HospitalInspections.org

Based on clinical record review and staff interviews, the hospital failed to ensure physician orders were obtained immediately following the use of a physical escort, a physical hold, and a restraint chair for 1 of 6 patients reviewed, Patient ID #1.

Findings are as follows:

The hospital's policy titled, "Patient Restraint and Seclusion," defines restraints as "Any intrusive method of suppressing the ability of the person to move their arms, legs, body, or head freely; or have normal access to their body due to equipment attached to, or adjacent to the patient..."

The policy also defines a violent restraint as "The use of restraint or seclusion when warranted by violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others."

The policy further states that "If the ordering provider is not present, the RN [Registered Nurse] will contact the ordering provider to obtain the order" and "In an emergency situation where the order cannot be obtained prior, the order must be obtained during the emergency application of restraint or immediately after (within minutes) the restraint was initiated. If an order is not obtained immediately, it will be considered restraint without an order."

A complaint submitted to the Rhode Island Department of Health alleged in part that Patient ID #1 was picked up by a male, slammed onto a bed and held "down so hard" causing bruising to their wrists and ankles. The complaint further alleged that Patient ID #1 was picked up again and placed in chair "where they aggressively strapped me in" which resulted in "cuts and bruising."

Clinical record review revealed that Patient ID #1 presented to the Emergency Department at Newport Hospital in November of 2025 due to suicidal ideations with a plan to overdose on prescribed medications.

According to the clinical record, the patient was placed under emergency certification due to the severity of their symptoms and an inability to develop a safety plan.

Further review revealed that after the patient was informed of their emergency certification status, she/he exited his/her room yelling at staff requesting to return home. After multiple attempts were made at calming the patient, nursing and security personnel placed the patient back in their room on their bed and proceeded to restraint the patient onto the bed.

Clinical record review revealed that at 6:30 PM on 11/30/2025 the patient was applied a 4-point violent restraints while on the bed which involved securing the right and left wrists and the right and left lower extremities.

Further record review revealed that the patient began to slip out of the 4-point violent restraint and was then transitioned to a restraint chair by 6:36 PM which was removed by 6:45 PM.

During a surveyor interview on 12/16/2025 at 2:57 PM with Employee A, Registered Nurse, she confirmed that she and a security guard physically escorted the patient and lifted him/her while a third person secured the patient's legs. Employee A stated that the patient was "picked up a little bit" and placed onto the bed where four-point restraints were applied.

During a surveyor interview on 12/17/2025 at 9:52 AM with Employee B, Security Guard, he confirmed that he picked up the patient, placed him/her on the bed and held him/her there while nursing staff administered injections. He explained that he lifted the patient by placing his arms and hands under the patient's armpits, maintaining control over the patient's upper body. He stated that the patient was "dead weighting," and confirmed that the patient's feet left the ground when he picked him/her up. Additionally, he stated that the patient continued to kick and repeatedly said, "[profanity] let me go."

During a surveyor interview on 12/17/2025 at 9:14 AM with Employee C, Registered Nurse, she explained that Patient ID #1 was guided onto the restraint chair and confirmed that the restraint straps were applied. Employee C further explained that when a patient is placed in a restraint chair their legs, arms, and waist are strapped and a last strap goes over their shoulders.

During a surveyor interview on 12/17/2025 at 10:13 AM with the Risk Manager, she confirmed that Employee D, Security Guard, and Employee A positioned themselves on the patient's sides and while the patient was pushing back, Employee B came up from behind the patient and the patient's legs went "up in the air" and she/he was "flailing." The Risk Manager confirmed that the patient was picked up by Employee B and placed on the bed while someone else assisted with the patient's feet.

The patient's medical record failed to reveal evidence that a physician order was obtained immediately after the patient was physically escorted to his/her room and physically held for the administration of injections prior to the placement of four-point restraints, in accordance with federal regulations and hospital policy. The medical record further failed to reveal evidence that a physician order for application of a restraint chair was obtained immediately after the restraint was applied.

During a surveyor interview on 12/17/2025 at 10:38 AM with the Clinical Nurse Specialist/Educator, she acknowledged that if a patient is pushing back and is being moved against their will, it is considered a restraint and expects this to be reflected in the physician's order. Additionally, she indicated that she would have expected the restraint chair to be included in the physician's order since the physician has the ability to select different restraint types in the same order.

Based on clinical record review and staff interviews, the hospital failed to ensure that staff monitored the condition of restrained patients in accordance with hospital policy. Specifically, staff failed to conduct a face-to-face assessment within 24 hours after the renewal of a non-violent restraint for Patient ID #2. Additionally, staff failed to document an initial assessment after restraint initiation for Patient ID #3 and every 15 minutes thereafter for both Patient ID #s 3 and 4 in accordance with hospital policy for 3 of 6 patients reviewed.

Findings are as follows:

The hospital's policy titled, "Patient Restraint and Seclusion," defines non-violent restraint as "The use of restraint to manage non-violent, non-self-destructive behavior that interferes with treatment or devices necessary to support medical healing" and violent restraint as "The use of restraint or seclusion when warranted by violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others."

Further, the policy states in part that for non-violent restraints, the ordering provider performs a face-to-face assessment of the patient, within 24 hours of the initiation of the restraint" and for violent restraints, Registered Nurses "assess at initiation and every 15 minutes thereafter."

The policy further stated that the Registered Nurse "ensures that the assessment is documented and addresses:
- If discharge criteria is met and need for continued restraint or discontinuation
- Physical and psychological status and comfort of the patient
- Response to restraint
- Correct application/position of restraint (as applicable)
- Signs of injury
- Skin integrity: circulation, sensation, movement (CSM) of restrained extremities, as applicable
- Range of Motion performed as applicable
- Level of consciousness (LOC)
- Nutrition and Hydration
- Hygiene and elimination
- Respiratory
- Vital signs

1. Clinical record review revealed that Patient ID #2 was admitted to the hospital in September of 2025 due to altered mental status.

The clinical record indicated that the patient required the use of non-violent right and left wrist restraints between 9/7/2025 through 9/14/2025 as she/he was interfering with medical interventions.

The record indicated that an order renewal for this type of restraint was obtained on 9/10/2025. However, the record failed to reveal evidence of a documented face to face assessment of the patient by the ordering provider.

During a review of clinical records with the Clinical Nurse Specialist/Educator on 12/17/2025 at 12:00 PM, she confirmed that she was unable to locate a documented face to face assessment for Patient ID #2 on 9/10/2025 after the non-violent restraint was reordered.

2. Clinical record review revealed that Patient ID #3 presented to hospital in October of 2025 due to chest pain, vomiting, and drug use.

According to the patient's medical record, at approximately 5:15 AM on 10/20/2025, the patient attempted to harm themselves with a needle used to insert intravenous lines that she/he retrieved from a cart in the Emergency Department.

The record indicated that the patient required restraints following their self-harm attempt.

Record review of nursing documentation revealed that security officers had to "put hands on the patient and put [him/her] on the ground ..." Further review revealed that the patient was then applied 4-point restraints at 5:24 AM while on the bed which involved securing the right and left wrists and the right and left lower extremities.

Further review of nursing progress notes revealed that the patient was unable to remain safe while on 4-points restraints as she/he tried to hit their head against the bed and attempted to bite the railings as well. The patient was then removed from 4-point restraints and transitioned to a restraint chair at 5:40 AM.

The clinical record failed to reveal evidence that a Registered Nurse conducted an assessment in accordance with hospital policy at the time the restraint chair was initiated as well as every 15 minutes thereafter for a total of 3 opportunities. The patient was not assessed by a Registered Nurse until 6:40 AM.

During a review of clinical records with the Clinical Nurse Specialist/Educator on 12/17/2025 at 1:01 PM, she acknowledged that the patient's restraint documentation was missing nursing assessments.

3. Clinical record review revealed that Patient ID #4 presented to hospital in October of 2025 after attempting to dive through a window.

The clinical record indicated that the patient required the use of violent restraints, including chemical and limb restraints, after becoming agitated and combative with staff.

The record revealed that restraints were initiated on 10/12/2025 at 9:29 PM and eventually discontinued by 1:16 AM on 10/13/2025.

During a review of clinical records with the Clinical Nurse Specialist/Educator on 12/17/2025 at 1:31 PM, she confirmed that although vital signs were consistently obtained for Patient ID #4, the violent restraint flowsheet was missing documentation of the required 15-minute nursing assessments for multiple time intervals.