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Based on observations, review of clinical records, policies and procedures and staff interview, the Hospital failed to ensure a physical and chemical restraint were ordered according to the Hospital's policies and procedures for ordering of restraints, for one (1) of five (5) patients requiring restraints.

Findings include:

The Surveyor reviewed the Hospital policies titled Restraint (Adult and Pediatric), Restraint Clinical Guidelines and Restraint Documentation on 8/6/14. The Restraint Clinical Practice Guidelines indicated an individual restraint order by a Licensed Independent Practitioner was required for each episode of restraint and a "Restraint for Behavioral Emergencies" order form must be completed.

Patient #5's clinical record was reviewed on 8/4/14 by the Surveyor. The Emergency Department Record, dated 6/13/14 at 5:12 P.M. indicated Patient #5 was a sixteen year old admitted to a Pediatric inpatient unit after several recent visits to the Emergency Department for dehydration and fluid resuscitation because Patient #5 was refusing food/fluids by mouth. Patient #5 was transferred from a residential psychiatric treatment hospital with a mental health worker assigned as a 1 to 1 observer.

The Pediatric Progress Note, dated 6/15/14 at 8:34 P.M., a late entry, indicated the events that occurred in the afternoon of 6/14/14. The Pediatric Progress Note indicated Patient #5 had become irate, struck out at staff, destroyed property and required a physical hold by the security staff in order to recieve an injection of Haldol. The Pediatric Progress Note indicated Patient #5 required an chemical restraint with Haldol, for agitated and agressive behaviors towards staff.

The Nursing Shift Summary, dated 6/14/14 at 4:30 P.M., indicated Patient #5 was administered a chemical restraint, Haldol (a medication used to treat certain mental/mood disorders) 5 mg Intra-muscular (IM) at 3:40 P.M., and Patient #5 was then placed in four point (wrist and ankle) mechanical restraints.

Patient #5's Physician Orders, dated 6/14/14, did not contain an order for a physical hold to administer the Haldol, no order for the four point (mechanical) restraints, nor was a "Restraint for Behavioral Emergencies" order form completed as required by the Hospital policy.

According to the "Restraint Documentation Guide", a restraint check must be done the same hour as the initiation order. The restraint check included patient assessment, circulation, sensation and movement of the extremities, a check of skin integrity and to assess physical comfort (i.e. hydration and toileting). Because the physician failed to order the restraint according to the Hospital policy, no restraint monitoring sheet was generated and no restraint monitoring documentation was included in Patient #5's clinical record.

The Pediatric Hospitalist was interviewed at 10:45 A.M. on 8/13/14. The Pediatric Hospitalist said Patient #5 lost control and grabbed the Senior Resident, became violent, broke the hospital call system and was attempting to grab the wall hung television. The Pediatric Hospitalist said Patient #5 was attempting to bite staff and was physically restrained by security staff by holding the Patient #5. The Pediatric Hospitalist said Patient #5 was then placed in four point mechanical restraints. The Pediatric Hospitalist said he did not remember Patient #5 vital signs being abnormal. The Pediatric Hospitalist said he had restraint training by the Hospital.

After the Survey, the Surveyor reviewed the Ambulance Report form, dated 6/14/14, from the Ambulance transport at 4:38 P.M. on 9/10/14. The Ambulance Report form indicated Patient #5 was transported back to his/her residential Hospital in four point restraints on a Section 12 (Temporary Involuntary) status. The physician failed to order for continued four point restraint or four point restraints during the ambulance transport on a Section 12.

Based on observations, review of clinical records, policies and procedures and staff interview, the Hospital failed to consistently adhere to policies and procedures for ongoing restraint assessment for one (1) of five (5) patients requiring restraints.

The Surveyor reviewed the Hospital policies titled Restraint (Adult and Pediatric), Restraint Clinical Guidelines and Restraint Documentation on 8/6/2014. The Restraint Clinical Practice Guidelines indicated a restraint order was to remain in effect no longer than 2 hours for children and adolescents 9 to 17 years of age.

Patient #5's clinical record indicated no order for restraint, thus a determination of a re-order time for Patient #5's restraint order could not be established.

Based on observations, review of clinical records, policies and procedures and staff interview, the Hospital failed to consistently adhere to policies and procedures for ongoing restraint assessment and monitoring for one (1) of five (5) patients requiring restraints.

The Surveyor reviewed the Hospital policies titled Restraint (Adult and Pediatric), Restraint Clinical Guidelines and Restraint Documentation on 8/6/2014. The Restraint policy indicated a monitoring and assessment tool was to be generated at the time of the restraint order. The monitoring and assessment tool contained the schedule for vital signs and restraint checks. The restraint check included patient assessment, circulation, sensation and movement of the extremities, a check of skin integrity and to assess physical comfort (i.e. hydration and toileting).

Because the physician failed to write the restraint order, the assessment and monitoring tool was not generated and a restraint monitoring schedule for Patient #5' was not established. There clinical record did not evidence vital signs or restraint checks for Patient #5 during the period of mechanical restraint.

The Risk Manager was interviewed at 11:00 A.M. on 8/6/14. The Risk Manager said there was no evidence in Patient #5's clinical record that Patient #5 was monitored per the Hospitals restraint policy.