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Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to follow their approved policy for the use of restraints and failed to use a restraint in accordance with the order of a physician for one of ten medical records reviewed (MR3).

Findings include:

Review on August 7, 2024, of Policy titled "Restraint and Seclusion Management" with a revision date of July 9, 2024, revealed "... I. POLICY: It is Crozer Health's desire to create a safe and appropriate environment in keeping with our mission and philosophy to protect patients and others. Restraints or seclusion are used when less restrictive interventions have been determined to be ineffective to protect the patient, staff, or others from harm. Interventions are discontinued at the earliest possible time, regardless of time of order expiration. Restraints/Seclusion are not used as a means of coercion, discipline, convenience or staff retaliation. The hospital uses restraints and seclusion ONLY to protect the immediate physical safety of the patient, staff, or others. ... V. PROCEDURE: To the extent possible, the impending need for behavioral restraint/seclusion is anticipated, and alternative treatments implemented to assist the patient to regain control. ... When behavioral restraint/seclusion is indicated, the following elements must be present: 1. Provider Order a. If conservative, non-physical strategies are unsuccessful in reducing the risk of: a. patient's behavior, the provider is notified, and if deemed medically appropriate, an order to implement behavioral restraint/seclusion is issued. b. In emergent situations, the professional nurse may implement behavioral restraint/seclusion prior to notification of the provider i. Following emergency implementation, the provider is immediately notified, and an order obtained. c. The order must include the following: i. Date and time of order ii. Rationale for use of behavioral restraint/seclusion iii. Type of Restraint iv. Location of Restraint ..."

Review of MR3 on August 8, 2024, revealed the patient was placed in 4-point soft locked violent restraints on July 19, 2024, at 22:00 and discontinued on July 19, 2024, at 23:00. Further review of the MR3 revealed there was no written order for the restraint.

Interview with employee EMP5 on August 9, 2024, at approximately 2:00 PM confirmed there was not a restraint order.

Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to follow their approved policy for the use of restraints and failed to ensure that a patient was seen face-to-face within 1 hour after the initiation of a restraint for one of ten medical records reviewed (MR3).

Findings include:

Review on August 7, 2024, of policy titled "Restraint and Seclusion Management" with a revision date of July 9, 2024, revealed "... I. POLICY: It is Crozer Health's desire to create a safe and appropriate environment in keeping with our mission and philosophy to protect patients and others. Restraints or seclusion are used when less restrictive interventions have been determined to be ineffective to protect the patient, staff, or others from harm. Interventions are discontinued at the earliest possible time, regardless of time of order expiration. Restraints/Seclusion are not used as a means of coercion, discipline, convenience or staff retaliation. The hospital uses restraints and seclusion ONLY to protect the immediate physical safety of the patient, staff, or others. ... V. PROCEDURE: To the extent possible, the impending need for behavioral restraint/seclusion is anticipated, and alternative treatments implemented to assist the patient to regain control. ... When behavioral restraint/seclusion is indicated, the following elements must be present: ... 2. A LIP (provider, physician assistant, CNPs) must see and evaluate the patient and document the following within one hour after initial implementation of behavioral restraint/seclusion for violent or self-destructive behavior: a. An evaluation of the patient ' s immediate situation b. The patient's reaction to the intervention c. The patient's medical and behavioral condition d. The need to continue or terminate the restraint ..."

Review of MR3 on August 8, 2024, revealed the patient was placed in 4-point soft locked violent restraints on July 19, 2024, at 22:00 and discontinued on July 19, 2024, at 23:00. Further review of the MR3 revealed there was no documentation of a physician assessing the patient within 1 hour of being placed in violent restraints.

Interview with EMP2 conducted via email on August 12, 2024, confirmed there was not a physician assessment of MR3.