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Based on document review and interview, the hospital failed to ensure the use of restraint was implemented in accordance with safe and appropriate restraint techniques as determined by hospital policy for 1 of 1 patients (P2) who was restrained in the Emergency Department (ED).

Findings include:

1. Review of the policy titled Restraints and Seclusion, Last Revised: 7/13/21, indicated the following for Violent Restraint:
Monitoring Includes:
a. Patient Safety - Based on the restraint employed, monitoring includes but is not limited to, breathing, circulation, distress and injury.
b. Patient Comfort - Providing comfort includes but is not limited to patient need for food, hydration, toileting, range of motion, repositioning and other comfort measures.
c. Decision to Continue or Discontinue - The need for continued restraint use is determined by assess the presence or absence of the circumstance triggering the restraint use...
d. Minimum documentation of on-going monitoring Violent Restraint:
i. Every fifteen (15) minutes a team member documents elements focused on Patient Safety.
ii. Every one (1) hour a team member documents the above elements and additional Patient Comfort elements.
iii. Every one (1) hour RN (Registered Nurse) assigned to the patient documents decision to continue or discontinue.

2. The MR of patient P2 indicated the patient was restrained for violent behavior as follows: On 10/21/21, at 1450 hours: The patient was held down by security and two RNs. Medication was given and the patient was put in bed in restraints. Restraint information was documented as follows: Initiation Time: 10/21/21 at 1307 hours, documented on 10/21/21 at 1507 hours. Device (types and locations): Locking limb (double locking) bilateral wrists and bilateral ankles. The MR lacked documentation of Violent Restraint monitoring to include assessment of patient safety every 15 minutes between 1307 hours and 1507 hours. The MR lacked documentation of 1 hours patient comfort assessment and 1 hour continuation decision making between 1307 hours and 1645 hours.

3. On 11/10/21, beginning at approximately 4:00 PM, A7, Clinical Nurse Specialist/Behavioral Health, verified the MR of patient P2 lacked documentation of monitoring as per hospital policy.

Based on document review and interview, the hospital failed to ensure an order for restraint was obtained for 1 of 1 patients (P2) restrained in the Emergency Department (ED)

Findings include:

1. Review of the policy titled Restraints and Seclusion, Last Revised: 7/13/21, indicated the following for Obtain/Provide and Order - Violent Restraint: A restraint order must be obtained from a LIP (Licesnsed Independent Practitioner) immediately prior to or within 30 minutes of initiating restraints or seclusion.

2. The MR of patient P2 indicated the patient was restrained for violent behavior as follows: On 10/21/21, at 1450 hours: The patient was held down by security and two RNs. Medication was given and the patient was put in bed in restraints. Restraint information was documented as follows: Initiation Time: 10/21/21 at 1307 hours, documented on 10/21/21 at 1507 hours. Device (types and locations): Locking limb (double locking) bilateral wrists and bilateral ankles. The MR lacked documentation of an order for mechanical/physical restraint(s).

3. On 11/10/21, beginning at approximately 4:00 PM, A7, Clinical Nurse Specialist/Behavioral Health, verified the MR of patient P2 lacked documentation of an order for the physical and/or mechanical restraints.

Based on document review and interview, the hospital failed to maintain an accurately written medical record (MR) by failing to ensure triage medication lists were current for the date of visit in the Emergency Department (ED) for 2 of 10 patients (P4 and P6).

Findings include:

1. Medical record review:
a. Accuracy of the MR of patient P4, admitted to ED 10/20/21 and discharged from ED 10/21/21, could not be determined due to variances in the triage Medical History. The Medical History, indicated to be "from Previous Visits", included medications with dates beyond the ED encounter as follows: Medication List. Normal Order: amantadine, Date: 11/9/21; quetiapine, Date: 11/9/21; Adderall, Date: 11/9/21. Prescription/Discharge Order: Adderall, Date: 10/27/21; melatonin. Date: 10/27/21. Home Meds (medications): atomoxetine, Date: 10/22/21. The MR lacked documentation of a current medication list for 10/20/21.

b. Accuracy of the MR of patient P6, admitted unconscious to the ED 8/18/21 and discharged from ED 8/18/21, could not be determined due to variances in the triage Medical History. The Medical History, included medications with dates beyond the ED encounter as follows: Medication List. Prescription/Discharge Order: azithroycin, Date: 11/9/21. Home Meds: sertraline, Date: 11/9/21; ethinyl estraradiol-norethindrone, Date: 11/9/21. The MR lacked documentation of a current medication list for 8/18/21.

2. On 11/10/21, beginning at approximately 2:00 PM, A5, RN Quality, verified MR findings.