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Based on review of facility policy, patient records, and confirmed in interview, the facility failed to ensure restraints were discontinued at the earliest possible time according to the physician orders and facility policy for two of ten patients (Patient #A, C) reviewed for restraints.

Specifically, Patient #A and C remained in soft bilateral 2 point restraints while nursing documentation indicated they were sleeping, indicating they met criteria for release.

Findings included:

Review of facility policy Patient Restrain Policy (PolicyStat ID 17125388, effective 03/2025), under Order for Restraint with Non-Violent or Non-self Destructive Behavior, it stated "staff assess, monitor, and re-evaluate the patient regularly and release the patient from restraint when criteria for release are met."

Patient #A
Patient #A is an 88 year old male who admitted on 07/08/2025 for right lower extremity pain and inability to bear any weight for several weeks.

Review of Patient #A's chart revealed an order for BUE (bilateral upper extremity) restraint ordered on 07/09/2025 at 10:29 PM. It was initiated on 07/09/2025 at 10:30 PM. Review of the order indicated the criteria for release of restraints is met when patient stops "attempts to remove device"

Review of the Restraint Monitoring form revealed Patient #A was sleeping at 07/10/2025 at 12:22 AM to 04:30 AM. The restraint was not discontinued until 09:10 AM.

Review of the Restraint Documentation flowsheet the nurse assessed the patient at 07/10/2025 at 12:00 AM and 2:00 AM and documented level of consciousness as 'sleeping' but selected 'no' for meets criteria for release.

Patient #C
Patient #C is a 73 year old female who presented to the ED on 06/28/2025 for worsening agitation and confusion. Prior to admission, pt reportedly had been attempting to wander around her neighborhood and became emotional, stating that she felt like she was being kept as a prisoner.

Review of Patient #C's chart revealed an order for BUE (bilateral upper extremity) restraint ordered on 06/29/2025 at 12:06 PM. It was initiated on 06/29/2025 at 12:06 PM. Review of the order indicated the criteria for release of restraints is met when patient stops "attempts to remove device"

Review of the Restraint Monitoring form revealed Patient #C was sleeping on 06/30/2025 at 01:37 AM to 05:30 AM.

In an interview with Staff #6 on 07/10/2025 at 3:10 PM, he acknowledged that both patients met criteria for release.