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Based on medical record review, document review and interview, in six (6) of 10 medical records reviewed, it was determined the facility failed to (a) write an order for the application of a 4 point physical restraint, (b) specify the time limit duration of an order for a 4 point physical restraint, (c) renew orders for restraints, (d) discontinue the use of restraints at the earliest possible time, (e) ensure restraints were released every two (2) hours as per the facility's policy, (f) reassess patients for continued use of a restraint and (g) ensure all individuals received appropriate training before they assisted with the application of restraints.

These practices may have placed patients at risk for harm.

Findings include:

Patient #5 was placed in a four (4) point physical restraint for the management of severe agitation. There was no documentation of a written physician's order for this intervention.

Refer to A 168.

Patient #4 was placed in a 4 point physical restraint for behavioral management. The physician's order for the restraint did not include a starting and ending time per the facility's policy "Restraint Management".

Refer to A 169.

Patient #2 and #3 were placed in bilateral wrist restraints for safety. Restraint orders were not renewed every 24 hours as per the facility's policy on "Restraint Management".

Refer to A 173.

Patient #6 was placed in 4 point physical restraint for behavioral management. The constant observation flow sheet revealed that the physical restraints were not discontinued as soon as possible as per facility's policy.

Refer to A 174.

Patient #6 who was placed in a 4 point physical restraint for behavior management. There was no documentation the restraints were released every two (2) hours as per facility's policy.

Refer to A 175.

Patients #1, #2 and #3 were placed in physical restraints for several consecutive days. Staff failed to document reassessments of these patients to justify the continued use of physical restraints.

Refer to A 188.

The facility enlisted the local police who did not have the required training for physical restraint application, to assist with the application of a 4 point physical restraints on Patient #4.

Refer to A 202.

Based on document review and staff interview, there was no evidence that all patients placed in physical restraints had a written physician's order for the application of restraints. This was evident in one (1) of four (4) medical records (MR) reviewed (Patient #5).

This failure may have placed patients at risk for harm.

Findings include:

Review of MR#5 revealed that this 40-year-old male was brought to the Emergency Room by the police on 3/25/18 at 8:40 p.m. with multiple abrasions on his body and head and extremely agitated. This patient's past medical history included substance abuse.

The patient was given two (2) intramuscular injections (IM) at 9:14 PM for behavior management and was placed in 4-point restraints 9:20 PM; "left wrist, right wrist, left ankle, right ankle." The physician was notified at the time the patient was placed in 4-point restraints. At 10:15 PM, the patient was placed in two-point restraints (left wrist and right wrist) and all restraints were removed at 10:25 PM.

The medical record indicated that the physician ordered chemical restraints, but there was no written order for physical restraints.

Review of facility's Policy & Procedure titled "Restraint Management," reviewed on 12/16/16, indicated that "Provider Orders The use of physical restraints requires written order by the provider, who has conducted a face to face physical assessment of the patient prior to writing the order."

Staff B, Nurse Manager was interviewed on 6/18/18 at 10:30 AM. Staff B verified that the staff did not follow the Policy "Restraint Management." Staff B stated that although the Physician was notified about the need for physical restraints, the Physician did not write an order for the restraints.

Based on medical record review, document review and interview, in one (1) of 10 medical records reviewed, it was determined the physician failed to specify the duration of an order for a 4 point restraint. This was evident for Patient #1.

Findings include:

Review of medical record #1 identified the following: this 28 year old patient presented to the emergency department (ED) on 4/19/18 for a psychiatric evaluation. On arrival the patient was agitated, combative, aggressive, restless and uncooperative. A physician wrote an order for a four (4) point restraint.

The order did not include the length of time for the use of the restraint.

The nursing staff documented the patient was placed in a four (4) point restraint on 4/19/18 at 9:43 AM; at 9:45 AM and 9:46 AM, the patient was given medications for severe agitation. The patient was asleep at 10:00 AM until 12:45 PM. The patient remained in the 4 point restraint until 1:26 PM when the nursing staff removed the restraints. The restraints were discontinued one (1) minute prior to the patient transfer to another acute care hospital.

The facility's policy titled "Restraint Management" which was last reviewed on 12/16/2016 states, "the order for restraint include starting and ending times."

These findings were shared with Staff A, Vice President of Quality on 6/15/18 at 3:00 PM.

Based on medical record review, document review and interview, in two (2) of four (4) medical records reviewed, it was determined the physician failed to renew orders for restraints. This was evident for Patient #2 and Patient # 3.

These practices may have placed the patients at risks for harm.

Findings include:

The facility's policy titled "Restraint Management" which was last reviewed on 12/16/2016 states: orders for restraints "must be renewed every 24 hours based upon a face to face assessment by the provider and must ensure a clinically justified use.

Review of medical record #2 identified the following: this seventy-eight year old patient was admitted to the facility on 12/26/17 with altered mental status with unresponsiveness associated with severe hypertension and acute kidney injury. The patient was disoriented, confused, unable to follow directions and she was pulling at tubes that were required to facilitate medical treatment. On 12/27/17 a physician ordered two (2) point wrist restraints and the patient was kept in the 2 point wrist restraints until 1/06/18 when she was transferred to hospice care.

There was documentation that orders for restraints were renewed on 1/04/18, 1/05/18 and 1/06/18.

Review of medical record #3 identified the following: this seventy-nine year old patient was admitted to the facility on 1/10/18 with diagnoses of septic shock, respiratory failure and rule out a cerebrovascular accident (stroke). She was intubated upon admission and 2 point wrist restraints were applied on 1/11/18 and remained in place until 2/05/18 because the patient attempted to remove her tubes (intravenous access and intubation access) which were essential for treatment.

There was no documentation in the medical record that the restraint order was renewed on 1/14/18, 1/15/18, 1/22/18 and 2/03/18.

This finding was shared with the Staff A, the Vice President of Quality on 6/18/18 at 3:30 PM.

Based on medical record review, document review and staff interview, in one (1) of four (4) medical records reviewed, there was no evidence that physical restraints were discontinued at the earliest possible time (Patient #6).

Findings include:

Review of MR#6 revealed that this 16-year- old male was brought to the Emergency Room by ambulance on 4/25/18 at 9:43 a.m. because he was "acting out at school" and displayed "aggressive behavior". The patient had a past medical history of Bipolar Disorder. At 10:07 am. & 10:08 a.m. the patient was given two (2) intramuscular ) injections for extreme agitation; at 10:15 a.m., the patient was placed in four (4) point restraints "left wrist, right wrist, side rails up x 4, left ankle, right ankle".

Constant Observation Flow Sheets documented that the patient was placed on constant observation from 10 a.m. to 3:45 p.m. These flow sheets documented that the patient was sleeping from 10:30 a.m. to 2 p.m. and that he was "cooperative" at 12:15 p.m.

Documentation in the medical record indicated that this patient remained in four (4) point restraints until his transfer to a Psychiatric Hospital that same day at 3:57 p.m.

Review of the facility policy & procedure titled "Restraint Management" last reviewed on 12/16/16, indicated: "Restraints should be discontinued as soon as it is safely possible..." The provider or qualified RN may release the patient from restraints before the orders expiration time if the patient's condition and overall assessment of behaviors improves".

The patient's record did not indicate the removal of the 4-point restraints after the patient was documented to be "cooperative".

During interview with Staff B, Nurse Manager on 6/18/18 at 10:30 a.m., she verified that the staff did not follow the policy titled "Restraint Management".

Staff B indicated that the direct patient care staff were not available for interview.

Based on medical record review, document review and staff interview, there was no evidence that physical restraints were released every two (2) hours as per the facility's policy. This was evident in one (1) of four (4) medical records reviewed (Patient #6).

Findings include:

Review of the facility's Policy & Procedure titled "Restraint Management" last reviewed on 12/16/16 indicated that "restraints will be released one (1) at a time very two (2) hours and range of motion and position change will be performed".

Review of the medical record for (Patient #6) revealed that this 16-year- old male was brought to the Emergency Room by ambulance on 4/25/18 at 9:43 a.m. because he was "acting out at school" and displayed "aggressive behavior". At 10:07 am. and 10:08 a.m., the patient was given intramuscular injections for extreme agitation; and at 10:15 a.m., the patient was placed in four (4) point restraints, "left wrist, right wrist, left ankle, right ankle and side rails up x 4".

There was no documentation in the medical record that the patient's restraints were released every two (2) hours as per the policy.

Staff B, the Nurse Manager was interviewed on 6/18/18 at 10:30 a.m. Staff B verified that the staff did not follow the policy titled "Restraint Management".

Based on medical record review, document review and interview, in one (1) of eight (8) medical records reviewed, it was determined the facility failed to ensure that staff conducted reassessments to justify the continued use of physical restraints (Patients #1, #2 and #3).

These practices may have placed patients at risk for harm.

Findings include:

The facility's policy titled "Restraint Management" which was last reviewed on 12/16/2016 states "the RN will assess the need for implementation, continuation and release of restraints."

Review of medical record #1 identified the following: this patient arrived at the facility on 4/19/18 at 9:18 AM with a chief complaint of psychiatric complaints.

The ED doctor saw the patient at 9:37 AM and noted that the "patient was currently extremely agitating, fighting and flailing with staff. Patient with extreme agitation and psychosis. Required sedation and restraints for safety for himself and others.

Nursing documentation revealed the patient was placed in four (4) point restraint at 9:43 AM for severe agitation and placed on constant observation. At 9:45 AM, 9:46 AM and 9:48 AM the patient was given medications for agitation.

The ED doctor documented that the patient was reevaluated at 9:59 AM and that the patient was sleeping.

The ED doctor documented that the patient was re-evaluated again at 12:09 PM and that the patient was medically cleared and stable for transfer to inpatient psychiatry.

Nursing documentation revealed the patient was sleeping and sedated at 10:00 AM until noon.

A security officer also documented that the patient was sleeping at 10:00 AM and 11:00 AM until 12:30 PM. The security officer documented that the patient was cooperative from 12:45 PM until 1:15 PM.

Nursing documentation revealed the restraints were removed at 1:26 PM and the staff transferred the patient to another hospital a minute later, at 1:27 PM.

There was no evidence in the medical record that each time the patient was reevaluated, there was documentation of the justification for continued use of restraints.

Similar findings regarding lack of documentation of justification for continued use of restraints were noted for Patients #2 and #3.

This finding was shared with the Staff A, the Vice President of Quality on 6/18/18 at 3:30 PM.

Based on medical record review, document review and interview, in one (1) of 10 medical records reviewed, it was determined that individuals who did not have training regarding the safe application of restraints were used to assist in the application of a four (4) point restraint. This was evident for Patient #4.

This failure may have placed patients at risk for harm.

Findings include:

Review of medical record #4 identified the following: the police brought this patient to the ED on 5/23/18 at 1:49 AM for a psychiatric evaluation. The patient was awake and alert and oriented to person, place and time, but was belligerent, disorganized and his impulse control was poor.

The ED physician saw the patient at 1:54 AM and documented that the patient had been brought in by police and EMS because he was behaving strangely. This physician's re-evaluation (not timed) indicated the patient was displaying aggressive behavior and was very uncooperative. "Police called to bedside to help restrain patient; Patient is medically cleared for psychiatric evaluation."

A late entry nurse's documentation also revealed security and police officers assisted with application of a four (4) point restraints after the patient's behavior continued to escalate (after receiving two (2) injections).

The facility's policy titled "Restraint Management" which was last reviewed on 12/16/2016 states, "only qualified White Plains staff may apply restraints."

Staff A, Vice President of Quality could not provide evidence that the police officer had appropriate training to assist with application of restraint.

The facility does not have a policy regarding the role of police officers in the management of agitated patients and in the application of physical restraints.

This finding was shared with Staff A, Vice President of Quality on 6/18/18 at 3:15 PM.