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Based on interviews, record review (RR) and document review, the facility failed to have consistent processes in place for the high-risk intervention of restraint to protect and promote each patient's rights in the Behavioral Health Services Unit (BHU). The investigation identified several deficiencies at the Standard level. The lack of consistent processes and the cumulative effect of the deficiencies, decreases the protection of patient rights and increases the likelihood of harm and resulted in a Condition level deficiency in Patient Rights.

Findings include:

1) The facility is an acute care hospital that is part of an integrated health system servicing the West Coast and Hawaii. The hospital operates an inpatient Behavioral Health Services Unit where patients receive services for full-range of psychiatric disorders.

Reviewed the "Systemwide Standard Policy" titled "Standard Policy: Restraint Management (Mechanical, Chemical, Seclusion) number 12579 last reviewed by individual entity, 06/2024. The policy summary included the statement " To outline an organizational approach to restraints that protects the patient's health and safety and preserves their dignity, rights and well being. This includes a description of patients basic rights, organizational intent to eliminate inappropriate and unnecessary use of restraint or seclusion and to manage restraint initiation, monitoring, discontinuation, staff education and reporting."
"J. Quality Assessment and Performance Improvement (QAPI) 1. The organization leadership is responsible for creating a culture that supports patient rights. Leadership ensures that the policy is followed as intended. Data will be collected on the use of restraint/seclusion. The use of restraint will be analyzed and measured for quality assurance/control, performance improvement, and identification of patterns, tends, and variations by the QAPI committee."

The investigation revealed a lack of effective administrative and clinical processes that led to areas of noncompliance at the standard level. Facility leadership was unaware of the issues of noncompliance and did not have an effective process in place to ensure their policy was followed. The cumulative effect of these deficiencies resulted in a Condition level deficiency in Patient Rights.

2) Cross Reference A-154 Patient Rights: Restraint
The facility leadership failed to ensure there was an organized effective quality improvement process in place to assess, monitor and identify needs for improvement in the use of restraint/seclusion to support patient's rights. The BHU audited restraint events, but did not identify noncompliance with regulations. In addition, the facility could not provide evidence restraint use was incorporated into the Quality Assurance Performance Improvement (QAPI) program.

3) Cross Reference A-168 Patient Rights: Restraint
The facility failed to obtain an order immediately (within a few minutes) from a LIP (Licensed Independent Practitioner operates within the scope of his or her license, consistent with individually granted privileges) after an emergency application of restraint on two patients (P)1 and P4, of a sample size of four.

4) Cross Reference A-170 Patient Rights: Restraint
There was lack of evidence that the LIP, responsible for the management and care of one patient (P)1 of a sample size of four, was made aware of an emergency restraint intervention.

5) Cross Reference A-178 Patient Rights: Restraint
The facility failed to ensure a LIP provided the face-to-face evaluations within one hour after emergency restraints were applied on three patients (P)1, P2, and P3 of a sample size of four. In addition, the facility policy for Restraint Management, that included the 1-hour face-to-face evaluation, was a "Systemwide Standard Policy," and did not specify what categories of practitioners (i.e. Registered nurses (RN), Advanced Practice Professionals) were authorized to conduct the evaluation at this facility.

6) Cross Reference A-179 Patient Rights: Restraint
Documentation is a key practice in any clinical treatment, but especially important when a high-risk intervention like restraint is used. The facility failed to ensure the face-to-face evaluation (clinical and behavioral assessments) met regulatory standards. In three patient's (P)1, P2, and P3 of a sample size of four, the 1-hour, face-to-face evaluations did not meet requirements because 1) the brief findings were documented by RN's, rather than the LIP when the evaluation was conducted, 2) the times entered by the RN's were the time the restraints were initiated. The actual tune the LIP conducted the evaluation is unknown, and 3) there was lack of documentation of a physical and behavioral assessment to rule out possible underlying causes or contributing factors to the patient's behavior.

Based on interviews, Medical Record Review and document review, facility leadership failed to ensure there was an organized effective quality improvement process in place to assess, monitor and identify needs for improvement in the use of restraint/seclusion to evaluate and support patient's rights. The Behavioral Health Services Unit (BHU) audited restraint events, but did not identify noncompliance with regulations. Specifically, there was trend on the evening/night shift the one-hour face-to-face did not include the actual time of the evaluations, were not completed tiennly, and the content of the assessments did not meet regulatory standards. In addition, the facility could not provide evidence restraint use throughout the facility was incorporated into the QAPI program.

Findings include:

1) Reviewed the Facility Systemwide Standard Policy number 12579, titled "Standard Policy: Restraint Management (Mechanical, Chemical, Seclusion), last reviewed 06/10/2024. The policy included:
Definition: "G. Quality Assessment and Performance Improvement (QAPI): The hospital must develop, implement, and maintain an effective, ongoing, hospital-wide, data driven quality assessment and performance improvement program. The hospital's governing body must ensure that the program reflects the complexity of the hospital's organization and services; involves all hospital departments and services ...; and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors."
"J. Quality Assessment and Performance Improvement (QAPI) 1. The organization leadership is responsible for creating a culture that supports patient rights. Leadership ensures that the policy is followed as intended. Data will be collected on the use of restraint/seclusion. The use of restraint will be analyzed and measured for quality assurance/control, performance improvement, and identification of patterns, tends, and variations by the QAPI committee.

Reviewed the Facility Behavioral Health Services Policy titled "Policy & Procedure: Suicide Prevention - Interventions in Behavioral Health Settings, Number CMBHPP060039, review date 06/17/2024. The policy included "G. Implementation and effectiveness of this policy shall be monitored via periodic validation audits with reporting of aggregate data to leadership and to the committee overseeing quality.

2) On 10/31/2024 at approximately 02:15PM, during an interview with the Director Quality (QD), she said the Manager of BHU recently left the position, and was unavailable for interview. She said the unit does a debriefing on all restraint events, and maintains a binder on the unit for chart audits. She went on to say, if anything was identified that needed referral for follow up, it would be reported to the Manager. Request was made for any documentation that the data was aggregated, reported and incorporated into the facility QAPI program. The QD said they would investigate and respond.

On 11/05/2024, the following correspondence was received by email from the QD. "The Behavioral Health Unit (BHU) Manager conducts ongoing reviews of restraint debriefing forms to ensure completeness. Key components of this review include verifying physician orders for restraints, alignment with care plans, adherence to policy for vital sign monitoring, timely face-to-face evaluations of patients, and discontinuing restraints at the earliest appropriate moment. Additionally, any potential patient harm events are reviewed by Patient Safety Council. A gap was identified in the routine reporting of the data (i.e. the review by the BH manager) to the appropriate council. To address this, a structured process for reporting restraint data to the quality council was established on 11/04/2024 with the first report scheduled for 11/25/2024. The restraint data is now integrated into the Quality Assurance and Performance Improvement (QAPI) program and will be reported quarterly to monitor for process gaps and drive any necessary improvements."

Based on interviews, medical record review (RR) and document review, the facility failed to obtain an order immediately (within a few minutes) after an emergency application of restraint on two patients (P)1 and P4, of a sample size of four. As a result of this deficiency the use of these restraints were not used 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 by hospital policy.

Findings include:

1) Reviewed the Facility Systemwide Standard Policy number 12579, titled "Standard Policy: Restraint Management (Mechanical, Chemical, Seclusion), last reviewed 06/10/2024. The policy included:
"Definitions: ... B. Emergency Situation: An immediate, urgent or critical situation of a temporary nature, regardless of its cause, which may seriously endanger or threaten the life, health, or safety of individuals."
"RN (Registered Nurse) may authorize/initiate mechanical or seclusion restraints (excluding chemical) in emergency situations without an order but must obtain an order from the LIP (licensed independent practitioner) during the emergency application of the restraint or seclusion, or immediately (within a few minutes) after the restraint has been applied."
" LIP or clinical psychologist is consulted, as soon as possible, if they did not order the restraint(s) or seclusion."

2) On 10/31/2024 at 12:50 PM, during an interview with a Psychiatric Mental Health Nurse Practitioner (PMHNP)1, she said she was employed by the hospital and the BHU had on site coverage with a LIP (MD/OD/PMHNP) every day from 07:00 AM until 07:00 PM. After hours, one of the BHU LIP's will be on call. She went on to say when emergency restraints are initiated during after hours, the nursing staff will usually notify the on call BHU provider for the restraint order, but will then notify the hospitalist (24/7 coverage) by pager, to come to the unit to do the face- to-face evaluation.

3) P1 was a 45 year old female brought to the Emergency Department (ED) on October 8, 2024. She had no known previous psychiatric history, but had a past pertient medical history of hypertension. P1 was admitted to the BHU at 02:33 AM on 10/09/2024, where she became intrusive with other peers, did not respond to verbal redirections, and required sedation and emergency restraint.

RR of P1's "Restraint/Seclusion Progress Record (45BHCS) revealed the following:
10/09/2024 at 03:45 AM, emergency restraint applied using the 5-pt (five point) restraint chair.

RR of P1's orders revealed the following:
10/09/2024 04:30 AM Restraint Order initiated (entered in electronic medical record) by Registered Nurse (RN)1
10/09/2024 04:30 AM Psychiatric Mental Health Nurse Practitioner (PMHNP)2 notified by phone. RN1 conducted readback (process to validate phone order).

RR of "Nursing Documentation - Flowsheet, which included the following entries documented by RN1 :
10/09/2024 at 03:45 AM: Documented PMHNP2 notified by phone regarding restraint. For physician communication results, RN1 documented "No orders received"
10/09/2024 at 03:58 AM: Hospitalist (MD)1 notified of restraint by phone, pager.
Although the nursing note documented the PMHNP2 was notified at 03:45 AM, there was no documentation of an order obtained or entered until 04:30 AM.

3) P4 was a 23 year old male admitted to the BHU due to suicidal and homicidal threats on 08/15/2024. On 08/16/2024, P4 had behaviors that required emergency restraint.
RR of P4's "Restraint/Seclusion Progress Record revealed the following:
08/16/2024 at 09:21 PM, emergency restraint applied using the restraint chair.

RR of P4's orders revealed the following:
08/16/2024 at 09:23 PM, order for "Restraint/Seclusion" entered by RN3.
08/16/2024 at 10:29 PM, "Communication Type: Phone w/ Readback" entered by RN3

Review of Nursing Documentation Flowsheet revealed the following entries:
08/16/2024 at 09:50 PM:
Physician (MD) notified: "MD2"
Notified by "phone"
Notified of "Restraint/Seclusion"
Physician communication results "Orders received"
"Comments/Attempts to notify "
This documentation was followed by corrected results, "Date and time corrected from 8/16/2024 21:23 (09:23 PM (time order entered by RN)) HST (Hawaii Standard Time) on 8/16/2024 22:37 (10:37 PM)," entered by RN3.
There was a delay in over an hour to obtain the order for emergency restraint.

Based on interviews, record review (RR) and document review, there is lack of evidence that the attending physician, responsible for the management and care of one patient (P)1 of a sample size of four, was aware of an emergency restraint intervention. As a result of this deficiency, the attending may not have information that may have a significant impact on the subsequent course of treatment.

Findings include:

1) P1 was a 45 year old female brought to the Emergency Department on October 8, 2024 by the police for psychiatric care after having religious preoccupation and delusion. She had no known previous psychiatric history, but had a past pertient medical history of hypertension. P1 was admitted to the Behavioral Health Services Unit (BHU) on a MH4 (involuntary 48 hour hold/ deemed to be at risk for harm to self or others). She was transported to the BHU at 02:33 AM. P1 became intrusive with other peers, and did not respond to verbal redirections, and required sedation and emergency restraint.

RR of P1's "Restraint/Seclusion Progress Record (45BHCS) revealed the following:
10/09/2024 at 03:45 AM, emergency restraint applied using the 5-pt (five point) restraint chair.
10/09/2024 at 07:40 AM, restraint terminated.

RR of P1's medical records revealed on 10/09/2024 at 04:30 AM, the on call LIP (Psychiatric Mental Health Practioner (PMHP)2) gave a phone order for the restraints, and LIP (MD1), conducted the 1 hour face-to-face evaluation. .

2) On 10/31/2024 at 01:15 PM, interviewed Registered Nurse (RN)1, who cared for P1 the night of the restraint. Inquired who notified P1's attending of the restraint, she said LIP1 doesn't take phone calls after she leaves the hospital, so would "normally notify the Medical Director if needed, and he would probably be the one to notify LIP, likely on the day shift.

On 10/31/2024 at 01:30 PM , interviewed RN2, a day shift charge, who said he wouldn't rely on the hospitalist who did the face to face evaluation to notify the attending, and said it would usually be nursing that would notify the attending in the morning and should be documented in the electronic medical record under "physician communication." He went on to say sometimes they use tiger text, to communicate, which would not be retrievable, or part of the medical record..

3) P1's attending was LIP1, the restraint was ordered by Psychiatric Mental Health Nurse Practitioner (PMHNP)2, and the 1 hour face-to-face was done by the Hospitalist (MD1). There is no documentation or evidence that the attending was made aware of the emergency restraint.

RR of LIP''s progress note dated 10/09/2024 at 11:39 AM, included "Per staff report, patient (P1) presents with bizarre behavior on the unit, intrusive with other peers, hugged roommate to "bless" her, did not respond to verbal redirections, requiring IM (intramuscularly) haldol, benadryl and ativan (sedatives) at 0309 and 1040. ..."

Based on interviews, medical record review (RR) and document review, the facility failed to provide evidence that a 1-hour face-to-face evaluations was conducted by a Licensed Independent Practitioner (LIP) after emergency restraints were applied on three patients (P)1, P2, and P3 of a sample size of four. As a result of these deficiencies, a prompt assessment was not done to evaluate the behavior that led to the intervention, and determine the continued need for the intervention. In addition, the facility policy for Restraint Management, that included the 1-hour face-to-face evaluation, was a "Systemwide Standard Policy,'" and did not specify what categories of practitioners (i.e. Registered nurses, Advanced Practice Professionals) were authorized to conduct the evaluation at this facility.

Findings include:

1) Reviewed the Facility Systemwide Standard Policy number 12579, titled "Standard Policy: Restraint Management (Mechanical, Chemical, Seclusion), last reviewed 06/10/2024. The policy included:
Definitions: "C. Face-to-Face Assessment: In -person evaluation documented by a licensed independent practitioner (LIP), or their designee, or registered nurse who has been trained according to the current regulatory requirement."
"F. Restraint Considerations- Violent/self-destructive: 3. If the face-to-face evaluation is conducted by a trained RN or Physician assistant, that RN or physician assistant must consult the LIP responsible for the care of the patient as soon as possible after completion of the 1-hour face-to-face evaluation."

2) On 10/30/2024, during an interview with the Quality Director (QD), inquired if the Registered Nurses (RN) were approved and to conduct the 1 hour face-to-face evaluation post emergency restraint. The QD, returned later and stated RN's are not approved to the evaluation and it must be a physician (MD/DO) or facility employed Psychiatric-Mental Health Nurse Practitioner (PMHNP)

3) P1 was a 45 year old female brought to the Emergency Department (ED) on October 8, 2024 by the police for psychiatric care after having religious preoccupation and delusion. P1 was admitted to the Behavioral Health Services Unit (BHU). When P1 became intrusive with other peers, did not respond to verbal redirection, and required sedation, emergency restraints were applied.
Review of P1's Medical records revealed the following:
- "Restraint/Seclusion Progress Record (45BHCS) revealed on 10/09/2024 at 03:45 AM, emergency restraint applied using the 5-pt (five point) restraint chair.
- "Nursing Documentation - Flowsheet" included the following entries documented by Registered Nurse (RN)1 :
10/09/2024 at 03:58 AM: Physician (MD)1 notified of restraint by phone, pager.
10/09/2024 at 04:09 AM: Physician Communication: "physician called back ... informed of restraints and asked if he can come and see patient. ..."
10/09/2024 at 05:17 AM, Clinical Nursing Note: "...At 0345 patient was placed in restraints, contact On call provider, contacted hospitalist (MD)1 (which we are still waiting for physician to see patient). contacted house supervisor. patient is currently in restraints at 0520 (05:20 AM) d/t (due to) not displaying safe behavior, still being verbally and physically aggressive to staff. ..."
-"Evaluation of Patient in Restraint/Seclusion" form: The form used to document the 1 hour face-to-face evaluation did not document the time MD1 actually completed the evaluation, but the nursing note above indicated it had not yet been completed at 05:20 AM, and was beyond the one hour requirement.

On 10/31/2024 at 01:15 PM, during a telephone interview with RN1, she confirmed she worked the night shift on 10/09/2024 and took care of P1 when the restraints were applied. She said she had a hard time tracking down the hospitalist to come do the evaluation that night. RN1 went on to say at night, they rely on the Hospitalist and it depends when they are able to come as they cover needs for the whole hospital. She confirmed she wrote in the time at the top of the evaluation, acknowledged it was the time the restraint was applied, and she did not know when MD1 actually did the evaluation. RN1 acknowledged there were "a few times they had a hard time getting the hospitalist to get up (to the BHU)."

4) P2 is a 20 year old female admitted to BHU from the ED on 07/06/2024 for suicidal ideation. On 07/10/2024, P2 had emergency restraint (restraint chair) applied for self harm behaviors.
-RR of P2's "Restraint/Seclusion Progress Record" included the following:
07/10/2024 at 10:23 PM, emergency restraint applied using the restraint chair.
07/10/2024 at 11:30 PM "RN + Doctor examine pt, release L (left) ankle.
This document revealed the face-to-face evaluation was completed by Provider (not identified on this form) over one hour from the time restraint was initiated.

5) P3 was a 36 year old female presented to the ED on 09/01/2024 with suicidal ideation and precipitated by multiple stressors. She was admitted to the BHU for psychiatric care where her behaviors required emergency restraint.
Review of P3's medical records revealed the following:
-"Restraint/Seclusion Progress Record:" On 09/01/2024 at 08:30 PM, emergency restraint applied using the restraint chair.
-"Evaluation of Patient in Restraint/Seclusion" form completed by the RN: The RN documented the time at the top of the form "2030 (08:30 PM)," which was the time P3's restraint was initiated. MD3 (illegible) signed the form, but there was no time documented to indicate when the evaluation was actually conducted.

Based on interviews, document review and medical record review (RR), three patient's (P)1, P2, and P3 of a sample size of four, did not have a documented 1-hour, face-to-face evaluation that met requirements. Specifically, 1) brief evaluation findings were documented by a Registered Nurse in preparation for the MD to sign, 2) the time documented on the form was the time the restraints were initiated, not the time of the qualified provider evaluation, and 3) the evaluation did not include a physical and behavioral assessment to rule out possible underlying causes or contributing factors to the patient's behavior.

Findings include:

1) Reviewed the Facility Systemwide Standard Policy number 12579, titled "Standard Policy: Restraint Management (Mechanical, Chemical, Seclusion), last reviewed 06/10/2024. The policy included: "After the initial intervention, patients will be seen face-to-face within 1 hour by a qualified LIP, registered nurse, or physician assistant who had reviewed education in accordance with requirements to evaluate: a. Patients immediate situation, b, Reaction to intervention, c. Medical and behavioral condition d. Need to continue or terminate the restraint (s),or seclusion."
standards, which includes both a physical and behavioral assessment.

The Centers for Medicare & Medicaid Services (CMS) interpretation is that an evaluation of the patients medical condition would include a complete review of systems assessment, behavioral assessment, as well as review and assessment of the patient's history, drugs and medications etc. The purpose of this evaluation is to complete a comprehensive review of the patient's condition to determine of other factors, such as drug or medication interactions, electrolyte imbalance, hypoxia, sepsis, etc., are contributing to the patient's violent or self destructive behavior.

2) Cross reference A-178 Patient Restraint
The quality practitioners authorized by the facility to conduct the 1 hour face-to-face evaluation after emergency restraint, included the categories of licensed independent practitioners (LIP) of MD (medical doctors), DO (Doctors of Osteopathic Medicine), and PMHNP (Pyschiatric Mental Health Nurse Practitioners). Registered Nurses are not authorized.

3) On 10/31/2024 at 12:50 during an interview with PMHNP1, she said the Behavioral Health Services Unit (BHU) had coverage on site from 07:00 AM until 07:00 PM. After hours, one of the Providers, MD, or PMHNP will be on call. She went on to say when emergency restraints are initiated during those hours, the RN staff will usually notify the on call BHU provider for the order, but will then notify the hospitalist on duty by pager, to come to the unit to do the face-to-face evaluation. PMHNP1 said nursing has a packet that contains all the required forms for restraints, and it includes a form for the provider to document the 1 hour face-to-face evaluation. She confirmed it is the providers responsibility to complete the form at the time of their evaluation.

4) Reviewed the form titled "Evaluation of Patient for Restraint/Seclusion," which had preprinted categories of Date, Time, Patient's Immediate Situation, Patient's reaction to the intervention, Patient's medical condition, Patient's behavioral condition, Continue or Terminate restraint or seclusion and Physician Signature.

5) P1 was a 45 year old female admitted to the Behavioral Health Services Unit (BHU) on October 8, 2024 for psychiatric care after having religious preoccupation and delusions. She had no known previous psychiatric history, but had a past pertient medical history of hypertension. P1 became intrusive with other peers, did not respond to verbal redirections, and required sedation and restraints.

RR of P1's "Restraint/Seclusion Progress Record revealed the following:
10/09/2024 at 03:45 AM, emergency restraint applied using the 5-pt (five point) restraint chair.
"Described behavior that justified restraint/seclusion: "screaming, physically aggressive, increasingly agitated."
"Described behavior that justified restraint/seclusion (second page): "Disorganized, impulsive, hostile, restless/pressured."
10/09/2024 at 07:40 AM, restraint terminated.

Reviewed P1's "Evaluation of Patient Restraint/Seclusion" form, completed by RN1. The form included:
"Date: 10/9/2024"
"Time: 0345"
"Patient's Immediate Situation: physically aggressive, lunged at staff, yelling, refusing to follow any direction."
"Patient's reaction to the intervention: continues to yell, verbally hostile, swearing."
"Patient's medical condition: stable"
"Patient's behavioral condition: currently still yelling, rocking in restraint chair, verbally hostile."
MD1 (illegible) signed the form, but there is no time noted.

On 10/31/2024 at 01:15 PM during a phone interview with RN1, who initiated the emergency restraint for P1 on 10/09/2024 confirmed the hospitalists do the face-to-face evaluations after 07:00 PM. When inquired who completes the "Evaluation of Patient in Restraint/Seclusion" form, RN1 said "the nurses do." She went on to say the Hospitalist signs the form when they come to the unit to see the patient.

The 1 hour face-to-face evaluation was not documented by the Provider, and does not reflect both a physical and psychological assessment of the patient in order to rule out possible underlying causes or contributing factors to the patient's behavior. .

6) P2 is a 20 year old female admitted to the BHU from the ED on 07/06/2024 for suicidal ideation. She had a past psychiatric history of schizophrenia and methamphetamine use. On 07/10/2024, P2 had emergency restraint (restraint chair) applied for self harm behaviors.

RR of P2's "Restraint/Seclusion Progress Record revealed the following:
07/10/2024 at 10:23 PM, emergency restraint applied using the restraint chair.
"Described behavior that justified restraint/seclusion: Banging doors, yelling, kicking, hurting self"
07/10/2024 restraint terminated at 11:55 PM.

Reviewed P2's face-to-face evaluation form, completed by the RN as follows:
"Date: 07/10/2024"
"Time: 2223 (10:23 PM)"
"Patient's Immediate Situation: pt. (patient/P2) banging door, kicking wall 2 staff yelling creaming; agitated"
"Patient's reaction to the intervention: medication was already given."
"Patient's medical condition: stable"
"Patient's behavioral condition: restless"
MD2 (illegible) signed the form, but no time documented.

The evaluation /assessment was not documented by the Provider, and does not reflect both a physical and psychological assessment of the patient in order to rule out possible underlying causes or contributing factors to the patient's behavior.

7) P3 was a 36 year old female has a history of borderline personality disorder, post traumatic stress disorder, attention deficit hyperactivity disorder, depression and agoraphobia (avoiding places or situations that might cause panic). She presented to the ED on 09/01/2024 with suicidal ideation precipitated by multiple stressors and was admitted to BHU for psychiatric care, where her behaviors required emergency restraint.

RR of P3's "Restraint/Seclusion Progress Record revealed the following:
09/01/2024 at 08:30 PM, emergency restraint applied using the restraint chair.
"Described behavior that justified restraint/seclusion: "Assaultiveness towards security and this writer upon admission, scratched writer on L (left) wrist; kicked at writer and security"
09/01/2024 restraint terminated at 10:00 PM.

Reviewed P3's face-to-face evaluation form, completed by the RN as follows:
"Date: 09/01/2024"
"Time: 2030 (08:30 PM)"
"Patient's Immediate Situation: aggressive, assaulted staff"
"Patient's reaction to the intervention: unwilling to process w/ (with) staff; wanting to leave or have a private room."
"Patient's medical condition: none"
"Patient's behavioral condition: crying, but not willing to participate on education."
Continue restraint was checked.
MD3 (illegible) signed the form, but no time documented.

The evaluation /assessment was documented by the RN, not the physician, and does not reflect an appropriate physical and psychological assessment of the patient in order to rule out possible underlying causes or contributing factors to the patient's behavior.