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Based on document review and interview, it was determined that for 1 of 2 clinical records (Pt. #3) reviewed for restraint documentation, the Hospital failed to ensure a physician order was obtained for a violent restraint.

Findings include:

1. On 8/6/2024, the Hospital's policy titled, "Restraint and Seclusion" (reviewed by hospital 1/18/2021) was reviewed and indicated, "...Violent restraint -if the use of restraint is necessary, an order for violent restraints must be placed within 1 hour of initiation (includes physical hold of patient)..."

2. On 8/6/2024, Pt. #3's clinical record (dated 7/2/2024) was reviewed and indicated:
-Pt. #3 was seen in the ED (emergency department) on 7/2/2024 with a diagnosis of psychosis (thoughts not based in reality).
-Pt. #3's ED course note dated 7/2/2024 indicated, "Pt. #3 attempted to elope. Pt. #3 is now in 4 point (both ankles and both wrists) restraints."
-Pt. #3 was placed in violent 4 point restraints (locked) on 7/2/2024 at 2:00 PM until 2:51 PM.
-Pt. #3's clinical record lacked documentation of a physician's order for the violent restraints.

3. On 8/7/2024 at 11:45 AM, an interview was conducted with the ED Charge Nurse (E #10). E # 10 stated that there should be a physician's order for violent restraints.

Based on document review and interview, it was determined that for 1 of 2 clinical records (Pt. #3) reviewed for violent restraint documentation, the Hospital failed to ensure every 15 minute monitoring was documented, as required.

Findings include:

1. On 8/6/2024, the Hospital's policy titled, "Restraint and Seclusion" (reviewed by hospital 1/18/2021) was reviewed and indicated, "Violent Restraints - locked -A sitter must provide continuous supervision and must document every 15 minute checks on the behavioral health flowsheet (location/activity/behavior)..."

2. On 8/6/2024, Pt. #3's ED (Emergency Department) clinical record (dated 7/2/2024) was reviewed and indicated:
-Pt. #3 was seen in the ED on 7/2/2024 with the diagnosis of psychosis (thoughts not based in reality).
-Pt. #3's ED course note dated 7/2/2024 indicated, "Pt. #3 attempted to elope. Pt. #3 is now in 4 point (both ankles and both wrists) restraints."
-Pt. #3's restraint documentation dated 7/2/2024 noted violent (locked - 4 points) restraints were applied on 7/2/2024 at 2:00 PM and discontinued at 2:51 PM.
-Pt. #3's restraint flowsheet documentation dated 7/2/2024 noted initiation of violent (4 point) restraint at 2:00 PM. The restraint flowsheet documented 15 minute checks at 2:15 PM but lacked documentation of 15 minute checks from 2:15 PM - 2:51 PM. The restraints were discontinued at 2:51 PM.

3. On 8/7/2024 at 11:45 AM, an interview was conducted with the ED Charge Nurse (E #10). E #10 stated that a patient in violent restraints should be monitored continuously and documented every 15 minutes.