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Based on interviews and record reviews, it was determined that the facility staff failed to modify the plans of care when restraints were added for 2 of 3 sampled patients who required restraint use while patients at the facility (Patient #7 and Patient #8).

The findings include:

The facility staff failed to modify Patient #7's and Patient #8's plans of care to address the addition of restraint use.

Patient #7's clinical record was reviewed electronically with a facility quality staff member (QSM #1) on 5/8/14. Review of Patient #7's clinical record revealed a physician order for restraints dated 4/28/14 at 4:20 a.m. Nursing documentation indicated that the restraints were applied on 4/28/14 at 4:20 a.m. and discontinued on 4/28/14 at 4:41 p.m. The facility's QSM #1 and the surveyor were unable to find modifications to Patient #7's plan of care addressing the use of restraints.

Patient #8's clinical record was reviewed electronically with a facility quality staff member on 5/8/14. Review of Patient #8's clinical record revealed a physician order for restraints dated 1/31/14 at 12:20 p.m. Nursing documentation indicated that the restraints were applied on 1/31/14 at 12:30 p.m. The QSM #1 and the surveyor were unable to find modifications to Patient #8's plan of care addressing the use of restraints.

During a survey team meeting, on 5/8/14 at 3:00 p.m., with the facility's Chief Executive Officer, Chief Nursing Officer, Corporate Director, and QSM #1, the failure of the facility staff to modify the plans of care to address the use of restraints for Patient #7 and Patient #8 was discussed for a final time; no additional information related to this issue was provided to the survey team.

Based on interviews and record reviews, it was determined that the facility staff failed to document when restraints were discontinued for 1 of 2 sampled patients who had restraints discontinued while a patient at the facility (Patient #8).

The findings include:

The facility staff failed to document the discontinuation of restraints for Patient #8.

Patient #8's clinical record was reviewed electronically with a facility quality staff member (QSM #1) on 5/8/14. Review of Patient #8's clinical record revealed a physician order for restraints dated 1/31/14 at 12:20 p.m. Nursing documentation indicated that the restraints were applied on 1/31/14 at 12:30 p.m. The last documentation found related to restraint use for Patient #8 was dated 2/1/14 at 6:00 p.m., this documentation indicated that two-point restraints continued to be in use. The QSM #1 and the surveyor were unable to find documentation to indicate when the restraints were discontinued for Patient #8.

Review of a facility policy entitled, 'Restraint and/or Seclusion: Care of the Patient/Application and Use of - Virginia Hospitals (No Behavioral Health Service)' revealed the following information under the heading 'Monitoring and Assessment of Continued Need for Restraint or Seclusion (Non Violent/Violent)': "Document duration of restraint or seclusion use and behavior upon release of restraint or seclusion in the patient's medical record."

During a survey team meeting, on 5/8/14 at 3:00 p.m., with the facility's Chief Executive Officer, Chief Nursing Officer, Corporate Director, and QSM #1, the failure of the facility staff to document when and if restrains were discontinued for Patient #8 was discussed for a final time; no additional information related to this issue was provided to the survey team.

Based on interviews and record reviews, it was determined that the facility staff failed to following the facility's policy and procedure related to the monitoring of 3 of 3 sampled patients who had required restraint use while patients at the facility (Patient #7, Patient #8, and Patient #9).

The findings include:

The facility staff failed to monitor Patient #7, Patient #8, and Patient #9 according to the facility's policy and procedure guiding the care of a patient in restraints.

Review of a facility policy entitled, 'Restraint and/or Seclusion: Care of the Patient/Application and Use of - Virginia Hospitals (No Behavioral Health Service)' revealed the following information under the heading 'Monitoring and Assessment of Continued Need for Restraint or Seclusion (Non Violent/Violent)':
- "At intervals no greater than fifteen (15) minutes, team members who perform safety checks must document visual observations of behavior regarding continued need for seclusion or restraint, observations of respiration, untoward effects of violent restraints and signs of distress."
- "At intervals no greater than one (1) hour, all restrained patient [sic] must be allowed the opportunity to toilet and offered fluids."

Patient #7's clinical record was reviewed electronically with a facility quality staff member (QSM #1) on 5/8/14. Review of Patient #7's clinical record revealed a physician order for restraints dated 4/28/14 at 4:20 a.m. Nursing documentation indicated that the restraints were applied on 4/28/14 at 4:20 a.m. and discontinued on 4/28/14 at 4:41 p.m. The QSM #1 and the surveyor were unable to find documented evidence of the fifteen minute safety checks as required by the facility's policy and procedure and were unable to find documented evidence of the hourly offering of fluids and the opportunity to toilet. Patient #7's clinical record did reveal restraint monitoring documentation approximately every two hours.

Patient #8's clinical record was reviewed electronically with a facility quality staff member (QSM #1) on 5/8/14. Review of Patient #8's clinical record revealed a physician order for restraints dated 1/31/14 at 12:20 p.m. Nursing documentation indicated that the restraints were applied on 1/31/14 at 12:30 p.m. The QSM #1 and the surveyor were unable to find documented evidence of the fifteen minute safety checks as required by the facility's policy and procedure and were unable to find documented evidence of the hourly offering for the opportunity to toilet. (Patient #8 would not have been offered fluids hourly due to being restricted from oral intake related to a medical condition.)

Patient #9's clinical record was reviewed electronically with QSM #1 on 5/8/14. Review of Patient #9's clinical record revealed the following order dated 11/8/13 at 1:35 p.m.: "Soft restraints for medical therapy while intubated." Patient #9's nursing documentation dated 11/8/13 at 1:45 p.m. stated: 'Restraints applied per (Doctor's name omitted) orders..." The QSM #1 and the surveyor was unable to find documented evidence of the fifteen minute safety checks as required by the facility's policy and procedure. (The patient's condition (i.e., intubated and unresponsive) would have limited the ability for the facility's staff to offer fluids and offer an opportunity to toilet.) (Intubated means the patient had a tube placed into his or her trachea (airway) to assist with breathing.)

During a survey team meeting, on 5/8/14 at 3:00 p.m., with the facility's Chief Executive Officer, Chief Nursing Officer, Corporate Director, and QSM #1, the failure of the facility staff to monitor Patient #7, Patient #8, and Patient #9 due to restraint use was discussed for a final time; no additional information related to this issue was provided to the survey team.