HospitalInspections.org

Based on interview and record review, the facility failed to document an order for placing a patient in four-point restraints for 1 (P-1) of 4 patients reviewed in restraints resulting in the increased likelihood of negative consequences for the patient. Findings include:

P-1's medical record was reviewed with Director of Quality Staff B and Charge Nurse Staff J. P-1's nursing flowsheet documentation revealed that P-1 was in behavioral restraints starting from 3/26/2025 at 2200 to discontinuation on 3/27/2025 at 0000. P-1's only restraint order on 3/26/2025 at 2200 was "Siderail x 4" for one day.

According to the facility's policy "Restraints: Violent Behavior or Seclusion," dated 6/2024 for "Initiation of Restraints or Seclusion, the order includes:
The type of restraint,
The number of limbs to be restrained: 4 points,
For locked Velcro restraints - the order must specify 4-point restraints* (Any deviation from this must include the documented rationale for < 4-point restraint.),
Duration,
If a verbal order was given to initiate restraints, the physician must sign the verbal order and complete a written order, which must take place within 1 hour.

According to the facility's policy "Restraints: Violent Behavior or Seclusion," dated 6/2024, "The use of restraint follows the orders of a physician or other LP responsible for the patient's care." The policy also revealed "If an LP is not available to issue an order, a Registered Nurse (LICENSED COMPETENT NURSE) may initiate using restraints based on an appropriate patient assessment. If the LICENSED COMPETENT NURSE initiates restraints, the attending physician is consulted as soon as possible and within one hour as specified in this policy."

Based on interview and record review, the facility failed to document a face-to-face evaluation after placing a patient in four-point restraints for 1 (P-1) of 4 patients reviewed in restraints resulting in the increased likelihood of negative consequences for the patient. Findings include:

On 3/26/2025 at 2200, P-1 was placed in four-point locking restraints and the medical record revealed no documentation that a face-to-face was completed following the restraint application. When queried whether a face-to-face evaluation was present, Charge RN Staff J confirmed the missing evaluation documentation at the time of discovery.

According to the facility's policy "Restraints: Violent Behavior or Seclusion," dated 6/2024,

"2. The patient for whom restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, is seen face-to-face as soon as possible, but no later than one (1) hour after the initiation of the intervention by the attending physician, another LP, or an RN."

The policy also revealed "3. The face-to-face is to evaluate:

3.1 The patient's immediate situation;
3.2 The patient's reaction to the intervention;
3.3 The patient's medical and behavioral condition; and
3.4 The need to continue or terminate the restraint or seclusion."

"4. If the face-to-face evaluation is conducted by a competent RN, LP, or a physician who is not the attending, that person consults the attending physician or other physician who is responsible for the care of the patient as soon as possible and no later than one (1) hour after the initiation of the restraint or seclusion to:

4.1 Obtain a telephone order for restraints or seclusion
4.2 Consult with the physician about the patient's status
4.3 The physician reviews the information and determines if the restraint or seclusion should continue
4.4 Supplies guidance to staff in identifying ways to help patient regain control"

Based on interview and record review, the facility failed to ensure a staff member completed the required annual competencies in a timely manner for 1 (Staff O) of 4 staff members reviewed resulting in the increased likelihood of negative findings for the patients in the behavioral health unit. Findings include:

On 4/29/2025 at 1400, Mental Health Technician Staff O's personnel file was reviewed with Director of Quality Staff B. Staff O has been working for the facility for three years. Staff B revealed Staff O did not have any documentation that annual competencies for the calendar year 2024 were completed. When queried, Staff B confirmed that Staff O was expected to complete competencies in 2024.

Staff B revealed the facility did not have a policy for completing annual competencies. Staff B provided a presentation packet titled, "Corporate Education & Competency Plan," dated 2025 edition, that revealed "Non-Licensed/Patient Facing Curriculum included "Patient Rights, Restraints, Abuse and Neglect, Informed Consent, and Advance Directives" were to be completed annually.