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Based on review of facility policy, medical records and staff interviews, facility staff failed to ensure an active, time-limited order for violent restraints for 1 of 3 medical records reviewed for patients placed in violent restraints (Patient #2).

The findings include:

Review on 07/08/2025 of facility policy "Restraint and Seclusion Use," effective 03/2023, revealed, "... 3. Restraints for Non-violent Behavior Restraints are used for patients with nonviolent behavior that is not self-destructive ... 4. Restraints for Violent Behavior Restraints are used for patients whose behavior is violent or self-destructive when restraint is necessary to ensure the immediate physical safety of the patient, a staff member, or others ... c. ... an RN (Registered Nurse) should obtain an order from and consult with a trained physician or a trained licensed practitioner about the patient's physical and psychological condition within 15 minutes after the restraint or seclusion has been initiated ... e. The order must be time-limited ... Each order for a physical restraint or seclusion must be limited to ... 2 hours for children and adolescents aged 9 to 17 ... f. ... When an order is about to expire, an RN must contact the physician or other licensed practitioner, report the results of his or her most recent assessment, and request that the original order be renewed ..."

Open medical record review on 07/01/2025 for Patient #2 (Pt) revealed an adolescent patient admitted to Facility A, Unit A on 04/12/2025 at 0825 with a diagnosis of altered mental status. Record review revealed orders were not obtained timely on the following occasions. Violent restraints were applied on 04/23/2025 at 0045. Review of the physician's order on 04/23/2025 at 0152 (1 hour and 7 minutes after initiation) revealed an order for "Restraints violent or self-destructive adolescent." The restraints were discontinued at 0200. Restraints were applied on 04/26/2025 at 1600. Review of the physician's order on 04/26/2025 at 1556 revealed a two-hour time limited order for "Restraints violent or self-destructive adolescent" which expired at 1756. The next order was obtained at 2016 (2 hours and 20 minutes after the previous order expired). Record review revealed Pt #2 was in 4-point restraints from 05/01/2025 at 1230 until 05/09/2025 at 1400 (for 8 days). Record review revealed two-hour time limited orders were not obtained timely on the following occasions. Review of the physician's order on 05/02/2025 at 0755 revealed an order for "Restraints violent or self-destructive adolescent" which expired at 0953. The next order was obtained at 1119 (1 hour and 26 minutes after expiration). Review of the physician's order on 05/02/2025 at 1719 revealed an order for "Restraints violent or self-destructive adolescent" which expired at 1919. The next order was obtained at 1936 (17 minutes after expiration). The order for "Restraints violent or self-destructive adolescent" at 1936 expired at 2126. The next order was obtained at 2158 (22 minutes after the previous order expired). Review of the physician's orders on 05/03/2025 at 1618 revealed an order for "Restraints violent or self-destructive adolescent" which expired at 1818. The next order was obtained at 1836 (18 minutes after the expiration). The order for "Restraints violent or self-destructive adolescent" at 1836 expired at 2036. The following order was obtained at 2153 (1 hour and 17 minutes after the previous order expired). The order for "Restraints violent or self-destructive adolescent" at 2153 expired at 2353. The next order was obtained on 05/04/2025 at 0014 (21 minutes after the previous order expired). Review of the physician's order on 05/05/2025 at 1119 revealed an order for "Restraints violent or self-destructive adolescent" which expired at 1319. The next order was obtained at 1352 (33 minutes after the expiration). Review revealed an order at 1452 for "Restraints violent or self-destructive adolescent" which expired at 1652. The following order was obtained at 1739 (47 minutes after the previous order expired). Review of the physician's order on 05/06/2025 at 0315 revealed an order for "Restraints violent or self-destructive adolescent" which expired at 0515. The next order was obtained at 0549 (34 minutes after the expiration). Review of the physician's order on 05/07/2025 at 0007 revealed an order for "Restraints violent or self-destructive adolescent" which expired at 0207. The next order was obtained at 0229 (22 minutes after the expiration). Review of the physician's order at 0956 revealed an order for "Restraints violent or self-destructive adolescent" which expired at 1156. The next order was obtained at 1243 (47 minutes after the expiration). Review of the physician's order at 1537 revealed an order for "Restraints violent or self-destructive adolescent" which expired at 1737. The next order was obtained at 1805 (28 minutes after the expiration). Review of the physician's order on 05/08/2025 at 1123 revealed an order for "Restraints violent or self-destructive adolescent" which expired at 1323. The next order was obtained at 1342 (19 minutes after the expiration). Review at 1657 revealed an order for "Restraints violent or self-destructive adolescent" which expired at 1857. The next order was obtained at 1933 (36 minutes after the expiration). The order for "Restraints violent or self-destructive adolescent" at 1933 expired at 2133. The next order was obtained at 2203 (30 minutes after the expiration). The order for "Restraints violent or self-destructive adolescent" at 2203 expired on 05/09/2025 at 0003. The next order was obtained on 05/09/2025 at 0023 (20 minutes after the expiration). Review of the physician's order at 0405 revealed an order for "Restraints violent or self-destructive adolescent" which expired at 0605. The next order was obtained at 0631 (26 minutes after the expiration). Record review revealed non-violent bilateral wrist restraints were applied on 05/11/2025 at 1730. Review of the physician's order on 05/11/2025 at 1846 (1 hour and 16 minutes after restraints were initiated) revealed an order for "Restraints non-violent or non-self destructive." Restraints were removed on 05/12/2025 at 1240.

Additionally, record review revealed non-violent restraints were ordered following a violent behavior event as follows. Review of the physician's note on 04/26/2025 at 2116 revealed, "19:33: Received page that a Behavioral Response was being called for patient ... patient positioned in 4-pt (point) violent restraints ... Nursing team reported that patient had been in the bathroom and again began hitting his head against the mirror, causing some visible facial swelling ..." Review of physician's order on 04/26/2025 at 2159 revealed an order for "Restraints non-violent or non-self destructive ... Restraint type: 4 Point ..." Review of the restraint order revealed no two-hour time limited order placed for the restraints following a violent behavior incident. Pt #2 remained in 4-point restraints until 04/30/2025 at 2145 (4 days). Pt #2 was placed in 4-point restraints after exhibiting violent behavior on 05/01/2025 at 1230. Review of physician's order on 05/01/2025 at 1444 (2 hours and 14 minutes after restraints were initiated) revealed an order for "Restraints non-violent or non-self destructive ... Restraint type: 4 Point ..." Review of the restraint order revealed no two-hour time limited order placed for the restraints following the violent behavior incident. Review of the nursing note at 2004 revealed, "... (Pt #2) jumped out of the bed again and attacked the Chaplain ... Multiple police officers and staff members required to apply restraints at 1230 ..." Pt #2 remained in 4-point restraints until 05/09/2025 at 1400 (8 days). Review of physician's order on 05/13/2025 at 1923 revealed an order for "Restraints non-violent or non-self destructive ... 2 Point - Wrist ..." Review of the restraint documentation revealed that violent 4-point restraints were applied at 1945. Review of the nursing note at 1952 revealed, "... patient picked up bedside commode over his head and threw bedside commode ... Feces splattered over the walls of the room, floor, as well as RN's present. Patient also punched daytime charge RN at this time ... MD gave verbal order for violent restraints to be placed at 1920 ... Upon looking at orders, RN discovered that incorrect restraint order was placed and ask (sic) MD to modify. Patient currently on violent 4 point restraints with 2 sitters at bedside ..." Review of physician's order at 2107 (1 hour and 23 minutes after violent restraints were placed on the patient) revealed a two-hour time limited order for violent restraints. Review of physician's order on 05/13/2025 at 2254 revealed a new order for "Restraints non-violent or non-self destructive ... Restraint Type: 4 Point ..." Pt #2 remained in 4-point restraints until 05/15/2025 0645. Pt #2 was transferred to Facility B on 05/16/2025 at 1521. Pt #2 was a current admission at Facility B during record review.

Interview on 07/03/2025 at 1336 with Registered Nurse (RN) Specialist #5 and RN Educator #6 revealed restraint orders should be obtained within 15 minutes of restraint initiation. Orders for violent restraints required a time limited order of 2 hours for adolescents.

Interview on 07/03/2025 at 1336 with RN Specialist #5 and RN Educator #6 revealed restraints were considered violent restraints when they were used on patients that were exhibiting aggressive behaviors toward others or harming themselves. RN Specialist #5 revealed a new order should be obtained prior to the restraint order's expiration if a patient needed to remain in restraints. The primary RN was responsible for monitoring the orders, the timing of expirations, and notifying the provider when a new order was needed.

Interview on 07/03/2025 at 1136 with RN #10 revealed the primary RN was responsible for making sure there was an active restraint order. Interview revealed RN #10 had difficulty sending the provider requests to update the order every 2 hours because of patient care responsibilities.

Interview on 07/07/2025 at 1105 with Medical Doctor #1 (MD) revealed violent restraints should be ordered when the patient is at high risk of harming themself or others. Non-violent 4-point restraints were not typically ordered following a violent event or if a patient was at risk for harming themself or others. Interview revealed MD #1 relied on nursing staff for reminders to place restraint orders.

Interview on 07/03/2025 at 1415 with MD #12 revealed MD #12 did not recall the rationale for ordering non-violent restraints after a violent behavior event.

Interview on 07/07/2025 at 1210 with MD #11 revealed an order for restraints should have been placed as soon as possible after the restraint was initiated. MD #11 stated Pt #2 could not control his behaviors and was at risk of causing significant harm to himself or others. Interview revealed violent restraints, instead of non-violent restraints, should have been ordered after an aggressive behavior incident.

MD #13, who ordered non-violent restraints after a behavioral event, was unavailable for interview.

In summary, orders were not obtained timely per facility policy for twenty-two occurrences. Non-violent restraints were ordered following a violent behavior event on three occasions.

Based on review of facility policy, credentialing files and staff interviews, the facility failed to ensure providers had completed restraint training according to facility policy for 2 of 3 sampled files reviewed for providers that ordered restraints (Medical Doctor #1 [MD], MD #2).

The findings include:

Review on 07/08/2025 of facility policy "Restraint and Seclusion Use," effective 03/2023, revealed, "... 3. Restraints for Non-violent Behavior Restraints are used for patients with nonviolent behavior that is not self-destructive ... 4. Restraints for Violent Behavior Restraints are used for patients whose behavior is violent or self-destructive when restraint is necessary to ensure the immediate physical safety of the patient, a staff member, or others ... Any physician or licensed practitioner permitted by law, hospital policy, and license, who has completed the restraint/seclusion training (a 'trained physician or a trained licensed practitioner'), can independently order restraints or seclusion for patients ... Restraints for Patients With Violent Behavior ... i. A physician or other licensed practitioner ... must evaluate the patient face-to-face and in person within one hour of the initiation of restraint/seclusion (even if the patient is no longer in restraint/seclusion) and document the findings, including the following information: 1. the patient's immediate situation; 2. the patient's reaction to the intervention; 3. the patient's medical and behavioral condition; and 4. the need to continue or terminate the restraint or seclusion ..."

1. Open medical record review on 07/01/2025 for Patient #2 (Pt) revealed an adolescent patient that was admitted to Facility A, Unit A on 04/12/2025 at 0825 with a diagnosis of altered mental status. Review revealed MD #1 ordered "Restraints violent or self-destructive adolescent" on 04/26/2025 at 1556. Record review failed to reveal a face-to-face assessment within one hour of initiation of the violent behavior restraint application. Pt #2 was transferred to Facility B on 05/16/2025 at 1521. Pt #2 was a current admission at Facility B during record review.

Review on 07/02/2025 of MD #1's credentialing file revealed MD #1 was credentialed from 08/16/2017 until time of the review. Review failed to reveal evidence of restraint training.

Interview on 07/07/2025 at 1105 with Medical Doctor #1 (MD) revealed a face-to-face assessment should be completed within one hour of ordering restraints for violent behavior. MD #1 did not recall a face-to-face note being completed for Pt #2 after MD #1 ordered violent restraints. Interview revealed MD #1 was unsure if restraint training had been provided.

Interview on 07/08/2025 at 1840 with Manager #3 revealed 2025 resident providers had received restraint training, but other providers had not received restraint training.

2. Open medical record review on 07/01/2025 for Patient #2 (Pt) revealed a 17-year-old patient that was admitted to Facility A, Unit A on 04/12/2025 at 0825 with a diagnosis of altered mental status. Review of MD #2's note on 04/26/2025 at 2116 revealed, "19:33: Received page that a Behavioral Response was being called for patient ... patient positioned in 4-pt (point) violent restraints ... Nursing team reported that patient had been in the bathroom and again began hitting his head against the mirror, causing some visible facial swelling ..." Review revealed MD #2 ordered "Restraints non-violent or non-self destructive ... Restraint type: 4 Point ..." on 04/26/2025 at 2159. Pt #2 was transferred to Facility B on 05/16/2025 at 1521.

Review on 07/02/2025 of MD #2's file revealed MD #2 was a resident provider at the facility for 3 years in the pediatric program. MD #2 graduated on 06/23/2025. Review failed to reveal evidence of restraint training.

Interview on 07/07/2025 at 1210 with MD #11 revealed violent restraints, instead of non-violent restraints, should have been ordered after an aggressive behavior incident.

Interview on 07/08/2025 at 1840 with Manager #3 revealed 2025 resident providers had received restraint training, but other providers had not received restraint training.

MD #2 was not available for interview.

Based on review of facility policy, medical records and staff interviews, the facility failed to ensure a face-to-face assessment was completed within one hour of initiation of violent restraints for 2 of 3 medical records reviewed for patients placed in violent restraints (Patient #2, Patient #11).

The findings include:

Review on 07/08/2025 of facility policy "Restraint and Seclusion Use," effective 03/2023, revealed, "... Restraints for Violent Behavior Restraints are used for patients whose behavior is violent or self-destructive when restraint is necessary to ensure the immediate physical safety of the patient, a staff member, or others ... Restraints for Patients With Violent Behavior ... i. A physician or other licensed practitioner ... must evaluate the patient face-to-face and in person within one hour of the initiation of restraint/seclusion (even if the patient is no longer in restraint/seclusion) and document the findings, including the following information: 1. the patient's immediate situation; 2. the patient's reaction to the intervention; 3. the patient's medical and behavioral condition; and 4. the need to continue or terminate the restraint or seclusion ..."

1. Open medical record review on 07/01/2025 for Patient #2 (Pt) revealed an adolescent patient that was admitted to Facility A, Unit A on 04/12/2025 at 0825 with a diagnosis of altered mental status. Record review revealed violent behavior restraints were applied as follows: on 04/23/2025 from 0045 until 0200; on 04/23/2025 from 1430 until 1715; and on 04/25/2025 from 2120 until 2330. Record review failed to reveal a face-to-face assessment within one hour of initiation for each of the three violent behavior restraint applications listed above. Violent behavior restraints were applied on 04/26/2025 at 1600. Pt #2 remained in 4-point restraints (restraints applied to all 4 extremities) until 04/30/2025 at 2145. Record review failed to reveal a face-to-face assessment within one hour of initiation of the violent behavior restraint application. Pt #2 was placed in 4-point restraints after exhibiting violent behavior on 05/01/2025 at 1230. Record review revealed face-to-face assessment notes on 05/03/2025 at 1000 (2 days after the initiation of restraints), on 05/04/2025 at 1100, and on 05/05/2025 at 1342. Pt #2 remained in 4-point restraints until 05/09/2025 at 1400. Violent behavior restraints were applied on 05/13/2025 at 1945. Pt #2 remained in 4-point restraints until 05/15/2025 0645. Record review failed to reveal a face-to-face assessment within one hour of initiation of the violent restraint application. Pt #2 was transferred to Facility B on 05/16/2025 at 1521. Pt #2 was a current admission at Facility B during record review.

Interview on 07/08/2025 at 0940 with Director #4 revealed all a face-to-face assessments were supposed to be completed within one hour of violent restraint initiation. Interview revealed there were no notes in the patient's record to indicate that face-to-face assessments were completed within an hour of initiation for each of the violent restraint applications.

Interview on 07/07/2025 at 1105 with Medical Doctor #1 (MD) revealed a face-to-face assessment should be completed within one hour of ordering restraints for violent behavior. MD #1 did not recall a face-to-face note being completed for Pt #2 after MD #1 ordered violent restraints.

Interview on 07/03/2025 at 1336 with Registered Nurse (RN) Specialist #5 and RN Educator #6 revealed a face-to-face assessment should be conducted by the provider within one hour of initiation of restraints for violent behavior. Interview revealed the face-to-face assessment must include the required elements listed in the restraint policy.

MD #7, a provider that cared for Pt #2, was not available for interview.

2. Closed medical record review on 07/08/2025 for Patient #11 (Pt) revealed an adolescent patient that was admitted to Facility A, Unit A on 06/09/2025 at 0338 with a diagnosis substance induced mood disorder. Review of the restraint record revealed Pt #11 was placed in restraints following violent behavior on 06/10/2025 at 1600. Record review failed to reveal a face-to-face assessment within one hour of initiation of violent restraints. Pt #11 was transferred to Unit B at 1629. Review of the nursing note at 1856 revealed, "... (Pt #11) arrived on the unit in 4 point restraints (restraints applied to all 4 extremities) ..." Record review failed to reveal documentation of when the restraints were discontinued. Pt #11 received further care and was discharged on 06/18/2025 at 1330.

Interview on 07/08/2025 at 1526 with RN #9 revealed restraints were removed immediately upon arrival to Unit B on 06/10/2025 at 1629 but RN #9 forgot to document the discontinuation of restraints in the medical record.

Interview on 07/08/2025 at 1640 with Director #8 revealed there was no documentation that a face-to-face assessment was completed within one hour of initiation of violent restraints on 06/10/2025 at 1600.

Interview on 07/07/2025 at 1105 with Medical Doctor #1 (MD) revealed a face-to-face assessment should be completed within one hour of ordering restraints for violent behavior.

Interview on 07/03/2025 at 1336 with Registered Nurse (RN) Specialist #5 and RN Educator #6 revealed a face-to-face assessment should be conducted by the provider within one hour of initiation of restraints for violent behavior. Interview revealed the face-to-face assessment must include the required elements listed in the restraint policy.

NC00230323; NC00231720; NC00231842; NC00228832; NC00230419