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Based on record review of documentation and facility staff interviews, the facility failed to ensure the use of restraint was in accordance with an order of a physician or other licensed independent practitioner (LIP) who was responsible for the care of the patient as specified under §482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law for 1 of 1 Patient reviewed, (Patient #1) with a complaint allegation following the implementation of restraints.

Specifically, Patient #1 was physically held down on the floor by facility staff without a physician or LIP order while awaiting the assistance of the local police department in order to implement a 4 point restraint (both wrists and ankles).

Findings included:

Review of the facility's policy regarding Restraint and Seclusion, effective 07/05/2015, indicated in part; for the definition of Physical Holds- Holding a patient in a manner that restricts the patient's movement against the patient's will is "considered a restraint." This includes holds that some members of the medical community may term "therapeutic holds." Further review revealed, a. "An order for restraint must be optioned from a LIP/physician who is responsible for the care of the patient prior to the application of restraint."

Record review of the complaint intake report dated 06/28/17 revealed "it took eight people to restrain" and hold Patient #1.

Record review of Patient #1's emergency department records revealed on 06/20/17 at 07:36 AM ED Registered Nurse (RN) #1 documented patient became severely agitated, escorted by security to his room where he was yelling and using belligerent language to security staff. During the verbal altercation the patient approached security staff #2 as if he was going to physically touch him and also putting his hand in the security staff #2's face. The guard blocked the patients hand when the patient became more aggressive prompting "security to use physical force." The patient pushed security staff #1 against the door with his forearm in his neck and at that point the patient had to be physical restrained by multiple staff. The patient was fighting all staff and spitting and it took over 8 staff (security included) to physically restrain the patient until local police department (PD) Officers arrived. At that time we were able to release the patient's legs and assist him onto the stretcher where he was physically restrained to the bed using 4 point restraints.

Review of the local Police Department (PD) report completed by Officer #1 dated 6/20/17 revealed at 07:10 a call came for an active disturbance at this facility. Upon arrival, Hospital Staff had a male [Patient #1] "on the floor with approximately 8 people on him." After speaking with male, the male was placed on the bed and restrained with soft restraints.

Review of Security Staff (#1) report dated 6/20/17 at 11:42 AM revealed on 6/20/17 at 7:15 AM Patient #1 was aggressive, combative, and "taken to ground" by security staff, technicians, and nurses. Officer from local PD arrived. Patient #1 was lifted up and placed in a 4 point restraint.

Review of Patient #1's ED records including all physician orders revealed there was not a physician's order obtained for the implementation of the "physical holding" on the ground initiated by facility staff on 6/20/17. There only was a physician assistant's (PA) order obtained for the use of a 4 point restraint (bilateral upper and lower extremities) on 6/20/17 at 07:40. The area noted for physical holding was blank with no checks.

During an interview on 7/5/17 at 12:32 PM with Security staff #1 revealed Patient #1 was aggressive, combative, and had to "apprehended and took to the floor." Security staff #1 stated that he and other staff held Patient #1 "pinned to the floor" until the local PD arrived in order to assist Patient #1 into a 4 point restraint.

During an interview on 7/14/17 at 7:10 AM RN #1 stated Patient #1 had to be held down on 6/20/17 until the local PD arrived in order to get him onto the stretcher in a 4 point restraint. RN #1 indicated a physician's order was not required to physically hold down a patient; when asked.

During an interview on 07/14/17 at 12:15 PM with PA #1 stated a physician's order was not required to physically hold down a patient; when asked. PA #1 indicated that staff need to hold patients at times to keep staff safe.

During an interview on 7/6/17 at 1:00 PM with the Vice President of Quality Management confirmed the physical hold of Patient #1 on the floor on 6/20/17 at approximately 07:15 AM would be defined as a restraint and would require a physician's order or LIP order for the physical holding in accordance with the facility's policy.

Based on review of documentation and facility staff interviews, the facility failed to ensure restraints were discontinued at the earliest possible time according to the physician orders and facility policy for 1 of 1 Patient reviewed (Patient #1) for restraints following a complaint allegation.

Specifically, Patient #1 remained in restraints while patient was noted to be asleep and/or calm.

Findings were:

Review of the facility's policy titled, "Patient Restrain/Seclusion" dated 07/05/15 stated in part: "Staff assess, monitor, and re-evaluate the patient regularly and release the patient from restrain when criteria for release are met." The patient in restraint is evaluated frequently and the intervention is ended at the earliest possible time.

1.) Review of Patient #1's Emergency Department (ED) Physician Assistant (PA) Order for Restraint dated 06/20/17 at 07:40 AM revealed an order for a 4 point restraint (bilateral upper extremities, and lower extremities). Restraint Clinical Justification: The boxes for physical aggression, destructive, danger to self/others, combative, and violent were checked. Further review revealed; Criteria for Release of Restraints are met when patient stops clinical Justification Behavior.

Review of the Patient Watch Log dated 06/20/17 at 07:15 AM documented Patient (PT) was asked to return to room, which he refused. Patient became hostile and was restrained and medicated. Local Police Department (PD) called and aided in restraining patient.

The next documentation was at 07:45 AM, "PT is now asleep."
Documentation revealed at 08:50 AM "PT taken out of restraints. PT is asleep."
Documentation of the Patient Monitoring form for 06/20/17 revealed Patient #1 remained in restraints while asleep for over 1 hour.

The behavior requiring restraint was absent while Patient #1 was asleep and should have been released from restraints when assessed to be sleeping since criteria was met for the release of restraints in accordance with the PA order.

2.) Further review of Patient #1's ED records revealed a second PA order for a behavioral 4 point restraint implemented on 06/20/17 at 22:41 pm; with a renewal PA order for restraint following 4 hours at 06/21/17 at 02:30 am for violent behavior. Restraint Clinical Justification: The boxes for physical aggression, and combative were checked. Criteria for Release of Restraints are met when patient stops clinical Justification Behavior.

Review of the every 15 minutes (Q 15) Patient Monitoring Sheet for 06/20/17 documented the following while Patient #1 was in restraints:

23:45 "6" for Restrained, and "G" for sleeping. There was no documentation for 06/21/17 from 00:00 through 01:30 (one hour and 45 minutes).

On 06/21/17 at 01:45 documented "6" and "A" for "calm."
At 02:00 6A (restrained and calm)
At 02:15 6A
At 02:30 6A
At 02:45 6A
At 03:00 6G (restrained and asleep)
At 03:15 2,6G (2-In room, restrained, and asleep)
At 03:30 2,6G
At 03:45 2,6G

The behavior requiring restraint was absent from at least from 01:45 through 03:45 (two hours) while Patient #1 was noted to be calm from 01:45 AM - 02:45 AM and then asleep from 03:00 to 03:45 AM. Patient #1 should have been released when criteria was met in accordance with the PA's order.

During an interview on 07/14/17 at 07:10 AM with ED Registered Nurse (RN) #1 stated she worked when Patient #1 was placed in restraints on 06/20/17. ED RN#1 stated that if a patient was asleep or "calm enough" while in restraints; that criteria would be met for release of the restraints as long as "the Doctor says" they can be released. ED RN#1 stated that most patients were only in restraints on average of 15 to 45 minutes and that Patient #1's restraints were an unusual situation.

During an interview on 07/14/17 at 12:15 PM with PA #1 stated that just because Patient #1 was asleep did not mean that criteria for release of restraints had been met. PA #1 stated it was dependent on how the Patient's behavior was before the implementation of restraint. PA#1 stated this was the first time he had ordered a 4 point restraint at this hospital and that Patient #1 was highly volatile and should have been transferred to another facility due to the severity of his behaviors.

Based on record review of facility documentation and staff interviews, the facility failed to have a physician or other licensed independent practitioner (LIP) see the patient; face-to-face within 1-hour after initiation of a restraint used for the management of violent or self-destructive behavior, and according to facility policy for 1 of 1 patient reviewed (Patient #1) with a complaint allegation following restraints.

Findings included:

Review of the facility's policy regarding Restraint and Seclusion, effective 07/05/2014, indicated in part, that "a. A face-to-face assessment by a physician or LIP, RN, or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. Further review of the policy indicated the required evaluation and documentation to be completed in the patient's record."

1.) Record review of Patient #1's emergency department records and restraint daily log revealed he had a behavioral restraint; 4 point (both wrists and both ankles) implemented on 6/20/17 at 07:30 am for violent behavior, intended to cause harm to self or others.

There was no documentation in Patient #1's medical records that a physician face to face assessment was completed for Patient #1 within one hour of restraint application on 6/20/17 at 07:30 am.

2.) Further record review of Patient #1's emergency department records and restraint daily log revealed he had a second behavioral 4 point restraint implemented on 06/20/17 at 22:41 pm; and with a renewal physician assistant order for restraint following 4 hours at 06/21/17 at 02:30 am for violent behavior.

There was no documentation in Patient #1's medical records that a physician face to face assessment was completed for Patient #1 within one hour of restraint application on 6/20/17 at 22:41 pm.

During an interview on 07/06/17 at 1:30 PM with the Director of the Emergency Department (ED) confirmed the above findings for Patient #1 after review of the records.

During an interview on 07/14/17 at 07:10 AM with ED Registered Nurse (RN) #1 stated the physician's or physician assistants were supposed to complete the one hour face to face assessment after the initiation of restraints for patients. RN #1 stated she worked when Patient #1 was placed in the second restraint on 06/20/17 at 22:41 pm. RN #1 stated that Physician Assistant (PA) #1 ordered the restraint for Patient #1 on 06/20/17 at 22:41; and had not gone into Patient #1's room to complete an assessment after he was restrained on 6/20/17 from 22:41 through 6/21/17 at 04:45 am.

During an interview on 07/14/17 at 12:15 PM with PA #1 confirmed he had not completed the required evaluation and documentation for Patient #1 after the initiation of restraint on 06/20/17 at 22:41.