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Based on medical record review, policy review, and staff interview, the facility failed to ensure each order for restraint use to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy for three of three patients reviewed with restraints (Patients #2, #9, and #10). The facility's census was 636.

Findings include:

Review of the policy titled, "Use of Restraints," effective 03/10/22, revealed restraint orders should be obtained before, or in an emergency, immediately after applying restraints. Renewal restraint orders should be obtained daily but not to exceed 30 hours. If restraints are removed and need reapplied, a new order was required.

1. Review of the medical record for Patient #2 revealed restraint orders daily from 07/08/23 through 07/22/23. The orders dated 07/13/23 at 2:11 PM, on 07/14/23 at 10:47 AM, and on 07/15/23 at 1:45 PM ordered mitts not tied down to left hand. The restraint flowsheet contained documentation on 07/14/23 from 10:00 AM through 8:00 PM of bilateral mitts. The restraint flowsheet contained documentation on 07/15/23 from 8:00 AM to 8:00 PM on 07/15/23 of left mitt tied down. The medical record lacked documentation of orders for the right hand to be restrained on 07/14/23 or the left hand mitt to be tied down on 07/15/23.

On 07/26/23 at 4:09 PM, this was verified by Staff B in an interview.

2. Review of the medical record for Patient #9 revealed an order dated 07/22/23 at 1:06 PM for bilateral soft wrist restraints. The patient was in the emergency department at this time. The nurses' note dated 07/22/23 at 4:38 PM noted patient not in restraints on arrival to the unit. At 8:00 PM on 07/22/23, the restraint flowsheet noted bilateral soft wrist restraints continued. The medical record lacked documentation of a new order for restraints since the restraints were not in place at 4:38 PM and the record lacked documentation of initiation of restraints prior to this time.

On 07/31/23 at 10:18 AM, this was verified by Staff B in an interview. On 07/31/23 at 11:03 AM, Staff C stated in a interview that the nurse caring for Patient #9 in the emergency department reported Patient #9 was not placed in restraints as the patient was re-directable.

3. Review of the medical record for Patient #10 revealed an order dated 07/27/23 at 6:14 PM for bilateral soft wrist restraints. The medical record contained an order dated 07/27/23 at 6:18 PM for soft restraints times four limbs. Both orders expired on 07/29/23, one at 12:04 AM and the other at 12:16 AM. The restraint flowsheet contained documentation of bilateral soft wrist restraints on 07/27/23 from 6:18 PM to 1:30 PM on 07/28/23.

On 07/31/23 at 12:00 PM, this was verified by Staff B in an interview.

Based on medical record review, policy review, and staff interview, the facility failed to ensure the condition of the patient who is restrained must be monitored by a physician, other licensed practitioner or trained staff at an interval determined by hospital policy for two of three patients reviewed for restraints (Patient #2 and #9). The facility's census was 636.

Findings include:

Review of the policy titled, "Use of Restraints," effective 03/10/22, revealed a patient in restraints should be evaluated every two hours and this evaluation should be documented in the medical record. Any use of restraints must be documented in the medical record, including initiation of restraints, monitoring every two hours, and discontinuation of restraints.

1. Review of the medical record for Patient #2 revealed restraint orders daily from 07/08/23 through 07/22/23. The medical record contained documentation of mitts not tied down to the left hand on 07/12/23 and 07/15/23. The medical record lacked documentation of two hour checks on 07/12/23 from 4:22 PM to 8:05 PM and on 07/15/23 from 8:00 PM to 12:00 AM on 07/16/23.

On 07/26/23 at 4:09 PM, this was verified by Staff B in an interview.

2. Review of the medical record for Patient #9 revealed an order dated 07/22/23 at 1:06 PM for bilateral soft wrist restraints. The patient was in the emergency department at this time. The nurse's note dated 07/22/23 at 4:38 PM noted patient not in restraints on arrival to the unit. At 8:00 PM on 07/22/23, the first documented monitoring of the restraints on the restraint flowsheet was noted as bilateral soft wrist restraints continued. The medical record lacked documentation of a new order for restraints since the restraints were not in place at 4:38 PM and the record lacked documentation of initiation of restraints prior to this time. The medical record contained documentation that restraints were discontinued on 07/28/23 at 11:30 PM. The medical record contained an order dated 07/29/23 at 3:25 PM for mitts and bilateral soft wrist restraints, and the order was discontinued at 5:09 PM on 07/29/23. The medical record lacked documentation of application or removal of the restraints on 07/29/23.

On 07/31/23 at 10:18 AM, this was verified by Staff B in an interview. On 07/31/23 at 11:03 AM, Staff C stated that the nurse caring for Patient #9 in the emergency department reported Patient #9 was not placed in restraints as the patient was re-directable.