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Based on document review and interview, the facility failed to follow its policy for restraint and seclusion and ensure documentation indicating a Face-to-Face evaluation was performed within 1 hour of initiating the restraint intervention for 3 of 9 MR (medical records) reviewed (patients #5, 6 & 7).

Findings include:

1. Review of the policy/procedure Restraint and Seclusion (approved 2-18) indicated the following: "When restraint is used for the management of violent or self-destructive behavior, a Face-to-Face evaluation is required ... The patient must be seen face-to-face within one (1) hour after the initiation of the intervention, to justify continuation of the intervention, by a physician, or a second RN who is qualified via training to evaluate the patients: (1) Immediate situation (2) Reaction to the intervention (3) Medical and behavioral condition (4) Need to continue or terminate the restraint."

2. Review of the MR for Patient #5 on 1-7-18 at 1245 hours indicated 4 point restraints were initiated for violent behavior and no MR documentation indicated a face-to-face evaluation was performed within 1 hour of initiating the restraint intervention.

3. On 5-23-18 at 1350 hours, the ED Manager, staff A3 and the Quality and Accreditation Specialist, staff A4 confirmed the MR for Patient #5 lacked documentation indicating a 1 hour Face-to-Face evaluation was performed by a Physician or qualified RN.

4. Review of the MR for Patient #6 on 3-2-18 at 0731 hours indicated 4 point restraints were initiated for violent behavior and no MR documentation indicated a face-to-face evaluation was performed within 1 hour of initiating the restraint intervention.

5. On 5-23-18 at 1513 hours, staff A3 and staff A4 confirmed the MR for Patient #6 lacked documentation indicating a 1 hour Face-to-Face evaluation was performed by a Physician or qualified RN.

6. Review of the MR for Patient #7 on 1-8-18 at 1659 hours indicated 4 point restraints were initiated for violent behavior and no MR documentation indicated a face-to-face evaluation was performed within 1 hour of initiating the restraint intervention.

7. On 5-23-18 at 1557 hours, staff A3 and staff A4 confirmed the MR for Patient #7 lacked documentation indicating a 1 hour Face-to-Face evaluation was performed by a Physician or qualified RN.

Based upon document review and interview, the ED (Emergency Department) nursing staff failed to follow their policy/procedures and maintain documentation of vital signs at least hourly for 3 of 9 medical records (MR) reviewed (Patients #5, 6 & 7).

Findings include:

1. Review of the policy/procedure Emergency Nursing Standards of Practice (approved 2-18) indicated the following: "Fundamental Emergency Department nursing interventions include, but are not limited to the following: a. Vital signs every 30 minutes on Level I & Level II patients, unless ordered more frequently; b. Vital signs every (1) hour on Level III, IV, and V patients, unless ordered more frequently..."

2. Review of the MR for Patient #5 on 1-7-18 at 1224 hours indicated a triage level of III and indicated vital signs were assessed at 1220, 1537 and 1837 hours.

3. On 5-23-18 at 1350 hours, The ED Manager, staff A3 and the Quality and Risk Analyst, staff A4 confirmed the MR for Patient #5 lacked documentation indicating vital signs were obtained at least hourly.

4. Review of the MR for Patient #6 on 3-1-18 at 2218 hours indicated a triage level of II and indicated vital signs were assessed on 3-1-18 at 2218 and 2245 hours and on 3-2-18 at 0118 and 0540 hours and no additional vital signs were documented prior to departing the ED at 1414 hours.

5. On 5-23-18 at 1513 hours, staff A3 and staff A4 confirmed the MR for Patient #6 lacked documentation indicating vital signs were obtained at least every 30 minutes as per policy.

6. Review of the MR for Patient #7 on 1-8-18 at 1624 hours indicated a triage level of II and indicated vital signs were assessed at 1624 hours and no additional vital signs were documented prior to discharge at 2008 hours.

7. On 5-23-18 at 1557 hours, staff A3 and staff A4 confirmed the MR for Patient #7 lacked documentation indicating vital signs were obtained at least every 30 minutes as per policy.