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Based on interview and record review, the hospital failed to ensure the care plan was updated to reflect the use of violent restraints for one of five sampled patients (Patient 1). This failure created the risk of substandard outcomes for the patient.

Findings:

Review of the hospital's P&P titled the Use of Restraints Including Seclusion dated December 2019 showed the patient's plan of care will be modified as appropriate.

On 10/28/24, an interview and concurrent review of Patient 1's medical record was conducted with the Director of Nursing Quality and Accreditation Coordinator 1. Patient 1's medical record showed the patient visited the ED on 10/17/24, and admitted to the hospital on 10/25/24.

Review of Patient 1's medical record showed the following:

* On 10/17/24 at 1802 hours, the hard restraints for all four extremities were initiated for the patient by the Behavioral Response Team and discontinued by the nursing staff at 2123 hours.

* On 10/22/24 at 0900 hours, the hard restraints for all four extremities were initiated for the patient by the Behavioral Response Team and discontinued by the nursing staff at 1035 hours.

* On 10/23/24 at 1100 hours, the hard restraints for all four extremities were initiated for the patient by the Behavioral Response Team and discontinued by the nursing staff at 1545 hours.

Review of the Plan of Care dated 10/17/24, showed the risk for injury related to the restraints was activated. However, further review of Patient 1's medical record failed to show the patient's care plan was updated to address the use of violent restraints on 10/22 and 10/23/24.

On 10/29/24 at 0951 hours, the Director of Nursing Quality verified the above findings.

Based on interview and record review, the hospital failed to ensure the use of hard restraints was not exceed four hours for one of five sampled patients (Patient 1). This failure posed the risk of substandard outcomes to the patient.

Findings:

Review of the hospital's P&P titled the Use of Restraints Including Seclusion dated December 2019 showed the orders for the restraints and/or seclusions for the patients with violent behavior management needs are limited to four hours for adults (18 years of age and over).

On 10/28/24, an interview and concurrent review of Patient 1's medical record was conducted with the Director of Nursing Quality and Accreditation Coordinator 1. Patient 1's medical record showed Patient 1 visited the ED on 10/17/24, and admitted to the hospital on 10/25/24.

Review of the Restraint Episode showed on 10/23/24, the hard restraints for all four extremities were initiated for Patient 1 by the Behavioral Response Team at 1100 hours and discontinued by the nursing staff at 1545 hours (or four hours and 45 minutes).

On 10/29/24 at 0951 hours, the Director of Nursing Quality verified the above findings.

Based on interview and record review, the hospital failed to ensure the monitoring and assessment were consistently performed as per the hospital's P&P for one of five sampled patients (Patient 1). This failure posed the risk of substandard outcomes to the patient.

Findings:

Review of the hospital's P&P titled the Use of Restraints Including Seclusion dated December 2019 showed the section for Monitoring and Assessment for Restraint or Seclusion for Violent, for direct patient care, the staff are to monitor by observation, interaction, or direct examination upon initiation and as follows:

- Every 15 minutes for signs of any injury to restraint site including restraint type and location; respiratory rate; and behavioral health patient's activity.

- Every two hours or sooner for nutrition and hydration; range of motion and extremity movement; hygiene and elimination; readiness for discontinuation of restraints; physical and psychological well-being including but not limited to mental, respiratory, neurological, circulatory status, and skin integrity.

On 10/28/24, an interview and concurrent review of Patient 1's medical record was conducted with the Director of Nursing Quality and Accreditation Coordinator 1. Patient 1 medical record showed the patient visited the ED on 10/17/24 and was admitted to the hospital on 10/25/24.

1. Review of Patient 1's medical record showed on 10/17/24, the hard restraints for all four extremities were initiated for the patient by the Behavioral Response Team at 1802 hours and discontinued by the nursing staff at 2123 hours.

a. Review of the Respiratory Rate showed on 10/17/24, the RR was measured every 15 minutes when Patient 1 was on hard restraints. However, there was no documented RR on 10/17/24 at 2015 hours.

b. On 10/28/24 at 0940 hours, an interview was conducted with the Director of Nursing Quality. When asked, the Director of Nursing Quality stated the readiness for discontinuation of the restraints would be assessed under the goal criteria for releasing restraints as the goal was either met or not met.

Review of the Restraint Episode dated 10/17/24, showed the goal criteria for releasing restraints were assessed at 1815 hours (or upon initiation) and 2123 hours (upon discontinuation). However, further review of Patient 1's medical record failed to show the readiness for discontinuation of restraints was assessed every two hours or less as per the hospital's P&P.

2. Review of Patient 1's medical record showed on 10/23/24, the hard restraints for all four extremities were initiated for the patient by the Behavioral Response Team at 1100 hours, and discontinued by the nursing staff at 1545 hours.

a. Review of the Respiratory Rate showed on 10/23/24, the RR was not measured every 15 minutes when Patient 1 was on hard restraints. There was no documented Patient 1's RR between 1100 hours to 1215 hours and 1245 hours to 1409 hours. There was no documented Patient 1's RR between 1409 hours to 1545 hours (upon discontinuation).

b. Review of the Restraint Episode dated 10/23/24, showed there was no documented evidence showing the patient's behavioral health patient's activity was monitored from 1330 hours to 1545 hours (or upon discontinuation).

c. Review of the Restraint Episode dated 10/23/24, showed the goal criteria for releasing restraints were assessed at 1000 hours upon initiation. However, further review of Patient 1's medical record failed to show the readiness for discontinuation of restraints were assessed every two hours or less as per the hospital's P&P, until the restraints were discontinued at 1545 hours.

On 10/29/24 at 0951 hours, the Director of Nursing Quality verified the above findings.