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Based on document review and interview, it was determined that for 1 of 1 (Pt #10) clinical record reviewed for a patient in violent restraints, the Hospital failed to remove a patient from restraints at the earliest possible time.

Findings include:

1. On 5/18/2021, the Hospital's policy titled, "Restraints and Seclusion for Violent or Self-Destructive Behavior," initiated 11/30/2005, was reviewed. The policy required, "Procedure... Provider Orders... Restraints or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order..."

2. On 5/18/2021, Pt. #10's clinical record was reviewed. Pt. #10 was admitted to the Hospital on 4/7/2021 with a diagnosis of heroin withdrawal. Physician's orders, dated 4/8/2021 at 8:05 AM, 12:00 PM, and 4:00 PM, required "locked 4 point" restraints due to "endanger self and others." Monitoring of safety and care provided was documented every 15 minutes and indicated that Pt. #10 was agitated and restless, until 4:00 PM, when Pt. #10 became and remained "quiet". However, Pt. #10 was not removed from restraints until 9:00 PM, 5 hours later.

3. On 5/18/2021 at 12:25 PM, an interview was conducted with the Director of Critical Care (E #5). E #5 stated that Pt. #10 "settled down" at 4:00 PM, but Pt. #10 had calmed down before and started up again, so the staff kept Pt. #10 in restraints.

Based on document review and interview, it was determined that for 2 of 5 (Pt #8 and Pt #9) clinical records reviewed for patients in non-violent restraints, the Hospital failed to ensure trained staff monitored a restrained patient every two hours, as required by policy.

Findings include:

1. On 5/18/2021, the Hospital's policy titled, "Restraints and Seclusion for Violent or Self-Destructive Behavior," initiated 11/30/2005, was reviewed. The policy also included non-violent/medical restraints and required, "Documentation Requirements... Ongoing Nursing Documentation... 13. Standard of Care: Injury & skin assessment, ROM [range of motion], Fluids, Food/Meal, Elimination, Physical Comfort, Circulation, Injury Assessment if any - Every 2 hours..."

2. On 5/18/2021, Pt. #8's clinical record was reviewed. Pt. #8 was admitted to the Hospital on 4/7/2021 with a diagnosis of alcohol intoxication. A physician's order, dated 4/20/2021 at 2:19 PM, required, "soft limb holder - arms" restraints due to "medically unsafe..." Pt. #8's restraint monitoring log lacked documentation of observation and care provided on both 4/20/2021 and 4/21/2021, between 4:00 PM and 8:00 PM, for 4 hours on each day.

3. On 5/18/2021, Pt. #9's clinical record was reviewed. Pt. #9 was admitted to the Hospital on 4/1/2021 with diagnoses of acute kidney injury and altered mental status. A physician's order, dated 4/21/2021 at 1:26 PM, required "soft limb holder - arms" restraints due to "potential to interrupt vital medical equipment..." Pt. #9's restraint monitoring log lacked documentation of observation or care provided on 4/21/2021, between 4:00 AM and 8:00 AM, and also on 4/22/2021, between 4:00 PM and 8:00 PM, for 4 hours on each day.

4. On 5/18/2021 at 12:25 PM, an interview was conducted with the Director of Critical Care (E #5). E #5 stated that restraint monitoring should have been documented every 2 hours for Pts. #8 & #9.