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Based on documentation review and interview, it was determined that for 1 of 9 (Pt #5) clinical record reviewed for restraints, the Hospital failed to ensure the use of restraints was in accordance with an order by a physician or licensed practitioner.

1. On 4/12/2021, the Hospital's policy titled, "Seclusion-Restraint" (effective 12/4/2018) was reviewed and required, "...Management of violent or self-destructive behavior is ordered by a physician..."

2. On 4/12/2021, Pt #5's clinical record, dated 2/10/2021 to 2/22/2021, was reviewed and indicated the following:
-Pt #5 was admitted to the BHU (Behavioral Health Unit) on 2/10/2021 with a diagnosis of suicidal ideation.
-Pt #5's nursing note (E #5) dated 2/17/2021 at 1:13 PM noted, "... Observed [Pt #5] anxious... threatening to harm self and attack safety attendant while attempting to stop [Pt #5] from scratching herself... Begin kicking and punching staff, becoming extremely combative... 1:1 interaction attempted... Pt #5 placed in 4 point restraints due to imminent danger to others." Pt #5's restraint documentation, dated 2/17/2021, noted that Pt #5 was in restraints from 1:05 PM to 5:00 PM ( 3 hrs and 55 minutes).
-Pt #5's clinical record lacked documentation of a physician's order for Pt #5's restraints on 2/17/2021.

3. On 4/12/2021 at 1:00 PM, an interview was conducted with the BHU Charge Nurse (E #1). E #1 stated that there should have been a physician's order for the use of restraints on 2/17/2021 for Pt #5.

Based on document review and interview, it was determined that for 1 of 9 records (Pt. #1) reviewed for restraint use, the Hospital failed to ensure that the patient's vital signs were monitored every 2 hours while restrained, as required by policy.

Findings include:

1. The Hospital's policy titled, "Seclusion-Restraint" (effective 12/4/2018), was reviewed on 4/12/2021 and required, "...Care While in Restraints-Observation requirements-... the following are performed at specific intervals: ...Vitals signs (Temperature, pulse, respiration, and blood pressure) are taken initially when patient is placed in restraints and then every 2 hours..."

2. The clinical record of Pt. #1 was reviewed on 4/12/2021 with the Charge Nurse (E#1). Pt. #1 was admitted on 9/1/2020, with a diagnosis of schizophrenia (mental disorder). The record included four orders for violent or self-destructive 4-point (both wrists and ankles) restraints on 9/1/2020 at 9:46 AM and 1:50 PM, and on 9/2/2020 at 9:11 AM and 1:15 PM. Each order was for 4 hours each, and the reason for restraints was due to aggressive behavior, danger to self/others, and assaulting staff. The clinical record indicated that Pt. #1 was in restraints on 9/1/2020 from 9:45 AM to 5:40 PM (approximately 8 hours) and on 9/2/2020 from 9:05 AM to 5:00 PM (approximately 8 hours). Each restraint episode was within the 4-hour limit. A new order was obtained after the 4 hours was up. Vital signs were taken initially when Pt #1 was placed in restraints. However, restraint flowsheets lacked documentation of vital signs on 9/1/2020, from 12:45 PM to 5:40 PM (nearly 5 hours); and on 9/2/2020, from 9:05 AM to 5:00 PM (nearly 8 hours, whole restraint episode). The record did not include documentation that Pt. #1 refused to have vitals taken during those periods.

3. An interview was conducted with the Charge Nurse (E#1) on 4/12/2021, at approximately 12:20 PM. E#1 stated that vitals signs should be monitored every 2 hours while the patient is in restraints. E#1 stated that if the patient refuses or staff are unable to obtain the vitals, the reason should be documented in the record. E#1 could not find documentation of a reason why vitals were not taken in Pt. #1's electronic medical record.