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Based on document review and interview, it was determined that for 1 of 8 clinical records reviewed for restraints (Pt#6), the Hospital failed to ensure that the use of a restraint was in accordance with a valid restraint order.

Findings include:

1. On 9/2/2021, the Hospital's policy, "Restraints - Violent" (effective 10/9/2018) was reviewed and indicated, "... D. Restraint Orders: i. The use of restraint and/or seclusion is used pursuant to an order by a physician or other LIP (licensed independent practitioner) who is primarily responsible for the patient's ongoing care, by his or her designee, or other physician/LIP [licensed independent practitioner]. In emergency situations, a registered nurse with supervisory responsibility (i.e. Charge Nurse) may initiate restraint or seclusion until a physician/LIP can be contacted for orders. ii. As soon as possible, but no longer than one hour after the initiation of the restraint and/or seclusion, qualified staff does the following: 1. Notifies and obtains an order from the physician/LIP that is responsible for the care of the patient..."

2. On 9/1/2021, Pt#6's clinical record was reviewed. Pt#6 was presented to the emergency department on 6/19/2021 with major depressive disorder. Pt#6's restraint documentation, dated 6/19/2021, indicated that restraints were initiated at 3:45 PM and discontinued at 4:45 PM. Pt#6's clinical record lacked a physician's order for restraints.

4. On 9/2/2021, at approximately 9:00 AM, an interview was conducted with the Director of Center for Behavioral Health (E#1). E#1 stated that every restraint performed should have an order.

Based on document review and interview, it was determined that for 1 of 8 clinical records reviewed for restraints (Pt#1), the Hospital failed to ensure that a valid restraint renewal order was placed for the necessary restraints.

Findings include:

1. On 9/2/2021, the Hospital's policy, "Restraints - Violent" (effective 10/9/2018) was reviewed and indicated, "... D. Restraint Orders: i. The use of restraint and/or seclusion is used pursuant to an order by a physician or other LIP (licensed independent practitioner) who is primarily responsible for the patient's ongoing care, by his or her designee, or other physician/LIP. ... Length of time the order is in effect, not to exceed: 2 hours for adolescents, ages 9 - 17."

2. On 9/1/2021, Pt#1's clinical record was reviewed. Pt#1 presented to the Emergency Department on 8/21/2021 with a chief complaint of aggressive behavior. Pt#1's restraint documentation, dated 8/25/2021, included physician's orders at 2:45 PM, 4:45 PM, and 8:45 PM, for restraints to all 4 extremities for 2 hours. Pt#1's Restraint Flow sheet indicated that Pt#1 was in restraints from 4:45 PM through 8:45 PM with no new order written for restraints at 6:45 PM.

3. On 9/2/2021, at approximately 9:00 AM, an interview was conducted with the Director of Center for Behavioral Health (E#1). E#1 stated that every restraint performed should have an order. E#1 also stated that if a previous order for restraints has expired (exceeded the 2 hour timeframe), a new order should be written if the restraints are still necessary.

Based on document review and interview, it was determined that for 4 of 8 (Pt. #1, Pt. #3, Pt. #5 and Pt. #8) clinical records reviewed for patients in violent restraints or seclusion, the Hospital failed to ensure that the patients were seen by a physician or licensed independent practitioner (LIP) face -to - face within 1 hour after the initiation of the restraints.

Findings include:

1. The Hospital's policy titled, "Restraints - Violent (10/9/2021)" was reviewed on 9/1/2021 and required, "Within one hour of the initiation of the restraint or seclusion, the patient must be seen by a physician/LIP (licensed independent practitioner) to conduct a face-to-face evaluation."

2. The clinical record of Pt. #1 was reviewed on 9/1/2021. Pt. #1 presented to the emergency department (ED) on 8/21/2021 with the complaint of aggression. The clinical record included restraint orders for 4 point (both wrists and ankles) violent restraints on
8/27/2021 at 10:30 AM and 8/31/2021 at 12:30 PM. For both of these restraint episodes, the clinical record lacked documentation of a face-to-face evaluation by a physician or licensed independent practitioner (LIP) face -to - face within 1 hour after the initiation of the restraints.

3. The clinical record of Pt. #3 was reviewed on 9/1/2021. Pt. #3 presented to the ED on 7/21/2021 with the complaint of mental disorder. The clinical record included a restraint order for 4 point violent restraints on 7/21/2021 at 5:45 AM. The clinical record lacked documentation of a face-to-face evaluation by a physician or licensed independent practitioner (LIP) face -to - face within 1 hour after the initiation of the restraints.

4. The clinical record of Pt. #5 was reviewed on 9/1/2021. Pt. #5 presented to the emergency department (ED) on 5/20/2021 with the complaint of delusional disorder. The clinical record included restraint orders for 4 point violent restraints on 5/20/2021 at 10:17 PM. The clinical record lacked documentation of a face-to-face evaluation by a physician or licensed independent practitioner (LIP) face -to - face within 1 hour after the initiation of the restraints.

5. The clinical record of Pt. #8 was reviewed on 9/1/2021. Pt. #1 presented to the emergency department (ED)on 8/13/2021 with the complaint of schizophrenia. The clinical record included restraint orders for seclusion on 8/18/2021 at 10:45 AM. The clinical record lacked documentation of a face-to-face evaluation by a physician or licensed independent practitioner (LIP) face -to - face within 1 hour after the initiation of the restraints.

6. During an interview on 9/2/2021 at approximately 9:00 AM, the Director of Center for Mental Health (E#1) stated that a face-to-face evaluation is required to be completed by a physician, within one hour, for every violent restraint episode.