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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0168 The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. Based on document review and interviews, the facility failed to ensure a physician order to restrain a patient in violent restraints was obtained for 1 of 1 patient records who were admitted to the Emergency Department (ED) with violent restraints in place.

A-0175 The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. Based on document review and interviews, the facility failed to monitor the condition of patients who were restrained in 1 of 1 patient records who were admitted to the Emergency Department (ED) with violent restraints in place (Patient #3).

Based on document review and interviews, the facility failed to ensure a physician order to restrain a patient in violent restraints was obtained for 1 of 1 patient records who were admitted to the Emergency Department (ED) with violent restraints in place (Patient #3).

Findings include:

Facility policy:

The Restraint policy, dated 11/30/17 read, orders for restraints have to be written by the physician responsible for the patient's care. All restraint orders must specify the time and date the restraint order was placed, the clinical justification for restraint use and the behavior based criteria required for removal of restraints. Orders for restraint due to violent or self-destructive behavior must be time limited and not exceed four hours. To continue violent or self-destructive behavior restraints a renewal order must be written by the physician every four hours. Restraint orders may be renewed in four hour increments for a maximum of 24 consecutive hours.

1. The facility failed to ensure a physician wrote an initial order and a renewal order for each four hour episode for a patient placed in violent or self-destructive restraints.

a. According to Patient #3's record review, Patient #3 was admitted to the ED on 3/27/21 at 7:11 p.m. The facility restrained Patient #3 on arrival to the ED with violent/self-destructive restraints. Patient #3 remained in restraints until 3/28/21 at 1:05 a.m. (six continuous hours). The record review revealed an initial physician order for the use of violent or self-destructive restraints was not obtained for Patient #3. Additionally, a physician did not write a renewal order for the use of violent or self-destructive restraints on Patient #3.

b. According to the Restraint policy, all restraint orders must have a physician order which specified the date and time in which restraint were initiated as well as the clinical justification for use and criteria for removal. The order must be renewed by the physician every four hours.

c. On 4/28/21 at 1:34 p.m., an interview was conducted with Registered Nurse (RN) #2. RN #2 stated physicians had to order restraints immediately or within 10 to 15 minutes after reviewing the use of restraints with the patient's RN. RN #2 stated the physician had to specify justification for restraint use in the order. RN #2 stated physicians had to write restraint orders for violent or self-destructive restraints since the facility did not allow verbal orders for violent or self-destructive restraints. RN #2 stated physicians had to write a new restraint order every four hours for patients placed in violent or self-destructive restraints. RN #2 stated she was not allowed to restrain a patient without a physician's order.

RN #2 reviewed the medical record for Patient #3. RN #2 stated she was unable to find any restraint orders in the medical record. RN #2 stated the RN should have checked for the restraint order and contacted Patient #3's physician if she could not find a written restraint order.

d. On 4/28/21 at 2:00 p.m., an interview was conducted with RN #1. RN #1 stated a physician had to write an order to restrain a patient. RN #1 stated he was able to initiate the use of restraints before restraint orders were written by the physician when the safety of staff and the patient were at risk. RN #1 stated a physician should write a restraint order no more than 15 minutes after restraints have been initiated. RN #1 stated he would only accept a verbal order to initiate restraints for patients "in crisis".

e. On 4/29/21 at 10:40 a.m., an interview was conducted with Physician #4. Physician #4 stated physicians had to place a written order to place a patient in restraints. Physician #4 stated the facility did not allow verbal restraint orders. Physician #4 stated RNs could initiate restraint use if patients posed a danger to themselves or others. Physician #4 stated the facility required physicians to write restraint orders within 15 minutes of restraint initiation. Physician #4 stated physicians had to write restraint orders even if the physician verbally instructed staff to initiate restraints.

Physician #4 stated patients in restraints were at risk for decompensation and physical harm. Physician #4 stated physicians were accountable for the well-being and care of the patients while patients were restrained.

Based on document review and interviews, the facility failed to monitor the condition of patients who were restrained in 1 of 1 patient records who were admitted to the Emergency Department (ED) with violent restraints in place (Patient #3).

Findings include:

Facility policy:

The Restraint policy, dated 11/30/17 read, staff were to monitor the appropriateness and necessity of restraint use at regular intervals. An initial restraint assessment should be performed at the time restraints were initiated. Subsequent restraint reassessments were to be completed every two hours. Restraint assessments were performed to review and evaluate patient vital signs, skin integrity, the need for range of motion and circulation exercises for restrained limb(s), the patients physical needs while restrained, protection of the patients safety, rights and dignity while restrained, provide patient education and restraint alternatives and lastly to evaluate patient readiness for restraint release. The restraint order, initiation/application of restraints, patient education, restraint use medical evaluation, termination of restraints, patient assessments and monitors performed while patients were restrained must be documented in the medical record.

1. The facility failed to ensure patients in restraints were assessed every two hours according to facility policy.

a. Record review of Patient #3's restraint documentation read, Registered Nurse (RN) #1 completed a restraint assessment for Patient #3 on 3/27/21 at 7:11 p.m. Review revealed the patient had been placed in restraints upon his arrival to the Emergency Department.

Staff should have completed restraint assessments at 9:11 p.m. and 11:11 p.m. A subsequent restraint assessment was not completed until 3/28/21 at 12:46 a.m., (five and a half hours after restraints were applied).

b. According to the restraint policy, a restraint assessment should be performed every two hours while a patient was restrained.

c. Interviews with staff revealed patients in restraints should be assessed every two hours.

i. On 4/28/21 at 1:34 p.m., an interview was conducted with Registered Nurse (RN) #2. RN #2 stated patients placed in restraints were assessed every two hours. RN #2 stated she had been trained how to complete documentation for the two hour restraint assessment.

RN # 2 reviewed the medical record for Patient #3. She stated the restraint documentation was incomplete and was not completed according to the facility policy.

ii. On 4/28/21 at 2:00 p.m., an interview was conducted with RN #1. RN #1 stated patients in restraints were constantly monitored. RN #1 stated restraint assessments were performed every two hours while patients were in restraints. RN #1 stated documentation must be entered in the medical record when the two hour restraint assessments were completed.

RN #1 stated he did not recall providing care for Patient #3. RN #1 stated he did not remember if he performed a restraint assessment for the patient.

iii. On 4/29/21 at 8:47 a.m., an interview was conducted with RN Manager (Manager) #3. Manager #3 stated patients in restraints must be assessed every two hours. Manager #3 stated the two hour restraint assessments were documented in the medical record.

Manager #3 stated restraint documentation for Patient #3 should have been more thorough and follow up with the physician should have occurred. Manager #3 stated restraint documentations were missing for Patient #3.