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Based on document review and interview, it was determined that for 4 of 5 patients' (Pt. #2, Pt. #3, Pt. #4, and Pt. #6) clinical records reviewed regarding use of restraints, the Hospital failed to ensure that the staff obtained a physician's order for the application of violent or non-violent restraints.

Findings include:

1. On 6/20/2023, the Hospital's policy titled, "Restraint Policy" (2/2021) was reviewed and included, "... Definitions... Episode: For non-violent restraints only and defined as the time when an order has been obtained for use of restraints and restraints have been applied until the restraints have been safely removed for longer than 60 minutes... Procedure... C... a. Non-violent restraints are used to limit mobility related to medical or post-surgical procedures in order to prevent interruption of care. i. Non-violent restraints require a provider (physician) order...iii. Renewal orders are required per episode... b. Violent restraints are used to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others. i. Violent restraints require a provider order..."

2. On 6/20/2023, the clinical record for Pt. #2 was reviewed. On 6/7/2023, Pt. #2 was admitted with diagnoses of abdominal pain, abdominal distention, nausea and vomiting. On 6/18/2023 at 8:00 PM through 6/20/2023 at 12:00 midnight, non-violent restraints were applied to Pt. #2. A renewal order for the application of non-violent restraints was not obtained.

3. On 6/20/2023, the clinical record for Pt. #3 was reviewed. On 6/18/2023, Pt. #3 was admitted with hallucinations and altered mental status. On 6/19/2023 at 2:00 PM through 6/20/2023 at 6:00 AM, non-violent restraints were applied to Pt. #3. A renewal order for the application of non-violent restraints was not obtained.

4. On 6/20/2023, the clinical record for Pt. #4 was reviewed. On 6/16/2023, Pt. #4 was admitted with a diagnosis of hyponatremia (low sodium in blood). On 6/18/2023 at 12:00 midnight through 6/19/2023 at 12:00 midnight, non-violent restraints were applied to Pt. #4. A renewal order for the application of non-violent restraints was not obtained.

5. On 6/21/2023, the clinical record for Pt. #6 was reviewed. On 4/25/2023, Pt. #6 was brought to the Hospital's ED (emergency department) for psychiatric evaluation. On 4/25/2023 at 4:30 PM through 5:30 PM, the clinical record indicated that violent restraints were applied to Pt. #6. A physician's order for the application of violent restraints was not documented.

6. On 6/20/2023 at approximately 10:30 AM and on 6/21/2023 at approximately 10:15 AM, findings were discussed with E #2 (Director of Nursing/Interim Intensive Care Unit/ICU Manager) E # 4 (Charge Nurse, ICU), and E # 7 (ED Director). E #4 stated that the clinical records did not include renewal orders regarding use of non-violent restraints. E #2, E #4 and E #7 stated that a physician's order should have been documented when applying violent or non-violent restraints.

Based on observation, document review and interview, it was determined that for 2 of 5 patients' (Pt. #2 and Pt. #6) clinical records reviewed regarding use of restraints, the Hospital failed to ensure that the staff documented the required assessments/reassessments while patients were in violent or non-violent restraints.

Findings include:

1. On 6/20/2023 between 10:00 AM through 10:45 AM, an observational tour of the Hospital's ICU (intensive care unit) was conducted. During the tour, Pt. #2 was observed with non-violent restraints (bilateral soft wrist restraints) on bilateral upper extremities.

2. On 6/20/2023, the Hospital's policy titled, "Restraint Policy" (2/2021) was reviewed and included, "... Procedure... C... a. Non-violent restraints are used to limit mobility related to medical or post-surgical procedures in order to prevent interruption of care... ii. Assessment and reassessment for continued need is required... iv. Documentation of patient care every two hours... b. Violent restraints... v. Assessment and reassessment for continued need is required... vii. Documentation of observation of patient every 15 minutes..."

3. On 6/20/2023, the clinical record for Pt. #2 was reviewed. On 6/7/2023, Pt. #2 was admitted with diagnoses of abdominal pain, abdominal distention, nausea and vomiting. On 6/20/2023 from 12:00 midnight through 10:35 AM, non-violent restraints were applied to Pt. #2. The clinical record lacked documentation for the continued need of non-violent restraints every two hours.

4. On 6/21/2023, the clinical record for Pt. #6 was reviewed. On 4/25/2023, Pt. #6 was brought to the Hospital's ED (emergency department) for psychiatric evaluation. On 4/25/2023 from 4:30 PM through 5:30 PM, violent restraints were applied to Pt. #6. Pt. #6 had a sitter for continuous observation, however, the clinical record lacked documentation for the continued need of violent restraints every 15 minutes.

5. On 6/20/2023 at approximately 10:30 AM, and on 6/21/2023 at approximately 10:15 AM, findings were discussed with E #4 (Charge Nurse, ICU), E #6 (Pt. #2's Nurse/RN), and E #7 (ED Director). E #4 and E #6 stated that Pt. #2 has been in non-violent restraints during the night shift (6/20/2023 12:00 midnight until this morning) . E #6 stated, "I did not have the time to document my assessments every two hours." E #4 and E #7 stated that nurses should document their assessments while a patient is in restraints according to the Hospital's policy.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #6) clinical records reviewed regarding use of violent restraints, the Hospital failed to ensure that a provider conducted a face to face assessment within one hour after the initiation of restraints.

Findings include:

1. On 6/20/2023, the Hospital's policy titled, "Restraint Policy" (2/2021) was reviewed and included, "... Procedure... C... b. Violent restraints are used to manage violent or self-destructive behavior... iii. Face-to-Face provider assessment is required within one hour of placing violent restraints. 1. The Nursing Supervisor can complete the assessment..."

2. On 6/21/2023, the clinical record for Pt. #6 was reviewed. On 4/25/2023, Pt. #6 was brought to the Hospital's ED (emergency department) for psychiatric evaluation. On 4/25/2023 from 4:30 PM through 5:30 PM, violent restraints were applied to Pt. #6. The clinical record lacked a provider's face to face assessment within one hour of placing the violent restraints.

3. On 6/21/2023, findings were discussed with E #7 (ED Director). E #7 stated that a physician normally conducts a face to face assessment within one hour of placing a patient in violent restraints. E #7 stated that there was no documentation that a provider conducted the required face to face assessment.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #6) clinical records reviewed regarding use of violent restraints, the Hospital failed to complete the required face to face evaluation within one hour after the initiation of the intervention.

Findings include:

1. On 6/20/2023, the Hospital's policy titled, "Restraint Policy" (2/2021) was reviewed and included, "... Procedure... C... b. Violent restraints are used to manage violent or self-destructive behavior... iii. Face-to-Face provider assessment is required within one hour of placing violent restraints... 2. This assessment must include the following: a. Evaluation of current status; b. Patient's response to the intervention; c. Patient's medical and behavioral status; d. Need to continue or terminate the restraints..."

2. On 6/21/2023, the clinical record for Pt. #6 was reviewed. On 4/25/2023, Pt. #6 was brought to the Hospital's ED (emergency department) for psychiatric evaluation. On 4/25/2023 from 4:30 PM through 5:30 PM, violent restraints were applied to Pt. #6. The clinical record lacked documentation that the following face to face evaluation/assessments were completed: Pt. #6's current status, response to intervention, medical and behavioral status, and need to continue or terminate the restraints.

3. On 6/21/2023 at approximately 10:00 AM, findings were discussed with E #7 (ED Director). E #7 stated that there was no documentation that the required face to face evaluation was completed.