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Based on interview and record review the facility failed to ensure that staff were following the safety policies for restraints as evidenced by the lack of safety rounds documentation in 2 of 10 patients , 9 out of 9 days for (Patient #2 and #3).

Findings:
Record Review of Patient #2 on 4/16/2019 at 1150 revealed that patient #2 did not have the restraint flow sheet for safety rounds on 5/7/19, 5/8/19, 5/9/19, 5/10/19, 5/11/19, 5/12/19, 5/13/19, 5/14/19, and 5/15/19.

Record Review of Patient #3 on 5/15/2019 at 1420 revealed that patient #3 did not have the restraint flow sheet for safety rounds on 5/7/19, 5/8/19, 5/9/19, 5/10/19, 5/11/19, 5/12/19, 5/13/19, 5/14/19, and 5/15/19.

Record Review on 5/16/2019 of Restraint Reduction Plan, Policy #CL-6.0 revised 5/2016.
Orders for Restraint for Violent or Self-Destructive Behavior Beyond 24 Hours
At a minimum, if a patient remains in restraint or seclusion for the management of violent or self-destructive behavior 24 hours after the original order, the physician or other LIP must see the patient and conduct a face-to-face re-evaluation before writing a new order for the continued use of restraint or seclusion.

When the physician or other LIP renews an order or writes a new order authorizing the continued use of restraint, there must be documentation in the patient's medical record that describes the findings of the physician's or other LIP's re-evaluation supporting the continued use of restraint.

ONGOING MONITORING & ASSESSMENT OF A PATIENT IN RESTRAINT
Determining the necessary frequency of assessment and monitoring should be individualized to the patient, 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.
Monitoring a Patient in Restraint
Monitoring means that the patient will be seen to determine if the use of restraint continues to be safely applied, and if there appears to be a need for an assessment of the patient to occur.

Minimum Frequency of Monitoring of a Patient in Restraint
Patients placed in restraint for safety, non-violent, and non-destructive behavior should be monitored at least every two hours.

Interview on 5/15/2019 at 1505 with the Chief Nursing Officer revealed that she was unaware that they had no restraint documentation for safety rounds. CNO Stated, "No, I thought they were using them".

Based on interview and record review the facility failed to ensure that a doctors order was present on 2 of 3 patients who had restraints (patient #2 and #3).

Findings:

Record review of patient #2 revealed that a request for restraints was made on 5/7/2019 and 5/11/2019 by the charge nurse (Name of nurses illegible). The order for restraints lacked a doctor's or Licensed Practitioner signature giving consent that the restraint was required for the patient.

Record review of patient #3 revealed that a request for restraints was made on 5/9/2019 by the charge nurse (Name of nurses illegible). The order for restraints lacked a doctor's or Licensed Practitioner signature giving consent that the restraint was required for the patient.

Record Review on 5/16/2019 of Restraint Reduction Plan, Policy #CL-6.0 revised
PURPOSE:
To define Cornerstone Hospitals' (hereinafter referred to as the "organization") policy regarding the restraint of a patient

Orders for Restraint for Violent or Self-Destructive Behavior Beyond 24 Hours
At a minimum, if a patient remains in restraint or seclusion for the management of violent or self-destructive behavior 24 hours after the original order, the physician or other LIP must see the patient and conduct a face-to-face re-evaluation before writing a new order for the continued use of restraint or seclusion.

Interview with the Chief Nursing Officer on 5/16/19 at 1445 acknowledged that a doctors order for a restraint should be present within an hour of application of a restraint. The CNO was then requested to read the nurses signature on the chart. The CNO stated "I do not Know" I can't read it, its illegible.

Based on Record Review the facility failed to ensure that an RN was documenting the patient's pre and post administraion assessments on 1 of 10 patients, (3 out of 3 times) (patient #1).

Findings:
Record Review of the patient's (Patient #1) medical chart (Medication Administration Record) revealed the following Morphine administrations:
DATE TIME MORPHINE 2 MILLIGRAMS
5-10-2019 0950 MORPHINE 2 MILLIGRAMS nurse unknown illegible signature
5-10-2019 2300 MORPHINE 2 MILLIGRAMS nurse unknown illegible signature
5-11-2019 2130 MORPHINE 2 MILLIGRAMS nurse unknown illegible signature
5-13-2019 DISCONTINUED

No pre or post assessments for pain were completed on 3 of 3 administrations of pain medication on patient #1. No reason for pain medication administrations were documented.

Interview with Chief Nursing Officer on 3/15/2019 at 1315 revealed that a patient needs to be assessed pre and post pain medication administration. It also need to be documented in the patient's medical record.

Cornerstone Specialty Hospital Pain Management Protocol Policy 3# CL-2.6 dated 5/2016 specifies the following:
Purpose:
1. To implement a pain assessment and reassessment process that focuses on appropriate identification and management of pain.
2. To provide a mechanism that is directed at fostering the patient's comfort and dignity thereby reducing the incidence and severity of the patient's pain. To promote optimal comfort of the patient.
3. To educate the patient and their families regarding pain management.

Documentation:
1. All pain treatment and interventions, including notification of physicians of patient's pain condition and recommendations for referral to a pain consultant.
2. Documentation of pain for all patients includes:
a. Type of pain
b. Location
c. Intensity scale
d. Activity if related
e. Side effects of treatment if any
f. Any changes in level of consciousness
g. Medication
h. Patient and family education
i. Treatment goal
j. Vital signs

Reassessment:
1. Reassessment should occur with each new report of pain, at a suitable interval following any pain control intervention ....
2. The patient will be reassessed for pain:
a. One=half hour to one hour after administration of pain control treatment.
b. Every shift and as needed
c. With any change in level of care
d. After pain management techniques

Based on interview and record review, the facility failed to ensure that the correct patient information was in the correct medical file on 4 of 10 patients (#1,2,3,4).

Findings:
Record Review of Patient #1 medical chart on 5/16/2019 at 1340 revealed the following patient information for patient (#3) was placed in the lower right corner of a Skin Assessment Sheet, that had patient #1's name written in a patient ID tag with a picture of the decubitus. The document was in patient #1's medical chart.

Record Review of Patient #1's medical chart on 5/16/2019 at 1330 revealed the following patient information (Patient #4's) nursing notes were in patient #1's medical chart.

Interview with CNO on 5/16/2019 at 1445. The CNO was approached with the charts to confirm the following documentation errors:
1. Illegible signatures
2. Lack of restraint flow sheets indicating observation and release
3. Lack of turning and positioning every 2 hours
4. Lack of doctors' orders for restraints
5. Lack of skin assessments by RN
6. The wrong patient records in the wrong chart
The CNO verbally acknowledged that these items are missing from the charts and that she became aware of these deficits after the last survey 2 weeks prior. She indicated that she is in the process of educating the staff and monitoring for compliance.

Interview with Quality Manager on 5/16/2019 at 1515. revealed that the wrong patient's name was on another patient's information then placed in the wrong chart. she said she was sorry and will address this issue.