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Based on document review and interview, the hospital failed to ensure that 1 of 10 patient medical records reviewed had the right to be free from restraint imposed as a means for convenience and discipline (P #9). See tag 0154


The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview, the hospital failed to ensure that 1 of 10 patient medical records reviewed had the right to be free from restraint imposed as a means for convenience and discipline (P #9).


Findings include:

1. Review of the policy titled "Seclusion and Restraint Policy", PolicyStat ID 11952429, last revised 06/2022.
Purpose: To ensure the appropriate use of seclusion and restraint.
Application: Restraint or seclusion will only be utilized in an emergency when it is necessary to prevent patients from harming themselves or others.

2. Review of medical records (MR) indicated the following:
MR P#9 indicated an order on 02/17/2023 at approximately 0931 hours from M #1 (psychiatric doctor) to N #1 (Registered Nurse) to shower patient, order for restraint followed on 02/17/2023 at approximately 1605 hours.

3. Incident Report on 02/17/2023 at approximately 1605 hours on unit 2E (two east), reported on 02/17/2023 at approximately 1850 hours by N#1 (Registered Nurse) indicated nurse received verbal order to shower and change patient #9. Patient refused all new clothes that social workers brought to him/her, patient said he/she was not going to shower until he/she had good clothes. Per doctor order, wrist and ankle soft restraints were applied. Patient went limp refusing to walk therefore he/she was carried safely by multiple staff without struggling to the shower. Patient was showered with soap and warm water from head to toe and then dressed in new clothes. Restraints were removed immediately after dressing. Total time in restraints was 20 (twenty) minutes.

4. Interview:
A. On 03/14/2023 beginning at approximately 1345 hours, A2 (Health Information System Director) confirmed order placed on 02/17/2023 at approximately 0931 hours by M #1 for patient #9 to shower; confirmed order on 02/17/2023 at approximately 1605 hours by M1 for behavioral restraint use on patient # 9.

B. On 03/14/2023 at approximately 1400 hours with A1 (Quality Assurance Director), he/she indicated it is not normal practice to restrain patients in order to complete ADLs, patients can refuse to clean themselves.