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Based on record reviews and interviews, the hospital failed to ensure the condition of patients, who were in restraints, were monitored every two (2) hours in accordance to hospital policy for two (2) of five (5) patients reviewed (Patient #1R and #3R).

Findings:

The hospital's "Restraint and Seclusion" policy, last reviewed 9/2021, requires the following, in part, for an ongoing assessment for non-violent non-self destructive restraints, "The qualified RN [Registered Nurse] ongoing documentation will include the following at a minimum of approximately every 2 (two) hours on the Non-Violent Non-Self destructive flowsheet in the EMR [Electronic Medical Record]:
a. Criteria to determine if a restraint meets the requirements for using non-violent, non-self-destructive restraint.
b. Behavioral observations of the patient in restraints are recorded at least every two (2) hours.
c. Interventions for needs are recorded approximately every two (2) hours.
d. Documentation of the termination of restraint will be documented on the Non-Violent Non-Self destructive flow sheet in the electronic health record.
e. The qualified RN must discontinue the order in the electronic documentation system (choose "no longer clinically indicated" from dropdown list)".

1. Patient #1R's medical record indicated right and left hand mitt restraints were ordered at 4:23 PM on 10/14/2021 and the order was discontinued at 10:12 AM on 11/15/2021. There was no evidence of the required documentation by the RN until the restraint was discontinued at 10:12 AM on 11/15/2021 (a duration of 17 hours and 49 minutes).

2. Patient #3R's medical record indicated right and left soft limb restraints were ordered at 7:58 PM on 11/13/2021, applied at 8:00 PM on 11/13/2021, and were discontinued at 12:47 PM on 11/14/2021. There was no evidence of the required documentation by the RN between 5:48 AM on 11/14/2021 through 12:47 PM on 11/14/2021 (a duration of 6 hours and 59 minutes).

On 11/15/2021 at approximately 12:01 PM, the above findings were confirmed with the Quality Improvement Specialist.

Based on document reviews and interviews, the hospital failed to ensure that Licensed Independent Providers ("LIP"), who had ordered restraints, completed annual restraint training for three (3) of four (4) LIPs reviewed (LIP #1, #2 and #3).

Findings:

The hospitals "Restraint and Seclusion" policy, last reviewed 9/2021, defines an LIP in part as, "An individual permitted by law and by the organization to provide care, treatment, and services without direction or supervision. A LIP operates within the scope of his or her license, consistent with individually granted clinical privileges"...and the "LIP or his or her designee must place the order to initiate restraint". The policy also states that LIPs must complete a self-study for restraints during orientation and at least every twenty-four (24) months.

Surveyors requested to review the restraint training for four (4) LIPs who were involved in ordering restraints in the last year. The following was noted:
- LIP #1 had no documented evidence of receiving restraint training since 2/5/2019; and
- LIP #2 and #3 had no documented evidence of receiving restraint training.

On 11/16/2021 at approximately 10:46 AM, the above findings were confirmed with the Director of Quality.