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Based on document review, medical record (MR) and interview, in 10 of 10 MRs (Patients #1- #10) the facility staff did not document the medications ordered in an emergency situation to control a patient's violent and/or self-destructive behavior were used as chemical restraints. This lack could place patients at risk for untoward outcomes.

Findings include:

-- Review of the facility's P&P titled "Restraint Standards for Non-Psychiatric Patient Care Units," last revised 12/2016, indicated that a drug or medication when used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition is considered a restraint.

-- Review of Patient #1's MR indicated, on 10/18/18 at 3:33 am, he presented to the emergency department (ED) after having 2 episodes of seizure-like activity during the day. He became verbally and physically aggressive towards staff and was medicated with Haldol 5 milligrams (mg) and Versed 5 mg intramuscularly (IM) . There was no documentation in the MR indicating the medications were used as a chemical restraint.

-- Review of Patient #2's MR indicated, on 8/12/18 at 8:21 pm, he presented to the ED via ambulance and police, who had him in handcuffs. He was agitated and combative with altered mental status and recent drug ingestion. He was placed in 4 point Twice as Tough restraints with assistance of security and given Versed 5 mg IM at 8:45 pm. He continued to be combative and was given a second dose of Versed 5 mg intravenously (IV) at 9:06 pm. There is no documentation in the MR indicating these medications were given as a chemical restraint.

The same lack of documentation indicating medications were used as a chemical restraint was noted in the MRs for Patients #3 - #10.

-- During interview of Staff A (Patient Safety Officer) on 12/11/18 at 10:30 am, he/she acknowledged the above findings.

Based on document review, medical record (MR) review and interview, in 2 of 10 MRs (Patient #3 and #4) the facility did not ensure a provider order was documented for the emergency application of restraints. This lack could place patients at risk for untoward outcomes.

Findings include:

-- Review of the facility's policy and procedure (P&P) titled "Restraint Standards for Non-Psychiatric Patient Care Units," last revised 12/2016 indicated, each episode of restraint must be initiated in accordance with the order of a MD/LIP (licensed independent practitioner) who is responsible for the care of the patient. If the patient was recently released from restraint and exhibits behavior that can only be handled through the re-application of a restraint, a new order is required.

-- Review of Patient #3's MR indicated, on 11/18/18 at 7:23 pm, she presented to the emergency department (ED) with suicidal ideations, combativeness and confusion. She was placed in 4 point Twice as Tough restraints at 7:50 pm due to escalating agitation and violent behavior. She also received 2 doses of Haldol 5 milligrams (mg) intramuscular (IM). Restraints were removed at 9:30 pm after she was calm and cooperative. Patient #3 became agitated again at 9:50 pm, she was verbally abusive and aggressive towards staff and attempted to flip the stretcher. She was again placed in 4 point Twice as Tough restraints; however, no new provider order was documented.

-- Review of Patient #4's MR indicated, on 12/4/18 at 6:08 pm, he presented to the ED via emergency medical services (EMS) with chief complaint of seizures, aggressive behavior. The patient had been found having seizures and was combative for EMS and received Versed 5 mg prior to ED arrival. At 6:15 pm, ED nursing staff documented placing the patient in 4 point Twice as Tough restraints. Restraints were in place until 7:15 pm when nursing staff documented that restraints were discontinued. There was no documentation of a physician order for the restraints.

-- During interview of Staff A (Patient Safety Officer) on 12/11/18 at 11:30 am, he/she acknowledged the above findings.

Based on document review, medical record (MR) review and interview, in 10 of 10 MRs (Patients #1 - #10) of patients restrained (mechanical and chemical) all lacked documentation of a 1 hour face-to-face evaluation by a provider. This lack of evaluation could place patients at risk for injury or untoward outcomes.

Findings include:

-- Review of the facility's policy and procedure (P&P) titled "Restraints Standards for Non-Psychiatric Patient Care Units," last revised 12/2016, indicated the violent or self-destructive patient must be seen face-to-face by a MD/LIP (licensed independent practitioner) responsible for the care within 1 hour after initiation of the intervention. The evaluation must include the following: the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the restraint or seclusion.

-- Review of Patient #2's MR indicated, on 8/12/18 at 8:21 pm, he presented to the emergency department (ED) with a chief complaint of drug overdose, altered mental status and aggressive behavior. Patient #2 was combative and a danger to others and was placed in 4 point Twice as Tough behavioral restraints at 8:45 pm and given Versed 5 milligrams (mg) intramuscular (IM). He was seen by a provider at 8:50 pm and numerous laboratory studies ordered. A second dose of Versed 5 mg was given intravenously at 9:06 pm for continued agitation. There was no documentation by the provider of a 1 hour face-to-face evaluation.

-- Review of Patient #5's MR indicated, on 10/20/18 at 2:33 am, she presented to the ED for a psychiatric evaluation after ingesting multiple drugs (e.g., heroin, molly, cocaine, alcohol) in an attempt to end her life. She became agitated and combative and was placed in 4 point Twice as Tough behavioral restraints at 3:00 am and was given Versed 2 mg IM. She continued to be aggressive and was given Versed 2 mg and Haldol 5 mg IM at 3:15 am. There was no documentation by the provider of a 1 hour face-to-face evaluation.

The same lack of documentation of a 1 hour face-to-face evaluation by a provider was noted in the MRs for Patients #1, #3, #4 and #6 - #10.

-- During interview of Staff A (Patient Safety Officer) on 12/11/18 at 11:30 am, the above findings were acknowledged.

Based on document review and interview, the facility could not provide documented evidence that resident physicians who evaluate and enter orders for patient restraints had the appropriate training. This lack of training could place patients at risk for harm while in restraints.

Findings include:

-- Review of the facility's policy and procedure (P&P) titled "Restraints Standards for Non-Psychiatric Patient Care Units," last revised 12/2016 indicated, decisions related to use of restraints, and the application, care and ongoing assessment of patients in restraints, are made only by qualified hospital staff as outlined in the policy. This applies to physicians, house staff, licensed independent practitioners (LIP), Nurse Practitioners and Physician's Assistants. Hospital staff covered in this policy must be deemed competent through orientation and annual review to ensure educational preparedness for use of restraints, including alternatives and preventative measures, safe use of restraints and care of the patient in restraints.

-- Review of training records for Staff B (Resident Physician) and Staff C (Resident Physician) did not contain documentation of training in restraint and seclusion.

-- During interview of Staff D (Director of Graduate Medical Education [GME]) on 12/11/18 at 1:00 pm, he/she indicated all residents sign off that they understand where the facility's policies and procedures (P&P) are found. There is no specific training through GME pertaining to restraints.