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Based on document review and interview, it was determined that in 2 of 3 (Pt #1 and 2) clinical records reviewed of patients that were restrained while in the Emergency Department (ED), the Hospital failed to ensure continuous 1 to 1 monitoring, as required.

Findings include:

1. Hospital policy entitled, "Restraints and/or Seclusion: Behavioral Emergencies," (dated August 2013) required, "Assessment and Monitoring: 3...Continuous observation by a staff member located near the patient. 4. Continuous 1:1 observation may be delegated ...however the registered nurse is responsible for assessing the behavior and need for continued restraint. 8. A staff member must remain with the patient in restraints/seclusion at all times..."

2. The clinical record of Pt #1 was reviewed on 2/4/15 at approximately 10:00 AM. Pt #1 was a 33 year old female who presented to the Hospital's ED on 12/14/14 for a psychiatric evaluation. Nursing documentation included that Pt #1 was in a restraint device on 12/14/14 from 2:00 PM until 6:44 PM; 12/15/14 from 6:00 AM until 8:30 AM; and from 11:45 AM until 11:45 PM without documentation of continuous 1:1 monitoring.

3. The clinical record of Pt #2 was reviewed on 2/5/15. Pt #2 was a 54 year old male that was brought to the Hospital's ED on 12/14/14 at 6:30 PM for a psychiatric evaluation. Pt #2 was triaged as a category 2. Nursing documentation included, "anxious, inappropriate, verbally abusive, combative..." Clinical documentation included Pt #2 was placed in 4 point restraints on 12/15 15 from 8:00 AM until 10:30 AM and from 2:40 AM until 10:10 PM without documentation of 1:1 monitoring.

4. The Director of Nursing stated during interviews on 2/3/15 at approximately 11:00 AM and 2/5/15 at 10:30 AM that the clinical records do not contain all the required 1:1 monitoring.

Based on document review and interview, it was determined that in 2 of 3 (Pt #1 and 2) clinical records reviewed of patients that were restrained while the Emergency Department (ED), the Hospital failed to ensure physicians' orders were received prior to the application of restraint devices.

Findings include:

1. Hospital policy entitled, "Restraints and/or Seclusion: Behavioral Emergencies," (dated August 2013) required, "Initiation: Each episode of restraint or seclusion for the patient shall be initiated: 1. Upon the order of a physician who is responsible for the care of the patient."

2. The clinical record of Pt #1 was reviewed on 2/4/15 at approximately 10:00 AM. Pt #1 was a 33 year old female who presented to the Hospital's ED on 12/14/14 for a psychiatric evaluation. Nursing documentation dated 12/14/14 at 2:00 PM indicated that Pt #1 was placed into 4 point restraints without the receipt of a physician's order. On 12/15/14 at 9:11 AM documentation included: "Security called to restrain Pt." The clinical record lacked a physician's order for the restraint application. On 12/16/14 at 2:00 AM documentation included, "Medicated and placed back in restraints." The clinical record lacked a physician's order for the reapplication of the restraints.

3. The clinical record of Pt #2 was reviewed on 2/5/15. Pt #2 was a 54 year old male that was brought to the Hospital's ED on 12/14/14 at 6:30 PM for a psychiatric evaluation. Pt #2 was triaged as a category 2. Nursing documentation included, "anxious, inappropriate, verbally abusive, combative..."Clinical documentation included Pt #2 was placed in 4 point restraints on 12/15 15 from 8:00 AM until 10:30 AM and from 2:40 PM until 10:10 PM without documentation of physician's orders authorizing the use of the restraints.

4. The Director of Nursing stated during interviews on 2/3/15 a approximately 11:00 AM and 2/5/15 at 10:30 AM that the clinical records do not contain physician's orders for the use of the restraints.

Based on document review and interview, it was determined that in 2 of 3 (Pt #1 and 2) clinical records reviewed of patients that were restrained while in the Emergency Department (ED), the Hospital failed to ensure physicians' orders were received every 4 hours for renewal of restraints, as required.

Findings include:

1. Hospital policy entitled, "Restraints and/or Seclusion: Behavioral Emergencies," (dated August 2013) required, "5. Length of time restraints are to be employed. a. 4 hours for individuals 18 and older...7. Renewal of orders. 1. A new order is obtained from the attending physician/designee if restraints/seclusion requires continuation beyond the expiration ...3. Each order may be renewed by the physician in accordance with the following: a. 4 hours for individuals 18 and older up to a maximum of 8 hours."

2. The clinical record of Pt #1 was reviewed on 2/4/15 at approximately 10:00 AM. Pt #1 was a 33 year old female who presented to the Hospital's ED on 12/14/14 for a psychiatric evaluation. Pt #1's clinical record contained a Restraint Monitoring Flowsheet dated 12/15/14 at 11:45 AM that indicated Pt #1 was in 4 point restraints. Documentation indicated Pt #1 remained in 4 point restraints until 12/15 14 at 7:00 PM, for a total of 8 hours, without a renewal for the restraints.

3. The clinical record of Pt #2 was reviewed on 2/5/15. Pt #2 was a 54 year old male that was brought to the Hospital's ED on 12/14/14 at 6:30 PM for a psychiatric evaluation. Pt #2 was triaged as a category 2. Nursing documentation included, "anxious, inappropriate, verbally abusive, combative..."Clinical documentation included Pt #2 was placed in 4 point restraints on 12/15 15 from 2:40 AM until 10:10 PM (7 hours and 30 minutes) without an renewal order.

4. The Director of Nursing stated during interviews on 2/3/15 a approximately 11:00 AM and 2/5/15 at 10:30 AM that the clinical records do not contain physicians' renewal orders, as required.

Based on document review and interview, it was determined that in 1 of 3 (Pt #1) clinical records reviewed of patients that were restrained while in the Emergency Department (ED), the Hospital failed to ensure the patient was monitored every 15 minutes as required.

Findings include:

1. Hospital policy entitled, "Restraints and/or Seclusion: Behavioral Emergencies," (dated August 2013) required, "Assessment and Monitoring: 2. Regardless of the type of restraint, the following parameters are monitored and documented in the patient record: circulation, skin integrity, removal of restraints with range of motion, hydration needs...Documentation of assessment and monitoring of the patient will be entered in the patient record. 3...continuous monitoring will occur every 15 minutes..4. Continuous 1:1 observation may be delegated ...however the registered nurse is responsible for assessing the behavior and need for continued restraint. 8. A staff member must remain with the patient in restraints/seclusion at all times...10. The following will be completed every 2 hours or more often if clinically appropriate.."

2. The clinical record of Pt #1 was reviewed on 2/4/15 at approximately 10:00 AM. Pt #1 was a 33 year old female who presented to the Hospital's ED on 12/14/14 for a psychiatric evaluation. Nursing documentation dated 12/14/14 at 2:00 PM indicated that Pt #1 was placed into 4 point restraints and remained in the restraints until 6:44 PM. The clinical record lacked the required every 15 minute checks from 2:00 PM until removal at 6:44 PM. Nursing documentation dated 12/16/14 at 2:00 AM indicated Pt #1 became aggressive and was placed back in restraints at 2:00 AM and remained in restraints until 7:00 AM. Pt #1's restraint monitoring flowsheet dated 12/16/14 included every 1 hour monitoring instead of every 15 minute monitoring from 2:00 AM until 7:00 AM.

3. The Director of Nursing stated during an interview on 2/3/15 a approximately 11:00 AM that the clinical record did not contain documentation of all the required 15 minute monitoring.

Based on document review and interview, it was determined that in 2 of 3 (Pt #1 and 2) clinical records reviewed of patients that were restrained while in the Emergency Department (ED), the Hospital failed to ensure a physicians' 1 hour evaluation to determine the appropriateness of the restraint device was needed to manage the patients' aggressive behavior.

Findings include:

1. Hospital policy entitled, "Restraints and/or Seclusion: Behavioral Emergencies," (dated August 2013) required, "4. The evaluation of the patient within 1 hour after initiation of the restraint must include evaluation and documentation of: a. The patients immediate situation. b. The patient's reaction to the intervention. c. The patient's medical and behavioral condition. d. The need to continue or terminate the restraint and/or seclusion."

2. The clinical record of Pt #1 was reviewed on 2/4/15 at approximately 10:00 AM. Pt #1 was a 33 year old female who presented to the Hospital's ED on 12/14/14 for a psychiatric evaluation. Nursing documentation included that on 12/14/14 at 2:00 PM Pt #1 was, "very loud and swearing and trying to leave the ER. Difficult to redirect..." and placed in restraints. At 6:00 AM documentation included, "Patient with increased agitation, delusional with aggressive behavior..." and at 9:11 AM documentation included, "Patient is agitated." On 12/16/14 at 2:00 AM nursing documentation included, "Patient became aggressive and belligerent...". The clinical record lacked documentation of the physician's 1 hour assessments of Pt #1's usage of the restraints to manage her violent and aggressive behavior.

3. The clinical record of Pt #2 was reviewed on 2/5/15. Pt #2 was a 54 year old male that was brought to the Hospital's ED on 12/14/14 at 6:30 PM for a psychiatric evaluation. Pt #2 was triaged as a category 2. Nursing documentation included, "anxious, inappropriate, verbally abusive, combative..."Clinical documentation included Pt #2 was placed in 4 point restraints on 12/15 15 from 8:00 AM until 10:30 AM and from 2:40 AM until 10:10 PM without documentation of 1:1 monitoring. The clinical record lacked documentation of the physician's 1 hour assessments of Pt #2's usage of the restraints to manage his violent and aggressive behavior.

4. The Director of Nursing stated during interviews on 2/3/15 a approximately 11:00 AM and 2/5/15 at 10:30 AM that the clinical records do not contain the physicians' evaluations.