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Based on policy review, medical record review, and interview, in two of six medical records reviewed, the physician did not complete a patient evaluation when ordering non-violent restraints for Patient #2 and Patient #3.

Findings include:

Review on 10/04/24 of policy "Restraints-Use of," last revised 08/2023 revealed "non-violent/non-self-destructive restraints are used when a patient is interfering with medical devices. A provider responsible for the patient's ongoing care must order the restraint after an initial evaluation is completed. The attending provider must be consulted as soon as possible, not to exceed 24 hours, if he/she did not order the restraint. The provider must then complete a face-to face comprehensive assessment within two hours of restraint placement and document."

Review on 10/04/24 of the medical record for Patient #2 revealed on 07/25/24 at 03:51 AM, they presented to the emergency department with septic shock and multi-organ failure. On 07/29/24 at 12:01 PM, bilateral wrist restraints were ordered by Staff (Z), Physician, for attempts to dislodge the endotracheal tube (flexible tube that is used to assist in breathing) . On 07/29/24 at 04:00 PM the bilateral wrist restraints were discontinued by nursing due to the discontinuation of the endotracheal tube. There was no evidence in the medical record indicating a provider completed an assessment of Patient #2, prior to and/or after the initiation of the bilateral wrist restraints.

Review on 10/04/24 of the medical record for Patient #3 revealed on 08/07/24 at 11:15 AM, they presented to the emergency department for a witnessed seizure and has a history of daily alcohol and fentanyl use. On 08/12/24 at 02:48 AM, Staff (AA), Registered Nurse entered a telephone order from Staff (Z), Physician, for bilateral wrist restraints to prevent removal of medical devices. There was no evidence in the medical record indicating a provider completed an assessment of Patient #3, prior to and/or after the initiation of the bilateral wrist restraints.

Interview on 10/04/24 at 10:45 AM with Staff (BB), Quality Coordinator, verified these findings. Interview at 02:07 PM with Staff (B), Chief Medical Officer, and Staff (C), Director of Quality, verified that provider evaluations for the use of non-violent restraints are required to be documented in the medical record.