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Based on medical record review, staff interviews, and review of facility policy, it was determined the facility failed to ensure that all non-violent restraints are implemented in accordance with the physician's order in one of four medical records reviewed (MR1).

Findings include:

On 01/28/25 during a review of Patient (P)1's medical record, in the presence of Staff (S)4 (Patient Safety Manager), and S12 (Assistant Director of PCU [Progressive Care Unit]), the following was revealed:

A nursing note written on 1/21/2025 by S28 (Registered Nurse [RN]) stated, "0745 (7:45 AM)-While receiving report, patient noted to be agitated pulling on chest leads ... [name, S28], RN bedside attempting to verbally de-escalate patient. ...patient began screaming not to touch [him/her] and became increasingly more agitated and aggressive. When asked if patient would return to bed, patient lunged at RN. Crisis called. Night RN and writer followed patient from a distance around unit, until meeting security in the elevator lobby. When security attempted to redirect patient, patient shoved security guard. Security physically restrained patient and escorted patient back to room. Patient placed back in bed and put in soft restraints. IM (intramuscular) Geodon (antipsychotic medication prescribed for symptoms of acute agitation) given as per MD (medical doctor) order. Patient placed back on central monitor, vitals noted to be stable."

The restraint order written by S26 (MD) on 1/21/25 at 0744 (7:44 AM), stated, "Restraints Non-Violent/Non-Self Destructive (Discontinued) ... Reason for Restraints: Pulling on Medical Devices; Response and Reaction of the Patient: Agitated; I have conducted a face to face assessment within 1 hour of initiation of restraint: Yes; Use of Restraints clinically appropriate: Yes; Less restrictive measures as indicated on restraint/seclusion flowsheet, attempted and unsuccessful: Yes; Type of Restraint: Non-Violent Restraint L (left) Wrist, Non-Violent Restraint R (right) ankle, Non-Violent Restraint R Wrist."

Review of the 'Restraints Flowsheet' in MR1 stated, "01/21/25 0800 (8:00 AM); Type of Order: 24 hours (Non-Violent); MD Notified: Yes; Order Obtained: Yes; Less Restrictive Alternative Prior to Restraint: Verbal De-Escalation; Clinical Justification: Danger to Others; Visual Check: Yes; Signs of Injury: No; Need for Continued Restraints: Yes; Non-Violent Restraint R Wrist: START; Non-Violent Restraint L Wrist: START." The medical record lacked documentation in the restraint flowsheet that Non-Violent Restraint was applied to the patient's right ankle per the order written by S26.

Upon interview, when asked if P1's right wrist, left wrist, and right ankle were placed in restraints on 01/21/25, S12 stated, "No, P1 was placed in 2-point non-violent restraints (right and left wrist only). We [PCU] do not allow anything more than that-there is no such thing as 3-point restraints (right wrist, left wrist, and right ankle). 4-point restraints (both wrists and both ankles) are considered 'Violent Restraints' which the unit does not permit. I do not know why S26 wrote the order for Non-Violent Restraints to be placed on the patient's R ankle." When asked if the restraint order should have been discontinued and an order for Non-Violent Restraints for the Right and Left wrist entered, S12 stated, "Yes."

On 01/28/25 at 1:05 PM, S4 and S12 confirmed that the orders in MR1 for Non-Violent Restraints to be placed on P1's right wrist, left wrist, and right ankle on 01/21/25 was incorrect. S12 confirmed the medical record lacked an order for the patient to be placed in 2-point non-violent restraints.

A review of the facility policy titled, "Use of Restraints and Seclusion" (Issued March 2023), the policy did not address the type of restraints to be applied to a patient's extremities, for non-violent restraints.

Based on medical record review, staff interviews, and review of facility documents, it was determined the facility failed to ensure that a 1-hour face-to-face assessment is conducted and documented for patients placed on non-violent restraints in one of four medical records reviewed (MR1).

Findings include:

Facility policy titled, "Use of Restraints and Seclusion" (Issued March 2023) stated, " ... Orders: A. Restraints and/or can be initiated as follows: 1. An individual written order by the LP (Licensed Practitioner); or 2. An RN (Registered Nurse) in response to an unanticipated or emergent situation a. The RN must immediately notify and consult with the LP after placing patient in restraints and/or seclusion. ... B. The LP will: 1. Conduct and document face-to-face assessment within one (1) hour of restraint placement ..."

On 1/28/25, during the review of P1's medical record, in the presence of Staff (S)4 (Patient Safety Manager) and S12 (Assistant Director of PCU [Progressive Care Unit]), the following was revealed:

On 1/21/25 at 7:44 AM, S26 (Medical Doctor) order for restraint indicated, "Restraints Non-Violent/Non-Self Destructive ... Reason for Restraints: Pulling on Medical Devices; Response and Reaction of the Patient: Agitated; I have conducted a face to face assessment within 1 hour of initiation of restraint: Yes; Use of Restraints clinically appropriate: Yes; Less restrictive measures as indicated on restraint/seclusion flowsheet, attempted and unsuccessful: Yes; Type of Restraint: Non-Violent Restraint L (left) Wrist, Non-Violent Restraint R (right) ankle, Non-Violent Restraint R Wrist."

Upon interview, S12 confirmed that the restraint order written by S26 documented that a face-to-face assessment was completed, however the MR lacked any details of the face-to-face assessment or provider note.

A CRT (Crisis Response Team) Note, documented by S26 on 1/21/25 at 7:54 AM, stated, "CRT with behavioral health doctor was called on this patient at approximately 7:33 am because patient was getting out of bed, taking [his/her] clothes off, and attempting to leave. When writer arrived to room, patient was being restrained. Patient was calm after restraints but did not answer questions appropriately. [He/She] did not appear to understand questions and was repeatedly speaking about [his/her] mother. Patient had difficult forming sentenced and repeated [himself/herself] several times. Primary team was not present, so writer ordered Geodon (an antipsychotic medication prescribed for symptoms of acute agitation) 10mg IM once for agitation. ..."

The medical record for P1 lacked documentation that S26 completed the face-to-face assessment within one (1) hour after P1 was placed in restraints and medicated with Geodon at 7:44 AM. In accordance with the facility's restraint policy, P1 should have received a face-to-face assessment from a provider by 8:44 AM on 01/21/25. The patient was next assessed at 11:09 AM by S27 (MD, Attending Physician, Neurology Department.)

On 1/28/25 at 1:10 PM, upon interview, S4 and S12 confirmed MR1 lacked documentation that a provider completed a face-to-face assessment within one hour of restraint placement as per facility policy.