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Based on record review, interview and observation, the facility failed to ensure the rights of 4 of 4 patients to safe restraint practices (Patients #1,7,8,9), as shown by these patients not receiving face-to-face evaluations within 1 hour of being restrained in a restraint chair.


Findings included:


Facility policy titled "Restraints", last revised 5/2023 states that the definition of
restraint (consistent with the federal definition of restraint-see tag A0159), is any manual method, physical, drug, or mechanical device, material, or equipment that immobilizes the ability of a patient to move their arms, legs, body, or head freely.

In addition, the policy states that a behavioral restraint assessment must be performed within one hour of restraint application. It also states that monitoring of the physical and psychological well-being of the patient who is restrained will occur, which includes respiratory status and vital signs.

Observation on 6/14/23 at 11:30 am showed the facility had a chair specifically designed to restrain patients: It had a padded back and seat with several straps to secure arms, legs, and the head. The chair also had a metal platform foot-rest and was equipped with wheels for mobility.

In an interview at the same time of observation, Staff #1 stated that the chair was specially designed and used to restrain patients during behavioral emergencies.

Record review of facility's incident report log and patient medical records showed Patient #s 1, 7, 8, and 9 had been restrained in the facility's restraint chair:

Patient #1 during hospital stay from 3/9/23-4/3/23;
Patient #7 on 3/4/23;
Patient #8 on 3/10/23, and;
Patient #9 on 3/12/23.

Further record review showed there were no face-to-face evaluations for all four patients performed within one hour post-restraint initiation, with the necessary components consisting of: assessment of the patient's immediate situation, a complete review of systems assessment, behavioral assessment, and the patient's reaction to the intervention.

Record review of restraint documentation for the four patients showed that although they did receive monitoring assessments every 15 minutes while being restrained that evaluated circulation and skin integrity, the assessments did not include respiratory status, vital signs, or psychological status per facility policy.

In an interview on 6/15/23 at 2:00 pm, Staff #1 stated that if a patient is restrained in the restraint chair, there is no face-to-face post restraint assessment performed within one hour after initiation of restraint; it would only be done if emergency medications were administered.