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Based on interviews and document review, the facility failed to ensure an order was obtained from a physician or licensed psychologist prior to, or immediately after, the initiation of each instance of physical restraint in 2 of 2 medical records reviewed of patients with documented use of physical restraints (Patients #1 and #2).

Findings include:

Facility policy:

According to the Restraint and Seclusion Policy, restraint/seclusion are only used when less restrictive interventions have been determined to be ineffective. When restraint/seclusion is required, the least restrictive method of restraint is chosen. An order for violent restraint and seclusion is required within 1 hour of application. Monitoring and Documentation: Type and location of the restraining device is documented. Violent restraint is a restriction of patient movement for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a member, or others.

Physical hold is a physical action of placing one's hands on an individual used to gain control in order to protect the person or others from harm after all attempts to verbally direct or de-escalate the person have failed. Physical management may be used when an emergency situation exists. Note: A physical hold of 5 minutes or longer OR when the patient is brought to the ground is a restraint.

Seclusion may only be used when other less restrictive methods have failed. Seclusion may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member, or others. Seclusion is the involuntary confinement of a person alone in a room or an area where the person is physically prevented from leaving.

Therapeutic hold is a physical hold of less than 5 minutes in duration as a behavioral intervention where the hold does not move to the floor. Note: A therapeutic hold does not require either an order or a face to face assessment.

1. The facility failed to obtain a new physician order for each instance of restraint.

a. Review of Patient #1's medical record revealed a Behavioral Therapeutic Hold Flowsheet that showed the patient was placed in a therapeutic hold on 11/28/18 from 12:28 p.m. until 12:40 p.m., for a total of 12 minutes.

Subsequently, according to the Restraint Summary Flowsheet, the patient was placed into seclusion on 11/28/18 at 12:40 p.m. Record review showed an order for seclusion was noted at 12:57 p.m.; however, there was no order for the physical hold which preceded the seclusion.

b. Review of Patient #2's medical record showed an Initiate Violent Restraint/Seclusion Flowsheet that revealed the patient was placed in a physical hold on 9/27/18 from 2:46 p.m. until 2:54 p.m., for a total of 8 minutes.

Further review of the medical record showed the patient was then placed into seclusion from 2:54 p.m. until 3:00 p.m. Only an order for seclusion was noted at 3:00 p.m. There was no physician's order for the physical hold restraint episode.

c. On 1/16/19 at 4:33 p.m. an interview with Registered Nurse (RN) #1 was conducted. RN #1 stated it was necessary to obtain a physician's order when a patient was placed in restraints because you were removing a patient's rights. RN #1 additionally stated an order was necessary for each form of restraint, including a physical hold and seclusion and these orders were separate because they were two different forms of restraint. RN #1 stated it was important to start with the least restrictive measure of restraint first. RN #1 stated the least restrictive measure was a therapeutic hold less than 5 minutes, which did not require a physician's order, followed by a physical hold (which was determined to be a restraint) and lastly, seclusion. RN #1 stated it was important to notify the physician of each escalating form of restraint so they may be informed of changes to the patient and adjust treatment accordingly.

d. On 1/17/19 at 8:40 a.m. a medical record review for Patient #1 was conducted with the charge nurse (RN #2). RN #2 confirmed Patient #1 was in a physical hold for 12 minutes and once the therapeutic hold exceeded 5 minutes it became a physical restraint. RN #2 confirmed there was no restraint documentation by the nurse for a physical hold. RN #2 acknowledged there was no order for a physical hold and the only order in Patient #1's medical record was for seclusion. RN #2 stated it was important to obtain an order after 5 minutes when transitioning from a therapeutic hold to a physical hold so the physician was aware the patient had transitioned into needing a higher level of intervention. RN #2 stated this was to ensure the provider was aware of changes to the patient so they could adjust treatment or medications and ensure patient safety.

e. On 1/17/19 at 12:07 p.m., an interview was conducted with the associate clinical manager of intensive psych services (Manager #3). Manager #3 stated there must be a specific order for physical restraint or seclusion from the physician. Manager #3 stated a therapeutic hold became a physical restraint after 5 minutes in the hold, which required a physician's order. Manager #3 stated an order by the physician for a physical restraint was necessary to protect the patient by ensuring the appropriate restraint was in place and the use of the restraint was justified.

Based on interviews and record review, the facility failed to ensure a qualified provider evaluated patients to determine the need to continue or terminate the seclusion restraint within one hour of the initiation of seclusion in 1 of 2 restraint records reviewed (Patient #1).

Findings include:

Facility policy:

According to the Restraint and Seclusion Policy, a face-to-face assessment shall be conducted as soon as possible, but no longer than one hour after the initiation of restraint. The face-to-face assessment and documentation include 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 intervention.

1. The facility failed to ensure face to face evaluations were performed within one hour of the initiation of seclusion.

a. Review of Patient #1's medical record revealed a Violent or Self-Destructive Flowsheet which showed he was placed in seclusion on 11/25/18 at 1:21 p.m. for being an imminent risk of harm to himself and others. Patient #1 was released from seclusion at 1:32 p.m.

Review of the Face to Face Assessment for Behavioral Restraint/Seclusion revealed the face to face evaluation was performed at 3:00 p.m., which was 1 hour and 39 minutes after initiation of seclusion. This was in contrast to the policy which requires the face to face evaluation to be performed within one hour after the initiation of restraint or seclusion.

Additional review of Patient #1's record revealed a Restraint Summary Flowsheet which showed he was again placed in seclusion on 12/2/18 at 7:16 a.m. for being an imminent risk of harm to himself and others. Patient #1 was released from seclusion at 7:36 a.m.

Review of the Face to Face Assessment for Behavioral Restraint/Seclusion revealed the evaluation was performed at 9:20 a.m., which was 2 hours and 4 minutes after initiation of seclusion.

b. On 1/16/19 at 4:33 p.m., an interview was conducted with Registered Nurse (RN) #1. RN #1 stated a face to face assessment was done on all patients within one hour of placing a patient in restraint or seclusion. RN #1 also stated the purpose of a face to face was to verify the patient was well, safe, and not being neglected. RN #1 further stated there was never a time a face to face assessment would not be done within a one hour time period. RN #1 confirmed the face to face assessment was not done within one hour for Patient #1 on 11/25/18.

c. On 1/17/19 at 12:07 p.m., an interview was conducted with Associate Clinical Manager of Intensive Psych Services (Manager) #3. Manager #3 stated all patients in restraint or seclusion needed a face to face assessment within 1 hour of being placed in restraints. Manager #3 stated a face to face assessment provided an opportunity for the provider to review the care being provided, as well as monitor the physical and emotional needs of the patient, and offer advice on the situation. Manager #3 confirmed the assessment time on the document, Face to Face Assessment for Behavioral Restraint/Seclusion, was the actual time the face to face assessment was completed by the provider.