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Based on document reviews and interviews, the hospital failed to ensure the hospital's policy for restraints and seclusion, related to the documenting of less restrictive measures tried before applying restraints, was implemented for one (1) of six (6) restrained patients (Patient 5R).

Finding:

The hospitals "Use of Restraints", last reviewed 05/17/2023, defines a physical hold as, "Holding a patient in a manner that restricts the patient's movement against the patient's will is considered a restraint. The application of force to physically hold a patient, in order to administer a medication against the patient's wishes, is considered a restraint".

The policy also states, in part, "The assessment must include the following ... Less restrictive alternatives considered or used, as appropriate to the situation, and why these alternatives proved ineffective ... ".

On 12/05/2023 at 2:00 PM, six (6) medical records were reviewed which indicated the following:

Documentation in Patient 5R's record revealed the following:
- On 11/18/2023, Provider #1 documented, in part, "[He/She] will require IM [Intra Muscular] medication administration due to patient and staff safety. [He/She] will require physical restraint ... ";
- On 11/18/2023 at 1:35 AM, Provider #1 ordered a physical hold; and
- There was no documented evidence in the medical record that less restrictive measures were attempted.

On 12/05/2023 at approximately 2:15 PM, this finding was confirmed at the time of the review.

On 12/06/2023 at 12:58 PM, a second review of Patient 5R's medical record was conducted with the Senior Director, Regional Accreditation and Regulatory Affairs and the above finding was confirmed.

Based on document reviews and interviews, the hospital failed to ensure the hospital's policy for restraints, related to the reason for the restraint, was implemented for one (1) of six (6) restrained patients (Patient 5R).

Finding:

The hospitals "Use of Restraints", last reviewed 05/17/2023, defines a physical hold as, "Holding a patient in a manner that restricts the patient's movement against the patient's will is considered a restraint. The application of force to physically hold a patient, in order to administer a medication against the patient's wishes, is considered a restraint".

The policy also states, in part, "RN [Registered Nurse] Documentation: 1. The trained RN documentation at the time of initiation of restraint will document the following on the Violent Self destructive flowsheet in the electronic medical record. a. Assessment of the patient's behavior leading to restraint b. Less restrictive alternatives considered or used, as appropriate to the situation, and why these alternatives proved ineffective. c. Date, time and type of restraint used. d. Request for a security officer, if circumstances warranted. e. The patient's response to the use of restraint. f. Notification and education provided to the patient/family regarding the necessity 2. The trained RN ongoing documentation will include the following at a minimum of approximately every 15 minutes on the Violent Self destructive flow sheet in the electronic health record. 3. Criteria to determine if a restraint meets the requirements for using non-violent, non-self-destructive restraint. 4. Documentation of the termination of restraint will be documented on the Violent Self destructive flow sheet in the electronic health record and the trained RN must discontinue the order in the electronic documentation system. (Choose "no longer clinically indicated" from dropdown list). The plan of care should be completed ... ".

On 12/05/2023 at 2:00 PM, six (6) medical records were reviewed which indicated the following:

Documentation in Patient 5R's record revealed the following:
- On 11/18/2023, Provider #1 documented, in part, "[He/She] will require IM [Intra Muscular] medication administration due to patient and staff safety. [He/She] will require physical restraint ... ";
- On 11/18/2023 at 1:35 AM, Provider #1 ordered a physical hold; and
- There was no evidence in the medical record that the RN documented any of the required information for the Patient 5R's restraint.

On 12/05/2023 at approximately 2:15 PM, this finding was confirmed at the time of the review.

On 12/06/2023 at 12:58 PM, a second review of Patient 5R's medical record was conducted with the Senior Director, Regional Accreditation and Regulatory Affairs and the above finding was confirmed.

Based on document reviews and interviews, the hospital failed to ensure a restraint was discontinued at the earliest time possible for one (1) of six (6) patients (Patient 5R).

Finding:

The hospitals "Use of Restraints", last reviewed 05/17/2023, defines a physical hold as, "Holding a patient in a manner that restricts the patient's movement against the patient's will is considered a restraint. The application of force to physically hold a patient, in order to administer a medication against the patient's wishes, is considered a restraint".

The policy also states, in part, "RN [Registered Nurse] Documentation: ... 4. Documentation of the termination of restraint will be documented on the Violent Self destructive flow sheet in the electronic health record and the trained RN must discontinue the order in the electronic documentation system. (Choose "no longer clinically indicated" from dropdown list). The plan of care should be completed ... ".

On 12/05/2023 at 2:00 PM, six (6) medical records were reviewed which indicated the following:

Documentation in Patient 5R's record revealed the following:
- On 11/18/2023, Provider #1 documented, in part, "[He/She] will require IM [Intra Muscular] medication administration due to patient and staff safety. [He/She] will require physical restraint ... ";
- On 11/18/2023 at 1:35 AM, Provider #1 ordered a physical hold;
- There was no nursing documentation regarding Patient 5R's restraint; and therefore,
- It could not be determined if the restraint was discontinued at the earliest possible time.

On 12/05/2023 at approximately 2:15 PM, this finding was confirmed at the time of the review.

On 12/06/2023 at 12:58 PM, a second review of Patient 5R's medical record was conducted with the Senior Director, Regional Accreditation and Regulatory Affairs and the above finding was confirmed.

Based on document reviews and interviews, the hospital failed to ensure the condition of a patient, who was in restraints, was monitored in accordance with hospital policy for one (1) of six (6) patients reviewed (Patient 5R).

Finding:

The hospitals "Use of Restraints", last reviewed 05/17/2023, defines a physical hold as, "Holding a patient in a manner that restricts the patient's movement against the patient's will is considered a restraint. The application of force to physically hold a patient, in order to administer a medication against the patient's wishes, is considered a restraint".

The policy also states, in part, " ... Patients in restraint for violent, self-destructive behavior require 1:1 staff observation in close proximity to the patient at all times. Assess approximately every 15 minutes and document the following using the violent, self-destructive flow sheet in the EHR: - Physical and psychological assessment - Observed patient behavior - Check circulation - Vital signs as ordered (BP, heart rate, respirations); at a minimum, respiratory rate assessment must be documented when a set of vital signs cannot be obtained. Psychological status - Dignity, privacy, and comfort maintenance - Clinical indicators for the continued use of restraint - Progress towards meeting criteria for release such as: - Willingness to accept staff redirection, ability to follow instructions. - Signs of injury associated with the use of restraints - Progress towards resolution of behaviors and/or resolution of medical condition that contributed to need for restraint. Approximately every two hours, the patient's hydration, nutrition needs, toileting, comfort needs, and range of motion will be assessed and offered".

On 12/05/2023 at 2:00 PM, six (6) medical records were reviewed which indicated the following:

Documentation in Patient 5R's record revealed the following:
- On 11/18/2023, Provider #1 documented, in part, "[He/She] will require IM [Intra Muscular] medication administration due to patient and staff safety. [He/She] will require physical restraint ... "; and
- On 11/18/2023 at 1:35 AM, Provider #1 ordered a physical hold;
- There was no nursing documentation regarding Patient 5R's restraint; and therefore,
- It could not be determined if the Patient 5R was monitored during this restraint.

On 12/05/2023 at approximately 2:15 PM, this finding was confirmed at the time of the review.

On 12/06/2023 at 12:58 PM, a second review of Patient 5R's medical record was conducted with the Senior Director, Regional Accreditation and Regulatory Affairs and the above finding was confirmed.