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Based on record review and staff interview, it was determined that the documentation for Restrained patients was inconsistent. Specifically, the records failed to ensure that: a) the Physician's Order correctly identified the Level of Restraint used, the Discontinuation Criteria and the Vital Signs Assessment frequency in two (2) of ten (10) Medical Records reviewed (Patients #3 and #4), and b) the required Nursing documentation of Assessment and Monitoring were performed in four (4) of ten (10) Medical Records reviewed (Patients #1, #2, #3 and #5).

Findings:

a) Review of Patient #4's Medical Record on 03/31/15 revealed that the patient presented to the Emergency Room on 10/09/14 with a diagnosis of Irritable Bowel Syndrome. The patient was documented as "agitated" and as a "risk to self and others". A Physician "Restraint / Seclusion Order Form" dated 10/09/14 at 1:00PM revealed a Restraint Order for a Level I Non-Violent Restraint. The documented reason for Restraint use and the type of Restraint ordered indicated the need for a Level II Restraint Order. The accompanying Nursing "Restraint Flow Sheet" dated 10/09/14 at 1:00PM to 3:30PM, revealed that Patient #4 was restrained in Level II Four (4) Point (Leather) Restraints, although a Level I Restraint was ordered.

Review of the Physician "Restraint / Seclusion Order Form" for Patient #4 dated 10/09/14 at 1:00PM failed to identify Vital Signs Assessment / Monitoring Frequency.

Review of the Physician "Restraint / Seclusion Order Form" for Patient #4, dated 10/09/14 at 1:00PM, revealed the "Discontinuation Criteria" Section was left blank. The record lacked documentation indicating the Restraint "Discontinuation Criteria"

Review of the Medical Record for Patient #3 revealed that the patient presented to the Emergency Room on 01/15/15 with Intoxication. The Physician ordered Level II Four (4) Point Restraints for Extreme Agitation and Aggression on 01/15/15 at 5:30PM. The "Restraint / Seclusion Order Form" dated 01/15/15 at 5:30PM and a subsequent Order at 11:00PM on 01/15/15, failed to identify Vital Signs Assessment / Monitoring Frequency.

Patient #3's Record also lacked documentation of the patient's behavior indicating what the Restraint "Discontinuation Criteria" was. The Behavioral Discontinuation Criteria was not identified and left blank on the Physician's Order Form.

b) Review of the Medical Record for Patient #2 documented on the "Restraint Flow Sheet" dated 03/29/15 at 11:45AM that the patient was placed in a Level II Four (4) Point Restraint for Agitation. There was no documented evidence of the required Monitoring every fifteen (15) minutes as per Policy at 12:00PM and 12:15PM. At 12:30PM, forty-five (45) minutes after the Four (4) Point Restraint was initiated, the patient was Assessed as "Remaining restless and not ready for release".

Review of the Physician "Restraint / Seclusion Order Form" for Patient #2 dated 03/29/15 at 11:57AM, documented the Physician frequency of Vital Signs Assessments ordered for every hour while restrained. There is no documented evidence of Vital Signs taken or recorded hourly on the "Restraint Flow Sheet" as per the Physician's Orders.

Review of the "Restraint Flow Sheet" for Patient #2 dated 03/29/15 at 11:45AM, revealed that the patient was placed in Four (4) Point Restraints and released at 1:30PM as required. At 1:30PM, the patient was Assessed as "No" in the column for RD (Readiness for Discontinuation) but identified as an "8" (eight) indicating calm for behavior. The Flow Sheet lacks documentation of further documented evidence of Patient Evaluation after 1:30PM.

Medical Record review on 03/31/15 for Patient #3 included a "Restraint Flow Sheet" dated 01/15/15 at 5:30PM which revealed the patient was placed in Four (4) Point Restraints and Monitored through to 9:30PM. The "Restraint Flow Sheet" documented an Assessment at 9:30PM to "Continue with Restraints". There is no other supporting documentation between 9:30PM to 11:00PM to indicate what safety measures were implemented. The patient was placed in Four (4) Point Restraints for a second episode at 11:00PM through to 3:00AM 01/16/15.

The "Restraint Flow Sheet" documented an Assessment for Patient #3 at 3:00AM to "Continue with Restraints". No additional documentation on the Flow Sheet indicated if the Restraints were continued. There is no follow up documentation for Patient Assessments when discontinuing / removing Restraints for the second episode at 3:00AM. Patient #3 was discharged from the ED at 9:30AM.

Medical Record review for Patient #5 revealed that the patient was admitted to 1 North on 09/15/14 with Bipolar Disorder. The patient was placed into Seclusion on 03/14/15 at 9:45PM for Severe Agitation. The "Seclusion Flow Sheet" documented Monitoring until 11:00PM. There is no follow up documentation in the Medical Record for Patient Assessments until 03/15/15 at 2:00PM.

Medical Record review for Patient #1 on 03/31/15, revealed the Physician's "Restraint / Seclusion Order Form" dated 02/18/15 at 5:55PM, ordered Level I Non-Violent Restraints for Patient #1. The "Restraint Flow Sheet" showed the patient remained in Restraints from 7:00PM through to 11:30PM. The patient coded at 12:02AM on 02/19/15. There was no evidence of Patient Evaluation documentation from 11:30PM on 02/18/15 to 12:02AM on 02/19/15 to indicate that safety measures were implemented.

Review on 03/31/15 of the facility's Policy titled "Restraints", dated 08/21/14, revealed this Policy is applicable to Seclusion, Level I Medical Restraints used for patients with Non-Violent or Non-Self Destructive Behaviors, and for Level II Four (4) Point Restraints for Violent or Self Destructive Behaviors. This Policy states that each episode of Restraint initiated requires written authorization by the Physician. The Physician's Order must include the type of Restraint, frequency of Vital Signs Assessment if more often than the required minimum of two (2) hours, the behaviors of the patient that require use of the Restraint, and Assessment Criteria for discontinuation of Restraints. The Policy states that Nursing is responsible for Assessment and Monitoring activities. All patients in Level I Restraints require a Patient Assessment and documentation by the Nurse at the initiation and every thirty (30) minutes while the patient is restrained. Level II Restraints must have a Patient Assessment and documentation by the Nurse at the initiation and every fifteen (15) minutes while the patient is restrained. Vital Signs are taken as ordered by the Physician. At a minimum, the Nurse must document Patient Vital Signs Assessment on the Safety Restraint Flow Sheet every two (2) hours. The Nurse may release the patient earlier then the Physician's Order expiration if Behavioral Criteria is met and must notify the Physician when there is early release from Restraints. Additionally, the Nurse must document the patient's response to interventions including rationale for the continued use of Restraints / Seclusion and individual Patient Reassessments.

These findings were confirmed during interviews conducted on 03/31/15 and 04/01/15 with Staff Members #9, #12 and #10. Staff #1 stated that the documentation was not there.