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Based on policy review, medical record review, and staff interview, the facility failed to ensure a physician order was obtained for non-violent restraints according to policy and procedure (A168). The facility failed to ensure restrained patients were monitored per policy (A175).

Based on policy review, medical record review, and staff interview, the facility failed to ensure a physician order was obtained for non-violent restraints according to policy and procedure for three of three medical records reviewed with restraints (Patient #1, #2, and #6). A total of ten medical records were reviewed. The facility census was 649.

Findings include:

Review of the policy titled, "CP-52 - Use of Restraints and Seclusion," revised October 2022, revealed restraints were used with a physician's order and at least every calendar day a new written restraint order must be obtained or the the restraint must be discontinued. Restraint orders must not exceed a calendar day for each order. When a restraint was discontinued then the restraint episode would end and a new restraint order must be obtained prior to reinitiating a new restraint episode.

1. Review of the medical record for Patient #1 revealed bilateral soft wrist restraints were applied on 02/04/23 at 12:20 AM and remained in place until they were discontinued on 02/07/23 at 1:26 PM. The medical record contained restraint orders dated 02/04/23 at 12:01 AM, 02/06/23 at 12:01 AM, and 02/06/23 at 6:05 PM. The medical record lacked documentation of a physician order for restraints on 02/05/23 and 02/07/23. The findings were verified in an interview with Staff A and B on 02/16/23 at 1:38 PM.

2. Review of the medical record for Patient #2 revealed bilateral soft wrist restraints were applied on 01/13/23 at 6:40 AM and discontinued on 01/17/23 at 11:16 AM. On 01/18/23 at 8:00 PM restraints were applied and discontinued on 02/07/23 at 10:30 AM. The medical record contained orders for restraints dated 01/13/23 at 6:30 AM, 01/15/23 at 12:01 AM, 01/17/23 at 12:00 AM, 01/19/23 at 12:00 AM, 01/20/23 at 12:00 AM, 01/22/23 at 12:00 AM, 01/24/23 at 12:01 AM, 01/26/23 at 12:01 AM, 01/28/23 at 7:00 PM, 01/30/23 at 12:01 AM, 01/31/23 at 12:00 AM, 02/01/23 at 4:19 PM, 02/03/23 at 12:01 AM, 02/04/23 at 2:53 AM, and 02/06/23 at 1:30 AM. The medical record lacked documentation of restraint orders dated 01/14/23, 01/16/23, 01/18/23, 01/21/23, 01/23/23, 01/25/23, 01/27/23, 01/29/23, 02/02/23, 02/05/23, and 02/07/23. The findings were verified in an interview with Staff A on 02/21/23 at 11:20 AM.

3. Review of the medical record for Patient #6 revealed bilateral soft wrist restraints were applied on 02/13/23 at 4:00 AM and were still in place on 02/21/23. The medical record contained orders for restraints dated 02/13/23 at 4:00 AM, 02/15/23 at 12:00 AM, 02/17/23 at 12:01 AM, 02/19/23 at 12:01 AM, and 02/21/23 at 12:00 AM. The medical record lacked documentation of restraint orders dated 02/14/23, 02/16/23, 02/18/23, and 02/20/23. The findings were verified in an interview with Staff A on 02/21/23 at 12:10 PM.

Based on policy review, medical record review, and staff interview, the facility failed to ensure restrained patients were monitored per policy for two of three medical records reviewed with restraints (Patient #2 and #6). A total of ten medical records were reviewed. The facility census was 649.

Findings include:

Review of the policy titled, "CP-52 - Use of Restraints and Seclusion," revised October 2022, revealed restraint assessment and monitoring must be documented every two hours.

1. Review of the medical record for Patient #2 revealed bilateral soft wrist restraints were applied on 01/13/23 at 6:40 AM and discontinued on 01/17/23 at 11:16 AM. On 01/18/23 at 8:00 PM restraints were re-applied and discontinued on 02/07/23 at 10:30 AM. The medical record lacked documentation of every two hour assessment and monitoring on 01/15/23 from 4:00 PM to 8:00 PM, on 01/19/23 from 8:00 PM to 01/20/23 at 12:00 AM, on 01/20/23 at 10:00 PM to 01/21/23 at 7:45 AM, on 01/23/23 at 8:00 PM to 01/24/23 at 12:00 AM, on 01/27/23 from 6:00 AM to 6:00 PM, on 01/28/23 from 7:00 AM to 5:00 PM, on 01/29 from 3:00 AM to 7:00 PM, on 01/29/23 from 11:00 PM to 01/30/23 at 7:00 AM, on 02/01/23 from 5:00 AM to 8:44 PM, on 02/02/23 from 8:04 AM to 9:30 PM, on 02/03/23 from 3:00 AM to 8:06 AM, on 02/04/23 from 7:00 AM to 7:00 PM, on 02/05/23 from 7:00 AM to 7:30 PM, and on 02/05/23 from 9:00 PM to 02/06/23 at 1:00 AM. The medical record lacked documentation restraints were discontinued for any of the above times. The findings were verified in an interview with Staff A on 02/21/23 at 11:20 AM.

2. Review of the medical record for Patient #6 revealed bilateral soft wrist restraints were applied on 02/13/23 at 4:00 AM and were still in place on 02/21/23. The medical record lacked documentation of every two hour assessment and monitoring on 02/14/23 from 4:00 PM to 8:00 PM, on 02/15/23 from 4:00 PM to 8:00 PM, on 02/16/23 from 4:00 AM to 8:00 AM, on 02/17/23 from 4:00 AM to 8:00 AM, on 02/17/23 from 12:00 PM to 02/18/23 at 8:00 AM, and on 02/19/23 from 3:00 PM to 8:00 PM. The medical record lacked documentation restraints were discontinued for any of the above times. The findings were verified in an interview with Staff A on 02/21/23 at 12:10 PM.