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Based on a review of clinical records, review of hospital policies and procedures, hospital documentation and interviews, the hospital failed to protect and promote the rights of ten (10) of ten (10) patient's reviewed for restraint use (Patients #1, 5, 7, 8, 9, 10, 11, 12, 13, and 14) by failing to:


1. Ensure that the patients care plan was updated to reflect the use of restraints. (A-166)

2. Ensure that the use of SOMA beds were utilized based on a LIP order, and/or that the order included all the required elements per facility policy. (A-168)

3. Ensure that a qualified practitioner and/or trained staff evaluated/monitored patients in restraints within the stipulated timeframe and in accordance with facility policy. (A-175)

Based on clinical record review, interview and policy review, the facility failed to develop a comprehensive plan of care that included issues pertaining to restraint use and/or potential for skin breakdown for two of ten (Patient #1 and 8) patient's reviewed. The findings include the following:

a. Patient #1 was admitted on 2/12/15 with diagnoses that included cerebral vascular accident (CVA). Review of the nursing admission assessment identified the patient had a reddened coccyx and a Braden score of 16-17 (risk for skin breakdown). The clinical record indicated that staff placed the patient in a SOMA enclosure bed during the period of 2/13/15 through 2/17/15. Review of the care plan on 2/17/15 failed to reflect problems related to the use of restraints and/or potential for skin breakdown.


b. Patient #8 was admitted on 2/12/15 with a diagnosis of acoustic neuroma. A physician's order dated 2/27/15 directed the use of a SOMA bed for "interfering with medical therapies". The record indicated that the patient remained in the SOMA bed until 3/3/15. Review of the care plan failed to reflect that the utilization of restraints (SOMA bed) had been incorporated into the plan of care. Review of the Nursing Documentation policy indicated that based on the initial assessment, an individualized care plan should be completed. The policy indicated that the RN should identify new problems and make changes to the plan of care based on ongoing assessments and change in status.

Review of the restraint policy indicated that the patients plan of care should be updated to reflect the eligibility of the patient to be released from restraints, notification of the family, patient/family teaching, special needs of the patient and the care plan should be updated at a period of no greater than every 24 hours for non-violent restraints and 12 hours for violent restraints.

Based on clinical record review, interview, and policy review, the facility failed to ensure that a SOMA bed (prevents patient from freely exiting the bed) was utilized based on a licensed independent practitioner's (LIP) order, and/or that the order included all the required elements per facility policy for 10 of 10 patients' (Patients # 1, 5, 7, 8, 9, 10, 11, 12, 13 and 14) reviewed for restraints. The findings include the following:

a. Patient #1 was admitted on 2/12/15 with diagnoses that included a CVA. Review of the physician order dated 2/13/15 at 1:06 PM directed the use of a SOMA bed for 24 hours secondary to interfering with medical therapies. Although the clinical record lacked evidence that the patient had a medical device (lines, tubes, or drains) the physician utilized this rationale to justify the need for a SOMA bed rather than the behavior exhibited by the patient in accordance with facility policy. Clinical record review indicated that the patient utilized the SOMA bed during the period of 2/13/15 through 2/17/15, absent an order for 2/16/15. The record indicated that throughout the day the patient attended therapy, was out of bed to the chair, and/or the sides of the SOMA bed were left unzipped while the patient was in bed for trial release, however, a new order for the SOMA bed was not obtained when the patient was placed back in the bed at night. Interview with the Administrator on 3/3/15 at 1:30 PM indicated that patients are removed from the SOMA bed for therapies and/or to trial the patients out of the SOMA beds, thus decreasing the patient's time in restraints, however, once removed from the restraint, a new LIP is required.


Review of the restraint policy indicated that when one or both sides of the enclosure bed are unzipped and placed on the top of the bed the order is considered discontinued. Review of the restraint policy indicated that a physician's order is required and is valid for 24 hours and can be renewed every 24 hours following an assessment by the MD. The LIP order must include the date, time, behaviors exhibited by the patient, type of restraint and duration for restraints.


b. Patient #5 was admitted on 12/3/14 with diagnoses that included a subdural hematoma. Review of the physician order dated 12/4/14 directed the use of a SOMA bed for 24 hours secondary to interfering with medical therapies. Although the clinical record lacked evidence that the patient had a medical device (lines, tubes, or drains) the physician utilized this rationale to justify the need for a SOMA bed rather than the behavior exhibited by the patient in accordance with facility policy. Clinical record review indicated that the patient utilized the SOMA bed during the period of 12/4/14 through 12/18/14, absent LIP orders for 12/5/14 through 12/17/14. The record indicated that throughout the day the patient attended therapy, was out of bed to the chair and/or the sides of the SOMA bed were left unzipped as a trial release, however, a new order was not obtained when the patient was placed back in the SOMA bed after release in accordance with facility policy. Record review and interview with RN #1 on 2/17/15 at 11:00 AM indicated that she was unable to locate LIP orders for the SOMA bed on the aforementioned dates.


c. Patient #7 was admitted on 2/12/15 with diagnoses that included hydrocephalus. A physician's order dated 2/13/15 directed the use of a SOMA bed for 24 hours secondary to interfering with medical therapies. Although the clinical record lacked evidence that the patient had a medical device (lines, tubes, or drains) the physician utilized this rationale to justify the need for a SOMA bed rather than the behavior exhibited by the patient in accordance with facility policy. Clinical record review indicated that the patient utilized the SOMA bed during the period of 2/13/15 through 2/28/15, absent LIP orders on 2/16/15, 2/24/15, 2/25/15, 2/26/15, and 2/27/15. Although documentation reflected periods of time the sides of the SOMA bed were unzipped, staff failed to obtain a new order when the sides were zipped resulting in a restraint. Record review and interview with RN #1 on 3/5/15 at 10:00 AM indicated that she was unable to locate LIP orders for the SOMA bed on the aforementioned dates.



d. Patient #8 was admitted on 2/12/15 with diagnoses that included a acoustic neuroma. A physician's order dated 2/27/15 directed the use of a SOMA bed for 24 hours secondary to interfering with medical therapies. Although the clinical record lacked evidence that the patient had a medical device (lines, tubes, or drains) the physician utilized this rationale to justify the need for a SOMA bed rather than the behavior exhibited by the patient in accordance with facility policy. Review of the monitoring flow sheets indicated that the patient utilized the SOMA bed on 2/28/15, and 3/1/15 absent a LIP order and was placed back in the SOMA bed without the benefit of a new order. Record review and interview with RN #1 on 3/5/15 during the period of 10:00 AM through 11:30 AM indicated that she was unable to find LIP orders for those dates.


e. Patient #9 was admitted to the facility on 2/12/15 with diagnoses that included cerebral vascular accident. A physician's order dated 2/13/15 directed the use of a SOMA bed for 24 hours secondary to interfering with medical therapies. Although the clinical record lacked evidence that the patient had a medical device (lines, tubes, or drains) the physician utilized this rationale to justify the need for a SOMA bed rather than the behavior exhibited by the patient in accordance with facility policy. Clinical record review indicated that the patient utilized the SOMA bed during the period of
2/13/15 through 3/2/15, absent LIP orders on 2/14/15, 2/16/15, 2/22/15, 2/24/15, 2/25/15 and 3/1/15. The record indicated that at various times the patient out of the SOMA bed and was placed back in the SOMA bed without the benefit of a new order. Record review and interview with RN #1 on 3/5/15 during the period of 10:00 AM through 11:30 AM indicated that she was unable to find LIP orders for those dates.


f. Patient #10 was admitted to the facility on 2/18/15 after a craniotomy and cerebral vascular accident. A physician's order dated 2/19/15 directed the use of a SOMA bed for 24 hours secondary to interfering with medical therapies. Although the clinical record lacked evidence that the patient had a medical device (lines, tubes, or drains) the physician utilized this rationale to justify the need for a SOMA bed rather than the behavior exhibited by the patient in accordance with facility policy. The record indicated that the patient was in a SOMA bed for the period of 2/19/15 through 3/4/15 and throughout the day, attended therapy, was out of bed to the chair and/or the sides of the SOMA bed were left unzipped as a trial release, however, a new order was not obtained when the patient was placed back in the SOMA bed after release. Record review and interview with RN #1 on 3/5/15 during the period of 10:00 AM through 11:30 AM indicated that she was unable to find an LIP order for 2/25/15 and/or when the SOMA bed was utilized at hour of sleep.


g. Patient #11 was admitted on 12/8/15 after a motor vehicle accident sustaining a traumatic brain injury and cervical fracture. A physician's order dated 12/9/14 directed the use of a SOMA bed for 24 hours secondary to interfering with medical therapies. Although the clinical record lacked evidence that the patient had a medical device (lines, tubes, or drains) the physician utilized this rationale to justify the need for a SOMA bed rather than the behavior exhibited by the patient in accordance with facility policy. The record indicated the patient utilized the SOMA bed during the period of 12/9/15 through 12/28/14 and throughout the day, attended therapy, was out of bed to the chair and/or the sides of the SOMA bed were left unzipped as a trial release, however, a new order was not obtained when the patient was placed back in the SOMA bed after release. Record review and interview with RN #1 on 3/5/15 during the period of 10:00 AM through 11:30 AM indicated that she was unable to find an LIP order for 12/16/14 and 12/21/14 and/or when the SOMA bed was utilized at hour of sleep.



h. Patient #12 was admitted to the facility on 12/25/14 after a motor vehicle accident. A physician's order dated 12/25/14 directed the use of a SOMA bed for 24 hours secondary to interfering with medical therapies. Although the clinical record lacked evidence that the patient had a medical device (lines, tubes, or drains) the physician utilized this rationale to justify the need for a SOMA bed rather than the behavior exhibited by the patient in accordance with facility policy. The clinical record indicated that the patient utilized the SOMA bed during the period of 12/25/14 through 1/6/15 and throughout the day, went to therapy, was out of bed to the chair and/or the sides of the SOMA bed were left unzipped as a trial release, however, a new order was not obtained when the patient was placed back in the SOMA bed after release. Record review and interview with RN #1 on 3/5/15 during the period of 10:00 AM through 11:30 AM indicated that she was unable to find an LIP order for 12/30/14 and/or when the SOMA bed was utilized at hour of sleep.


i. Patient #13 was admitted to the facility on 11/14/14 with a diagnosis of brain tumor. A physician's order dated 11/14/14 directed the use of a SOMA bed for 24 hours secondary to interfering with medical therapies. Although the clinical record lacked evidence that the patient had a medical device (lines, tubes, or drains) the physician utilized this rationale to justify the need for a SOMA bed rather than the behavior exhibited by the patient in accordance with facility policy. The clinical record indicated that the patient utilized the SOMA bed for the period of 11/14/14 through 11/28/14 and throughout the day, went to therapy, was out of bed to the chair and/or the sides of the SOMA bed were left unzipped as a trial release however a new order was not obtained when the patient was placed back in the SOMA bed after release. Record review and interview with RN #1 on 3/5/15 during the period of 10:00 AM through 11:30 AM indicated that she was unable to find an LIP order for 11/18/14, 11/19/14, 11/20/14, 11/21/14, 11/22/14 and 11/26/14 and/or when the SOMA bed was utilized at hour of sleep.


j. Patient #14 was admitted on 12/11/14 with a diagnosis of a cerebral bleed. A physician's order dated 12/12/14 at 1:18 PM directed the use of a SOMA bed for 24 hours secondary to interfering with medical therapies. Although the clinical record lacked evidence that the patient had a medical device (lines, tubes, or drains) the physician utilized this rationale to justify the need for a SOMA bed rather than the behavior exhibited by the patient in accordance with facility policy. Review of the clinical record indicated that the SOMA bed was utilized through 12/29/14, absent LIP orders for 12/18/14, 12/19/14, 12/20/14, 12/21/14 and 12/24/14. Record review and interview with RN #1 on 3/5/15 during the period of 10:00 AM through 11:30 AM indicated that she was unable to find an LIP orders for the aforementioned dates and/or when the SOMA bed was utilized at hour of sleep.


Interview with the Nurse Manager and the Administrator on 3/5/15 at 1:30 PM identified that while the justification for the SOMA beds for the patients' identified was "interfering with medical therapy" there were no medical therapies in place that would support the use of the SOMA bed.

Based on clinical record review, interview, and policy review, the facility failed to ensure that 10 of 10 patients' (Patients # 1, 5, 7, 8, 9, 10, 11, 12, 13 and 14) reviewed for restraints were monitored by the LIP and/or trained staff in accordance with facility policy. The findings include the following:

a. Patient #1 was admitted on 2/12/15 with diagnoses that included a CVA. Clinical record review indicated that the patient utilized the SOMA bed during the period of 2/13/15 through 2/17/15, absent face to face assessments documented by the LIP. Review of the monitoring flow sheets during the same time period failed to indicate that the RN monitored the patient minimally every four (4) hours and/or the RN/Nurse Aide (NA) monitored the patient every two (2) hours consistently in accordance with facility policy. Interview with the Administrator on 2/18/15 at 2:30 PM stated that the LIP evaluation should be located in the comment section of the order and RN/NA assessments should be documented as directed.


Review of the policy, Management of the Patient with Non-violent Behavior, directed that the LIP order for restraints are valid for 24 hours and can be renewed every 24 hours following an assessment by the MD. The attending LIP must perform a daily face-to-face evaluation of the patient to assess the need for restraints and document the patient's psychological and physiological condition in the medical record.


The RN must document an assessment of the patient's behaviors, mental status, and orientation that warranted use, and the patient's response including rationale for continued use of the intervention minimally every four hours. The RN/NA must document repositioning, fluids and nutrition provided, toileting, range of motion, and behaviors observed minimally every two hours.


b. Patient #5 was admitted on 12/3/14 with diagnoses that included a subdural hematoma. Clinical record review indicated that the patient utilized the SOMA bed during the period of 12/4/14 through 12/18/14, absent face to face assessments documented by the LIP. Review of the monitoring flow sheets during the same time period failed to indicate that the RN monitored the patient minimally every four (4) hours and/or the RN/Nurse Aide (NA) monitored the patient every two (2) hours consistently in accordance with facility policy.


c. Patient #7 was admitted on 2/12/15 with diagnoses that included hydrocephalus. Clinical record review indicated that the patient utilized the SOMA bed during the period of 2/13/15 through 2/28/15, absent face to face assessments documented by the LIP. Review of the monitoring flow sheets during the same time period failed to indicate that the RN monitored the patient minimally every four (4) hours and/or the RN/Nurse Aide (NA) monitored the patient every two (2) hours consistently in accordance with facility policy.


d. Patient #8 was admitted on 2/12/15 with diagnoses that included a acoustic neuroma. Clinical record review indicated that the patient utilized the SOMA bed during the period of 2/27/15 through 3/3/15 absent face to face assessments documented by the LIP. Review of the monitoring flow sheets during the same time period failed to indicate that the RN monitored the patient minimally every four (4) hours and/or the RN/Nurse Aide (NA) monitored the patient every two (2) hours consistently in accordance with facility policy.


e. Patient #9 was admitted to the facility on 2/13/15 with diagnoses that included cerebral vascular accident. Clinical record review indicated that the patient utilized the SOMA bed during the period of 2/13/15 through 3/2/15, absent face to face assessments documented by the LIP. Review of the monitoring flow sheets during the same time period failed to indicate that the RN monitored the patient minimally every four (4) hours and/or the RN/Nurse Aide (NA) monitored the patient every two (2) hours consistently in accordance with facility policy.


f. Patient #10 was admitted to the facility on 2/18/15 after a craniotomy and cerebral vascular accident. Clinical record review indicated that the patient utilized the SOMA bed during the period of 2/19/15 through 3/4/15, absent face to face assessments documented by the LIP. Review of the monitoring flow sheets during the same time period failed to indicate that the RN monitored the patient minimally every four (4) hours and/or the RN/Nurse Aide (NA) monitored the patient every two (2) hours consistently in accordance with facility policy.



g. Patient #11 was admitted on 12/8/15 after a motor vehicle accident sustaining a traumatic brain injury and cervical fracture. Clinical record review indicated the patient utilized the SOMA bed during the period of 12/9/15 through 12/28/14, absent face to face assessments documented by the LIP. Review of the monitoring flow sheets during the same time period failed to indicate that the RN monitored the patient minimally every four (4) hours and/or the RN/Nurse Aide (NA) monitored the patient every two (2) hours consistently in accordance with facility policy.



h. Patient #12 was admitted to the facility on 12/25/14 after a motor vehicle accident. Clinical record indicated that the patient utilized the SOMA bed during the period of 12/25/14 through 1/6/15, absent face to face assessments documented by the LIP. Review of the monitoring flow sheets during the same time period failed to indicate that the RN monitored the patient minimally every four (4) hours and/or the RN/Nurse Aide (NA) monitored the patient every two (2) hours consistently in accordance with facility policy.



i. Patient #13 was admitted to the facility on 11/14/14 with a diagnosis of brain tumor. Clinical record review indicated that the patient utilized the SOMA bed for the period of 11/14/14 through 11/28/14, absent face to face assessments documented by the LIP. Review of the monitoring flow sheets during the same time period failed to indicate that the RN monitored the patient minimally every four (4) hours and/or the RN/Nurse Aide (NA) monitored the patient every two (2) hours consistently in accordance with facility policy.



j. Patient #14 was admitted on 12/11/14 with a diagnosis of a cerebral bleed. Clinical record review indicated that the patient utilized the SOMA bed during the period of 12/12/14 through 12/29/14, absent face to face assessments documented by the LIP. Review of the monitoring flow sheets during the same time period failed to indicate that the RN monitored the patient minimally every four (4) hours and/or the RN/Nurse Aide (NA) monitored the patient every two (2) hours consistently in accordance with facility policy.