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Based on a review of restraint/seclusion policy, and restraint records for 4 patients, Patient #10 received an incomplete restraint order, disparate documentation of the number of points used during the restraint, and no assessments during the 2-hour restraint, and Patient #12 had a personal protection equipment (PPE) mask applied to his face during restraint.
The hospital Patient Restraint and Seclusion policy (revised 2/13) states in part for Behavioral restraints "Assessment and monitoring by the nurse of the following every 15 minutes, at a minimum: a. circulation checks; b. respiration checks; body alignment; d. hydration and nutritional needs, e. elimination needs, f. skin integrity, g. mental status; h. appropriateness of continuing restraints." The policy does not address the use of a PPE mask as a spit mask, nor does it address the use of spit mask design for that purpose.

Patient #10 is a homeless female, age 26, who presented to the Emergency Department (ED)at 0145 on 12/16/14 with a chief complaint of seizure and an adverse response to medication causing heavy sedation. A physician evaluation revealed an altered mental status. Patient #10 was admitted and was found to be cocaine positive.

A nursing note timed as 0350 states " heard pt screaming from the room, found lying on the floor jerking, awake, stating she fell. Pt got back into the bed with 2 RN and security. " An untimed RN note states in part that "IV ( Intravenous line) pulled out, IV fosphenytoin finished, security in to hold pt down as trying to get out of bed. (with) jerking movement, yelling. Pt moved to monitored room. CM (cardiac monitor) applied. Medicated (with) (ativan) __ four-point restraint applied. RN __ attempting to place IV. "

An ED physician order of 0420 states "Soft restraints." The order lacked specific required information including restraint time limitations, the number of restrained points, or a rationale for the restraints. Based on this order, the number of restraint points to use, the maximum time duration of the restraint, and the rationale for which the restraints were to be used was up to the discretion of the nurse. Based on nursing documentation nursing chose a 4-point restraint , which is a restraint process for violent behavior.

The nursing behavioral restraint/seclusion record (BRSR) states that patient #10 was placed in Wrist restraint at 0430. This contradicts the earlier nursing documentation that 4-point restraints were applied . Further, it is only on this nursing form that a duration of 1-4 hours is clarified by nursing. Reasons for restraint on the nursing form were checked as physically aggressive, extreme agitation, impulsive, confused, and irrational.

Patient #10 was released from restraint at 0600. However, 15-minute nursing assessments or other documentation were not found during the two-hour restraint period. While the form clearly states "RN Assessment and Monitoring for Restraint/Seclusion every 15-minutes at a minimum, " only two entries, both appearing to be at 0415 indicate a check-box status of "skin integrity check " and " restraints. " While the form does have an area to document assessment behaviors which could justify continuing the restraint, this area was not completed. Therefore, there was no documentation that patient #10 did not receive the 15-minute monitoring and assessments for violent restraint per hospital policy.

In summary, the restraint order for patient #10 was incomplete, necessitating the RN to decide on the restraint intervention. RN documentation reveals a disparity between the number of restraint points actually used and the number ordered by the physician. No RN assessment documentation related to the restraint was found. Each of these elements represent an unsafe restraint process.

Patient #12 is a 42 year-old male admitted on 1/2/15 due to altered mental status characterterized as as violent behavior with suicidal edeation. Patient #12 has a past medical history of multiple sclerosis with paraplegia, neurogenic bladder status post suprapubic catheter pleacement, schizoaffective disorder, ESBL producing organisms causing urinary tract infections, colostomy status due to complications of fecal peritonitis. The patient was sent to the hospital for further evaluation and to rule out infection as the cause of his altered mental status.


On entry to care, he was found to have an altered mental status a urinary tract infection, and command hallucinations to burn his bed. Patient #12 was treated with antipsychotics and originally admitted to behavioral health until it became apparent that his medical issues could not be treated there. He was transferred to a medical bed with psychiatry following.


On admission day two patient #12 became agitated, pulled on his lines, and removed his colostomy bag twice to throw at staff. He was placed in two-point soft restraints. He continued to use profane language, verbal abuse, and threats to harm staff. Patient #12 spit on staff, and a personal protective equipment (PPE) mask was placed on his face to prevent spitting on others. There was no documentation of an order for a spit mask in the patient's medical record. The use of a PPE spit mask is not approved for restraint use as the mask cannot be removed by the patient who is otherwise restrained; staff cannot observe the patient's mouth for appropriate breathing; and the mask creates a risk of aspiration should the patient vomit.


Nursing documentation at 1845 on day 2 states in part "Patient being uncooperative. Yelling/using profanity. Pulled out HL (heplock). Pt began spitting at sitter. Security called. Pt then took off colostomy bag and threw it at security officers. Pt digging at abdominal skin graph site producing bleeding: Cleansed with NS (normal saline), Cavillion applied after wrist restraints applied by security. Pt then spit at writer. Mask need to be placed on patient to cover mouth due to his continued attempt to spit at staff. Colostomy bag replaced. HL #22 replaced to (R) UE (upper extremity). Pt continued to attempt to spit w/mask on; using profanity towards staff. Sitter remains at bedside." There is no documentation regarding how long the PPE mask was used.


In summary, the hospital's use of a PPE mask as a spit mask restraint could have resulted in patient injury. Therefore, the hospital failed to provide a safe restraint intervention for patient #12.

Based on a review of restraint/seclusion policy, and restraint records for 4 patients, it is revealed that patient #10 received an incomplete restraint order and non-violent restraint orders for patient #12 had no restraint maximum duration.

The hospital Patient Restraint and Seclusion policy (revised 2/13) states in part for Behavioral Restraints that they "Must be ordered by a physician or other LIP (Licensed Independent Practitioner)" and "The order must be specific to each incident, time limited and based on the age of the patient being restrained. "

Patient #10 is a homeless female, age 26, who presented at Emergency Department (ED) at 0145 on 12/16/14 with a chief complaint of seizure and an adverse response to medication causing heavy sedation. A physician evaluation revealed an altered mental status. Patient #10 was admitted and was found to be cocaine positive.

A nursing note of 0350 states " heard pt screaming from the room, and found lying on the floor jerking, awake, Stating she fell. Pt got back into the bed with 2 RN and security. " An untimed RN note states in part "IV pulled out, IV fosphenytoin finished, security in to hold pt down as trying to get out of bed. (with) jerking movement, yelling. Pt moved to monitored room. CM (cardiac monitor) applied. Medicated (with) (ativan) __ four-point restraint applied. RN __ attempting to place IV. "

As noted in CMS tag A-0167, an ED physician order of 0420 states "Soft restraints." No other information was found in the order regarding restraint time limitations, the number of restrained points, or a rationale for restraint. Based on this order nursing staff was given the decision-making for how many restraint points to use, the maximum time duration of the restraint, and the rationale for which the restraints were to be used. Based on nursing documentation, nursing chose a 4-point restraint indicative of a patient being restrained for violent and assaultive behavior.
The nursing behavioral restraint/seclusion record (BRSR) states that patient #10 was placed in "Wrist" restraint at 0420. This contradicts the earlier "4-point" nursing documentation. Further, it is only on this nursing form that a duration of 1-4 hours is clarified by nursing.

In summary, patient #10 received an incomplete restraint order, necessitating the RN to decide on the restraint intervention.

Based on a review of restraint documentation for patient #8, it is revealed that the hospital failed to document patient #8's behaviors during restraint, and gave inappropriate release criterion of making a "Safety contract."


Patient #8 is 21 year old male who presented on emergency petition in police handcuffs at 0100 on 12/27/14 after becoming aggressive and threatening in a public restaurant. The Police report stated that patient #8 was combative, violent and threatening violence verbally to himself. Emergency Medical Technicians gave Versed, Haldol and Benadryl in the field. The physician physical exam revealed that patient #8 was alert and agitated and combative.

At 0104 the physician ordered 4 point restraints for Patient #8 for a duration of 4 hours. The restraint was initiated at 0110. The nursing assessment for continued Restraint/Seclusion every 15 minutes has a check box for behavioral checks, but no actual behavioral description was documented from 0110 to 0155. The only documentation was in a box checked "Yes" indicating that restraints should be continued for each of those 15-minute assessments. Within the 15-minute monitoring documentation area is a space to describe why the restraints were to be continued. There was no descriptive behavioral documentation in the spaces provided.

Under an area labeled "Criteria for Release from Restraint/Seclusion" are form-printed criteria for release. These include: Follow directions, verbalize no intention of harm to self/others, agrees to comply with expected behaviors. Per regulation, the only appropriate criterion is a behavioral one in which the patient ceases the behavior for which he was restrained.

From 0210 to 0255, every 15-minute area is also checked "Yes" to continue restraints with a reason of "No safety contract." Making a "safety contract" is not listed on the printed criteria for release from restraint, nor is it an acceptable criterion as some patients may not be able to conceive of what " a safety contract" means.

Also printed on the seclusion/restraint documentation form are pre-printed criteria for release or no release from restraint/seclusion. The criteria for no release are too agitated, too disorganized, too angry/hostile, and unable to focus.

The nurse documented a check in the "Unable to focus " box indicating that for this reason patient #8 did not receive instruction on the expected behaviors for release. While patient behaviors might interfere with education, every patient has a right to know why they are in restraint and what behaviors will secure them exit from those restraints. A nursing note of 0350 states "Contracts for safety, restraint d/c ' d." Based on a lack of behavioral documentation and inappropriate criteria there is no evidence that nursing discontinued restraint at the earliest possible time.