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Based on record review and staff interview, it has been determined that the facility failed to ensure the use of a restraint has been applied in accordance with the order of a physician or other licensed independent practitioner for 1 of 5 relevant sample patients ID # 3.

Findings are as follows:

Record review reveals patient ID #3 was restrained on 6/4/2015 at approximately 12:40 AM due to aggressive behavior. The record reveals the restraints were removed at approximately 1:16 AM.

During a review of the patient's electronic medical record with the Risk Manager on 1/15/2015 at approximately 11:00 AM, she was unable to provide evidence of an order from a physician or other licensed independent practioner.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the physician's order for a restraint renewal not exceed 24 hours for 1 of 5 relevant sample patients ID #29.

Findings are as follows:

Record review reveals patient ID #29 was restrained on 4/22/2015 at approximately 1:19 AM. The record reveals the restraints were reordered on 4/24/2015 (48 hours later).

During a review of the patient's electronic medical record with the Risk Manager and Informatics Nurse on 1/27/2015 at approximately 10:00 AM, they were unable to provide evidence that the restraints were reordered within a 24 hours time frame.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the condition of the patient who is restrained, is monitored at an interval determined by hospital policy, for 2 of 5 relevant sample patients, ID #'s 27 and 28.

Findings are as follows:

The Hospital Policy for "Violent Restraints or Seclusions" states: "The RN assesses the patient at the initiation of restraint or seclusion, and no less than every 1 hour thereafter..."

"Non-Violent Restraint" states: "The RN assesses the patient at the initiation of restraint, and no less than every 2 hours thereafter..."

1. Record review reveals patient ID #27 was restrained on 6/16/2015 at approximately 5:10 AM due to aggressive behavior. The restraints were discontinued at approximately 6:45 AM, the record lacked evidence of an RN (registered nurse) assesment of the condition of the patient at the initiation of the application of the restraints and no less than 1 hour after, in accordance with hosptial policy.

2. Record review for patient ID #28 reveals the patient was restrained while in the ICU (intensive care unit) on 5/8/2015. The record lacks evidence of an RN assessment of the condition of the patient every 2 hours after the application of the restraints in accordance with hospital policy.

During a review of the patient's electronic medical records with the Risk Manager and Informatics Nurse on 1/27/15 at approximately 10:00 AM, they were unable to provide evidence that these patients were monitored after the application of the restraints in accordance with hospital policy time intervals.

Based on record review and staff interview, it has been determined that the facility failed to ensure a patient is seen face-to-face within 1-hour after the initiation of a restraint for 1 of 5 relevant sample patients ID #26.

Findings are as follows:

Record review revealed patient ID #26 has a physician's order dated 4/3/2015 at 1:25 AM, for limb restraints due to aggressive behavior. The restraints were discontinued at approximately 3:12 AM. The record lacks evidence of a face-to-face assessment by a physician or other licensed independent practitioner within an hour of the initiation of the restraint.

During a review of the patient's electronic medical record with the Risk Manager and Informatics Nurse on 1/27/15 at approximately 10:00 AM, they were unable to provide evidence that the face-to-face evaluation of the patient had been done within an hour of the restraint application.


"You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the Rules and Regulations for Hospitals, they are deficiencies under State regulations and grounds for licensure sanctions."