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Based on review of 3 behavioral health patient records, it was determined that the hospital failed to release 2 of 3 reviewed restrained patients from restraints at the earliest possible time.

Patient #3 (P3) was a 30+ year old who presented to the Emergency Department (ED) for a psychiatric evaluation. While in the ED, the patient had periods of verbal and physical aggression toward staff and security personnel. P3 was placed in four-point limb violent restraints based on behavior. P3 received a psychiatric evaluation which determined that the patient would be admitted involuntarily to the behavioral health unit.

P3 was restrained for approximately 2 ½ hours during one restraint episode on the first day of arrival to the ED. Nursing documentation revealed periods when the patient was not physically aggressive toward staff, and restraints could have been discontinued.

At 4:40 PM, the nurse documented that, while in four-limbed restraints, P3 was "physically aggressive towards female officer ....administered 200mg [sedative] in right upper lower extremity."

Thirty-five minutes later, at 5:15 PM, the nurse modified P3's restraints without obtaining a new order from the provider. Restraint documentation at 5:15 pm revealed that the nurse discontinued two of the four restrained limbs. A nursing note at 5:23 PM identified that the patient was restless, but did not exhibit any other behaviors. Nursing documentation of no aggressive behavior, followed by the nurse's removal of two restraints, identified an opportunity in which the four-limbed restraints could have been discontinued.

P3 continued to exhibit cooperative behavior, as evidenced by nursing documentation at 6:00 PM, which stated, "[P3] is showing signs of calming since being medicated and two of the four restraints will be removed. Less restrictive attempts of decreasing stimulation and reorientation to surroundings are also being used and seem to be effective. [P3] will continue to be observed by nursing staff at bedside until all restraints are removed."

P3 restraint documentation at 6:15 PM stated that all restraints were being discontinued. Based on documentation in the medical record, P3's physically and verbally aggressive behavior ceased at 5:15 p.m. when the nurse discontinued two of the four restraints. The patient could have had all restraints removed at that time.

Patient #5 (P5) was a 25+ year old patient who was brought to the Emergency Department (ED) for a psychiatric evaluation after an episode of aggression involving another person. The patient had a history of a chronic psychiatric condition and had been admitted to this hospital within the previous few months. On presentation to the ED, nursing staff documented that the patient was acting aggressive, agitated, and threatening to staff. The patient was placed in 4-point restraints (both wrists and both ankles) and given IM (intramuscular) medications. P5 was evaluated and it was determined that the patient would be admitted involuntarily to the behavioral health unit.

During the above-mentioned episode of 4-point restraints in the ED, the nursing staff documented that P5 was sleeping 45 minutes after the application of the restraints. It was also documented at that time that the nursing staff released only one of the restraints. Over the next hour, one restraint was released every 15 minutes. It was documented during that entire hour that the patient was either sleeping or was subdued. Therefore, P5 remained in restraints for at least an hour after the documented behaviors that required the restraints had ceased.

In summary, P3 and P5 remained in violent restraints despite having ceased the behaviors that precipitated the need for restraints.

Based on review of 3 behavioral health patient records, it was determined that the hospital failed to allow 1 of 3 patients reviewed to be free of chemical restraints, as evidenced by administration of forced medications to Patient #3 (P3) in the absence of violent or self-destructive behaviors.

P3 was a 30+ year old who presented to the ED for a psychiatric evaluation. Based on the evaluation, P3 was certified by two physicians for an involuntary admission and was admitted to hospital's inpatient behavioral health unit for treatment. The clinical team developed a behavioral treatment plan for P3 during their admission. Consequences for not following the behavior plan included ... "If you begin verbally or physically threatening or intimidating staff or peers you may be medicated." P3 was verbally aggressive with staff on several occasions and was offered oral (PO) medications to assist with managing aggression.

On days 2 and 4 of the inpatient admission, P3 refused PO medications and subsequently received medications via an intramuscular (IM) injection against P3's wishes. There was no documentation found that the patient was behaving in a violent or self-destructing manner at the time of forced medication administration. Verbal aggression displayed by P3, in the absence of physically threatening behavior, did not pose a risk of imminent harm to the patient, staff, or others; thus, it could not be used as means of justification for the use of an emergency intervention in the form of forced medications.

The hospital violated the patient's right to refuse medications and used medications as a chemical restraint to assist with a behavior that did not pose an imminent threat to the safety of the patient, staff, or others.

Based on review of 2 restraint records for Patient #3 (P3), it was determined that face-to-face assessments for P3 were not conducted within one hour after restraint initiation in 2 of 2 restraint episodes.

P3 was a 30+ year old who presented to the Emergency Department (ED) for a psychiatric evaluation. Based on the evaluation, P3 was certified by two physicians for an involuntary admission to receive inpatient psychiatric treatment. While in the ED, P3 was placed in four-limb restraints due to physical aggression, as P3 attempted to kick, bite, and punch the ED staff and security personnel.

Medical record review reflected that the physician orders were written for two restraint episodes at 6:58 AM and 3:42 PM on the first day of presentation to the ED. The restraint monitoring was documented by nurses for both episodes and indicated that the initiation of restraints occurred at 07:15 AM and 3:44 PM respectively. The physician one-hour face-to-face assessments for these restraint episodes were documented at 6:58 AM and 3:42 PM, 17 and 2 minutes prior to the actual initiation of the restraints. There was no other face-to-face documentation found in the record for either of the episodes.

In summary, the above-described face-to-face assessments were documented concomitantly with the restraint orders and prior to the application of restraints and could not accurately describe what the patient's response to the intervention was or the need to continue the restraints.

Based on review of 2 restraint records for Patient #3 (P3), it was determined that the face-to-face assessments for P3 failed to address all regulatory elements in 2 of 2 restraint episodes.

P3 was a 30+ year old who presented to the Emergency Department (ED) for a psychiatric evaluation. Based on the evaluation, P3 was certified by two physicians for an involuntary admission to receive inpatient psychiatric treatment. While in the ED, P3 was placed in four-limb restraints on several occasions due to physical aggression. Medical record review reflected that provider orders were written for each restraint episode and restraint monitoring was documented by nurses.

The mandatory one-hour assessments by a provider, also known as face-to-face assessments, were found to be documented several minutes before the restraints were actually initiated (see Tag A-0178). Review of the ED medical record also revealed four headers for the face-to-face evaluation documented for P3 as: Patient's reaction to the intervention, Patient's behavioral condition since restraint/seclusion initiation, Patient's medical condition since restraint/seclusion initiation, and Intervention. The hospital's face-to-face evaluation template did not address the patient's immediate situation or the need to continue or terminate the restraint or seclusion. No other documentation was found in the record to confirm that the two missing elements of the face-to-face evaluation were completed for P3.