HospitalInspections.org

Based on review of medical records (MR), review of documents and interview with staff (EMP). It was determined that the facility failed to: provide patients the right to be free from restraint, imposed as a means of convenience and discontinuing the restraints at the earliest possible time (A-0154), failing to use the least restrictive restraint intervention on patients (A-0165), failing to place physician orders prior to the use of restraints (A-0168), failing to discontinue restraints at the earliest possible time (A-0174) and failed to provide evidence that the patient's condition warranted the use of restraints (A-0187).

Cross Reference: §482.13(e) Patient Rights: Restraint or Seclusion

Based on employee (EMP) interviews, review of medical records (MR), and facility document review, it was determined the facility failed to ensure that all patients were provided the right to be free from restraints, imposed as a means of staff convenience, and that restraints were discontinued at the earliest time possible for three (3) of eleven (11) patient records sampled. MR2, MR6, MR7.

The findings include:

A review of the facility's policy "Restraints for Nonviolent, Non-Self-Destructive Patient Situations: Medical Use of Restraints", effective February 10, 2025 indicated in part: "...Limited use of restraints is an interdisciplinary process that is supported by administrative leadership, medical staff, nursing staff, and other disciplines. Patients will be maintained in the least restrictive environment conducive to their safety and general well-being.. ...Safe Application/Monitoring/Documentation/Removal...2. Monitoring/Documentation...b) Monitor changes in the individual's clinical condition that may allow a less restrictive method or termination of physical restraints. Release patient if application criteria no longer exists...3. Removal, a) The decision to discontinue the intervention should be based on the determination that the medical need for restraint is no longer present or the patient's needs can be met with less restrictive methods...B. Clinical Justification: 1. The use of restraints is limited to clinically appropriate and adequately justified situations in which the individual's actions pose an imminent risk of injury to self and/or serious disruption of treatment (medical necessity). Clinical Justification for Non-Violent restraints may include: a) Pulling at lines, dressing or equipment, b) Involuntary movement to cause harm...C. Alternatives - Least Restrictive...The use of restraint occurs when other less-restrictive interventions have been attempted but found ineffective for providing a safe and therapeutic environment for the patient, staff, and others...b) Monitor changes in the individual's clinical condition that may allow a less restrictive method or termination of physical restraints. Release patient if application criteria no longer exists...3. Removal, a) The decision to discontinue the intervention should be based on the determination that the medical need for restraint is no longer present or the patient's needs can be met with less restrictive methods...d) Absence of the behavior that required restraints allows for the removal or termination of the restraint...".

A review of the facility's policy "Restraints or Seclusion for Violent, Self-Destructive Patient Situations: Medical Use of Restraints", effective April 29, 2025 indicated in part: "...Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time...A. Assessment: Restraint or seclusion use for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others is considered an emergency intervention with imminent risk that could not be managed safely by less restrictive interventions...C. Alternatives - Least Restrictive...The use of restraint occurs when other less-restrictive interventions have been attempted but found ineffective for providing a safe and therapeutic environment for the patient, staff, and others...E. Initiation...4. Conditions or circumstances which may contraindicate the use of physical restraints or seclusion: a) Convenience of staff, b) Discipline of the individual...F. Safe Application/Monitoring/Documentation/Removal...3. Removal or Discontinuation, a) The decision to discontinue the intervention should be based on the determination that the medical need for restraint or seclusion is no longer present or the patient's needs can be met with less restrictive methods...F. Safe Application/Monitoring/Documentation/Removal...3. Removal or Discontinuation, a) The decision to discontinue the intervention should be based on the determination that the medical need for restraint or seclusion is no longer present or the patient's needs can be met with less restrictive methods...".

A review of the facility's policy "Individual Rights and Responsibilities", effective May 15, 2025, indicated in part: "A. Patient/Resident/Client Rights...5. Safety, Individuals have the right to...Be free from restraints (physical or chemical) or seclusion unless they are needed to protect the patient or others from immediate threats to their physical safety. Restraint or seclusion shall not be imposed as a means of coercion, discipline, convenience, or retaliation by staff...".

MR2's medical record revealed that the patient remained in restraints on May 19, 2024, from 3:00 PM through 11:00 PM while it was documented by the assigned Registered Nurse (RN) that the patient was either sedated or asleep. There was no documentation to describe how MR2's actions posed an imminent risk of injury to self and/or serious disruption of treatment or that staff attempted to discontinue the restraints after the patient was no longer displaying the behavior that necessitated the use of restraints.

On May 20, 2024, from 1:00 AM through 7:00 AM and from 3:00 PM through 11:00 PM the assigned RNs documented that MR2 was asleep or resting. The medical record contained no documentation that nursing staff attempted to release the patient from restraints during the time that the patient was sleeping, rested, or sedated. At 9:39 AM, an RN documented MR2 removed their clothing, urinated on the floor, grabbed a nurse's shirt and badge, was unable to be redirected and attempted to leave the unit. It was documented that the MD and staff determined removing restraints increased MR2's risk of harm, wandering, and other non-directable behavior, and the restraints were reapplied. There was no other documentation to describe how MR2's actions posed an imminent risk of injury to self and/or serious disruption of treatment.

On May 23, 2024, MR2's attending provider documented that they were approached by the RNs who requested sedative medication and soft restraints. The attending provider placed the order at the RNs request. It was documented described MR's behavior as "...Patient agitated pacing the room, spitting on the floor & throwing items at the walls. Unable to be re-directed by ER staff". There was no other documentation to describe how MR2's actions posed an imminent risk of injury to self and/or serious disruption of treatment.

On May 24, 2024, MR2's attending provider documented that the RNs requested soft restraints again because MR2 was not cooperating with ED staff and not seen in their room. The provider's restraint order documented the reason for MR2's restraints were for interference with medical treatment and involuntary movements to cause harm. There was no other documentation provided to describe how MR2's actions posed an imminent risk of injury to themselves and/or serious disruption of treatment.

On May 25, 2024, MR2 remained in restraints between the hours of 9:28 AM and 11:00 PM. The consulting psychiatrist documented that MR2 continued to be in soft restraints due to "taxing behaviors". The RN documented that MR2 was agitated and restless during those hours. There was no other documentation provided to describe how MR2's actions posed an imminent risk of injury to themselves and/or serious disruption of treatment or that staff attempted to discontinue the restraints after the patient was no longer displaying the behavior that necessitated the use of restraints.

On May 26, 2024, MR2 remained in restraints from 1:00 AM through 8:30 PM for being agitated and restless. The consulting psychiatrist documented that MR2 remained in restraints due to "intrusive behaviors". The RN also documented that MR2 was wandering the halls and grabbing "stuff". There was no other documentation provided to describe how MR2's actions posed an imminent risk of injury to themselves and/or serious disruption of treatment or that staff attempted to discontinue the restraints after the patient was no longer displaying the behavior that necessitated the use of restraints.

On May 27, 2024, MR2's attending physician documented that MR2's restraints were removed and MR2 went to the doctor's station, began shuffling to the trash can, was not redirectable so MR2's restraints were reapplied. The attending provider later documented that they renewed MR2's restraint order at the request of the nurses. There was no other documentation provided to describe how MR2's actions posed an imminent risk of injury to themselves and/or serious disruption of treatment.

On May 28, 2024, MR2 remained in restraints until they were discharged at 11:40 AM. The consulting psychiatrist documented that MR2's moods were "even" and that MR2 was not aggressive or violent in any way. There was no other documentation provided to describe how MR2's actions posed an imminent risk of injury to themselves and/or serious disruption of treatment.

Medical Record #6's (MR6) medical record documented:
On June 6, 2025, the documentation revealed that MR6 was placed in bilateral wrists and ankle restraints as well as all four (4) siderails up for the patient becoming aggressive during medication administration. The RN documented between June 6, 2025, 10:03 PM, through June 7, 2025, at 1:46 AM as the patient being "asleep". MR6's restraints were removed at 1:46 AM after the RN documented that the patient was oriented, alert and waking up. The medical record failed to contain documentation to describe how MR6's actions posed an imminent risk of injury to themselves and/or serious disruption of treatment and that staff attempted to discontinue the restraints after the patient was no longer displaying the behavior that necessitated the use of restraints.

Medical Record #7 (MR7) documented:
On June 5, 2025, the documentation revealed that MR7 was administered ketamine, Haldol and placed in "hard/4 point" restraints (per RN documentation). The RN documented between 2:30 AM through 4:15 AM that MR7 was "asleep" and "sedated" and remained in restraints. MR7's restraints were removed and discontinued at 4:25 AM after MR7 awoke. The medical record failed to contain documentation of the reason why both chemical and physical restraints were necessary. There was no evidence that nursing staff attempted to discontinue the physical restraints after the patient was no longer displaying the behavior that necessitated the restraint use.

On June 24, 2025, at 12:20 PM, an interview was conducted with EMP19 (Registered Nurse). EMP19 indicated that if a patient was in restraints (physical and chemical) and was sleeping, they would "wean" the patient off the restraints by removing one ankle/wrist at a time, to see how the patient responded before fully removing. EMP19 stated that staff kept patients in the restraints while they were sedated or sleeping because most patients woke up with aggressive behavior.

On June 24, 2025, at 1:00 PM, an interview was EMP13. EMP13 stated that nurses may have kept patients in restraints if a patient were sedated just to "err on the side of caution" for when the patient woke up and was aggressive.

On June 24, 2025, at 1:25 PM, an interview was conducted with EMP5. EMP5 stated that the facility leadership expectations were for staff to use the least restrictive means for restraints. Facility leadership did not want to see the combined use of chemical and physical restraints. EMP5 stated the goal was to remove restraints from a patient once the patient was calm and able to keep themselves and others safe. EMP5 stated that the facility only had and used soft restraints. They did not have any hard restraints. EMP5 stated that the expectation of monitoring a patient who was in restraints was every two (2) hours and to take the patient off restraints if the patient were sleeping. EMP5 stated that the facility had opportunities for improvements when it came to the use of restraints.

On June 24, 2025, at 2:10 PM, an interview was conducted with EMP12. EMP12 stated they ordered Haldol and Ketamine to be used as a chemical restraint for MR7. EMP12 stated that they chose to administer ketamine to the patient because it was a quicker sedative than Haldol. EMP12 stated that Ketamine took about one (1) minute to sedate a patient, whereas Haldol took about two (2) - three (3) minutes to sedate a patient. EMP12 indicated that they "had no idea" whether an order should have been placed for a chemical restraint. EMP12 was unable to verbalize the facility's expectation for monitoring patients receiving a chemical restraint.

Based on interview, medical record and facility document review, it was determined the facility failed to use the least restrictive type of restraints prior to the application for two (2) of eleven (11) sampled patient records reviewed (MR6 and MR7).

The findings include:

A review of the facility's policy "Restraints for Nonviolent, Non-Self-Destructive Patient Situations: Medical Use of Restraints", effective February 10, 2025, indicated in part: "...B. Patients will be maintained in the least restrictive environment conducive to their safety and general well-being...4 siderails (or 2 full length siderails) in the up position are considered a restraint...".

A review of the facility's policy "Restraints or Seclusion for Violent, Self-Destructive Patient Situations", effective 4/29/25, indicated in part: "...Restraint or seclusion use for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others is considered an emergency intervention with imminent risk that could not be managed safely by less restrictive interventions...IV. Definitions. Chemical Restraint: A drug or medication, when it is used as a restriction to manage the patient's behavior due to danger to self or others AND is not a standard treatment or standard dosage for the patient's condition, is considered a restraint...".

MR6's medical record revealed that MR6 arrived at the facility's Emergency Department (ED) on June 6, 2025. MR6's record documented that MR6 was administered Benadryl and Ativan. It was documented that MR6 was also placed in 4-point restraints (wrist and ankles) as well as having having all four (4) bed siderails placed in the upright position.

MR7's arrived at the facility's ED on June 5, 2025. MR7's medical record revealed that was administered Ketamine and Haldol and placed in 4-point restraints. EMP12 only placed an order for physical restraints in medical record.

On June 24, 2025, at 2:10 PM, an interview was conducted with EMP12. EMP12 stated that they ordered Ketamine for MR7 to be used as a chemical restraint because Ketamine was a quicker, more effective medication to sedate a patient.

On June 24, 2025, at 1:25 PM, an interview was conducted with EMP5. EMP5 stated that facility leadership expected for staff to use the least restrictive means for restraints and they did not want to see the combined use of chemical and physical restraints.

Based on interviews, medical records review and facility document review, it was determined the facility failed to obtain physician orders for the use of restraints in three (3) of eleven (11) sampled patient records (MR2, MR6 and MR7).

The findings include:

A review of the facility's policy "Restraints for Nonviolent, Non-Self-Destructive Patient Situations: Medical Use of Restraints", effective February 10, 2025, indicated in part: "...D. Restraint Order...1. An order from a physician or authorized practitioner is required for all instances of restraint...b) Each episode of restraint use must be associated with a new order...IV. Definition of Terms. Chemical Restraint: A drug that is used as a restraint and is a medication used to control behavior or to restrict a patient's freedom of movement and is not a standard treatment for the patient's medical or psychiatric condition...".

A review of the facility's policy "Restraints or Seclusion for Violent, Self-Destructive Patient Situations: Medical Use of Restraints", effective April 29, 2025, indicated in part: "...D. Restraint or seclusion order...a. Any type of violent restraint including, but not limited to, 4-point restraints, chemical restraints...requires a provider order...IV. Definitions. Chemical Restraint: A drug or medication, when it is used as a restriction to manage the patient's behavior due to danger to self or others AND is not a standard treatment or standard dosage for the patient's condition, is considered a restraint...".

MR2's medical record revealed a physician order for restraints to expire on May 20, 2024, at 11:59 PM. The Registered Nurse (RN) documented continuous two (2) hour restraint monitoring from May 21, 2024, at 12:00 AM through May 21, 2024, at 7:48 AM. There was no evidence that a physician placed an order for restraints for MR2 from 12:00 AM through 7:48 AM on May 21, 2024.

MR6 medical record revealed on June 6, 2025, at 7:56 PM, the RN administered the medications Benadryl and Ativan to MR6, ordered by EMP13. EMP13 placed an additional order for ketamine that was never administered to MR6. MR6 was placed in bilateral wrist and ankle restraints. EMP13 did not place an order for a chemical restraint.

MR7's medical record revealed on June 5, 2025, at 1:50 AM, that MR7 was administered the medication Ketamine. After being placed in restraints, MR7 was administered the medication Haldol. There was no evidence of EMP12 placing an order for a chemical restraint for MR7.

On June 24, 2025, at 1:00 PM, an interview was conducted with EMP13. EMP13 stated that the determination to use medications as a chemical restraint were dependent on which medications a patient was currently on and their medical condition. EMP13 stated a combination medication of ketamine, Ativan and Benadryl could be used as a chemical restraint.

On June 24, 2025, at 2:10 PM, an interview was conducted with EMP12. EMP12 stated that they used Ketamine as a chemical restraint for MR7 and "had no idea" why they did not place an order for a chemical restraint.

Based on interviews, medical record and facility document review, it was determined the facility failed to discontinue restraints at the earliest possible time for three (3) of eleven (11) sampled patient records reviewed (MR2, MR6 and MR7).

The findings include:

A review of the facility's policy "Restraints for Nonviolent, Non-Self-Destructive Patient Situations: Medical Use of Restraints", effective February 10, 2025, indicated in part: "B. Clinical Justification: 1. The use of restraints is limited to clinically appropriate and adequately justified situations in which the individual's actions pose an imminent risk of injury to self and/or serious disruption of treatment (medical necessity). Clinical Justification for Non-Violent restraints may include: a) Pulling at lines, dressing or equipment, b) Involuntary movement to cause harm...3. Removal: a) The decision to discontinue the intervention should be based on the determination that the medical need for restraint is no longer present or the patient's needs can be met with less restrictive methods...d) Absence of the behavior that required restraints allows for the removal or termination of the restraint...".

A review of the facility's policy "Restraints or Seclusion for Violent, Self-Destructive Patient Situations", effective 4/29/25, indicated in part: "...B. Clinical Justification: When restraint or seclusion are used for the management of violent or self-destructive behavior, the clinical justification includes: 1. The immediate physical safety of the patient, 2. The immediate physical safety of a staff member, 3. The immediate physical safety of the Patient and others...3. Removal or Discontinuation: a) The decision to discontinue the intervention should be based on the determination that the medical need for restraint or seclusion is no longer present or the patient's needs can be met with less restrictive methods...".

MR2's medical record documented that MR2 was placed in restraints daily between May 19 through May 28, 2024. MR2's medical record documented that MR2 was either awake and calm or asleep intermittently throughout the entire period that MR2 continued to be restrained. There was no documentation that staff attempted to discontinue the restraints after the patient was no longer displaying the behavior that necessitated the use of restraints.

MR6's medical record documented that MR6 was placed in restraints on June 6, 2025, at 8:03 PM. Between 10:03 PM and 12:03 AM on June 7, 2025, the RN documented that MR6 was asleep. MR6's restraints were discontinued at 1:46 AM when they awoke. There was no documented evidence found to indicate that staff attempted to discontinue the restraints after the patient was no longer displaying the behavior that necessitated the use of restraints.

MR7's medical record documented that MR7 was placed in restraints on June 5, 2025. It was documented from 2:30 AM through 4:15 AM that MR6 was asleep and sedated. At 4:25 AM, MR7's restraints were removed after the patient awoke. There was no documentation that staff attempted to discontinue the restraints after the patient was no longer displaying the behavior that necessitated the use of restraints.

On June 24, 2025, at 1:25 PM, an interview was conducted with EMP5. EMP5 stated the goal was to remove restraints from a patient once the patient was calm and able to keep themselves and others safe. EMP5 stated that the expectation was to remove restraints if the patient were sleeping.

Based on medical records and facility document review, it was determined the facility failed to provide evidence that the patient's condition warranted the use of restraints.

The findings include:

A review of the facility's policy "Restraints for Nonviolent, Non-Self-Destructive Patient Situations: Medical Use of Restraints", effective February 10, 2025, indicated in part: "...B. Clinical Justification: 1. The use of restraints is limited to clinically appropriate and adequately justified situations in which the individual's actions pose an imminent risk of injury to self and/or serious disruption of treatment (medical necessity). Clinical Justification for Non-Violent restraints may include: a) Pulling at lines, dressing or equipment, b) Involuntary movement to cause harm...".

On May 20, 2024, at 9:39 AM, a RN (Registered Nurse) note documented in MR2's medical record, "Attempted to discontinue soft restraints with (attending physician) at bedside but patient began disrobing, urinating on the floor. Pt grabbed primary RN's shirt and would not let go, then (they) grabbed another RN's badge and then attempted to leave the unit. Pt is undirectable. Pt continues to attempt to grab staff. MD and staff determined removing soft-restraints increased risk of harm, wandering and other non-directable behavior. Will continue soft-restraints per MD request". At 9:32 AM, the attending physician documented that the patient was "significantly agitated" and "will give IM Thorazine now for patient's safety and reenter restraints...". There was no other documentation to describe how MR2's actions posed an imminent risk of injury to self and/or serious disruption of treatment.

On May 23, 2024, at 11:21 AM, MR2's attending physician documented "Approached by RNs at 11 to request sedative medication...I am hesitant to give additional sedatives until those (previously administered sedative medications) have fully taken effect. In the meantime, I was asked for soft restraints. Order placed". At 12:00 PM, a "Violent Restraint Face-to-Face Evaluation" note documented "...Patient agitated pacing the room, spitting on the floor & throwing items at the walls. Unable to be re-directed by ER staff. Patient placed in non-violent bilateral wrists restraints". There was no other documentation to describe how MR2's actions posed an imminent risk of injury to self and/or serious disruption of treatment.

On May 24, 2024, at 4:49 PM, MR2's attending physician documented "Even despite IM Ativan, patient not cooperating with ED staff and not seen in room. RNs have asked for soft restraints again". The Provider's restraint order documented "interference with medical treatment, involuntary movements to cause harm". There was no other documentation provided to describe how MR2's actions posed an imminent risk of injury to self and/or serious disruption of treatment.

On May 27, 2024, at 8:39 AM, MR2's attending physician documented "Soft restraints were removed. Immediately following this the patient came over to the doctor's station and then began shuffling to the trash can, was not redirectable. Soft restraints reapplied...". The Provider's restraint order documented "interference with medical treatment, involuntary movements to cause harm". There was no other documentation provided to describe how MR2's actions posed an imminent risk of injury to self and/or serious disruption of treatment.

Based on employee (EMP) interviews, review of medical records (MR) and facility document review, it was determined the facility failed to develop and implement policies and procedures related to documentation of physician progress notes and the expectation for the frequency of physician visits to each patient in the emergency department.

The findings include:

A review of the facility's "Medical Staff Rules and Regulations", approved January 2, 2019, indicated in part: "A. Admission and Discharge...4. A physician member of the Medical Staff shall be responsible for the medical care and treatment of each patient in the Hospital, for the prompt completeness and accuracy of the medical record...B. Medical Records, The physician...licensed independent practitioner, within the scope of his/her privileges, shall be held responsible for a complete medical record for each patient...B. Pertinent progress notes shall be recorded at the time of observation sufficient to permit continuity of care and transferability. Whenever possible, each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders as well as results of tests and treatment. Progress notes shall be written daily on all patients..13. Discharge Summaries, In order to provide information to other caregivers and facilitate the patient's continuity of care, the medical record contains a concise discharge summary...".

On June 24, 2025, a review of MR2's medical record revealed that MR2 was brought into the facility's Emergency Department (ED) on May 19, 2024 and remained "boarding" in the ED while awaiting transfer to another facility, through May 28, 2024. MR2's record contained one (1) ED attending provider progress note documented on May 19, 2024. There were no other ED progress notes or a discharge summary found. The only progress notes found were documented by the consulting psychiatrist.

On June 24, 2025, at 1:00 PM, an interview was conducted with EMP13. EMP13 stated that MR2 was boarding in the ED waiting for a transfer to another facility. MR2 had been "medically cleared" by an ED Provider after arrival at the ED. EMP13 stated that since patient was medically cleared, there was no reason to see or assess MR2, unless there was a medical change. EMP13 stated that they documented "addendum notes" in the ED "course notes" section of the Electronic Medical Record (EMR). EMP13 stated that the consulting psychiatrist was responsible for writing progress and discharge notes.

On June 24, 2025, an interview was conducted with EMP1. EMP1 verified that progress notes should be completed on every patient. EMP1 also stated that there were no specific facility policies addressing the care of patients who were boarding in the ED awaiting transfer to another facility.