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Based on document review and interview, it was determined that the facility staff failed to ensure ongoing monitoring, assessment and documentation of Patients (P) in restraints to include skin integrity, circulation, respiration, intake and output, hygiene and injury for one (1) of two (2) Patients (P # 2); and
failed to document an assessment of the Patient's condition by a Physician for one (1) of two (2) Patients (P # 2).

The findings include:

On June 6, 2023 at 9:30 a.m., P # 2's Clinical Record review revealed the following:

A progress note dated June 5, 1:14 p.m. reads in part "Admission Date: 06/03/2023. Acute Pancreatitis."
Restraint order Date/Time "06/05/2023 11:40 p.m. Indication for restraint: disrupting lines, tubes, medical equipment. Type of restraints: soft. Soft -limbs to be restrained: Bilateral upper ext. Documentation required, use, restraint. Will reassess patient and document within the hour. Criteria to DC restraints: absence of behavior."

When questioned about Physician documentation, Staff Member # 3 stated "There was no documentation of an assessment by the Physician regarding the application of restraints."

There was no documentation by the nurse between 12:05 a.m. and 3:51 a.m. to include skin integrity, circulation, respiration, intake and output, hygiene and injury.

On June 6, 2023, a review of the facility policy titled "Restraint and Seclusion" reads in part "Restraint monitoring and documentation of basic patient care needs shall include circulation, range of motion, fluids, food/meal, and elimination and shall be documented at least every 1.5 - 2.5 hours."
A review of the document titled "System Restraint Changes and Updates, January 2023" reads in part "Providers will still have to document restraints in their daily MD note."

On June 6, 2023, the findings were discussed with Staff Members # 1, # 2 and # 4 during the exit interview.