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Based on interview and document review, the acute care hospital failed to ensure patients were free from unnecessary restraints for 6 of 6 patients (P1, P3, P4, P5, P11, & P12) on the geriatric mental health unit (GMHU), who were manually restrained without an individualized assessment or physicians notification/approval.

Due to the serious nature of this failure the hospital is unable to ensure adequate Patient Rights.

Therefore the hospital is unable to meet the Conditions of Participation of Patient Rights at 42 CFR 482.13.

Findings include:
See A154: Based on interview and document review, the acute care hospital failed to ensure patients were free from unnecessary restraints for 6 of 6 patients (P1, P3, P4, P5, P11, & P12) on the geriatric mental health unit (GMHU), who were manually restrained without an individualized assessment or physicians notification/approval.
See A160: Based on interview and document review, the acute care hospital failed to ensure patients were free from unnecessary chemical restraints for 6 of 6 patients (P1, P3, P4, P5, P11, and P12) on the geriatric mental health unit (GMHU) who were manually restrained to administer intramuscular anti-psychotic medications.
See A168: Based on interview and document review, the acute care hospital failed to notify or obtain a physician order for the use of a manual restraint for 6 of 6 patients (P1, P3, P4, P5, P11, and P12) who were on the geriatric mental health unit and reviewed for the use of restraints.

Based on interview and document review, the acute care hospital failed to ensure patients were free from unnecessary restraints for 6 of 6 patients (P1, P3, P4, P5, P11, & P12) on the geriatric mental health unit (GMHU), who were manually restrained without an individualized assessment or physicians notification/approval.

Review of the facility incident/security report dated 3/15/19, at 6:55 p.m. indicated security was called to the GMHU to assist P1, who was being aggressive (hitting, kicking, biting) towards staff. When security arrived on the unit, registered nurse (RN) and a nursing assistant (NA) were observed to have P1 in a manual hold by holding his hands and legs down. P1 was yelling during this time. The security guard assisted by sitting on P1's legs and held the left arm while the RN administered an intramuscular anti-psychotic medication. After 20 minutes of manually holding the patient he was then released. During this time, P1 attempted to bite the security guard who then quickly forced the patients head to the side towards the wall. The patient had a scab on his left hand that opened and started to bleed during the incident. Review of P1's medical record included an admission date of 3/11/19. P1's history and physical (H&P) included diagnosis of dementia with paranoia, behavioral complications, mood disorder, history of alcoholism, opioid use, chronic low back pain, fibromyalgia and active medical problems. Review of the progress notes dated 3/15/19, from 3:00 p.m.-7:30 p.m. indicated security was called to assist with P1's aggressive behaviors. When security arrived it required 2 staff and the security guard to hold the patient down. He was then given Haldol (anti-psychotic) medication intramuscular. P1 was in a manual hold by 3 staff for 30 minutes. The progress note further indicated P1 became aggressive again after a few minutes and required another manual hold by staff, but did not indicate for how long. The medical record did not include an individualized assessment that included de-escalation interventions prior to the manual hold nor did it include notification/order for the manual restraint.

P3's medical record included an admission date of 3/12/19. P3's history and physical (H&P) included diagnosis of dementia with behavioral disturbances, hypertension, obstructive sleep apnea, Alzheimer's and active medical problems. Review of P3's progress notes did not provide further information regarding the above incident that occurred on 3/13/19, nor did it include an individualized assessment that included de-escalation interventions prior to the manual hold or physician notification/order for the manual restraint. Review of the facility incident/security report dated 3/13/19, at 3:33 p.m. indicated security was called to the GMHU to assist P3, who was being combative (hitting, yelling) towards staff. When security arrived on the unit, facility staff were observed to be "restraining" P3. The security guard grasped the patient's left hand while another staff held the patient's right arm. The RN then administered an anti-psychotic medication intramuscular.

P4's medical record included a hospital admission stay from of 1/7/19 to 2/4/19. P4's history and physical (H&P) included diagnosis of Alzheimer's, dementia with paranoia, anxiety, depressive disorder and active medical problems. Review of the progress notes dated 1/19/19, from 7:00 a.m.-7:00 p.m. indicated P4 was held down on the floor by staff due to aggressive behaviors that included hitting, kicking and biting staff. Security was called and arrived on the unit to assist with manually holding the patient down to administer Zyprexa (antipsychotic) intramuscular. Review of the facility incident/security report dated 1/19/19, at 12:35 p.m. indicated security was called to the GMHU to assist P4, who was being aggressive (scratching, biting) towards staff. When security arrived on the unit, he assisted with P4 by "restraining" the patient on the floor. The RN then administered an intramuscular anti-psychotic medication. After 5 minutes, P4 became aggressive again and security "restrained" the upper body of P4's body for an extended time. Review of an incident at 8:25 p.m., security was called to the geriatric mental health unit to assist P4, who was swinging his fists at staff. When security arrived on the unit, the guard held P4 down in a chair so the nurse could administer a anti-psychotic medication intramuscular. P4's medical record did not included an individualized assessment that included de-escalation interventions prior to the manual hold nor did it include a physicians notification/order for the manual restraint.

P5's history and physical (H&P) included diagnosis of advanced dementia, possible Alzheimer's disease and other medical problems. Review of the progress notes dated 7/30/19, and 7/31/19, from 7:00 p.m.-7:00 a.m. indicated security was called to assist with P5's aggressive behaviors. When security arrived the staff had assisted the patient to the floor. The security guard assisted with a manual hold and the RN administered ativan (anti-anxiety) medication intramuscular. Review of the facility incident/security report dated 7/30/18, at 2:45 a.m. indicated security was called to the GMHU to assist P5, who was being aggressive (hitting) towards staff. When security arrived on the unit, he assisted with P5 by holding his arms behind his back while 2 NA's held his legs so the RN could administered an intramuscular anti-psychotic medication. Review of P5's medical record included a hospital admission stay from 6/27/18 to 8/3/18. The medical record did not included an individualized assessment that included de-escalation interventions prior to the manual hold nor did it include a physicians notification/order for the manual restraint.

P11's history and physical (H&P) included diagnosis of dementia, Parkinson's disease, depression, anxiety, obsessive compulsive disorder (OCD) and intellectual disability disorder. Review of the progress notes dated 3/4/19, and 3/5/19, from 7:00 p.m.-7:00 a.m. indicated security was called to assist with P11's aggressive behaviors. At this time P11 was administered Ativan intramuscular. This required assistance of 4 staff to manually hold the patient. Review of the facility incident/security report dated 3/4/19, at 10:55 p.m. indicated security was called to the GMHU to assist P11, who was being combative towards staff. When security arrived on the unit, he assisted with P11 by manually holding him in place so the nurse could administer an anti-psychotic medication intramuscular. Review of P11's medical record included a hospital admission stay from of 3/3/19, to 3/14/19. The medical record did not included an individualized assessment that included de-escalation interventions prior to the manual hold nor did it include physician notification/order for the manual restraint.

P12's history and physical (H&P) included diagnosis of advanced dementia with paranoia, mood disorder with anxiety and other active medical problems. Review of the progress notes dated 12/16/19, at 3:30 a.m. indicates security was called to assist with P12's aggressive (grabbing, swinging fist, swearing, yelling, kicking) behaviors. P12 was reassured he was safe, but did not understand. Security staff manually held the patient so staff could administer Zyprexa (anti-psychotic) intramuscular. Review of the facility incident/security report dated 12/16/18, at 3:30 a.m. indicated security was called to the GMHU to assist P12, who was being uncooperative towards staff. When security arrived on the unit, he assisted with P12 by manually holding him in place so the nurse could administer an anti-psychotic medication intramuscular. Review of P12's medical record included a hospital admission stay from of 12/15/18 to 12/27/18. The medical record did not included an individualized assessment that included de-escalation interventions prior to the manual hold nor did it include physician notification/order for the manual restraint.

During interview with the facility vice president (VP) of patient care services and the nurse manager (NM) of the GMHU on 3/18/19, at 1:00 p.m. both indicated restraints were not being utilized on the geriatric mental health unit. The VP indicated she was not aware of the manual holds that were being done and would consider a manual hold a restraint. The VP and NM both verified the facility had not been following facility policy related to the use of restraints that included the manual holds. The VP and NM also confirmed individualized assessments were not being done, nor was a physician order obtained when implementing a manual hold on the above patients.

During interview on 3/19/19, at 12:45 p.m. RN-A indicated she worked on the GMHU. RN-A confirmed manual holds were being implemented when a patient was extremely agitated, and to assist with administering a medication for aggressive behaviors. RN-A indicated she had been trained on the use of restraints in the past year, but did not identify these manual holds as restraints.

During interview on 3/19/19, at 1:00 p.m. RN-B indicated she worked on the GMHU. RN-B confirmed manual holds were being implemented when a patient was agitated and when administering medication to control aggressive behaviors. RN-B indicated she had been trained on the use of restraints in the past year, but did not identify these manual holds as restraints.

During interview on 3/19/19, at 1:15 p.m. NA-A indicated she worked on the GMHU. NA-A confirmed manual holds were being implemented for medical reasons. NA-A indicated the manual holds were only being implemented for short durations of time, and for aggressive behaviors. NA-A verified she had been trained on the use of restraints in the past year, but did not consider the manual holds as a restraint.

During interview on 3/19/19, at 1:05 p.m. NA-B indicated she worked on the GMHU. NA-B confirmed manual holds were being implemented for extremely aggressive patients. NA-B indicated she had been trained on the use of restraints in the past year, but did not consider the manual holds as a restraint.

During interview on 3/20/19, at 1:20 p.m. the facility security manager (SM) indicated security assistance would be called to the GMHU when needing assistance with an aggressive patient. The SM further indicated security staff often would be called to hold a patient down so the nurse could administer a medication. The SM indicated security would attempt to de-escalate the patients behavior upon arrival to the unit, but often the behaviors had already escalated. The SM confirmed he was not aware of the interventions that the unit staff had implemented prior to calling security or what had lead up to the patients escalating behaviors.

During interview on 3/20/19, at 11:00 a.m. the medical director (MD) for the facility GMHU indicated if a restraint is utilized he would expect to be notified. The MD indicated he would expect the staff implement less restrictive interventions to de-escalate the patient's behaviors prior to utilizing a restraint. The MD further included he often was informed of the manual hold on the following day, and he was under the impression that manual holds were utilized in only urgent situations. The MD confirmed any orders for restraints should be contained either in the physician's orders or medical progress notes if he had been notified. Further, the MD stated he had a nurse practitioner that worked with him to treat patients on the GMHU, and she also was meticulous about documenting anything that was discussed including restraints in her notes.

Review of the most current meeting minutes from the workplace violence committee (committee that reviews the facility/incident reports) dated 6/7/18, indicated there were no noted concerns related to security response incidents.

Review of the facility policy Restraints/Seclusion with a revision date of 8/17, included guidelines for the use of restraints throughout the hospital, to ensure patient safety, rights and dignity and well being. The policy included the definition of a restraint as being the use of a manual method, physical, mechanical or chemical that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely: any drug or medication when used as a restriction to manage the patients behavior or restrict the patients freedom of movement and is not a standard treatment or dosage for the patients condition. The policy further identified steps to follow when implementing a restraint that included an individualized comprehensive assessment that contained: (1) will the patient be at greater risk if restraint is not used; (2) to be used in such a manner as to not cause any undue physical discomfort, harm or pain, not used for punishment, for convenience in place of staffing; (3) because of a history of dangerous behavior or previous restraint use; (4) not to be applied to a patient in prone position and least restrictive and removed as soon as possible; (5) not to be used as needed (PRN) restraint; (6) develop and promote preventive strategies; (7) attempt an alternative measure to modify behavior prior to utilizing restraints; (8) use least restrictive restraint . The policy further indicated restraints for violent or self-destructive behavior requires not only an assessment of the patients behavior but a physician order that includes consulting the physician as soon as possible if a restraint is not ordered by the attending physician as well as the requirements for renewal and a face/face assessment by the physician within 1 hour after the initiation of the restraint.

Based on interview and document review, the acute care hospital failed to ensure patients were free from unnecessary chemical restraints for 6 of 6 patients (P1, P3, P4, P5, P11, and P12) on the geriatric mental health unit (GMHU) who were manually restrained to administer intramuscular anti-psychotic medications.

Findings include:

Review of the facility incident/security report dated 3/15/19, at 6:55 p.m. indicated security was called to the GMHU to assist P1, who was being aggressive (hitting, kicking, biting) towards staff. When security arrived on the unit, registered nurse (RN) and a nursing assistant (NA) were observed to have P1 in a manual hold by holding his hands and legs down. P1 was yelling during this time. The security guard assisted by sitting on P1's legs and held the left arm while the RN administered an intramuscular anti-psychotic medication. After 20 minutes of manually holding the patient he was then released. During this time, P1 attempted to bite the security guard who then quickly forced the patients head to the side towards the wall. The patient had a scab on his left hand that opened and started to bleed during the incident. Review of P1's medical record included an admission date of 3/11/19. P1's history and physical (H&P) included diagnosis of dementia with paranoia, behavioral complications, mood disorder, history of alcoholism, opioid use, chronic low back pain, fibromyalgia and active medical problems. Review of the progress notes dated 3/15/19, from 3:00 p.m. -7:30 p.m. indicated security was called to assist with P1's aggressive behaviors. When security arrived it required 2 staff and the security guard to hold the patient down. He was then given Haldol (anti-psychotic) medication intramuscular. P1 was in a manual hold by 3 staff for 30 minutes. The progress note further indicated P1 became aggressive again after a few minutes and required another manual hold by staff, but did not indicate for how long. The medical record did not include implementation of interventions in attempt to deescalate R1's aggressive behaviors, prior to the use of the chemical restraint.

Review of the facility incident/security report dated 3/13/19, at 3:33 p.m. indicated security was called to the GMHU to assist P3, who was being combative (hitting, yelling) towards staff. When security arrived on the unit, facility staff were observed to be "restraining" P3. The security guard grasped the patients left hand while another staff held the patients right arm. The RN then administered an anti-psychotic medication intramuscular. Review of P3's medical record included an admission date of 3/12/19. P3's history and physical (H&P) included diagnosis of dementia with behavioral disturbances, hypertension, obstructive sleep apnea, Alzheimer's and active medical problems. Review of the progress notes did not provide further information regarding the above incident that occurred on 3/13/19, nor did it include implementation of interventions in attempt to deescalate P3's aggressive behaviors, prior to the use of the chemical restraint

P4's medical record included a hospital admission stay from of 1/7/19 to 2/4/19. P4's history and physical (H&P) included diagnosis of Alzheimer's, dementia with paranoia, anxiety, depressive disorder and active medical problems. Review of the progress notes dated 1/19/19, from 7:00 a.m.-7:00 p.m. indicated P4 was held down on the floor by staff due to aggressive behaviors that included hitting, kicking and biting staff. Security was called and arrived on the unit to assist with manually holding the patient down to administer Zyprexa (antipsychotic) intramuscular. Review of the facility incident/security report dated 1/19/19, at 12:35 p.m. indicated security was called to the GMHU to assist P4, who was being aggressive (scratching, biting) towards staff. When security arrived on the unit, he assisted with P4 by "restraining" the patient on the floor. The RN then administered an intramuscular anti-psychotic medication. After 5 minutes, P4 became aggressive again and security "restrained" the upper body of P4's body for an extended time. Review of an incident at 8:25 p.m., security was called to the geriatric mental health unit to assist P4, who was swinging his fists at staff. When security arrived on the unit, the guard held P4 down in a chair so the nurse could administer a anti-psychotic medication intramuscular. The medical record did not include implementation of interventions in attempt to deescalate P4's aggressive behaviors, prior to the use of the chemical restraint

P5's history and physical (H&P) included diagnosis of advanced dementia, possible Alzheimer's disease and other medical problems. Review of the progress notes dated 7/30/19 and 7/31/19, from 7:00 p.m.-7:00 a.m. indicated security was called to assist with P5's aggressive behaviors. When security arrived the staff had assisted the patient to the floor. The security guard assisted with a manual hold and the RN administered Ativan (anti-anxiety) medication intramuscular. The medical record did not include implementation of interventions in attempt to deescalate P5's aggressive behaviors, prior to the use of the chemical restraint. Review of the facility incident/security report dated 7/30/18, at 2:45 a.m. indicated security was called to the GMHU to assist P5, who was being aggressive (hitting) towards staff. When security arrived on the unit, he assisted with P5 by holding his arms behind his back while 2 NA's held his legs so the RN could administered an intramuscular anti-psychotic medication. Review of P5's medical record included a hospital admission stay from 6/27/1,8 to 8/3/18.

P11's history and physical (H&P) included diagnosis of dementia, Parkinson's disease, depression, anxiety, obsessive compulsive disorder (OCD) and intellectual disability disorder. Review of the progress notes dated 3/4/19 and 3/5/19, from 7:00 p.m.-7:00 a.m. indicated security was called to assist with P11's aggressive behaviors. At this time P11 was administered Ativan intramuscular. This required assistance of 4 staff to manually hold the patient. Review of the facility incident/security report dated 3/4/19, at 10:55 p.m. indicated security was called to the GMHU to assist P11, who was being combative towards staff. When security arrived on the unit, he assisted with P11 by manually holding him in place so the nurse could administer an anti-psychotic medication intramuscular. Review of P11's medical record included a hospital admission stay from of 3/3/19, to 3/14/19. The medical record did not include implementation of interventions in attempt to de-escalate P11's aggressive behaviors, prior to the use of the chemical restraint

P12's history and physical (H&P) included diagnosis of advanced dementia with paranoia, mood disorder with anxiety and other active medical problems. Review of the progress notes dated 12/16/19, at 3:30 a.m. indicated security was called to assist with P12's aggressive (grabbing, swinging fist, swearing, yelling, kicking) behaviors. P12 was reassured he was safe, but did not understand. Security staff manually held the patient so staff could administer Zyprexa (anti-psychotic) intramuscular. Review of the facility incident/security report dated 12/16/18, at 3:30 a.m. indicated security was called to the GMHU to assist P12, who was being uncooperative towards staff. When security arrived on the unit, he assisted with P12 by manually holding him in place so the nurse could administer an anti-psychotic medication intramuscular. Review of P12's medical record included a hospital admission stay from of 12/15/18 to 12/27/18. The medical record did not include implementation of interventions in attempt to deescalate P12's aggressive behaviors, prior to the use of the chemical restraint

During interview with the facility vice president (VP) of patient care services and the nurse manager (NM) of the GMHU on 3/18/19, at 1:00 p.m. both indicated restraints were not being utilized on the geriatric mental health unit. The VP and NM both verified the facility had been utilizing anti-psychotic medications frequently for aggressive behaviors prior to making ever effort to deescalate the patients behavior. The VP and NM also confirmed manual restraint holds were being implemented prior to administering the medications. The VP and NM verified according to facility policy, these medications could be considered chemical restraints.

During interview on 3/19/19, at 12:45 p.m. RN-A indicated she worked on the GMHU. RN-A confirmed manual holds and anti-psychotic medications were being implemented for aggressive behaviors. RN-A indicated she had been trained on the use of restraints in the past year, but did not identify the use of the anti-psychotic medications as a chemical restraints and that the staff did not always utilize deescalating interventions prior to use.

During interview on 3/19/19, at 1:00 p.m. RN-B indicated she worked on the GMHU. RN-B confirmed manual holds were being implemented when a patient was agitated and when administering medication to control aggressive behaviors. RN-B indicated she had been trained on the use of restraints in the past year, but did not identify anti-psychotic medications as a chemical restraint and that the staff did not always implement deescalating interventions prior to use.

During interview on 3/20/19, at 11:00 a.m., the medical director (MD) for the facility GMHU indicated if a restraint is utilized he would expect to be notified. The MD indicated he would expect the staff implement less restrictive interventions to deescalate the patients behaviors prior to utilizing a manual or chemical restraint. The MD further included he often is informed of the manual hold on the following day and he was under the impression that manual holds were utilized in only urgent situations. The MD confirmed any orders for restraints should be contained either in the physician's orders or medical progress notes if he had been notified. Further, the MD stated he had a nurse practitioner that worked with him to treat patients on the GMHU and she also was meticulous about documenting anything that was discussed including restraints in her notes.

Review of the facility policy Restraints/Seclusion with a revision date of 8/17, included guidelines for the use of restraints throughout the hospital, to ensure patient safety, rights and dignity and well being. The policy included the definition of a restraint as being the use of a manual method, physical, mechanical or chemical that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely: any drug or medication when used as a restriction to manage the patients behavior or restrict the patients freedom of movement and is not a standard treatment or dosage for the patients condition. The policy further identified steps to follow when implementing a restraint that included an individualized comprehensive assessment that contained: (1) will the patient be at greater risk if restraint is not used; (2) to be used in such a manner as to not cause any undue physical discomfort, harm or pain, not used for punishment, for convenience in place of staffing; (3) because of a history of dangerous behavior or previous restraint use; (4) not to be applied to a patient in prone position and least restrictive and removed as soon as possible; (5) not to be used as needed (PRN) restraint; (6) develop and promote preventive strategies; (7) attempt an alternative measure to modify behavior prior to utilizing restraints; (8) use least restrictive restraint . The policy further indicated restraints for violent or self-destructive behavior requires not only an assessment of the patients behavior but a physician order that includes consulting the physician as soon as possible if a restraint is not ordered by the attending physician as well as the requirements for renewal and a face/face assessment by the physician within 1 hour after the initiation of the restraint.

Based on interview and document review, the acute care hospital failed to notify or obtain a physician order for the use of a manual restraint for 6 of 6 patients (P1, P3, P4, P5, P11, and P12) who were on the geriatric mental health unit and reviewed for the use of restraints.

Findings include:

Review of the facility incident/security report dated 3/15/19, at 6:55 p.m. indicated security was called to the GMHU to assist P1, who was being aggressive (hitting, kicking, biting) towards staff. When security arrived on the unit, registered nurse (RN) and a nursing assistant (NA) were observed to have P1 in a manual hold by holding his hands and legs down. P1 was yelling during this time. The security guard assisted by sitting on P1's legs and held the left arm while the RN administered an intramuscular anti-psychotic medication. After 20 minutes of manually holding the patient he was then released. During this time, P1 attempted to bite the security guard who then quickly forced the patients head to the side towards the wall. Review of P1's progress notes dated 3/15/19, from 3:00 p.m.-7:30 p.m. indicated security was called to assist with P1's aggressive behaviors. When security arrived it required 2 staff and the security guard to hold the patient down. He was then given Haldol (anti-psychotic) medication intramuscular. P1 was in a manual hold by 3 staff for 30 minutes. The progress note further indicated P1 became aggressive again after a few minutes and required another manual hold by staff, but did not indicate for how long. The medical record did not include evidence a physician's order had been obtained for the use of the manual restraint.

Review of the facility incident/security report dated 3/13/19, at 3:33 p.m. indicated security was called to the GMHU to assist P3, who was being combative (hitting, yelling) towards staff. When security arrived on the unit, facility staff were observed to be "restraining" P3. The security guard grasped the patients left hand while another staff held the patients right arm. The RN then administered an anti-psychotic medication intramuscular. Review of P3's progress notes did not provide further information regarding the above incident that occurred on 3/13/19, nor did it include evidence a physician's order had been obtained for the use of the manual restraint.

Review of the facility incident/security report dated 1/19/19, at 12:35 p.m. indicated security was called to the GMHU to assist P4, who was being aggressive (scratching, biting) towards staff. When security arrived on the unit, he assisted with P4 by "restraining" the patient on the floor. The RN then administered an intramuscular anti-psychotic medication. After 5 minutes, P4 became aggressive again and security "restrained" the upper body of P4's body for an extended time. Review of an incident at 8:25 p.m., security was called to the geriatric mental health unit to assist P4, who was swinging his fists at staff. When security arrived on the unit, the guard held P4 down in a chair so the nurse could administer a anti-psychotic medication intramuscular. Review P4's progress notes dated 1/19/19, from 7:00 a..m.-7:00 p.m. indicated P4 was held down on the floor by staff due to aggressive behaviors that included hitting, kicking and biting staff. Security was called and arrived on the unit to assist with manually holding the patient down to administer Zyprexa intramuscular. The medical record did not include evidence a physician's order had been obtained for the use of the manual restraint.

Review of the facility incident/security report dated 7/30/18, at 2:45 a.m. indicated security was called to the GMHU to assist P5, who was being aggressive (hitting) towards staff. When security arrived on the unit, he assisted with P5 by holding his arms behind his back while 2 NA's held his legs so the RN could administered an intramuscular anti-psychotic medication. Review of P5's progress notes dated 7/30/19 and 7/31/19, from 7:00 p.m.-7:00 a.m. indicated security was called to assist with P5's aggressive behaviors. When security arrived the staff had assisted the patient to the floor. The security guard assisted with a manual hold and the RN administered Ativan (anti-anxiety) medication intramuscular. The medical record did not include evidence a physician's order had been obtained for the use of the manual restraint.

Review of the facility incident/security report dated 3/4/19, at 10:55 p.m. indicated security was called to the GMHU to assist P11, who was being combative towards staff. When security arrived on the unit, he assisted with P11 by manually holding him in place so the nurse could administer an anti-psychotic medication intramuscular. Review of P11's medical record included a hospital admission stay from of 3/3/19 to 3/14/19. Review of P5's progress notes dated 3/4/19 and 3/5/19, from 7:00 p.m.-7:00 a.m. indicated security was called to assist with P11's aggressive behaviors. At this time P11 was administered Ativan intramuscular. This required assistance of 4 staff to manually hold the patient. The medical record did not include evidence a physician's order had been obtained for the use of the manual restraint.

Review of the facility incident/security report dated 12/16/18, at 3:30 a.m. indicated security was called to the GMHU to assist P12, who was being uncooperative towards staff. When security arrived on the unit, he assisted with P12 by manually holding him in place so the nurse could administer an anti-psychotic medication intramuscular. Review of P12's progress notes dated 12/16/19, at 3:30 a.m. indicated security was called to assist with P12's aggressive (grabbing, swinging fist, swearing, yelling, kicking) behaviors. P12 was reassured he was safe, but did not understand. Security staff manually held the patient so staff could administer Zyprexa (anti-psychotic) intramuscular. The medical record did not include evidence a physician's order had been obtained for the use of the manual restraint.

Interview with the facility vice president (VP) of patient care services and the nurse manager (NM) of the GMHU on 3/18/19, at 1:00 p.m. both indicated restraints were not being utilized on the geriatric mental health unit. The VP indicated she was not aware of the manual holds that were being done and would consider a manual hold a restraint. The VP and NM both verified the facility had not been following facility policy related to the use of restraints that included the manual holds. The VP and NM also confirmed individualized assessments were not being done nor was a physician order obtained when implementing a manual hold on the above patients.

Interview on 3/19/19, at 12:45 p.m. RN-A indicated she worked on the GMHU. RN-A confirmed manual holds were being implemented when a patient was extremely agitated and to assist with administering a medication for aggressive behaviors. RN-A indicated she had been trained on the use of restraints in the past year, but did not identify these manual holds as restraints.

During interview on 3/20/19, at 11:00 a.m., the medical director (MD) for the facility GMHU indicated if a restraint is utilized he would expect to be notified. The MD indicated he would expect the staff implement less restrictive interventions to deescalate the patients behaviors prior to utilizing a restraint. The MD further included he often is informed of the manual hold on the following day and he was under the impression that manual holds were utilized in only urgent situations. The MD confirmed any orders for restraints should be contained either in the physician's orders or medical progress notes if he had been notified. Further, the MD stated he had a nurse practitioner that worked with him to treat patients on the GMHU and she also was meticulous about documenting anything that was discussed including restraints in her notes.

Review of the facility policy Restraints/Seclusion with a revision date of 8/17, included guidelines for the use of restraints throughout the hospital, to ensure patient safety, rights and dignity and well being. The policy included the definition of a restraint as being the use of a manual method, physical, mechanical or chemical that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely: any drug or medication when used as a restriction to manage the patients behavior or restrict the patients freedom of movement and is not a standard treatment or dosage for the patients condition. The policy further identified steps to follow when implementing a restraint that included an individualized comprehensive assessment that contained: (1) will the patient be at greater risk if restraint is not used; (2) to be used in such a manner as to not cause any undue physical discomfort, harm or pain, not used for punishment, for convenience in place of staffing; (3) because of a history of dangerous behavior or previous restraint use; (4) not to be applied to a patient in prone position and least restrictive and removed as soon as possible; (5) not to be used as needed (PRN) restraint; (6) develop and promote preventive strategies; (7) attempt an alternative measure to modify behavior prior to utilizing restraints; (8) use least restrictive restraint . The policy further indicated restraints for violent or self-destructive behavior requires not only an assessment of the patients behavior but a physician order that includes consulting the physician as soon as possible if a restraint is not ordered by the attending physician as well as the requirements for renewal and a face/face assessment by the physician within 1 hour after the initiation of the restraint.