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Based on clinical record review, review of hospital documentation, and interview for one of three patients who were reviewed for the use of restraints (Patient #10), the hospital failed to ensure timely removal of the restraint when the patient was no longer a danger to self or others. The findings include:

Patient #10's diagnoses included schizoaffective disorder-depressive type, post traumatic stress disorder, and borderline personality disorder.

A Physician's monthly progress review dated 8/25/2021 identified that while attending a team progress meeting Patient #10 was observed looking down at the floor, seemingly to adjust his/her socks. The patient picked up a staple from the floor and used it to scratched his/her left forearm. The scratches were identified as superficial lacerations and were bleeding. The patient was restrained by staff, an emergency was called, and the patient was placed in four point restraints.

A nurse's initial assessment dated 8/25/21 identified that Patient #10 became upset regarding the discussion in the meeting, found a stable and scratched him/her self. Deescalation techniques were initiated and were ineffective. The justification for use of a restraint was identified as imminent risk of serious physical assault or self destructive behavior. A physical hold was implemented on 8/25/2021 at 11:15 AM and stopped at 11:20 AM. At 11:20 AM four point restraints were applied and released at 1:14 PM, a total of one hour and fifty nine minutes.

The nurse's behavioral assessment dated 8/25/2021 at 11:30 AM (ten minutes after the four point restraints were applied) identified Patient #10 was engaging appropriately with staff. At 11:45 AM the patient was identified as restless, at 11:45 AM and 12:00 PM the patient was identified as agitated and restless, and from 12:15 PM to 1:14 PM the patient was identified as restless.

Between 11:30 AM and 1:14 PM, Patient #10 remained in four point restraints despite exhibiting no behaviors to warrant the continued use of the restraint.

Interview, review of the clinical record and review of hospital documentation on 9/1/2021 at 2:00 PM with the Manager of Quality identified that restlessness is not an appropriated justification for the use of restraints. Attempts to reduce or release from the four point restraints should have been attempted when the patient was no longer a danger to self or others.

The hospital failed to ensure timely removal of the restraint when the Patient was no longer a danger to self or staff.

The Hospital's Restraint Policy identified that restraints may only be imposed to ensure the immediate physical safety of the patient, staff members, and others and must be discontinued at the earliest possible time.