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Based on record review and interview the facility failed to ensure the Registered Nurse monitored and documented every two hours on patients while being restrained for 1 (P (patient) P3) of 10 (P1-P10) patients. This deficient practice could likely lead to, serious injury, harm or death for all patients restrained at this facility.

The findings are:

A. Record review of facility's policy title "Restraint/Seclusion in Patient Management, ADM POL 14-7" dated 08/2022, on page 5 under section 5. Monitoring and Reassessment stated, "Will be monitored and documented every 2 hours for: recognizing and providing for nutritional and hydration needs, checking circulation and range of motion in the extremities, addressing hygiene and elimination, addressing physical and psychological status and comfort including skin Integrity and neurovascular condition [condition that affects the blood supply in the brain or spinal cord], recognition of readiness for discontinuing restraint, recognition of signs of any incorrect application of restraints and the removal of same with ROM [the movement potential of a joint]."

B. Record review of P3's medical records revealed that patient was restrained from 01/20/24 through 01/23/24, no documentation regarding monitoring of restraints was conducted from 01/21/24 at 6:00 PM till 01/22/24 at 08:00 AM.

C. During an interview on 02/27/24, at 3:55 PM, with Staff (S)10, Registered Nurse (RN) Quality Coordinator confirmed there was no documentation regarding monitoring of restraints on P3's medical record from 01/21/24 at 6:00 PM till 01/22/24 at 08:00 AM.

D. During an interview on 02/28/2024, at 12:34 PM, with S12, Emergency Department Nurse confirmed that when the patient is first restrained, they monitor and document every 15 minutes for the 1st hour then every hour after.