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Based on record review, document review, and interview, it was determined the facility staff failed to obtain an order for the use of a restraint for the management of one (1) violent or self-destructive patient (MR2).

Findings:

Review of facility document, Restraints or Seclusion for Violent, Self-Destructive Patient Situations, under the heading "D. Restraint or Seclusion Order (to manage violent or self-destructive behavior)", it partly reads: "1. Any type of violent restraint including, but not limited to, 4-point restraints, chemical restraints, physical hold, or use of force in order to medicate a patient, seclusion, etc. requires a provider order. 2. In the absence of an order, the RN may initiate use of restraints or seclusion in emergency situations. In emergency situations, the order must be obtained either during the emergency application of the restraint or initiation of seclusion or immediately (within a few minutes) after the restraint has been applied or seclusion has been initiated. Failure to immediately obtain an order is viewed as the application of a restraint or seclusion without an order. [CMS.482.13(e)(5)]...". The document was effective November 20, 2025, with a change relating to the removal of immediate notification and CNO within 4 hours. The prior version of the document was effective June 23, 2025.

A comprehensive review of MR2 revealed that on September 30, 2025 at 3:30 PM, MR2 was observed becoming "increasingly agitated" walking back to the stretcher after using the restroom. EMP11 noted that the patient was screaming and was moved into room 17 with law enforcement remaining at the bedside.

EMP13 entered a note at 4:29 PM that read, "The patient increasingly agitated in the emergency department, kicking, threatening to bite, and spitting on staff. Patient required physical restraint by staff followed by 4 point forensic restraints to shackled the patient to the bed. [Patient] received 5 mg of IM Haldol as well as 5 mg of IM Valium for chemical restraint".

Interview on December 17, 2025 at 3:34 PM, EMP13 indicated that MR2's behavior began to escalate and continued to escalate. EMP13 acknowledged that MR2 was offered medication, but "[patient] continued to decline it". MR2's behavior escalated to the point that "[patient] became physical with staff" and "we had to take the action most appropriate at the time of the incident". EMP13 acknowledged that a physical hold (by facility staff) was necessary to de-escalate the patient and administer IM medications.

A review of the orders during MR2's ED visit did not reveal a physician's order for restraints; for either the physical hold or the chemical restraint.

Based on record review, document review, and interview, it was determined the facility staff failed to monitor two (2) patients in restraints as directed by facility procedure (MR2 and MR8).

Findings:

Review of facility document, Restraints for Nonviolent, Non-Self-Destructive Patient Situations: Medical Use of Restraints, under the heading "V. Procedure", it partly reads: "... F. SAFE APPLICATION / MONITORING / DOCUMENTATION / REMOVAL ... 2. Monitoring / Documentation a) A patient's physical and emotional needs are considered while the individual is in restraint. The basic rights of human dignity and respect are maintained, ... c) Assessment of the patient during restraint use is the responsibility of the Registered Nurse or LPN under the supervision of the RN ... d) Every 2 hours, perform the following: i. Continued Justification ii. Visual/Safety check iii. Circulation / Skin Integrity iv. Range of Motion v. Fluids vi. Food and Meal vii. Elimination e) Vital signs as indicated by patient status...". The document was effective on October 27, 2025.

Review of facility document, Restraints or Seclusion for Violent, Self-Destructive Patient Situations, under the heading "F. SAFE APPLICATION / MONITORING / DOCUMENTATION / REMOVAL", it partly reads: "... 2. Monitoring / Documentation a) Any patient placed in restraints or seclusion for the management of violent or self-destructive behavior must be monitored continuously by trained staff until the restraints are removed or seclusion is discontinued... g) Assessment of the patient during restraint or seclusion use is the responsibility of the Registered Nurse... h) Minimum Documentation in the medical record from restraints or seclusion related to violent and/or self-destructive behavior includes: i. Every 15 minutes, assess the need for intervention on the following: a. Checking Circulation & Restraint applied properly (not applicable to seclusion) b. Continuous Observation c. Physical Comfort d. Psychological status...". The document was effective November 20, 2025, with a change relating to the removal of immediate notification and CNO within 4 hours. The prior version of the document was effective June 23, 2025.

A review of MR8 revealed an order for "restraints non-violent or non-self-destructive" was entered on November 1, 2025 at 6:15 PM. The restraint type used were soft bilateral (both) wrist and they were applied at 6:30 PM. The restraints were discontinued on November 2, 2025 at 1:01 AM. Between the time of application and the time of discontinuation, there was no documentation to indicate the patient was monitored every two hours as the facility's procedure instructs.

A comprehensive review of MR2 revealed that on September 30, 2025 at 4:29 PM, EMP13 entered a note that read, "The patient increasingly agitated in the emergency department, kicking, threatening to bite, and spitting on staff. Patient required physical restraint by staff followed by 4 point forensic restraints to shackled the patient to the bed. [Patient] received 5 mg of IM Haldol as well as 5 mg of IM Valium for chemical restraint".

Interview on December 17, 2025 at 3:34 PM, EMP13 indicated that MR2's behavior began to escalate and continued to escalate. EMP13 acknowledged that MR2 was offered medication, but "[patient] continued to decline it". MR2's behavior escalated to the point that "[patient] became physical with staff" and "we had to take the action most appropriate at the time of the incident". EMP13 acknowledged that a physical hold (by facility staff) was necessary, lasting "approximately about twenty minutes", to de-escalate the patient and administer IM medications.

There was no documentation to indicate that MR2 was monitored as instructed by the facility's procedure for violent, self-destructive restraints.