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Based on record review and staff interview, it has been determined that the hospital failed to ensure the use of restraints was in accordance with the order of a physician for 2 of 7 patients reviewed (Patient ID #'s 1 and 3).

Findings are as follows:

1. Record review revealed that Patient ID #1 was admitted to the hospital in April of 2024 after experiencing an infusion reaction. His/her diagnoses include, but are not limited to, cancer and high blood pressure. While in the hospital, the patient's condition was complicated by hypercapnic respiratory failure (a condition in which too much carbon dioxide is present in the blood) that was likely due to aspiration pneumonia, requiring the application of a Bilevel Positive Airway Pressure (BiPAP) machine, a machine used to help people breathe.

According to the record, Patient ID #1 experienced increased agitation and delirium overnight on 4/11/2024 and again on the morning of 4/12/2024, which required the application of restraints.

Review of restraint documentation revealed that on 4/11/2024 at 10:21 PM, non-violent restraints were applied to Patient ID #1's wrists and ankles due to agitation, restlessness, and confusion. The restraints were then discontinued on 4/12/2024 at 7:00 AM.

The record revealed that a physician's order for non-violent restraints was obtained on 4/11/2024 at 10:21 PM, at the time the above-mentioned restraint was initiated for Patient ID #1. However, the order indicated the restraint was for a "physical hold of the patient" rather than the application of a mechanical limb restraint, which was used on the patient's wrists and ankles.

During a surveyor interview on 9/27/2024 at approximately 3:00 PM with the Risk Manager, she revealed that the ordering provider intended to order a mechanical limb restraint for the patient but incorrectly ordered a physical hold restraint instead.

2. Record review revealed that Patient ID #3 was admitted to the hospital in August of 2024 due to significant weight loss, difficulty swallowing, memory difficulties, paranoia, and anxiety. His/her diagnoses include, but are not limited to, type 2 diabetes.

According to the record, Patient ID #3 experienced increased agitation overnight on 8/26/2024, which required the application of restraints.

Review of restraint documentation revealed that on 8/26/2024 at 7:05 PM, non-violent restraints were applied to Patient ID #3's left wrist and right ankle due to agitation and restlessness. The restraints were then discontinued on 8/27/2024 at 12:25 AM.

The record revealed that a physician's order for non-violent restraints was obtained on 8/26/2024 at 7:04 PM, at the time the above-mentioned restraint was initiated for Patient ID #3. However, the order indicated that the restraint was for a "physical hold of the patient," rather than the application of a mechanical limb restraint, which was used on the patient's left wrist and right ankle.

During a surveyor interview on 9/27/2024 at approximately 2:40 PM with the Risk Manager, she acknowledged that the ordering provider incorrectly ordered a physical hold restraint instead of a mechanical limb restraint for the patient.

Based on record review and staff interview, it has been determined that the hospital failed to ensure restraints were discontinued at the earliest time possible in accordance with federal regulation and hospital policy for 2 of 7 patients reviewed who met restraint discontinuation criteria (Patient ID #'s 2 and 3).

Findings are as follows:

The hospital's policy titled, "Lifespan Patient restraint And Seclusion" effective 11/2023 states in part,

" ...Restraint or seclusion must be discontinued at the earliest time ...when the patient no longer exhibits behaviors that interfere with treatment or devices to support medical healing (for non-violent restraint) ..."

1. Record review revealed that Patient ID #2 was admitted to the hospital in September of 2024 due to septic shock. His/her diagnoses included diabetes and chronic obstructive pulmonary disease. While in the hospital, the patient was diagnosed with severe sepsis, she/he became hemodynamically unstable, and became "confused" and "intermittently responsive." The patient's code status was changed to comfort measures and she/he later passed away on 9/13/2024 at 1:48 PM.

Record review of a nursing progress note dated 9/13/2024 at 10:47 AM revealed that Patient ID #2 was "flailing" his/her arms and "knocked off" his/her Bilevel Positive Airway Pressure (BiPAP) machine, a machine used to help people breathe. As a result, soft restraints were applied to the patient's wrists and right ankle.

Review of restraint documentation revealed that non-violent restraints were applied to Patient ID #2's wrists and right ankle due to agitation and restlessness on 9/13/2024 at 10:45 AM as this interfered with medical treatment. The patient was then reassessed at 12:00 PM by Employee A, Registered Nurse, who indicated in his assessment that the patient was "sleeping."

The record indicated that Patient ID #2's restraints were not removed until 1:00 PM, an hour after she/he was "sleeping."
During a surveyor interview with the Risk Manager on 9/27/2024 at approximately 3:00 PM, she was unable to provide evidence that between 12:00 PM and 1:00 PM on 9/13/2024, Patient ID #2 continued to exhibit behaviors that warranted the need for non-violent restraints.

2. Record review revealed that Patient ID #3 was admitted to the hospital in August of 2024 due to significant weight loss, difficulty swallowing, memory difficulties, paranoia, anxiety, and suicide risk. His/her diagnoses include, but are not limited to, type 2 diabetes.

Record review of a nursing progress note dated 8/26/2024 at 8:00 PM revealed that Patient ID #3 "became agitated" shortly after being admitted and attempted to get out of bed and leave. The note indicates that staff attempted to redirect the patient without success, and as a result, non-violent restraints were applied to the left wrist and right ankle.

Review of restraint documentation revealed that the restraints were applied to Patient ID #3 on 8/26/2024 at 7:05 PM. The patient was then reassessed at 9:00 PM and again at 11:00 PM by Employee B, Registered Nurse, who indicated in both of her assessments that the patient was "calm", but the restraints were not removed.

Further review of restraint documentation revealed that Patient ID #3 was reassessed a third time at 12:25 AM by another nurse on 8/27/2024 who indicated that the patient was "calm" and the restraints were discontinued.

During a surveyor interview on 9/27/2024 at 2:50 PM with the Risk Manager and the Clinical Manager of 4 East, the Risk Manager was unable to provide evidence that Patient ID #3 continued to exhibit behaviors that warranted the need for non-violent restraints between 9:00 PM on 8/26/2024 through 12:25 AM on 8/27/2024, upon discontinuation. The Clinical Manager of 4 East indicated that according to hospital policy, the expectation is for restraints to be removed as early as possible. The Clinical Manager revealed she reviews restraint documentation but indicated she was unaware that Patient ID #3 was restrained on 8/26/2024.