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Based on Clinical Record review, document review and interview, it was determined that the facility failed to document offering fluids and nourishment, toileting/elimination, range of motion, exercise of limbs and systematic release of restrained limbs per the facility's policy and procedure for one (1) of three (3) restraint Patients (Patient # 2).

The findings include:

On March 2, 2022 at approximately 10:30 a.m., the Clinical Record for Patient # 2 was reviewed with Staff Members # 6 and # 7 navigating. The review revealed a Physician's order for restraint dated February 28, 2022 at 5:12 p.m. Documentation revealed Patient # 2 had bilateral soft limb restraints to the upper extremities for non-violent behavior. Restraints initiated for safety due to Patient confusion and agitation. There was no documentation to include offering fluids and nourishment, toileting/elimination, range of motion, exercise of limbs and systematic release of restrained limbs between 2:33 a.m. and 8:16 a.m.

An interview with Staff Members # 6 and # 7 revealed "there is no documentation between 2:33 a.m. and 8:16 a.m."

On March 2, 2022 at 10:45 a.m., a review of the facility policy provided by Staff Member # 1 titled "Restraint and Seclusion Management: Non Violent or Self Destructive Behavior in Non Behavioral Health Area" reads in part "Monitor and document restraint safety according to patient need. Monitoring shall included circulation, range of motion, fluids, food/meal and elimination and shall be documented at least every 1.5 - 2.5 hours and may need to be more often; adjust to more often according to patient need."

The findings were discussed with Staff Members # 1, # 2, # 3, # 8, # 9, # 10 and # 11 on March 2, 2022 during the exit interview.