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Based on documentation and interview, the facility failed to ensure restraints were not applied as a form of convenience for one out of four patients (P4) reviewed for restraints when nonviolent bilateral restraints were applied by nursing to prevent falls, and other non-invasive interventions were not attempted.

P4 presented to the emergency department (ED) via ambulance on 8/28/25 at 3:38 p.m. for concerns of weakness and altered mental status. P4's relevant medical history included autism spectrum disorder requiring very substantial support, seizures, and dysphagia.

A provider note dated 8/28/25 at 3:41 p.m. indicated P4 presented from longstanding group home with increased incidence of falls and decreased responsiveness. The note indicated P4 would be admitted on an observation basis.

A nursing note written by registered nurse (RN)-A dated 8/28/25 at 4:15 p.m. indicated P4 baseline was nonverbal and presented with their group home staff member. The note indicated P4 made multiple attempts to leave bed, requiring nursing staff intervention for each instance.

A nursing note written by RN-A dated 8/28/25 at 6:40 p.m. indicated P4's baseline in the community was to be restless and pacing.

On 8/28/25 at 4:34 p.m., a provider order for nonviolent bilateral soft wrist and ankle restraints was placed.

A nonviolent restraint flowsheet entry by RN-A on 8/28/25 at 4:56 p.m. indicated soft wrist restraints were applied to P4's left and right wrist due to his high fall risk. The flowsheet indicated RN-A attempted calming techniques, emotional support, offering medication, and having P4's group home staff member at bedside. The flowsheet did not indicate if a 1:1 safety monitoring assistant was attempted.

A fall risk completed on 8/28/25 at 5:00 p.m. indicated P4 was within staff's reach, and universal fall precautions were in place per best practice. The fall risk indicated P4 was at risk for falls due to generalized weakness.

A nonviolent restraint flowsheet entry by RN-A on 8/28/25 at 6:56 p.m. indicated P4 continued in restraints due to high fall risk.

A nonviolent restraint flowsheet 8/28/25 at 8:56 p.m. indicated P4 continued in nonviolent restraints due to concerns with pulling at lines and tubes.

On 8/28/25 at 10:22 p.m., P4 was transferred to observation.

On 8/29/25 at 3:27 p.m. P4 was transferred to south 10, a neuro and general medicine inpatient unit.

On 8/29/25 at 11:59 p.m., the order for nonviolent bilateral soft wrist and ankle restraints was renewed.

On 8/30/25 at 2:00 a.m., P4 was removed from restraints.

On 8/29/25 at 3:36 a.m., nursing staff noted the use of a safety assistant at the bedside was used to maintain safety.

A safety assistant hourly documentation flowsheet created at 8/29/25 at 7:47 a.m. indicated P4 was kept in bed through verbal redirection, reorientation, and distraction.

On 8/29/25 at 10:05 a.m., an order for a safety assistant was placed.

During an interview on 9/17/25 at 11:31 a.m., RN-B stated nonviolent restraints are used if a patient is not redirectable and pull-on lines and tubing that put their health at risk. RN-B stated prior to using restraints, the staff should attempt other interventions such as medication, video monitoring, distracting the patient, or having family present at bedside.

During an interview on 9/17/25 at 11:48 a.m., RN-C stated the use of soft or nonviolent restraints is only if a patient is trying to remove lines or tubing. RN-C stated staff can attempt verbal de-escalation or recognizing the patient's triggers.

During an interview on 9/17/25 at 12:03 p.m., RN-D stated nonviolent restraints are used only when staff have attempted all other interventions and patient is still pulling on their lines. RN-D stated staff can try music therapy, massage, as needed medications, or high low beds as alternatives to restraints. RN-D stated P4 was a patient who wanted to be up and walking around and interacting with the unit. RN-D stated they used a 1:1 safety assistant to push P4 around the unit and P4 did not need to be in restraints.

During an interview on 9/18/25 at 10:42 a.m., nurse manager-A stated restraints are used on patients who are a danger to themselves or other. Nurse manager-A stated nursing staff must begin with the least restrictive methods, such as reorientation, reeducation, medications, or a 1:1 patient safety assignment. Nurse Manager-A stated if an unstable patient is trying to leave bed, the staff should reorient or reeducate the patient on the safety risks and importance of staying in bed.

During an interview on 9/18/25 at 12:11 p.m., RN-E stated P4 was placed on a 1:1 for his own safety because he needed two staff to ambulate. RN-E stated P4 needed constant redirection, but he could follow directions.

During an interview on 9/18/25 at 1:05 p.m., RN-F stated soft restraints are used if a patient is removing important tubing and medical equipment or are a safety risk to themselves. RN-F stated prior to using restraints, staff should attempt other interventions such as higher levels of supervision, video safety assistants, bed alarms, calming measures, 1:1 staff assignment, or as needed medications.

During an interview on 9/18/25 at 3:42 p.m., RN-A stated nonviolent restraints can be used for patient safety, such as pulling at lines and tubes and those who are fall risks. RN-A stated staff should attempt to redirect, reorient, or distracting the patient. RN-A stated she did not know how soon after applying restraints she needs to get an order. RN-A stated restraints are removed from a patient if they are oriented, able to follow commands, and understand why they cannot pull at lines. RN-A stated if a patient is nonverbal, staff may discontinue the restraints if the patient is "not trying to crawl out of bed." RN-A stated she did not remember caring for P4.

During an interview on 9/18/25 at 1:56 p.m., nurse manager-B stated staff apply restraints when patients are pulling at lines, tubing, or medical devices. Nurse manager-B stated restraints are not used to prevent falls. Nurse manager-B stated if a patient continues to try and get out of bed, staff need to use bed or chair alarms and remind the patient to stay in bed.

During an interview on 9/18/25 at 4:26 p.m., the director of nursing for medical surgical and acute rehabilitation services stated restraints are typically not a strategy the hospital uses to prevent falls. The director stated staff need to begin with low beds, bed alarms, chair alarms, video safety assistants, or in-person safety assistant monitoring. The director stated the interventions attempted are dependent on the patient's needs.

An undated facility policy titled "Restraint (Non-violent and Violent) and Seclusion Policy" indicated non-violent restraints may be applied if less restrictive measures have been applied. The policy indicated least restrictive interventions may be safety monitoring, coping techniques, or offering medications.