 PM to 2:30 PM of MR30 revealed the patient was in a bed enclosure starting on March 7, 2019 at 4:13 PM through March 8, 2019, at 5:00 PM.

There was no documentation the patient was assessed every two hours as follows:
March 7, 2019 between 4:30 PM and 7:00 PM, and 9:00 PM and 12:25 AM on March 8, 2019.
March 8, 2019 between 12:40 AM and 2:50 AM.

Interview on November 5, 2019, at 1:13 PM with EMP5 confirmed the above findings for MR30.

Interview with EMP5 on November 1, 2019, revealed MR29 was sleeping on March 24, 2019 at 2:00 AM, which was why there was no circulation/skin, nutrition/hydration, or toileting documentation completed. EMP5 noted this was also the case on March 26, 2019 at the 1:52 AM and the 6:03 AM assessments. EMP5 also stated that as far as circulation checks, this was a bed enclosure restraint so it was not impeding circulation, which was probably why it was missing in most cases.

Based on a review of facility documents, observations, and staff interview (EMP), it was determined that Encompass Health Rehabilitation Hospital of Sewickley failed to ensure dietary staff and visitors in the dietary department had all hair restrained as required by facility policy and failed to ensure shredded cheese, Pedialyte, liquid margarine, and soy sauce were dated when opened.

Findings include:

1. Review on October 30, 2019, at 1:45 PM of the facility policy "Food Safety Program Food Safety Standards [and] Requirements," dated March 27, 2019, revealed " ... Company Standards / Guidelines ... 3. Employees must wear approved hair restraints, beard restraints, clean uniforms, aprons and shoes. Company Standards / Guidelines: Hair restraints (hairnets, hats or caps) must cover hair sufficiently to effectively keep hair from contacting exposed food, clean equipment, utensils, linens, and unwrapped single-service and single-use articles as well as to minimize hand contact with hair. ... Hair and beard restraints should be made available for all personnel/visitors. ..."

Tour of the dietary department on October 30, 2019, at 11:35 AM revealed a hairnet was not visible nor offered by EMP13, until requested by the surveyor. The hairnets were located on a shelf behind the tray line. Observation revealed EMP15 and EMP16 were wearing hairnets with hair hanging below the hairnet. EMP14 and EMP21 were not offered hairnets for the tour until it was requested by the surveyor.

Interview with EMP13 on October 30, 2019, at the time of the observations confirmed EMP14 and EMP15 were preparing food without all hair restrained.

2. Review October 30, 2019, at 1:35 PM of the facility policy "Food Safety Program Food Safety Standards [and] Requirements" revised March 27, 2019, revealed " ... Dry food, which is opened or removed from original packaging, should be stored properly covered, in food grade containers and clearly labeled. ... 6. All foods prepared in operation must be covered and labeled as to contents and date of preparation prior to storage in refrigerators and freezers. Company Standards / Guidelines: ... Purchased, ready-to-eat foods removed from original container and not served during the next meal must be labeled and dated. ...."

Review on October 30, 2019, at 2:30 PM of facility policy and procedure "Food Product Code Dating Reference," revised January 30, 2012, revealed, "... What types of foods are dated? 'Open dating' is primarily on perishable foods such as meat, poultry, eggs and dairy products. ..."

Tour of the dietary department on October 30, 2019, at approximately 11:45 AM revealed the following:

The refrigerator located behind the tray line contained an opened bag of shredded cheese that was not labeled or dated. It could not be determined when the bag of cheese was opened.

The walk in cooler contained a bottle of Pedialyte that was half full and a container of liquid margarine that was less than half full. The Pedialyte and liquid margarine did not contain a label with the date they were opened.

The dry good storage room contained a large bottle of soy sauce that was half full. The soy sauce was not labeled with the date it was opened.

EMP13 confirmed the above findings at the time of the observations.