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Based on review of seven open and seven closed medical records, it was determined That two patients had physical holds for forced medication administration with no physican orders. For patient #13, several of the incidents of "physical hold" on March 8, 9, 2018, had either no orders or orders that were written were untimed. The "physical hold" was used on multiple occasions during patient 13's admission, to administer medication deemed necessary by the physician that the patient refused or was too violent to safely administer an IM injection.

During review of patient 14's medical record, three incidents of physical holds for medication administration were identified on 02/09/2018, 02/13/2018, and 02/16/2018 for which no corresponding restraint orders were found.

Based on a review of seven open and seven closed medical records, including four restraint records, it was determined the hospital failed to discontinue restraints at the earliest possible time for 1 of 14 patients reviewed. Patient #7 (Pt# 7) presented to the Emergency Department (ED) with self-reported suicidal ideation and self-injurious behavior and was admitted to the adult psychiatric unit. Pt# 7 was placed in violent 4-point restraints per a physician order at 0023hrs due to attempts of self-injurious behavior. Pt# 7 was in violent restraints from 0023hrs until 0155hrs. Documentation review revealed Pt# 7's restraints were not released at the earliest possible time. Record review revealed Pt# 7's bilateral lower extremities were released at 0053hrs as stated in patient record, Pt# 7's "left arm restraint discontinued at 1:05am and right arm discontinued at 1:55am".

Based on a review of seven open and seven closed medical records, including four restraint records, it was determined the ordering physician failed to conduct a face-to-face assessment within one hour of initiation of violent restraints in 2 of 14 patients reviewed on two separate violent restraint episodes. Patient #7 (Pt# 7) presented to the Emergency Department (ED) with self-reported suicidal ideation and self-injurious behavior and was admitted to the adult psychiatric unit. At 0023hrs, Pt# 7 was placed in 4-point, violent restraints due to "imminent danger to self", based on a new physician order. Pt# 7 remained in restraints from 0023hrs until 0155hrs. No evidence of a face-to-face assessment was found in Pt# 7's medical record within one hour of initiation of the violent restraint episode (episode #1). A new physician order for hard 2-point violent restraints due to "imminent danger to self" was placed at 2105hrs and Pt# 7 remained in 2-point violent restraints until 2205hrs. No evidence of a face-to-face assessment was found in Pt# 7's medical record within one hour of initiation of the violent restraint episode (episode #2).

Review of patient 13's medical record identified that many of the incidents of "physical hold" on March 8, 9, 2018, had no face-to-face recorded in the medical record.