HospitalInspections.org

Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that a restraint order was obtained after a patient was placed in restraints in one of two medical records reviewed (Patient (P)3).

Findings include:

Facility Policy titled, Restraints - Violent and Non-Self-Destructive Procedure, effective on 9/19/2024, states, "...3. Procedure: Performed by LP [Licensed Practitioner]... Supplemental Guidance The need for restraint may occur so quickly that an order cannot be obtained prior to the application of restraint. In these emergency application situations, the order must be obtained either during the emergency application or immediately (within a few minutes) after the application."

On 7/17/2025 at 11:49 AM, a review of P3's medical record was conducted and revealed the following:

The ED Note from 7/5/25 at 4:49 PM, stated, "Patient is AAOx3 [awake, alert, and oriented times three]. Brought in by EMS found unconscious on the train. 4 of Narcan given in the field. Patient refusing to be treated stating [he/she] wants to get home, [he/she] lives in Pennsylvania and doesn't know how [he/she] got her [sic]. Patient was trying to leave, DR [name] at bedside evaluating patient, patient refusing to answer questions. Patient attempted to leave security called and patient placed in restraints."

The ED Provider Note from 7/6/25 at 7:21 AM, stated, " ... Date of Service 7/5/2025 at 4:35 PM ... History of Present Illness ... [He/she] is belligerent to staff, refusing to provide any information and demanding to leave ... ED Course & MDM [medical decision making] ... patient awoke and became belligerent ... Patient initially refused to answer any questions and demanded to leave. And due to [his/her] attempting to leave without my evaluation of [his/her] having capacity, and concern for possible ICH [intracranial hemorrhage] as cause of agitation and belligerence, patient was momentarily restrained. Patient restrained for approximately 3 minutes."

At 1:50 PM, an interview was conducted in the Emergency Department (ED) with Staff (S)3. When asked if a patient was restrained for a minute or two, would he/she need to obtain a restraint order from the doctor, S3 stated, "yes, you need an order, it doesn't matter how long the restraints are on, the doctor needs to assess the patient."

The medical record lacked evidence of a restraint order.

On 7/17/2025 at 11:52 AM, all of the above findings were confirmed with S1.