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Based on interview with patients and/or their designees, staff interview, review of medical records, and review of grievance documentation, it was determined the hospital failed to identify grievances and/or respond to them for 5 of 6 patients (#8 - #12) whose medical records and/or grievances were reviewed. This resulted in incomplete investigation and resolution of grievances. Findings include:

1. Patient #8 was a 74 year old female, who was admitted to the facility for care related to a diagnosis of acute, hypoxic respiratory failure. Patient #8 was also receiving treatment for complications related to a motor vehicle accident, when she sustained multiple rib fractures bilaterally, a T1 transverse process fracture (spinal fracture at the thoracic level,) a left tibial fracture and injury to the cervical spine. Additional diagnoses included severe sepsis with shock, which was resolved, clostridium difficile (bacteria in the large colon, causing infectious diarrhea,) which resulted in surgery and placement of a colostomy (a surgical procedure in which an opening is formed by pulling the healthy end of the large intestine through an incision in the abdominal wall and suturing it in place, providing an alternative channel for feces to leave the body,) acute renal failure, bacteremia (presence of bacteria in the blood,) a UTI, a chronic seizure disorder, protein-calorie malnutrition and a blood clot in the left leg.

During the survey, patients and their designees were interviewed about their understanding of the hospital's grievance process. Patient #8's caregiver, her daughter, was interviewed on 10/30/15, beginning at 9:10 AM. Patient #8's daughter stated she was satisfied with the overall care her mother received but described an incident when her mother had complained of severe pain and requested medication to alleviate it. Patient #8's daughter said a nurse came to her mother's room with the pain medication and tried to scan her mother's hospital wrist band for the purpose of identification, but was unable to complete the scanning process. She stated the nurse left the room in an attempt to resolve the problem and did not return for 3 hours. Patient #8's daughter said she then went to the hospital's administration office and talked to someone about the problem. Afterward, she stated the RN Supervisor talked with her, and she relayed the details of the incident to him. Patient #8's daughter was unaware of the events that transpired after her discussion with the RN Supervisor. She was unable to recall the date the incident occurred.

The Director of Quality Management was interviewed on 10/30/15, beginning at approximately 1:55 PM. She stated the complaint voiced by Patient #8's daughter was not recognized or investigated as a grievance.

The policy titled, "Patient Complaint and Grievance Process" was reviewed during the survey. The policy included the following definition:

"Patient complaint: Grievance: Any expression of the dissatisfaction (written or verbal) related to an occurrence within [Name of Hospital], which is of such severity that it is not able to be resolved to the satisfaction of the complainant at a departmental level by the staff present. Complaints that require further investigation, further actions for resolution, or are postponed for later resolution are considered grievances. Complaint type examples include but are not limited to: ...Patient care: coordination of care, quality of care, department-to-department communication, etc..."

On 10/30/15, beginning at approximately 8:40 AM, the RN Supervisor on duty was interviewed regarding the hospital's grievance process. He stated patients and family members could file a grievance using a complaint form that was included in their admission packets. The RN Supervisor also stated every patient in the hospital was assigned an "ambassador." He defined an ambassador as a patient representative from hospital administration. The RN Supervisor stated patients' ambassadors checked in weekly with patients and family members in an attempt to address any concerns they might have. When asked to explain his understanding of the difference between complaints and grievances, the RN Supervisor said the severity of a complaint determined whether the complaint was addressed as a grievance.

On 11/04/15, beginning at approximately 8:45 PM, a different RN Supervisor who was on duty, was interviewed regarding the complaint voiced by Patient #8's daughter. The RN Supervisor presented a document, titled "PATIENT COMPLAINT RESOLUTION." He stated he had completed the document. The document described a grievance voiced by Patient #8, to her daughter, who then relayed the grievance to the RN Supervisor. The document included the date the grievance was received and resolved as 10/26/15. However, the document was not completed, signed and dated by the RN Supervisor, until 11/03/15. The RN Supervisor stated the grievance was not filed at the time of the event.

The "PATIENT COMPLAINT RESOLUTION" form documented Patient #8 was awakened at 4:00 AM for vital signs and assessment, and was unable to get back to sleep because of discomfort. According to the documentation, Patient #8 complained to her daughter that staff did not come in her room between the hours of 4:00 AM and 7:00 AM, though she had her call light on during that time. Under the section, "Desired Resolution...," the form then indicated Patient #8's medical record showed a nurse administered pain medication, for back and neck pain, at 5:49 AM. The form also included that the record showed Patient #8 was repositioned. Under the heading "Actions Taken to bring Resolution," the form included that the RN Supervisor instructed the nursing staff to try not to wake the patient when she was sleeping, if possible. Also, the nursing staff was instructed to be more attentive to Patient #8's pain medication regime. The form did not include evidence that the RN Supervisor followed up with the nurse who was caring for the patient, or the patient and daughter. Though the complaint required investigation and involved the care of Patient #8, the RN Supervisor stated he did not believe the documented complaint was a grievance.

Facility staff did not adequately understand the hospital's policy related to the grievance process. Hospital staff was unable to accurately explain the difference between the facility's definition of a complaint, versus the facility's definition of a grievance.

The facility failed to ensure the process for grievance identification and resolution had been thoroughly developed and implemented.



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2. The policy "Patient Complaint and Grievance Process," not dated, stated "A written complaint is always considered a grievance." The policy also stated "A written response is sent to the complainant upon resolution of the grievance."

a. A "PATIENT COMPLAINT RESOLUTION" form regarding Patient #9, dated 10/07/15, alleged a nurse "...yelled at [Patient #9] for one hour for not getting up for breakfast at 7:30." The form stated a family member requested a different nurse care for Patient #9. Under the heading "Actions taken to bring Resolution:" the form stated the author verified a different nurse was assigned and the charge nurse was interviewed. No other investigation or findings were documented and the form did not state if the allegation was substantiated. A written response to the patient was not documented.

The DQM was interviewed on 10/30/15 beginning at 1:55 PM. She stated documentation of an investigation of Patient #9's grievance was not present. She stated no written response was sent to the complainant.

The hospital failed to investigate and respond to Patient #9's grievance.

b. A "PATIENT COMPLAINT RESOLUTION" form regarding Patient #10, dated 9/09/15, included a written grievance, dated 9/08/15. The form alleged there were care issues involving an allergic reaction, a fluid restriction, and therapy scheduling. The form listed some actions that had been taken in response to the grievance but it did not document an investigation of the allegations. A response to the complainant was not documented.

The DQM was interviewed on 10/30/15 beginning at 1:55 PM. She stated documentation of an investigation of Patient #10's grievance was not present. She stated no written response was sent to the complainant.

The hospital failed to investigate and respond to Patient #10's grievance.

c. A "PATIENT COMPLAINT RESOLUTION" form regarding Patient #11, dated 9/03/15, stated a family member complained that a nurse failed to perform appropriate hand hygiene and failed to wear gloves when needed. The form stated staff discussed the allegations with the complainant but an interview with the nurse was not documented. The form stated there was a delay in the investigation due to a decline in the patient's condition and staffing issues. A determination of the validity of the allegations was not documented. Actions to resolve the complaints were not documented. A written response to the complainant was not documented.

The DQM was interviewed on 10/30/15 beginning at 1:55 PM. She stated documentation of an investigation of Patient #11's grievance was not present. She stated no written response was sent to the complainant.

The hospital failed to investigate and respond to Patient #11's grievance.

d. A "PATIENT COMPLAINT RESOLUTION" form regarding Patient #12, dated 9/08/15, included allegations of delays in answering call lights, showers not being given, delays in turning, and not receiving medications. An accompanying email, dated 9/09/15, was attached. The form stated the author spoke with Patient #12's daughter and sister and the issues had been resolved but did not include specifics. An investigation, including interviews with staff, was not documented. The validity of the allegations was not documented. A written response to the complainant was not documented.

The DQM was interviewed on 10/30/15 beginning at 1:55 PM. She stated documentation of an investigation of Patient #12's grievance was not present. She stated no written response was sent to the complainant.

The hospital failed to investigate and respond to Patient #12's grievance.

Based on staff and patient interviews and review of medical records and grievance documents, it was determined the hospital failed to ensure patients were informed of who to contact to file a grievance for 7 of 8 patients (#1, #2, #4, #5, #6, #7, and #8), whose medical records were reviewed. In addition, the hospital failed to ensure the Governing Body maintained responsibility for the effective operation of the grievance process. This resulted in the inability of the hospital to maintain an effective grievance process. Findings include:

1. Patient #8 was a 74 year old female, who was admitted to the facility for care related to a diagnosis of acute, hypoxic respiratory failure. Patient #8's caregiver, her daughter, was interviewed on 10/30/15, beginning at approximately 9:10 AM. Patient #8's daughter stated she was satisfied with the care her mother had received overall, but described an incident when her mother had complained of severe pain and requested medication to alleviate the pain. Patient #8's daughter said a nurse came to her mother's room with the pain medication and tried to scan her mother's hospital wrist band for the purpose of identification, but was unable to complete the scanning process. She stated the nurse left the room in an attempt to resolve the problem and did not return for 3 hours. Patient #8's daughter said she was not aware of who to contact to file a grievance. She stated she did not remember receiving information from the hospital regarding grievances.

Additionally, 7 patient medical records (Patients #1, #2, #4, #5, #6, #7, and #8) did not contain evidence that patients or their representatives were informed of who to notify to file a grievance.

The CCO was interviewed on 10/30/15 beginning at 3:15 PM. She stated on admission patients were given a booklet with helpful information which included the grievance procedure and whom to notify to file a grievance. She stated the hospital had run out of these booklets 6-8 months ago and had not provided the grievance information to patients since that time.

Patients were not informed of the hospital's grievance process.

2. The CEO was interviewed on 11/02/15 beginning at 8:20 AM. He stated at Governing Body meetings the Board was informed of grievance statistics such as the number of grievances and the number of responses to complainants. He stated he could not think of any meetings since 1/01/15 where the Board had discussed the grievance process or reviewed any grievances in order to determine whether procedures were followed. He stated Board minutes did not contain documentation that the process had been reviewed.

The hospital's Governing Body did not maintain responsibility for the grievance process.

Based on policy review and staff interview, it was determined the hospital failed to ensure patients were provided with written notice of grievance investigations, including the name of the hospital contact person for 27 of 28 grievances filed in 2015. This resulted in a lack of information being provided to patients. Findings include:

The policy "Patient Complaint and Grievance Process," not dated, stated "A written response is sent to the complainant upon resolution of the grievance."

The DQM was interviewed on 10/30/15 beginning at 1:55 PM. She stated 28 grievances had been filed since 1/01/15. Of these 28 grievances she stated only 1 written response had been provided to the complainant. She stated most complainants had been provided verbal responses.

The hospital failed to provide complainants with written notification of grievance decisions and the name of the hospital contact person.

Based on observation, staff interview, and review of medical records, it was determined the hospital failed to ensure restraints were used only after a comprehensive risk assessment and when less restrictive interventions were determined to be ineffective to protect 2 of 3 restrained patients (#1 and #3) from harm. This resulted in the unnecessary use of restraints. Findings include:

1. Patient #3 was an 81 year old male admitted to the hospital on 7/15/14 and discharged on 8/14/14. His diagnoses included a history of aortic valve replacement in February 2014 and prostate surgery in June 2014. He developed an infection and was admitted to the hospital for long term IV antibiotic therapy. Other diagnoses included protein calorie malnutrition and dementia. He had a urinary catheter. On 7/22/14 he began bleeding from his urinary tract. A continuous bladder irrigation was started.

A "Restraint Order and Flow Record, Medical" form stated bilateral wrist restraints were ordered for Patient #3. The time they were applied was not documented but the form stated the physician was notified of their use at 9:47 AM on 7/23/14. The form included checked boxes stating "Reason for Restraint Use...Pulling at tubing/dressing [and] Unable to follow safety instructions." Another section stated "Less restrictive intervention used/considered that are ineffective [were] Pain relief/comfort measures...re-orientation, verbal reminders [and] Limit setting." A comprehensive assessment of Patient #3's need for restraint was not documented.

A progress note by the NP and authenticated by the physician, was dated 7/23/15 at 4:09 PM. The note did not mention restraints. Also, except for the boxes checked on the "Restraint Order and Flow Record, Medical" form, dated 7/23/14, no documentation of a nursing assessment of the need for restraints was present on 7/23/14 or 7/24/14.

A "Restraint Order and Flow Record, Medical" form, dated 7/24/14 was signed by Patient #3's physician on 7/24/15 but was not timed. The form continued the order for wrist restraints. The form included checked boxes stating "Reason for Restraint Use...Pulling at tubing/dressing [and] Unable to follow safety instructions." Another section stated "Less restrictive intervention used/considered that are ineffective [were] Pain relief/comfort measures...Environmental modifications...re-orientation, verbal reminders...Diversional activities [and] Limit setting." None of the checked boxes were explained. Again a comprehensive assessment of Patient #3's need for restraint was not documented.

Patient #3's record contained another progress note by the NP and authenticated by the physician, dated 7/24/15 at 4:39 PM. This note also did not mention restraints.

At some point on 9/24/14 or 9/25/14, Patient #3's restraints were discontinued. The record did not document when this took place and did not contain an assessment stating restraints were no longer needed.

On 7/23/14 at 5:32 AM and 5:35 AM, orders were documented to give Patient #3 0.5 mg IV Lorazepam, an antianxiety drug, and 0.5 mg IV Haldol, an antipsychotic drug. The orders did not state why the medications were ordered. A second set of orders for 1 mg IV Lorazepam and 1 mg IV Haldol was dated 7/23/14 at 9:20 AM. This time, the orders stated the medications were ordered for delirium. The medications were administered as ordered.

Progress notes by the NP and signed by the physician for 7/22/14 and 7/23/14 did not mention delirium and Patient #3's diagnoses did not include delirium. A Neuropsychiatric Evaluation by a psychologist, dated 7/25/14 at 3:00 PM, did not mention the recent use of restraints nor did it mention delirium.

Patient #3's orders for Lorazepam and Haldol coincided with the orders for wrist restraints. The medication orders appeared to be a chemical restraint. There was no documentation that less restrictive measures were tried prior to the use of chemical restraints.

The DQM was interviewed on 10/29/15 beginning at 1:25 PM. She confirmed the episodes of physical restraints for Patient #3. She stated an assessment of the need for restraints was not documented except for the boxes checked on the restraint order forms. She stated the use of less restrictive interventions was not documented except for the checked boxes on the orders. She stated documentation was not present to show specifically when restraints were applied and when they were removed.

The CCO was interviewed on 10/03/15 beginning at 9:35 AM. She stated documentation to support a diagnosis of delirium for Patient #3 was not present in the medical record.

A nursing progress note on 7/29/14 at 1:53 AM, stated Patient #3 pulled out his PICC line. The note stated he was a little confused and accidentally pulled the line taking off his gown. The note stated the physician was notified and orders for wrist restraints were obtained. A comprehensive assessment of Patient #3's need for restraint was not documented. The PICC line was no longer present, therefore, the wrist restraints were not placed to protect the line.

A "Restraint Order and Flow Record, Medical" form, dated 7/29/14 at 7:00 AM, stated bilateral wrist restraints were ordered for Patient #3. The form included checked boxes stating "Reason for Restraint Use...Pulling at tubing/dressing [and] Unable to follow safety instructions." The section stated Patient #3 pulled his PICC line out. Another section stated "Less restrictive intervention used/considered that are ineffective [were] re-orientation, verbal reminders [and] Diversional activities." A comprehensive assessment of Patient #3's need for restraint was not documented.

A nursing progress note on 7/29/14 at 12:36 PM, stated Patient #3 was sitting up in bed with his daughter at the bedside. The note stated "Restraints are off with family at bedside." An assessment of the need for restraints at this time was not documented. It appeared the restraints were not reapplied but the time restraints were discontinued was not clearly documented. An order for "sitter to bedside 24 [hours]" was dated 7/29/14 but was not timed.

The DQM was interviewed on 10/29/15 beginning at 1:25 PM. She confirmed the episodes of physical restraints for Patient #3 on 7/29/14. She stated an assessment of the need for restraints was not documented except for the boxes checked on the restraint order forms. She stated the use of less restrictive interventions was not documented except for the checked boxes on the orders. She stated documentation was not present to show specifically when restraints were applied and when they were removed.

The hospital did not conduct a comprehensive assessment for Patient #3 to determine that the risks associated with the use of the restraints were outweighed by the risks of not using the restraints.

2. Patient #1 was an 84 year old male who was admitted to the hospital on 10/23/15. He was currently a patient as of 11/03/15. His diagnoses included stroke with left hemiplegia and diabetes type II.

Patient #1 was observed in bilateral restraints on 10/29/15 at 9:20 AM. He appeared to be sleeping and was not moving. He had a nasogastric tube and a PICC line with IV fluids running.

Bilateral wrist restraint orders for Patient #1 were dated 10/23/15 at 8:30 PM. The "Restraint Order and Flow Record, Medical" order form indicated the restraints were applied at 8:00 PM on that date. The form included checked boxes stating "Reason for Restraint Use...Pulling at tubing/dressing [and] Unable to follow safety instructions." Another section stated "Less restrictive intervention used/considered that are ineffective [were] Pain relief/comfort measures...Environmental modifications...Visual Supervision [and] Medication/Sedation."

A comprehensive assessment of Patient #1's need for restraint was not documented. The "Nursing ICU Admission Assessment," dated 10/23/15 at 7:35 PM, stated Patient #3 was non-verbal and had "Light sedation (Briefly awakens with eye contact to voice less than 10 seconds)." The assessment also stated he responded "...only to painful stimuli." The assessment did not contain any information that Patient #3 required restraints.

The History and Physical, dated 10/24/15 at 8:43 AM, stated Patient #1 was not moving his left arm but said he did move his right leg. Restraints and the need for them were not documented.

Further restraint orders for Patient #1 were documented on 10/24/15 at 7:00 AM, 10/27/15 at 7:00 AM, and 10/28/15 when no time was documented. The record showed Patient #1 was restrained on these dates.

There was no documentation Patient #1 was restrained on 10/25/15 or 10/26/15. An assessment indicating Patient #1 required restraints on 10/27/15 and 10/28/15 was not documented.

Daily provider progress notes dated 10/25/15 - 10/29/15 did not mention restraints.

Except for checked boxes, only 1 nursing progress note addressed restraints. A "Patient Care Note" by the RN, dated 10/29/15 at 12:46 AM, stated "Pulls at gown tubings and anything placed in his hands. Remains restrained bilateral hands at this time."

The RN caring for Patient #1 was interviewed on 10/29/15 beginning at 10:15 AM. He stated Patient #1 occasionally pulled at tubes but stated these were not purposeful movements. He stated since Patient #1's movements were not purposeful, mitts instead of restraints might be sufficient to protect the tubes.

After observing Patient #1, his medical record was reviewed with the CCO on 10/29/15 beginning at 9:20 AM. She confirmed the documentation and stated a comprehensive assessment of the need for restraints was not included in Patient #1's medical record.

The hospital did not conduct a comprehensive assessment for Patient #1 to determine that the risks associated with the use of the restraints was outweighed by the risks of not using the restraints.

Based on observation, staff interview, and review of medical records, it was determined the hospital failed to ensure the least restrictive restraint was used to protect 1 of 3 restrained patients (#1) from harm. This resulted in a patient's ability to move being more restricted than necessary. Findings include:

Patient #1 was an 84 year old male who was admitted to the hospital on 10/23/15. He was currently a patient as of 11/03/15. His diagnoses included stroke with left hemiplegia and diabetes type II.

Patient #1 was observed in bilateral restraints on 10/29/15 at 9:20 AM. He appeared to be sleeping and was not moving. He had a nasogastric tube and a PICC line with IV fluids running.

The "Restraint Order and Flow Record, Medical" order form stated bilateral wrist restraints were applied at 8:00 PM on 10/23/15. The form included checked boxes stating "Reason for Restraint Use...Pulling at tubing/dressing [and] Unable to follow safety instructions."

A comprehensive assessment including the type of restraints needed to protect Patient #1 was not documented. The "Nursing ICU Admission Assessment," dated 10/23/15 at 7:35 PM, stated Patient #3 was non-verbal and had "Light sedation (Briefly awakens with eye contact to voice less than 10 seconds)." The assessment also stated he responded "...only to painful stimuli." The assessment did not contain any information that Patient #3 required restraints.

Further restraint orders for Patient #1 were documented on 10/24/15 at 7:00 AM, 10/27/15 at 7:00 AM, and 10/28/15 when no time was documented. The record showed Patient #1 was restrained on these dates.

After observing Patient #1, his medical record was reviewed with the CCO on 10/29/15 beginning at 9:20 AM. She confirmed the documentation and stated a comprehensive assessment including the type of restraints needed to protect Patient #1 was not included in his medical record.

The RN caring for Patient #1 was interviewed on 10/29/15 beginning at 10:15 AM. He stated Patient #1 occasionally pulled at tubes but stated these were not purposeful movements. He stated since Patient #1's movements were not purposeful, mitts instead of restraints might be sufficient to protect the tubes.

The hospital did not conduct a comprehensive assessment for Patient #1 to determine that the least restrictive restraints were used.

Based on observation, staff interview, and review of medical records, it was determined the hospital failed to ensure less restrictive interventions were clearly documented prior to the use of restraints for 2 of 3 patients (#1 and #3) reviewed, for whom restraints were used. This resulted in the inability of the hospital to justify the use of restraints. Findings include:

1. Patient #3 was an 81 year old male admitted to the hospital on 7/15/14 and discharged on 8/14/14. His diagnoses included a history of aortic valve replacement in February 2014 and prostate surgery in June 2014. He developed an infection and was admitted to the hospital for long term IV antibiotic therapy. Other diagnoses included protein calorie malnutrition and dementia.

A "Restraint Order and Flow Record, Medical" form stated bilateral wrist restraints were ordered for Patient #3. The time they were applied was not documented but the form stated the physician was notified of their use at 9:47 AM on 7/23/14. The form included checked boxes stating "Less restrictive interventions used/considered that are ineffective [were] Pain relief/comfort measures...re-orientation, verbal reminders [and] Limit setting."

A nursing shift assessment report by the RN, dated 7/23/14 at 9:30 AM, stated Patient #3 had bladder pain and was medicated and repositioned. The report stated "in the absence of patient self report, nursing assessment of possible pain-Nonverbal sounds (crying, gasping, moaning, or groaning) Vocal complaints of pain (e.g.. that hurts, ouch stop) Protective movements or postures." The report did not state which of these behaviors Patient #3 exhibited.

RN Patient Care Notes dated 7/23/14 at 4:22 AM stated Patient #3 had been transferred to a local emergency department and returned to the hospital at that time with a continuous bladder irrigation. The note stated Patient #3 was "...anxious and irritable reporting pain and discomfort. A PRN Norco was given." The next nursing note documenting his behavior was dated 7/24/14 at 5:38 PM. No nursing notes specifically addressed the other less restrictive interventions including "...re-orientation, verbal reminders [and] Limit setting." In addition, verbal reminders and limit setting were not defined.

A progress note by the NP and authenticated by the physician, was dated 7/23/15 at 4:09 PM. The note did not mention restraints or less restrictive measures.

A "Restraint Order and Flow Record, Medical" form, dated 7/24/14 was signed by Patient #3's physician on 7/24/15 but was not timed. The form continued the order for wrist restraints. The form included checked boxes stating "Less restrictive intervention used/considered that are ineffective [were] Pain relief/comfort measures...Environmental modifications...re-orientation, verbal reminders...Diversional activities [and] Limit setting." None of the checked boxes were explained. Again, less restrictive measures were not defined and specifics were not documented.

The DQM was interviewed on 10/29/15 beginning at 1:25 PM. She stated the use of less restrictive interventions was not documented except for the checked boxes on the orders.

The hospital did not document less restrictive interventions than restraints for Patient #3.

2. Patient #1 was an 84 year old male who was admitted to the hospital on 10/23/15. He was currently a patient as of 11/03/15. His diagnoses included stroke with left hemiplegia and diabetes type II.

Patient #1 was observed in bilateral restraints on 10/29/15 at 9:20 AM. He appeared to be sleeping and was not moving. He had a nasogastric tube and a PICC line with IV fluids running.

Bilateral wrist restraint orders for Patient #1 were dated 10/23/15 at 8:30 PM. The "Restraint Order and Flow Record, Medical" order form indicated the restraints were applied at 8:00 PM on that date. The form included checked boxes stating "Reason for Restraint Use...Pulling at tubing/dressing [and] Unable to follow safety instructions." Another section stated "Less restrictive intervention used/considered that are ineffective [were] Pain relief/comfort measures...Environmental modifications...Visual Supervision [and] Medication/Sedation."

A comprehensive assessment of Patient #1's need for restraint was not documented. A Nursing Admission Assessment, dated 10/23/15 at 7:35 PM stated Patient #1's "Best motor response" was "Purposeful movement to painful stimuli." The assessment also stated his neurological status was "Light sedation (Briefly awakens with eye contact to voice, less than 10 seconds)." No RN Patient Care Notes dated 10/23/15 documented specific less restrictive interventions. The "Less restrictive interventions used/considered that are ineffective" noted above were not defined.

The History and Physical, dated 10/24/15 at 8:43 AM, stated Patient #1 was not moving his left arm but said he did move his right leg. Restraints and less restrictive interventions were not documented.

Further restraint orders for Patient #1 were documented on 10/24/15 at 7:00 AM. The order form stated "Less restrictive intervention used/considered that are ineffective [were] Pain relief/comfort measures...Environmental modifications...Visual Supervision [and] Medication/Sedation." These less restrictive measures were not defined in Patient #1's medical record.

After observing the Patient #1, his medical record was reviewed with the CCO on 10/29/15 beginning at 9:20 AM. Except for the order forms, she stated less restrictive interventions were not documented.

The hospital did not document less restrictive interventions than restraints for Patient #1.

Based on observation, staff interview, and review of medical records, it was determined the hospital failed to ensure 2 of 3 restrained patients' medical records (#1 and #3) contained documentation of their response to the restraints and the rationale for the continued use of those restraints. This resulted in the inability of the hospital evaluate the efficacy of the restraint use. Findings include:

1. Patient #3 was an 81 year old male admitted to the hospital on 7/15/14 and discharged on 8/14/14. His diagnoses included a history of aortic valve replacement in February 2014 and prostate surgery in June 2014. He developed an infection and was admitted to the hospital for long term IV antibiotic therapy.

A "Restraint Order and Flow Record, Medical" form stated bilateral wrist restraints were ordered for Patient #3. The time they were applied was not documented but the form stated the physician was notified of their use at 9:47 AM on 7/23/14. The form included checked boxes stating "Reason for Restraint Use...Pulling at tubing/dressing [and] Unable to follow safety instructions." A comprehensive assessment of Patient #3's need for restraint was not documented.

A "Restraint Order and Flow Record, Medical" form, dated 7/24/14 was signed by Patient #3's physician on 7/24/15 but was not timed. The form continued the order for wrist restraints. The form included checked boxes stating "Reason for Restraint Use...Pulling at tubing/dressing [and] Unable to follow safety instructions." Another section stated "Less restrictive intervention used/considered that are ineffective [were] Pain relief/comfort measures...Environmental modifications...re-orientation, verbal reminders...Diversional activities [and] Limit setting." None of the checked boxes were explained. A comprehensive assessment of Patient #3's need for continued restraint was not documented.

Patient #3's record contained another progress note by the NP and authenticated by the physician, dated 7/24/15 at 4:39 PM. This note did not mention restraints.

At some point on 9/24/14 or 9/25/14, Patient #3's restraints were discontinued. The record did not document when this took place and did not contain an assessment stating restraints were no longer needed. Nursing notes did not include Patient #3's response to the restraints. Nursing notes also did not include assessments that justified the continued use of restraints.

The DQM was interviewed on 10/29/15 beginning at 1:25 PM. She confirmed the episodes of physical restraints for Patient #3. She stated except for the boxes checked on the daily restraint order forms, the justification for the continued use of restraints for Patient #3 and his response to the restraints was not documented in nursing or provider notes.

The hospital did not document Patient #3's response to restraints or the rationale for the continuation of restraints.

2. Patient #1 was an 84 year old male who was admitted to the hospital on 10/23/15. He was currently a patient as of 11/03/15. His diagnoses included stroke with left hemiplegia and diabetes type II.

Patient #1 was observed in bilateral restraints on 10/29/15 at 9:20 AM. He appeared to be sleeping and was not moving. He had a nasogastric tube and a PICC line with IV fluids running.

Bilateral wrist restraint orders for Patient #1 were dated 10/23/15 at 8:30 PM. The "Restraint Order and Flow Record, Medical" order form indicated the restraints were applied at 8:00 PM on that date.

A comprehensive assessment of Patient #1's need for restraint was not documented. The "Nursing ICU Admission Assessment," dated 10/23/15 at 7:35 PM, stated Patient #3 was non-verbal and had "Light sedation (Briefly awakens with eye contact to voice less than 10 seconds)." The assessment also stated he responded "...only to painful stimuli." The assessment did not contain any information that Patient #3 required restraints.

The History and Physical, dated 10/24/15 at 8:43 AM, stated Patient #1 was not moving his left arm but said he did move his right leg. Restraints and the need for them were not documented.

Further restraint orders for Patient #1 were documented on 10/24/15 at 7:00 AM, 10/27/15 at 7:00 AM, and 10/28/15 when no time was documented. The record showed Patient #1 was restrained on those dates. There was no documentation stating Patient #1's response to restraints or the rationale for the continuation of restraints.

Daily provider progress notes dated 10/25/15 - 10/29/15 did not mention restraints.

Except for checked boxes, only 1 nursing progress note addressed restraints. A "Patient Care Note" by the RN, dated 10/29/15 at 12:46 AM, stated "Pulls at gown tubings and anything placed in his hands. Remains restrained bilateral hands at this time."

After observing Patient #1, his medical record was reviewed with the CCO on 10/29/15 beginning at 9:20 AM. She stated except as noted above, Patient #1's medical record did not document his response to restraints or the rationale for the continuation of restraints.

The hospital did not document Patient #1's response to restraints or the rationale for the continuation of restraints.

Based on medical record review and staff interview, it was determined the facility failed to ensure thorough nursing care plans were developed, and/or followed, for 3 of 8 patients (#2, #5, and #6) whose care plans were reviewed. Lack of a complete care plan and failure to follow care plan interventions had the potential to result in patient care needs that were not addressed and interfered with coordination of patient care among disciplines. Findings include:

1. Patient #5 was a 37 year old female who was admitted to the facility on 9/18/15 for care related to a history of a multidrug-resistant UTI, acute renal failure secondary to sepsis and possible protein calorie malnutrition. She was currently a patient as of 11/03/15. Her diagnoses included dyslipidemia (abnormal amount of lipids in the blood), hypertension, chronic pain, anxiety and depression, osteoarthritis, obstructive sleep apnea and debility. She was morbidly obese, had been intubated prior to arrival at the facility, and on 9/11/15, a tracheotomy was performed. Patient #5 also had wounds on her back, around the buttocks area.

Patient #5's care plan, dated 9/18/15, did not include information related to her skin integrity and/or prevention of further skin breakdown.

Patient #5's record was reviewed with the CCO on 10/30/15, beginning at approximately 9:10 AM. Patient #5's care plan was reviewed. The CCO confirmed a problem related to skin integrity, and/or prevention of further skin breakdown, should have been identified on the care plan, but was not.

The nursing care plan did not thoroughly reflect the individual needs of Patient #5.

2. During an interview on 10/29/15 at 3:30 PM, the CCO stated a dietician completed a nutritional assessment, including dietary orders and a nutritional plan, for every patient in the facility. The CCO said information from the nutritional assessment should then be identified on the nursing care plan, and appropriate interventions should be entered on the care plan and followed by nursing staff.

However, nursing interventions were not consistently documented, as follows:

a. Patient #5's care plan dated 9/18/15, identified a problem related to alteration in nutritional status. Under the problem related to altered nutritional status, there were interventions which included, but were not limited to, monitoring intake of meals, offering supplements if she ate less than 50% of a meal, and dietary supplements or snacks.

A page in Patient #5's EMR, titled "Intakes/Outputs," included daily documentation for fluid intake and consumption of meals and supplements/snacks. There was no documentation of the percentage of dinner consumed or supplements/snacks for 10/26/15, 10/28/15, or 10/2915 and there was no documentation of the percentage of lunch consumed or supplements/snacks for 10/27/15.

Patient #5's record was reviewed with the CCO on 10/30/15, beginning at approximately 9:10 AM. Patient #5's care plan was reviewed. The CCO confirmed documentation of meals and snacks should have been accurately entered each shift, by nursing staff.

b. Patient #2 was an 81 year old female, who was admitted to the hospital on 10/21/15, for care related to encephalopathy (general term describing a disease that affects the function or structure of the brain), UTI with possible urosepsis (septic poisoning resulting from retained and absorbed urinary substances), hypotension and hypoglycemia. Additional diagnoses included diabetes mellitus, hyperlipidemia, dementia, hallucinations, debility and protein calorie malnutrition.

Patient #2's medical record included a document titled, "Nutritional Assessment." The assessment was dated 10/22/15 and identified Patient #2 as at a "...moderate risk due to 30 lb. weight loss in 4 months, need for therapeutic diet..." Also included on the assessment was an order for a 2 gram sodium diet with no concentrated sweets, and a diet plan. The diet plan included orders for snacks 3 times daily, as well as a liquid protein supplement with meals.

Patient #2's care plan, dated 10/21/15, identified a problem related to alteration in nutritional status. Under the problem related to altered nutritional status, there were interventions, which included, but were not limited to, monitoring intake of meals and dietary supplements or snacks.

A page in Patient #2's EMR, titled "Intakes/Outputs," included daily documentation for fluid intake and consumption of meals and supplements/snacks. There was no documentation of the percentage of breakfast or dinner consumed or supplements/snacks for 10/22/15, there was no documentation of the percentage of dinner consumed or supplements/snacks for 10/23/15, 10/27/15, and 10/28/15 and there was no documentation of the percentage of lunch consumed or supplements/snacks for 10/24/15 and 10/25/15.

Patient #2's record was reviewed with the DQM on 10/29/15, beginning at approximately 9:30 AM. She confirmed the care plan was not followed and that documentation of meals and snacks should have been accurately entered each shift by nursing staff.

c. Patient #6 was an 86 year old female admitted to the hospital on 7/22/14, for care related to acute onset, chronic respiratory failure. Other diagnoses included COPD exacerbation, possible CHF exacerbation, community acquired pneumonia, acute renal failure, acute blood loss anemia, hypertension, recent UTI and decubitus ulcer(s) on right foot and right buttock.

Patient #6's medical record included a document titled, "Nutritional Assessment." The assessment was dated 7/24/14 and identified Patient #6 as at "...high nutritional risk due to wounds, need for renal/ADA diet, edema..." Also included on the assessment was an order for a renal diet, and a diet plan. The diet plan included orders for a liquid, protein supplement 3 times daily.

Patient #6's care plan, dated 7/22/14, identified a problem related to alteration in nutritional status. Under the problem related to altered nutritional status, there were interventions, which included, but were not limited to, monitoring intake of meals and dietary supplements or snacks.

A page in Patient #6's EMR, titled "Intakes/Outputs," included daily documentation for fluid intake and consumption of meals and supplements/snacks. There was no documentation of the percentage of breakfast, lunch or supper consumed, and no documentation of protein supplement on 8/01/14, there was no documentation of the percentage of breakfast consumed for 7/25/14, there was no documentation of the percentage of dinner consumed on 7/28/14, 7/31/14, 8/02/14, and 8/03/14, there was no documentation for the protein supplement for 7/25/14, 7/28/14, and 8/03/14.

Patient #6's record was reviewed with the CCO on 11/02/15, beginning at approximately 1:30 PM. She confirmed the care plan was not followed and that documentation of meals and supplements should have been accurately entered each shift by nursing staff.

The hospital failed to ensure documentation of nursing interventions was completed.