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Based on review of facility documents, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to use restraints only with the order of a physician or other licensed practitioner responsible for the care of the patient for two out of four medical records reviewed for restraints (MR2 and MR4).
Findings include:
On July 27, 2022, review of facility policy titled, "NON-VIOLENT, NON-SELF DESTRUCTIVE RESTRAINTS (MED/SURG)", last revised February 2022, revealed "...Order: A time-limited order for restraint is initiated on the order of a physician. In some situations, the need for a restraint may occur so quickly that an order cannot be obtained prior to the application of the restraint. In these emergency situations, the order must be obtained either during the emergency application, or immediately after the restraint has been applied...A restraint order must be renewed daily...".
On July 27, 2022, review of facility policy titled, "USE OF RESTRAINTS FOR BEHAVIORAL HEALTH CARE REASONS ", last reviewed June 2022, revealed "...Restraints for behavioral health care reasons requires a physician ' s or Advanced Professional Provider order...".
On July 28, 2022, MR2, admission date 07/20/2022, revealed that the order for violent restraints was placed on 07/20/2022 at 0644. Corresponding violent restraint flowsheet showed the restraint start documented at 0345. Order for non-violent restraints from July 20, 2022, at 1007 expired on July 21, 2022, at 1007 and was not renewed until 1454. Corresponding non-violent flowsheet documentation showed the patient was in restraints continuously at this time. Order for non-violent restraints from July 23, 2022, at 0736, expired on July 24, 2022, at 0736, no new order placed at this time. Corresponding non-violent flowsheet documentation showed the patient was in restraints continuously at this time until they were discontinued on July 24, 2022, at 2000.
On July 28, 2022, MR4, admission date 06/23/2022, revealed that the order for non-violent restraints from July 8, 2022, at 2250, expired on 0709/2022 at 2250, no new order placed at this time. Corresponding non-violent flowsheet documentation showed the patient was in restraints continuously at this time and until new order was placed. Order for non-violent restraints from July 14, 2022, at 0734, expired on July 15, 2022, at 0734, no new order placed at this time. Corresponding non-violent flowsheet documentation showed the patient was in restraints continuously at this time until new order was placed. Order for non-violent restraints from July 16, 2022, at 1709, expired on July 17 2022, at 1709 no new order placed at this time. Corresponding non-violent flowsheet documentation showed the patient was in restraints continuously at this time until new order was placed. Per non-violent restraint documentation on July 22, 2022, at 0800, restraints were documented as started, but there was no active order for restraints at this time.
On July 28, 2022, at 11am, EMP3 confirmed the above findings.

Based on review of facility documents, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure that the condition of the patient who is restrained was monitored for two out of four restraint medical records (MR2 and MR4).
Findings include:
On July 27, 2022, review of facility policy titled, "NON-VIOLENT, NON-SELF DESTRUCTIVE RESTRAINTS (MED/SURG)", last revised February 2022, revealed "...Continuation of Restraints: The patient ' s functional status must be reassessed every 2 hours...".
On July 27, 2022, review of facility policy titled, "USE OF RESTRAINTS FOR BEHAVIORAL HEALTH CARE REASONS", last reviewed June 2022, revealed "...Assessment and Monitoring...will be assessed at the initiation of the restraints and every 15 minutes thereafter...".
On July 28, 2022, MR2, admission date 07/20/2022, revealed "Restraint Monitoring Q15 Minutes" were not documented on 07/20/2022 at 0400, 0700, and 0715.
On July 28, 2022, MR4, admission date 06/23/2022, revealed "Restraint Monitoring Q2 Hours" were not documented on 07/02/2022 from 1100-1800; 07/03/2022 at 1800; 07/06/2022 at 0800; 07/10/2022 at 0200; and 07/24/2022 from 0600-1500.
On July 28, 2022, at 11am, EMP3 confirmed the above findings.