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Based on review of 4 medical records containing restraint/seclusion documentation, hospital policy, and other pertinent documents, it was determined that the hospital failed to obtain an order for 1 physical restraint/hold for 1 of 4 patients reviewed.

The findings include:

The surveyor reviewed the policy titled "Restraint and/or Seclusion for the Patient with Violent/Self-Destructive Behavior Policy." Section "V. Responsibility" stated, "B. Authorized Prescribers shall: 4. Provide a time-limited order promptly but not later than 1 hour after application of Restraint or initiation of Seclusion unless otherwise specified in state/jurisdictional appendix."

Patient #6 (P6) was a minor patient who was admitted to the inpatient pediatric psychiatric unit for approximately 10 days. The patient required psychiatric treatment and medication adjustments throughout their stay.

On day 6 of the admission, the hospital staff placed P6 in a physical restraint/hold after P6 had exhibited self-injurious behaviors and attempts to barricade themselves in their room. Registered Nurse (RN) documentation related to this episode stated, " ...[Patient] was resistant to walking to quiet room and security officer [name], RN [name], and CNA (Certified Nursing Assistant) [name] provided a physical escort to the quiet room ..." A document titled "Restraint/Seclusion Face-to-Face Evaluation" completed by the provider stated the physical restraint/hold began at 8:17 PM for the patient's safety. The provider also documented that they saw the patient and the patient was "examined personally" by 9:05 PM. The surveyor was not able to locate an order for this physical restraint in the patient's medical record.

Based on review of 4 medical records containing restraint/seclusion documentation, hospital policy, and other pertinent documents, it was determined that the hospital failed to document the need to continue or terminate the restraint during a face-to-face evaluation for 1 of 4 patients reviewed.

The findings include:

The surveyor reviewed the policy titled "Restraint and/or Seclusion for the Patient with Violent/Self-Destructive Behavior Policy." Section "VI. Process" stated, "3. Within 1 hour of applying Restraints and/or of Seclusion, an in-person (face-to-face) evaluation must be performed by an authorized prescriber. a. The face-to-face evaluation shall include: i. The patient's immediate situation. ii. The patient's reaction to the intervention. iii. The patient's medical (temperature elevations, hypoxia, hypoglycemia, electrolyte imbalances, drug interactions and drug side effects) and behavioral condition. Iv. The need to continue or terminate the Restraint/Seclusion."

Patient #9 (P9) was a 40 + year old patient who walked into the Emergency Department (ED) and began disrobing and yelling. A behavioral code was called and the patient was placed in 4-point restraints during which the patient began spitting and attempting to strike staff. The patient was taken back to the treatment area of the ED where it was determined that he/she was under the influence of illegal substances.

Review of the restraint documentation for this episode determined that the patient was in restraints for approximately 2 hours and 20 minutes. The surveyor was unable to locate a standardized "Face-to-Face Evaluation" electronic form within the patient's medical record. There was a note completed by a provider within 10 minutes after the initiation of the restraints that described the event; however, this note did not include the required element of the face-to-face evaluation describing the need to continue or terminate the restraint.