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Based on record review, interview, and facility policy review, the Hospital failed to protect and promote the patient's rights for 1 (Patient 6) of 3 sampled patients reviewed for restraints. This deficient practice has the potential to place patients at risk for harm and injury.

Findings Included:

1. The hospital failed to ensure that the use of restraints was in accordance with a written modification to the patient's plan of care. (A-0166)

2. The hospital failed to ensure that patients who were restrained were monitored as required by hospital policy. (A-0205)

Based on interview, record review, and facility policy review, the facility failed to ensure that the use of restraints was in accordance with a written modification to the patient's plan of care for 1 (Patient 6) of 3 sampled patients reviewed for restraints.

Findings Included:

A facility policy titled, "Restraint Policy," approved 09/14/22, indicated, "Each restraint episode will be documented in the patient's medical record, and will include: "1. In-person evaluations by the LIP(s) [licensed independent practitioner]." The policy specified, "13. Revisions to the patient's plan of care, in accordance with restraint use."

Review of Patient 6's "History & Physical," dated 07/13/24 at 11:04 PM, revealed the facility admitted the patient on 07/13/24 for syncope (fainting or passing out).

Patient 6's "Order Detail" flowsheet revealed an order for "Restraint Initiate Violent 18 Years and Older." The Order Detail contained an order for "4-Point Hard" restraints dated 07/16/24 at 4:17 AM. The Order Detail flowsheet contained an order, dated 07/16/24 at 4:17 AM, that indicated "Document restraint monitoring every 15 minutes or more frequent if needed." The Order Detail revealed a stop date of 07/16/24 at 8:16 AM.

Patient 6's "Restraint Face to Face Evaluation Violent" note indicated an evaluation was performed on 07/16/24 at 5:20 AM. The Restraint Face to Face Evaluation Violent note revealed that 4-point hard restraints were on and that the restraints were to be continued.

Patient 6's "Restraints" flowsheet dated 07/16/24 at 5:20 AM, revealed 4-point hard restraints were on and indicated they were to continue.

Patient 6's "Interdisciplinary Care Plan" flowsheets revealed no evidence that restraints were included in the patient's plan of care.

During an interview on 12/10/24 at 3:08 PM, Nursing Director (ND) 1 stated that if the restraints were not placed on the patient, the nurse would not have initiated the care plan. ND 1 stated that Patient 6 may have been "talked down," and the restraints were never placed on them. ND 1 stated that she did not see a care plan related to restraints.

Based on interview, record review, and facility policy review, the facility failed to ensure patients who were restrained were monitored as required by hospital policy for 1 (Patient 6) of 3 sampled patients reviewed for restraints.

Findings Included:

A facility policy titled, "Restraint for Violent and or Self-Destructive Behavior," approved 09/14/22, indicated, "Patient Care Management" included "C. Ongoing care while patient is restrained: 1. Assign a staff member for continuous observation. Document monitoring/ interventions at the following frequencies: a. Every 15 minutes: i. Physical restraints are secure ii. Patient is safely positioned iii. Physical restraints: circulatory status not impaired iv. Patient's behavior b. Every 30 minutes: i. Respiratory rate ii. Pulse c. Every hour (for physical restraints only): Skin condition of restraint contact areas. d. At least every two hours, when patient's behavior allows, and while ensuring adequate staff assistance: i. Release physical restraints (one limb at a time). Assist with active or passive range of motion (ROM) to each extremity, and repositioning. ii. Offer food or fluids, if diet permits. If patient is not allowed oral intake, offer oral hygiene. iii. Offer assistance with elimination needs."

Review of Patient 6's "History & Physical," dated 07/13/24, revealed the facility admitted the patient on 07/13/24 for syncope (fainting or passing out).

Patient 6's "Order Detail" flowsheet revealed an order for "Restraint Initiate Violent 18 Years and Older." The Order Detail contained an order for "4-Point Hard" restraints dated 07/16/24 at 4:17 AM. The Order Detail flowsheet contained an order, dated 07/16/24 at 4:17 AM, that indicated "Document restraint monitoring every 15 minutes or more frequent if needed." The Order Detail revealed a stop date of 07/16/24 at 8:16 AM.

Patient 6's "Restraint Face to Face Evaluation Violent" note indicated an evaluation was performed on 07/16/24 at 5:20 AM. The Restraint Face to Face Evaluation Violent note revealed that 4-point hard restraints were on and that the restraints were to be continued.

Patient 6's "Restraints" flowsheet dated 07/16/24 at 5:20 AM, revealed 4-point hard restraints were on and indicated they were to continue.

Patient 6's medical record revealed no evidence to indicate documentation of initiation, monitoring, or discontinuation of the restraints.

During an interview on 12/10/24 at 3:06 PM, the Chief Nursing Officer (CNO) stated it appeared that the nurse asked for restraint order for Patient 6 and an order was placed. The CNO stated that there was no nursing documentation on the restraints, but the face-to-face evaluation indicated that the restraints were on.

During an interview on 12/11/24 at 12:35 PM, Medical Doctor (MD) 9 stated that he was made aware of the question regarding Patient 6's restraints on 12/10/24, after staff completed chart review, and he did go back and look at the chart and records to re-familiarize himself. MD 9 stated that he did not recall the patient. MD 9 stated that he was night coverage that shift and was "running around." MD 9 stated that the patient had been admitted, and their withdrawal symptoms escalated. Per MD 9, he knew especially in the case of hard restraints, that documentation was required. MD 9stated that he assumed he was there, saw the patient, and the record indicated the restraints were on the patient would have been an error, but that would be "mere surmising and speculation." MD 9stated that he did not remember the encounter at all. MD 9 stated that he knew that if the patient had restraints on, it would have required more documentation to show as such.