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Based on interview and document review, the facility failed to appropriately document the type of restraints used for one of four patients (P1) reviewed for restraint application when P1 was placed in violent restraints to prevent imminent harm to others.

Findings include:

P1 presented to the emergency department on 6/28/25 at 3:11 p.m. via ambulance after being found unresponsive in the community. P1 did not have a chief complaint on file and did not have a relevant medical history.

An order dated 6/28/25 at 4:31 p.m. indicated P1 was placed in bilateral wrist and ankle non-violent restraints to prevent pulling at lines and tubes. There was no order for placement of violent restraints in P1's medical record.

Flowsheet documentation under non-violent restraints on 6/28/25 at 4:40 p.m., bilateral soft wrist restraints were applied to P1 for pulling lines and tubes. The flowsheet documentation indicated alternative methods could not be attempted due to P1's condition. Flowsheet documentation did not indicate P1 was placed in violent restraints during his hospitalization.

A provider note dated 6/28/25 at 4:54 p.m., indicated P1 had run out of his room while screaming and hitting equipment and furniture. Security was involved and P1 was placed in four-point restraints. The note indicated despite restraints, P1 continued violent behavior, and multiple medications were administered to chemically sedate the patient. Despite additional medications, P1 continued to scream and fight the restraints, creating a high-risk of self-harm. The note indicated P1 was given additional medication and then intubated for airway protection.

During an interview on 7/9/25 11:19 a.m., registered nurse (RN) -A stated staff are trained how to use nonviolent restraints, which are often called soft restraints. RN-A stated staff can place patients in four-point locking restraints as well, which are often referred to as hard restraints.

During an interview on 7/9/25 at 2:32 p.m., RN-B stated four-point violent restraints are used to if a patient is threatening or hurting staff or others. RN-B stated non-violent restraints are to protect a patient if they are pulling at their tubes supporting their airway.

During an interview on 7/10/525 at 9:12 a.m., medical doctor (MD)-A stated he had been caring for P1 in the ED on 6/28/25. MD-A stated he observed as security, nursing, and the police transferred to P1 to a bed and was placed in four-point restraints. MD-A stated P1 was so agitated the decision was made to chemically sedate P1 and intubate to protect his airway as he was a risk to hurting himself while restrained. MD-A stated P1 was then transitioned to non-violent restraints.

During an interview on 7/10/25 at 11:00 a.m., security guard (SG) - A stated he was trained how to use multiple types of medical restraints, including violent restraints and soft restraints. SG-A stated he assisted in placing P1 into four-point hard restraints, and then medical staff intubated P1.

During an interview on 7/10/25 at 11:21 a.m., SG-B stated he was trained in soft restraints and four-point locked restraints. SG-B stated he assisted placing P1 in four-point hard restraints in the ED.

During an interview on 7/10/25 at 1:47 p.m., RN-C stated she was working in the ED on 6/28/25 when P1 began having a behavioral episode. RN-C stated when P1 was placed into four-point restraints, she administered an IM dose of a chemical restraint with a verbal order from a provider.

During an interview on 7/10/25 at 2:03 p.m., RN-D stated violent restraints requiring documentation by a nurse every fifteen minutes.

During an interview on 7/14/25 at 8:36 a.m., RN-E stated she was at break during P1's behavioral outburst on 6/28/25. RN-E stated when she returned, P1 was being manually held on the bed by staff as they waited for sedation to take effect. RN-E stated afterwards, they placed P1 into bilateral wrist soft restraints.

During chart review on 7/14/25 at 9:49 a.m., the nursing informatics program manager stated there was no order in P1's chart for violent restraints, and there was no charting for placement of violent restraints.

During an interview on 7/14/25 at 11:44 a.m., the nursing supervisor of the ED stated restraints violent restraints should be documented on every 15 minutes by the nurse.

An undated facility policy titled "Restraint (Non-violent and Violent) and Seclusion Policy," indicated upon initiation of restraint there must be documentation of the type of intervention used.