HospitalInspections.org

Based on a review of medical records, facility policies and documents, and staff interviews, the facility failed to promote and protect patient rights:

a) that require for a restraint or seclusion to only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.

Findings were:

Patients # 3, 7, and 11 were placed in behavioral restraint based on orders that exceeded the 4 hour time limit based on regulatory requirements. Cross refer CFR 482.13(e)(8)
The restraints of Patient # 3, 7, and 11 were not discontinued at the earliest possible time. Cross refer to CFR 482.13(e)(9).
Patients #3, 7, and 11 were not adequately monitored and assessed while in restraints. Cross refer to CFR 482.13(e)(10), 482.13(e)(12), 482.13(e)(12), and 482.13(e)(16)(v).
Staff members involved in the restraints of Patients # 3, 7, and 11 were not adequately trained and educated regarding restraints. Cross refer CFR 482.13(f), 482.13(f)(1), 482.13(f)(2)(iv), 482.13(f)(2)(iv), and 482.13(f)(4).

Based on direct observation, record review, and interviews, it was determined that the governing body failed in its responsibility to insure that services were available in compliance with all applicable conditions of participation and standards.

Findings included:

Facility policy entitled " Restraint and Seclusion " dated 10/24/12 stated in part: " Use of restraint or seclusion is only imposed to ensure the immediate physical safety of the patient, a staff member, or others; and is discontinued at the earliest possible time based on individualized patient assessment and re-evaluation regardless of the scheduled expiration of the order ... "
A review medical records revealed that 3 of 3 patients required behavioral restraint, the restraints were not discontinued at the earliest possible time.

The medical records of Patients # 3 and 11 revealed both patients remained in restraints after falling asleep. The behavior requiring restraint was absent while asleep requiring that both patient ' s should have been released when assessed to be sleeping.

A review of the medical record for Patient # 7 revealed that the patient was in 4 point restraints from 10/08/12 at 2045 until 10/09/12 1940. This exceeded the 4 hour limit on behavioral restraint orders. The order was not renewed. There was no documented behavior or rationale for continuation of the restraint from 10/09/12 at 00:00 until 10/09/12 at 0900 or from 10/09/12 at 1330 until 10/09/12 at 1440.

Facility policy entitled " Restraint and Seclusion " dated 10/24/12 stated in part:
" C. ORDERS ...
4. Maximum Time Limits for Orders...
b. Violent /Self Destructive Restraints/Seclusion
i. Initial Orders:
1) Patient ' s 18 years of age or older-Order must not exceed 4 hours " .

A review of medical records revealed 3 of 3 patients with behavioral restraint orders that exceeded the 4 hour limit per facility based policy and regulatory requirements.
Patient # 3 had an order for " Restraints-Violent/Self destructive " with a start date and time of 10/27/12 at 1600 and stop date and time of 10/27/12 at 2255. Patient # 7 had an order for " Restraints-Behavioral " with a start date and time of 10/08/12 at 2030 and a stop date and time of 10/09/12 at 0719. Patient # 11 had an order for " Restraints-Behavioral " with a start date and time of 08/25/12 at 1725 and a stop date and time of 08/28/12 at 1400.
Facility policy entitled " Restraint and Seclusion " dated 10/24/12 stated in part:
" E. Documentation: At a minimum, documentation in the Medical Record will include the following: ...
2. A description of the patient ' s behavior and the interventions used;
5. The patient ' s response to the interventions used, including the rational for continued use of the
intervention ... "

According to Patient # 3 ' s medical record, restraint progress note/assessments were completed for the following dates and times:
10/27/12 at 17:00 indicated the reason for restraint on the care plan portion as, " Patient is in danger of injury to self (sic) Patient n (sic) danger of injury to others (sic) Patient is attempting to harm self " . There was no documentation of the patient's response to the intervention.

According to Patient # 7 ' s medical record, restraint progress note/assessments were completed for the following dates and times:
10/08/12 at 20:45 indicated the reason for restraint on the care plan portion as, " Patient is in danger of injury to self. Patient is n (sic) danger of injury to others. Patient is confused and combative. " There was no documentation of the patient's response to the intervention.
10/08/12 at 21:45 rationale for restraint listed as " Patient is in danger of injury to self. Patient is confused and combative " . There was no documentation of the patient's response to the intervention.
10/08/12 at 22:35 rationale for restraint was listed the same as above. " There was no documentation of the patient's response to the intervention.
10/09/12 at 00:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
10/09/12 at 02:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
10/09/12 at 03:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
10/09/12 at 05:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
10/09/12 at 07:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
10/09/12 at 09:00 rationale for restraint was listed as " Patient is in danger to self " . There was no documentation of the patient ' s response to the intervention.
10/09/12 at 13:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
10/09/12 at 15:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
10/09/12 at 17:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
10/09/12 at 19:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
On 10/09/12 at 19:40 it was documented that the patient was released from restraints.

According to Patient # 11 ' s medical record, restraint progress note/assessments were completed for the following dates and times:
08/25/12 at 17:01 indicated the reason for restraint on the care plan portion as, " Pt remains screaming and yelling at staff. " There was no documentation of the patient's response to the intervention.
On 08/25/12 at 17:08 indicated restraints remained on.
On 08/25/12 at 18:10 it was documented that the patient was released from restraints.

Facility policy entitled " Restraint and Seclusion " dated 10/24/12 stated in part:
" E. Documentation: At a minimum, documentation in the Medical Record will include the following:
1. The 1 hour face to face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior; ...
I. Additional Requirements for Violent/Self-destructive Restraint/Seclusion:
1. One Hour Face-to-Face
a. The physician or other LIP must complete a face-to-face assessment within one hour of initiation of violent/self-destructive restraint/seclusion
b. The 1 hour face-to-face evaluation must be conducted in person, a telephone call or telemedicine methodology is not permitted
c. During the face-to-face assessment, the LIP evaluated:
i. The patient ' s immediate situation
ii. The patients ' reaction to the intervention
iii. The patient ' s medical and behavioral condition (i.e. systems review, medical condition, behavioral assessment, review of patient ' s history, drugs and medications and most recent lab results, etc.)
iv. Need to continue or terminate the restraint or seclusion
v. Supplies staff with guidance in identifying ways to help the patient regain control in order for restraint to be discontinued
vi. Makes any necessary revisions to the patient ' s treatment plan and
vii. If indicated, and as authorized, supplies a written order with specific timeframes
d. The 1 hour face-to-face will be documented in the patient ' s medical record
e. If the patient ' s behavior resolves and the intervention is discontinued before the 1 hour face-to-face is conducted, the LIP is still required to see the patient face-to-face and conduct the evaluation within one hour after the initiation of the intervention. "
A review of the medical record for Patients #3, 7, and 11 revealed no documented face to face assessment by a physician within 1 hour after initiation of the intervention to evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the restraint.
Facility policy entitled " Restraints " dated 3/22/12 stated in part: "...Restraint Monitoring is continuous and in-person for behavioral restraint as long as the person is in the behavioral restraint. In-person means the observer must have direct eye contact with the patient however this can occur through a window or through a doorway since staff presence in the room could be dangerous and further agitate the patient ...For medical effectiveness restraint, monitoring occurs at a minimum every two hours or more frequently as determined by the patient ' s condition ..."

Facility policy entitled " Restraint and Seclusion " dated 10/24/12 stated in part:
" E. Documentation: At a minimum, documentation in the Medical Record will include the following: ...
6. Individual patient assessments and reassessments ...
G. Reassessment/Monitoring:
Frequency:
a. The selection of an intervention and determination of the necessary frequency of assessment and monitoring should be individualized, taking into consideration variables such as the patient ' s condition, cognitive status, risks associated with the use of the chosen intervention and other relevant factors.
b. Maximum Timeframes for monitoring and assessment are:
i. Nonviolent Restraints -Every two hours; With the exception of vital signs, respiratory status, intake and output, and cardiac status which may be taken as clinically indicated and/or ordered.
ii. Violent/Self destructive Restraint/Seclusion - Every 15 minutes; with the exception of vital signs respiratory status, intake and output, and cardiac status, which may be taken as clinically indicated and/or ordered.
c. The above time frames are not to be exceeded, but the qualified LIP may determine based on patients ' needs and situation factors if more frequent monitoring is required. The requirement for more frequent monitoring should be documented on the EMR order entry worksheet. "
According a review of the medical record, Patient # 3 was not monitored every 15 minutes per current facility policy. Restraint assessment was documented:
On 10/27/12 at 17:00 there was no documented assessment of the patient ' s skin integrity, circulation, and/or respiratory status. There was no documentation of the patient ' s cardiac status noted in the assessment. This was the only assessment documented while the patient was restrained form 1550-1830.

According a review of the medical Patient # 7 was not monitored every 2 hours per the facility policy in effect at the time. Restraint assessments were documented at the following times:
10/08/12 at 20:45 the patient ' s skin integrity and circulation were assessed. Respiratory status was not assessed.
10/08/12 at 21:45 the patient ' s skin integrity and circulation were assessed. Respiratory status was not assessed.
10/08/12 at 22:35 the patient ' s skin integrity and circulation were assessed. Respiratory status was not assessed.
10/09/12 at 00:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 02:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 03:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 05:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 07:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 09:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 13:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 15:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 17:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 19:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
On 10/09/12 at 19:40 it was documented that the patient was released from restraints. The patient ' s skin integrity and circulation were assessed. Respiratory status was not documented. There was no documentation of the patient ' s cardiac status noted in the assessments.

Facility policy entitled " Restraint and Seclusion " dated 10/24/12 stated in part:
"Release Criteria:
a. Nonviolent Restraint Release Criteria:
i. Line Protection - No longer pulling at or interfering with invasive tubes/lines resulting in injury/harm to self and alternative interventions successful or not needed
ii. Surgical/Wound Maintenance -No longer picking at site in a manner that hinders the healing process resulting in injury/harm to self and alternative interventions successful or not needed.
iii. Patient Safety -No longer actively exhibiting behaviors resulting in injury/harm to self ; the risk of self-injury no longer outweigh the risks of restraint use and alternative interventions successful or not needed
b. Violent/Self destructive Restraint/Seclusion Release Criteria
i. No longer exhibiting violent or self-destructive behavior impacting the therapeutic environment in which the patient ' s behavior poses a serious and imminent danger to the physical safety of self, staff and others and alternative interventions successful or not needed. "
The medical records of Patients # 3 and 11 revealed both patients remained in restraints after falling asleep. The behavior requiring restraint was absent while asleep requiring that both patient ' s should have been released when assessed to be sleeping.

A review of the medical record for Patient # 7 revealed that the patient was in 4 point restraints from 10/08/12 at 2045 until 10/09/12 1940. This exceeded the 4 hour limit on behavioral restraint orders. The order was not renewed. There was no documented behavior or rationale for continuation of the restraint from 10/09/12 at 00:00 until 10/09/12 at 0900 or from 10/09/12 at 1330 until 10/09/12 at 1440.

Facility policy entitled " Restraint and Seclusion " dated 10/24/12 stated in part:
"Training and Competency
a. Training Intervals - Based on the population served, staff is to be trained and competent to minimize use of restraint and to assure their safe use. Staff will have validated restraint competencies before they participate in any use of restraint/seclusion (including discontinuation and removal) during initial orientation and annually thereafter.
b. Documentation -All training and competencies will be documented at required timeframes and incorporated into staff personnel records. "
Patient # 3 ' s behavioral restraint was overseen and documented on by Staff member # 7. Staff member #7 did not have adequate training in relation to restraints. A review of staff competencies and training for Staff Member #7 revealed the " Orientation/Skill Review Topic " form included " Restraint Documentation " which was blank and not marked as completed. The Organizational and Department Orientation Checklist included " A. Safety ...6. Use of Restraints " was validated on 09/05/12 through " Policy/Practice Discussed " The " self-assessed knowledge level after orientation " was marked as a 2 indicating " Some Knowledge; May require additional " . The PACU/Pre-OP Competency Validation Summary " under the portion titled " Restraints " which stated, " Completes policy review. Completes return demonstration of application and release of restraints. Documentation requirements in SCM discussed and able to verbalize requirements. " dated 09/17/12 indicated the competency level as 1 indicating " Little or no experience; training required " . Based on this personnel record, Staff member # 7 was inadequately trained in restraints application and documentation. There was no documented training for monitoring, assessment, and providing care for a patient in restraint.
Patient # 11 ' s behavioral restraint was overseen and documented on by Staff member # 4. Staff member #4 did not have adequate training in relation to restraints. A review of staff competencies and training for Staff Member #4 revealed the competencies for Restraint documentation were completed on 04/09/12. The Organizational and Department Orientation Checklist included " A. Safety ...6. Use of Restraints " was validated on 07/03/12 through " Policy/Practice Discussed " . There was no documented specific training regarding the application of restraints, monitoring, assessment, and providing care for a patient in restraint.

Based on review of documentation, the facility failed to ensure restraints were discontinued at the earliest possible time.

Findings were:

A review medical records of 3 of 3 patients requiring behavioral restraint revealed the restraints were not discontinued at the earliest possible time.

The medical records of Patients # 3 and 11 revealed both patients remained in restraints after falling asleep. The behavior requiring restraint was absent while asleep requiring that both patient ' s should have been released when assessed to be sleeping.

A review of the medical record for Patient # 7 revealed that the patient was in 4 point restraints from 10/08/12 at 2045 until 10/09/12 1940. This exceeded the 4 hour limit on behavioral restraint orders. The order was not renewed. There was no documented behavior or rationale for continuation of the restraint from 10/09/12 at 00:00 until 10/09/12 at 0900 or from 10/09/12 at 1330 until 10/09/12 at 1440.

Based on review of documentation, the facility failed to ensure that each order for restraint used for the management of violent or self-destructive behavior that immediately jeopardizes the immediate physical safety of the patient was utilized in accordance with a 4 hour time limit for adults with renewal up to 24 hours.

Findings were:

Facility policy entitled " Restraint and Seclusion " dated 10/24/12 stated in part, "C. ORDERS ...
4. Maximum Time Limits for Orders...
b. Violent /Self Destructive Restraints/Seclusion
i. Initial Orders:
1) Patient ' s 18 years of age or older-Order must not exceed 4 hours"

A review of medical records revealed 3 of 3 patients with behavioral restraint orders that exceeded the 4 hour limit per facility based policy and regulatory requirements.
Patient # 3 had an order for " Restraints-Violent/Self destructive " with a start date and time of 10/27/12 at 1600 and stop date and time of 10/27/12 at 2255. Patient # 7 had an order for " Restraints-Behavioral " with a start date and time of 10/08/12 at 2030 and a stop date and time of 10/09/12 at 0719. Patient # 11 had an order for " Restraints-Behavioral " with a start date and time of 08/25/12 at 1725 and a stop date and time of 08/28/12 at 1400.

Based on review of documentation, the facility failed to ensure restraints were discontinued at the earliest possible time.

Findings were:

Facility policy entitled " Restraint and Seclusion " dated 10/24/12 stated in part: " Use of restraint or seclusion is only imposed to ensure the immediate physical safety of the patient, a staff member, or others; and is discontinued at the earliest possible time based on individualized patient assessment and re-evaluation regardless of the scheduled expiration of the order ... "
A review of medical records revealed 3 of 3 patients requiring behavioral restraint revealed that the restraints were not discontinued at the earliest possible time.

The medical records of Patients # 3 and 11 revealed both patients remained in restraints after falling asleep. The behavior requiring restraint was absent while asleep requiring that both patient ' s should have been released when assessed to be sleeping.

A review of the medical record for Patient # 7 revealed that the patient was in 4 point restraints from 10/08/12 at 2045 until 10/09/12 1940. This exceeded the 4 hour limit on behavioral restraint orders. The order was not renewed. There was no documented behavior or rationale for continuation of the restraint from 10/09/12 at 00:00 until 10/09/12 at 0900 or from 10/09/12 at 1330 until 10/09/12 at 1440.

Based on review of documentation and interviews, the facility failed to ensure the patients who were restrained were monitored by a physician, other licensed independent practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy.

Findings were:

Facility policy entitled " Restraints " dated 3/22/12 stated in part: "...Restraint Monitoring is continuous and in-person for behavioral restraint as long as the person is in the behavioral restraint. In-person means the observer must have direct eye contact with the patient however this can occur through a window or through a doorway since staff presence in the room could be dangerous and further agitate the patient ...For medical effectiveness restraint, monitoring occurs at a minimum every two hours or more frequently as determined by the patient ' s condition ..."

Facility policy entitled " Restraint and Seclusion " dated 10/24/12 stated in part:

"E. Documentation: At a minimum, documentation in the Medical Record will include the following:...
6. Individual patient assessments and reassessments
7. The Intervals for monitoring....
G. Reassessment/Monitoring:
Frequency:
a. The selection of an intervention and determination of the necessary frequency of assessment and monitoring should be individualized, taking into consideration variables such as the patient ' s condition, cognitive status, risks associated with the use of the chosen intervention and other relevant factors.
b. Maximum Timeframes for monitoring and assessment are:
i. Nonviolent Restraints -Every two hours; With the exception of vital signs, respiratory status, intake and output, and cardiac status which may be taken as clinically indicated and/or ordered.
ii. Violent/Self destructive Restraint/Seclusion - Every 15 minutes; with the exception of vital signs respiratory status, intake and output, and cardiac status, which may be taken as clinically indicated and/or ordered.
c. The above time frames are not to be exceeded, but the qualified LIP may determine based on patients ' needs and situation factors if more frequent monitoring is required. The requirement for more frequent monitoring should be documented on the EMR order entry worksheet."
According a review of the medical record, Patient # 3 was not monitored every 15 minutes per current facility policy. Restraint assessment was documented:
On 10/27/12 at 17:00 there was no documented assessment of the patient ' s skin integrity, circulation, and/or respiratory status. There was no documentation of the patient ' s cardiac status noted in the assessment. This was the only assessment documented while the patient was restrained form 1550-1830.

According a review of the medical record, Patient # 7 was not monitored every 2 hours per the facility policy in effect at the time. Restraint assessments were documented at the following times:
10/08/12 at 20:45 the patient ' s skin integrity and circulation were assessed. Respiratory status was not assessed.
10/08/12 at 21:45 the patient ' s skin integrity and circulation were assessed. Respiratory status was not assessed.
10/08/12 at 22:35 the patient ' s skin integrity and circulation were assessed. Respiratory status was not assessed.
10/09/12 at 00:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 02:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 03:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 05:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 07:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 09:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 13:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 15:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 17:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
10/09/12 at 19:00 the patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
On 10/09/12 at 19:40 it was documented that the patient was released from restraints. The patient ' s skin integrity and circulation were assessed. Respiratory status was not documented.
There was no documentation of the patient ' s cardiac status noted in the assessments.

Patient # 3 ' s behavioral restraint was overseen and documented on by Staff member # 7. Staff member #7 did not have adequate training in relation to restraints. A review of staff competencies and training for Staff Member #7 revealed the " Orientation/Skill Review Topic " form included " Restraint Documentation " which was blank and not marked as completed. The Organizational and Department Orientation Checklist included " A. Safety ...6. Use of Restraints " was validated on 09/05/12 through " Policy/Practice Discussed " The " self-assessed knowledge level after orientation " was marked as a 2 indicating " Some Knowledge; May require additional " . The PACU/Pre-OP Competency Validation Summary " under the portion titled " Restraints " which stated, " Completes policy review. Completes return demonstration of application and release of restraints. Documentation requirements in SCM discussed and able to verbalize requirements. " dated 09/17/12 indicated the competency level as 1 indicating " Little or no experience; training required " . Based on this personnel record, Staff member # 7 was inadequately trained in restraints application and documentation. There was no documented training for monitoring, assessment, and providing care for a patient in restraint.
Patient # 11 ' s behavioral restraint was overseen and documented on by Staff member # 4. Staff member #4 did not have adequate training in relation to restraints. A review of staff competencies and training for Staff Member #4 revealed the competencies for Restraint documentation were completed on 04/09/12. The Organizational and Department Orientation Checklist included " A. Safety ...6. Use of Restraints " was validated on 07/03/12 through " Policy/Practice Discussed " . There was no documented specific training regarding the application of restraints, monitoring, assessment, and providing care for a patient in restraint.

Based on review of documentation, the facility failed to ensure that when a restraint was used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient was seen face-to-face within 1-hour after the initiation of the intervention by a physician or other licensed independent practitioner.

Findings were:

Facility policy entitled " Restraint and Seclusion " dated 10/24/12 stated in part:

""E. Documentation: At a minimum, documentation in the Medical Record will include the following:
1. The 1 hour face to face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior;...
I. Additional Requirements for Violent/Self-destructive Restraint/Seclusion:
1. One Hour Face-to-Face
a. The physician or other LIP must complete a face-to-face assessment within one hour of initiation of violent/self-destructive restraint/seclusion
b. The 1 hour face-to-face evaluation must be conducted in person, a telephone call or telemedicine methodology is not permitted
c. During the face-to-face assessment, the LIP evaluated:
i. The patient ' s immediate situation
ii. The patients ' reaction to the intervention
iii. The patient ' s medical and behavioral condition (i.e. systems review, medical condition, behavioral assessment, review of patient ' s history, drugs and medications and most recent lab results, etc.)
iv. Need to continue or terminate the restraint or seclusion
v. Supplies staff with guidance in identifying ways to help the patient regain control in order for restraint to be discontinued
vi. Makes any necessary revisions to the patient ' s treatment plan and
vii. If indicated, and as authorized, supplies a written order with specific timeframes
d. The 1 hour face-to-face will be documented in the patient ' s medical record
e. If the patient ' s behavior resolves and the intervention is discontinued before the 1 hour face-to-face is conducted, the LIP is still required to see the patient face-to-face and conduct the evaluation within one hour after the initiation of the intervention."
A review of the medical record for Patients #3 and 7 revealed no documented face to face assessment by a physician within 1 hour after initiation of the intervention.

Based on review of documentation, the facility failed to ensure that when restrained patients were seen face to face within 1 hour after the initiation to evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the restraint or seclusion.

Findings were:

Facility policy entitled " Restraint and Seclusion " dated 10/24/12 stated in part:

"E. Documentation: At a minimum, documentation in the Medical Record will include the following:
1. The 1 hour face to face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior;...
I. Additional Requirements for Violent/Self-destructive Restraint/Seclusion:
1. One Hour Face-to-Face
a. The physician or other LIP must complete a face-to-face assessment within one hour of initiation of violent/self-destructive restraint/seclusion
b. The 1 hour face-to-face evaluation must be conducted in person, a telephone call or telemedicine methodology is not permitted
c. During the face-to-face assessment, the LIP evaluated:
i. The patient ' s immediate situation
ii. The patients ' reaction to the intervention
iii. The patient ' s medical and behavioral condition (i.e. systems review, medical condition, behavioral assessment, review of patient ' s history, drugs and medications and most recent lab results, etc.)
iv. Need to continue or terminate the restraint or seclusion
v. Supplies staff with guidance in identifying ways to help the patient regain control in order for restraint to be discontinued
vi. Makes any necessary revisions to the patient ' s treatment plan and
vii. If indicated, and as authorized, supplies a written order with specific timeframes
d. The 1 hour face-to-face will be documented in the patient ' s medical record
e. If the patient ' s behavior resolves and the intervention is discontinued before the 1 hour face-to-face is conducted, the LIP is still required to see the patient face-to-face and conduct the evaluation within one hour after the initiation of the intervention."
A review of the medical record for Patients #3, 7, and 11 revealed no documented face to face assessment by a physician within 1 hour after initiation of the intervention to evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the restraint.

Based on review of documentation and interviews, the facility failed to ensure the documentation of rationale for continued use and/or the patient's response to the intervention.

Findings were:

E. Documentation: At a minimum, documentation in the Medical Record will include the following:...
5. The patient ' s response to the interventions used, including the rational for continued use of the intervention..."

According to Patient # 3 ' s medical record, restraint progress note/assessments were completed for the following dates and times:
10/27/12 at 17:00 indicated the reason for restraint on the care plan portion as, " Patient is in danger of injury to self (sic) Patient n (sic) danger of injury to others (sic) Patient is attempting to harm self " . There was no documentation of the patient's response to the intervention.

According to Patient # 7 ' s medical record, restraint progress note/assessments were completed for the following dates and times:
10/08/12 at 20:45 indicated the reason for restraint on the care plan portion as, " Patient is in danger of injury to self. Patient is n (sic) danger of injury to others. Patient is confused and combative. " There was no documentation of the patient's response to the intervention.
10/08/12 at 21:45 rationale for restraint listed as " Patient is in danger of injury to self. Patient is confused and combative " . There was no documentation of the patient's response to the intervention.
10/08/12 at 22:35 rationale for restraint was listed the same as above. " There was no documentation of the patient's response to the intervention.
10/09/12 at 00:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
10/09/12 at 02:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
10/09/12 at 03:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
10/09/12 at 05:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
10/09/12 at 07:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
10/09/12 at 09:00 rationale for restraint was listed as " Patient is in danger to self " . There was no documentation of the patient ' s response to the intervention.
10/09/12 at 13:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
10/09/12 at 15:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
10/09/12 at 17:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
10/09/12 at 19:00 no rationale for continued restraint was indicated. There was no documentation of the patient ' s response to the intervention.
On 10/09/12 at 19:40 it was documented that the patient was released from restraints.

According to Patient # 11 ' s medical record, restraint progress note/assessments were completed for the following dates and times:
08/25/12 at 17:01 indicated the reason for restraint on the care plan portion as, " Pt remains screaming and yelling at staff. " There was no documentation of the patient's response to the intervention.
On 08/25/12 at 17:08 indicated restraints remained on.
On 08/25/12 at 18:10 it was documented that the patient was released from restraints.

Based on review of documentation, the facility failed to ensure patients maintained that the right to safe implementation of restraint or seclusion by trained staff.

Findings were:

Facility policy entitled " Restraint and Seclusion " dated 10/24/12 stated in part:
"Training and Competency
a. Training Intervals - Based on the population served, staff is to be trained and competent to minimize use of restraint and to assure their safe use. Staff will have validated restraint competencies before they participate in any use of restraint/seclusion (including discontinuation and removal) during initial orientation and annually thereafter.
b. Documentation -All training and competencies will be documented at required timeframes and incorporated into staff personnel records. "
Patient # 3 ' s behavioral restraint was overseen and documented on by Staff member # 7. Staff member #7 did not have adequate training in relation to restraints. A review of staff competencies and training for Staff Member #7 revealed the " Orientation/Skill Review Topic " form included " Restraint Documentation " which was blank and not marked as completed. The Organizational and Department Orientation Checklist included " A. Safety ...6. Use of Restraints " was validated on 09/05/12 through " Policy/Practice Discussed " The " self-assessed knowledge level after orientation " was marked as a 2 indicating " Some Knowledge; May require additional " . The PACU/Pre-OP Competency Validation Summary " under the portion titled " Restraints " dated 09/17/12 indicated the competency level as 1 indicating " Little or no experience; training required " . There was no other documentation of restraint training.

Based on review of documentation, the facility failed to ensure staff members were trained and able to demonstrate competency in the application of restraints, monitoring, assessment, and providing care for a patient in restraint before performing any of the actions specified in this paragraph.

Findings were:

Patient # 3 ' s behavioral restraint was overseen and documented on by Staff member # 7. Staff member #7 did not have adequate training in relation to restraints. A review of staff competencies and training for Staff Member #7 revealed the " Orientation/Skill Review Topic " form included " Restraint Documentation " which was blank and not marked as completed. The Organizational and Department Orientation Checklist included " A. Safety ...6. Use of Restraints " was validated on 09/05/12 through " Policy/Practice Discussed " The " self-assessed knowledge level after orientation " was marked as a 2 indicating " Some Knowledge; May require additional " . The PACU/Pre-OP Competency Validation Summary " under the portion titled " Restraints " which stated, " Completes policy review. Completes return demonstration of application and release of restraints. Documentation requirements in SCM discussed and able to verbalize requirements. " dated 09/17/12 indicated the competency level as 1 indicating " Little or no experience; training required " . Based on this personnel record, Staff member # 7 was inadequately trained in restraints application and documentation. There was no documented training for monitoring, assessment, and providing care for a patient in restraint.
Patient # 11 ' s behavioral restraint was overseen and documented on by Staff member # 4. Staff member #4 did not have adequate training in relation to restraints. A review of staff competencies and training for Staff Member #4 revealed the competencies for Restraint documentation were completed on 04/09/12. The Organizational and Department Orientation Checklist included " A. Safety ...6. Use of Restraints " was validated on 07/03/12 through " Policy/Practice Discussed " . There was no documented specific training regarding the application of restraints, monitoring, assessment, and providing care for a patient in restraint.

Based on review of documentation and interview, the facility failed to ensure staff members were educated, trained, and demonstrated knowledge of the safe application and use of all types of restraint.

Findings were:

Patient # 3 ' s behavioral restraint was overseen and documented on by Staff member # 7. Staff member #7 did not have adequate training in relation to restraints. A review of staff competencies and training for Staff Member #7 revealed the " Orientation/Skill Review Topic " form included " Restraint Documentation " which was blank and not marked as completed. The Organizational and Department Orientation Checklist included " A. Safety ...6. Use of Restraints " was validated on 09/05/12 through " Policy/Practice Discussed " The " self-assessed knowledge level after orientation " was marked as a 2 indicating " Some Knowledge; May require additional " . The PACU/Pre-OP Competency Validation Summary " under the portion titled " Restraints " dated 09/17/12 indicated the competency level as 1 indicating " Little or no experience; training required " . Staff member #7 received inadequate training regarding the safe application and use of all types of restraint.
Patient # 11 ' s behavioral restraint was overseen and documented on by Staff member # 4. Staff member #4 did not have adequate training in relation to restraints. A review of staff competencies and training for Staff Member #4 revealed the competencies for Restraint documentation were completed on 04/09/12. The Organizational and Department Orientation Checklist included " A. Safety ...6. Use of Restraints " was validated on 07/03/12 through " Policy/Practice Discussed " . There was no documented specific training regarding the safe application of restraints.
In an interview on 10/08/12, Staff member # 17 confirmed that the facility does not currently have standardized training program for all staff member in the hospital regarding the safe application or restraints.

Based on review of documentation, the facility failed to ensure staff members were educated, trained, and demonstrated knowledge specific behavioral changes that indicate that restraint or seclusion is no longer necessary.

Findings were:

Facility policy entitled " Restraint and Seclusion " dated 10/24/12 stated in part:

"Release Criteria:
a. Nonviolent Restraint Release Criteria:
i. Line Protection - No longer pulling at or interfering with invasive tubes/lines resulting in injury/harm to self and alternative interventions successful or not needed
ii. Surgical/Wound Maintenance -No longer picking at site in a manner that hinders the healing process resulting in injury/harm to self and alternative interventions successful or not needed.
iii. Patient Safety -No longer actively exhibiting behaviors resulting in injury/harm to self ; the risk of self-injury no longer outweigh the risks of restraint use and alternative interventions successful or not needed."

The medical records of Patients # 3 and 11 revealed both patients remained in restraints after falling asleep. The behavior requiring restraint was absent while asleep requiring that both patient ' s should have been released when assessed to be sleeping. Patient # 11 ' s behavioral restraint was overseen and documented on by Staff member # 4. Patient # 3 ' s behavioral restraint was overseen and documented on by Staff member # 7. A review of Staff members # 4 and 11 ' s personnel records revealed neither employee received specific training reading knowledge specific behavioral changes that indicate that restraint or seclusion is no longer necessary.

Based on review of documentation and interview, the facility failed to document in the staff personnel records that the training and demonstration of competency were successfully completed.

Findings were:

Facility policy entitled " Restraint and Seclusion " dated 10/24/12 stated in part:
"Training and Competency
a. Training Intervals - Based on the population served, staff is to be trained and competent to minimize use of restraint and to assure their safe use. Staff will have validated restraint competencies before they participate in any use of restraint/seclusion (including discontinuation and removal) during initial orientation and annually thereafter.
b. Documentation -All training and competencies will be documented at required timeframes and incorporated into staff personnel records. "
Patient # 3 ' s behavioral restraint was overseen and documented on by Staff member # 7. Staff member #7 did not have adequate training in relation to restraints. A review of staff competencies and training for Staff Member #7 revealed the " Orientation/Skill Review Topic " form included " Restraint Documentation " which was blank and not marked as completed. The Organizational and Department Orientation Checklist included " A. Safety ...6. Use of Restraints " was validated on 09/05/12 through " Policy/Practice Discussed " The " self-assessed knowledge level after orientation " was marked as a 2 indicating " Some Knowledge; May require additional " . The PACU/Pre-OP Competency Validation Summary " under the portion titled " Restraints " which stated, " Completes policy review. Completes return demonstration of application and release of restraints. Documentation requirements in SCM discussed and able to verbalize requirements. " dated 09/17/12 indicated the competency level as 1 indicating " Little or no experience; training required " . Based on this personnel record, Staff member # 7 was inadequately trained in restraints application and documentation. There was no documented training for monitoring, assessment, and providing care for a patient in restraint.
Patient # 11 ' s behavioral restraint was overseen and documented on by Staff member # 4. Staff member #4 did not have adequate training in relation to restraints. A review of staff competencies and training for Staff Member #4 revealed the competencies for Restraint documentation were completed on 04/09/12. The Organizational and Department Orientation Checklist included " A. Safety ...6. Use of Restraints " was validated on 07/03/12 through " Policy/Practice Discussed " . There was no documented specific training regarding the application of restraints, monitoring, assessment, and providing care for a patient in restraint.
In an interview on 10/08/12, Staff member # 17 confirmed that the facility does not currently have standardized training program for all staff member in the hospital regarding the safe application or restraints.

Based on observation during a tour of the facility with hospital staff, the facility failed to provide a sanitary environment for the preparations, service and storage of food.

Findings were:

During a tour of the kitchen area at 2 pm on 11/7/12 with the Director of Dietary Services and Administrative Staff the following items were observed to be in an unsanitary condition with a covering of dust and grease on horizontal surfaces, which indicated a lack of proper cleaning:
? The top of the dishwasher
? The shelf above the food prep area
? The iced tea brewer
? The ice machine
? The top of the steamer

The following items were available for patient food preparation:
? 8 out of 8 pans stacked together on the clean storage shelves were observed to be wet with water drips in between the pans. 3 of the pans had dried food particles and debris adhering to the inside of the pan. In another stack, 3 out of 3 pans were observed to be wet and 1 pan had a white powdery substance which appeared to be dried soap adhered to the inside of the pan. The interior of the blender contained water. The water and food debris on the pans, which were available for patient food preparation, indicated a lack of cleaning or proper drying and presented the potential for bacterial contamination.
? In the walk-in refrigerator, a package of crepe shells was cracked and food was exposed, creating a risk for contamination.
? In the walk-in freezer, a package of parsley was open and exposed, creating a risk for contamination; also in the walk-in freezer, a box of what appeared to be pizza crusts was open and the crusts were exposed, creating a risk for contamination.
? There was condensation on the lights and ice on the ceiling of the walk-in deep freezer.
? There were 3 pots with a greasy surface.
? There was a brownish substance that appeared to be food in 2 of 2 muffin tins.
? The large food mixer had a dried substance which appeared to be food, on the mixer above the bowl, indicating a need for cleaning and creating a risk for contamination.
? A mechanical can opener was in the utensil drawer with a ? x ? piece of dried food adhered near the blade and the handles were dirty.
? In another utensil drawer, there was a dirty large knife with a food-like substance adhered and the blade was incorrectly sharpened on the same knife leaving raised metal areas and creating a risk for metal shavings/pieces to flake off into food; a dirty apron was found in the same drawer.
? The front of the steamer was greasy and there was a 5 x 5 inch sticky residue that was greasy with dirt adhered on the surface of the door.
The above findings were confirmed during the tour in an interview with the Director of Dietary and Administrative Staff the afternoon of 11/6/12.