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Based on policy review, medical record review, and staff interview, the facility failed to ensure a physician's order was obtained for restraints according to policy and procedure for one of five medical records reviewed with restraints (Patient #1). A total of ten medical records were reviewed. The facility census was 800.

Findings include:

Review of the policy titled, "Use of Restraints," effective 03/10/22, revealed restraints for non-violent, non-self destructive behavior, in the event of an emergency, immediately after applying restraints, an order must be obtained for the restraints. Restraints for violent or self destructive behavior, in the event of an emergency, immediately after applying restraints, an order must be obtained for the restraints. The Licensed Independent Practitioner should evaluate the patient face to face within one hour of the application of the restraint and complete the initial order within one hour.

Review of the medical record for Patient #1 revealed documentation on the restraint monitoring flowsheet of bilateral soft wrist restraints applied on 04/24/23 at 9:00 AM. The restraint monitoring flowsheet contained documentation of untied bilateral mitts added at 11:00 AM on 04/24/23. The first restraint order documented in the medical record was on 04/24/23 at 11:18 AM for untied mitts to bilateral hands. On 04/24/23 at 1:52 PM, untied mitts to right hand and bilateral soft wrist restraints were ordered. On 04/25/23 at 8:52 AM, the untied mitt to right hand and bilateral soft wrist restraints were re-ordered. The restraint monitoring flowsheet contained documentation of bilateral ankle restraints added to the bilateral soft wrist restraints on 04/25/23 at 12:00 PM. The medical record contained an order dated 04/25/23 at 8:52 AM for untied mitts to bilateral hands and bilateral soft wrist restraints. The progress note dated 04/25/23 at 2:41 PM noted received message from nursing regarding agitation and combativeness requiring four point restraints. Examined patient at bedside. Patient in bed resting and tearful, visibly restless and making faces suggestive of pain. Removed bilateral ankle restraints as patient is not combative at this time. The medical record lacked documentation of an order for the bilateral wrist restraints for almost five hours and no order for the ankle restraints or need for behavioral restraints. On 06/27/23 at 2:15 PM, Staff C verified the above findings.

This deficiency represents noncompliance investigated under Substantial Allegation OH00142893.

Based on policy review, medical record review, and staff interview, the facility failed to ensure restrained patients were monitored per their policy for one of five medical records reviewed with restraints (Patient #1). A total of ten medical records were reviewed. The facility census was 800.

Findings include:

Review of the policy titled, "Use of Restraints," effective 03/10/22, revealed restraints should be evaluated every two hours for physical safety and documented in the medical record.

Review of the medical record for Patient #1 revealed documentation on the restraint monitoring flowsheet of untied mitts to bilateral hands and bilateral soft wrist restraints on 04/24/23 and 04/25/23. The medical record lacked documentation of restraint monitoring on 04/25/23 from 12:00 PM through 8:00 PM. The medical record lacked documentation of removal of restraints during this time. The 8:00 PM restraint documentation on 04/25/23 noted bilateral wrist restraints continued. On 06/27/23 at 2:15 PM, Staff C verified the above findings.

This deficiency represents noncompliance investigated under Substantial Allegation OH00142893.