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Based on document review and staff interview it was determined the facility failed to ensure a physician's order was obtained immediately or within a few minutes of a patient being restrained. This failure was identified in three (3) of thirty (30) medical records reviewed (patients #4, 6 and 10). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #4 revealed the patient was restrained on 3/4/19. The order for restraints was dated 3/4/19 and timed 11:01 p.m. The order stated, "Start Date/Time: 3/4/19 05:04 PM Stop Date/Time: 3/4/2019 06:03 PM." Patient #4 was restrained from 5:04 p.m. to 5:16 p.m. The order for restraints was noted after the restraint episode.

2. A review of the medical record for patient #6 revealed the patient was restrained on 2/15, 2/20, 2/23, 3/4, 3/6 and 3/7/19. An order for restraints for 2/15/19 was dated 2/15/19 and timed 4:20 p.m. The order stated, "Start Date/Time: 2/15/2019 03:14 PM Stop Date/Time: 2/15/2019 04:13 PM." Patient #6 was restrained from 3:14 p.m. to 4:13 p.m. The order for restraints was noted after the restraint episode.

An order for restraints was dated 2/20/19 and timed 9:09 a.m. The order stated, "Start Date/Time: 2/20/2019 08:50 AM Stop Date/Time: 2/21/2019 08:49 AM." Patient #6 was restrained from 8:50 a.m. to 8:55 a.m. The order for restraints was inappropriate for age and duration of restraints.

An order for restraints was dated 2/23/19 and timed 8:00 p.m. The order stated, "Start Date/Time: 2/23/2019 06:20 PM Stop Date/Time: 2/23/2019 07:19 PM." Patient #6 was restrained from 6:20 p.m. to 6:25 p.m. The order for restraints was noted after the restraint episode.

An order for restraints was dated 3/4/19 and timed 10:57 p.m. The order stated, "Start Date/Time: 3/4/2019 05:12 PM Stop Date/Time: 3/4/2019 06:11 PM." Patient #6 was restrained from 5:10 p.m. to 5:18 p.m. The order for restraints was noted after the restraint episode.

An order for restraints was dated 3/6/19 and timed 9:23 a.m. The order stated, "Start Date/Time: 3/6/2019 08:45 AM Stop Date/Time: 3/6/2019 09:44 AM." Patient #6 was restrained from 8:45 a.m. to 8:57 a.m. The order for restraints was noted after the restraint episode.

An order for restraints was dated 3/7/19 and timed 10:34 p.m. The order stated, "Start Date/Time: 3/7/2019 09:31 PM Stop Date/Time: 3/7/2019 10:30 PM." Patient #6 was restrained from 9:31 p.m. to 9:45 p.m. The order for restraints was noted after the restraint episode.

An order for restraints was dated 3/8/19 and timed 10:45 a.m. The order stated, "Start Date/Time: 3/9/2019 12:32 AM Stop Date/Time: 3/10/2019 12:31 AM." Patient # 6 was not restrained on 3/9/19. No orders can be written prior to the use of restraints.

3. A review of the medical record for patient #10 revealed the patient was restrained on 3/13/19. An order for restraints was dated 3/13/19 and timed 1:32 p.m. The order stated, "Start Date/Time: 3/13/2019 11:19 AM Stop Date/Time: 3/13/2019 01:18 PM." Patient #10 was restrained from 11:20 a.m. to 11:40 a.m. The order for restraints was noted after the restraint episode.

4. A review of the policy titled "Seclusion and Restraint", revised 4/18, revealed it stated in part: "Seclusion and Restraint requires a time limited physician's order. All Restraints are physician ordered and that order is time-limited based on the age of the patient. Children: Ages 9-17 - "2" hours for each order Under the age of 9 - "1" hour for each order."

5. An interview was conducted with the Director of Nursing on 3/27/19 at 8:45 a.m. She stated the registered nurses (RNs) can initiate a restraint then notify the physician as soon as possible. She stated there is no set time frame for getting an order for restraints. She stated, "I am not saying it is ideal. Our process is the RN initiates the restraints then call the physician; sometimes it is after the fact, fifteen (15) minutes or less." She stated the time entered for the orders is when the RNs are entering the orders, not when received. She concurred with the times for all restraints orders cited.

5. An interview was conducted with the Clinical Liaison on 3/27/19 at approximately 1:15 p.m. He concurred with the times of the restraint orders cited.

Based on record review and document review it was determined the facility failed to ensure orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis. This failure was identified in one (1) out of thirty (30) clinical records reviewed (patient #10). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of clinical record for patient #10 revealed the patient's 'Individual Crisis Management Plan (ICMP)' in section 'Intervention Strategies' and documented in 'Triggering/Agitation' revealed it stated in part: "B-The treatment team met and physician #1 on 12/10/18 and stated that due to patient #10's degree of aggression and self-harm coupled with his sexually inappropriate behaviors, urinating and attempting to defecate on staff etc. necessitated that if hands-on intervention is needed, the staff are supposed to go directly to a 4/5 point restraint." Review of the nursing shift note dated 12/11/18, written at 10:59 p.m., documents in part: "After evening snack he began screaming the snack was not enough, threw milk down hall, became aggressive and dangerous, hitting staff; requiring a hold; per ICMP patient to go directly to restraints; see safety packet."

2. A review of the facility policy titled "Seclusion and Restraint", last revised 4/18, revealed it states in part: "To provide for the use of seclusion or physical, mechanical or chemical restraint as an emergency measure to protect a patient from imminent danger and injury to him/herself or others. The least restrictive method of seclusion/restraint will be utilized." Review of the section titled "Objective" revealed it states in part: "The purpose of this policy is to outline the hospital's guidelines for the use of restraint or seclusion in such a way that restraint is not viewed as or does not become a punitive process." Review of the section titled "Documentation In Restraint/Seclusion/Safety Packet" revealed it states in part: "1. Documentation of Patient's behavior and the events that led up to the last resort of restraint/seclusion this must include the imminent danger to self or others. 2. Least Restrictive Interventions and Behavioral Support Techniques attempted."

Based on record review and document review it was determined the facility failed to ensure physicians and other licensed independent practitioners, authorized to order restraint or seclusion by hospital policy and in accordance with State law, had a working knowledge of hospital policy regarding the use of restraint or seclusion. This failure was identified in one (1) out of thirty (30) clinical records reviewed (patient #10). This failure has the potential to adversely affect all patients.

1. A review of clinical record for patient #10 revealed the patient's 'Individual Crisis Management Plan (ICMP)' in section 'Intervention Strategies' and documented in 'Triggering/Agitation' revealed it states in part: "B-The treatment team met and physician #1 on 12/10/18 and stated that due to patient #10's degree of aggression and self-harm coupled with his sexually inappropriate behaviors, urinating and attempting to defecate on staff etc. necessitated that if hands-on intervention is needed, the staff are supposed to go directly to a 4/5-point restraint." Review of the nursing shift note dated 12/11/18, written at 10:59 p.m. documents in part: "After evening snack he began screaming the snack was not enough, threw milk down hall, became aggressive and dangerous, hitting staff; requiring a hold; per ICMP patient to go directly to restraints; see safety packet."

2. A review of the facility policy titled "Seclusion and Restraint", last revised 4/18, revealed it states in part: "To provide for the use of seclusion or physical, mechanical or chemical restraint as an emergency measure to protect a patient from imminent danger and injury to him/herself or others. The least restrictive method of seclusion/restraint will be utilized." Review of the section titled "Objective" revealed it states in part: "The purpose of this policy is to outline the hospital's guidelines for the use of restraint or seclusion in such a way that restraint is not viewed as or does not become a punitive process." Review of the section titled "Documentation In Restraint/Seclusion/Safety Packet" revealed it states in part: "1. Documentation of Patient's behavior and the events that led up to the last resort of restraint/seclusion this must include the imminent danger to self or others. 2. Least Restrictive Interventions and Behavioral Support Techniques attempted."

3. A review of the facility's Medical Staff Rules and Regulations, page 11, revealed it states in part: "Physicians and RNs have the education and training to initiate seclusion or physical restraint."

4. A review of the facility policy titled "Treatment Team" revealed it states in part: "2. Treatment team includes, but is not limited to, the attending physician, the charge nurse, the case manager, the therapist, the unit manager, and the family/guardian involved in each patient's care...8. The physician will provide direction and authority over the Master Treatment Plan and Treatment Team meetings."

5. A review of training requirements by physicians titled "Health and Safety Compliance - Restraint and Seclusion by CareLearning.com" in section 'Lesson 1: Objectives' revealed it states in part: "After completion of this course you will be able to: Define restraint and seclusion; Identify alternatives to restraint; Recognize an appropriate order for restraint." Review of the section titled 'Introduction' revealed it states in part: "Every patient/resident should be treated with respect and dignity. Each has the right to be free from physical or mental abuse, and corporal punishment. This includes the right to be free from the inappropriate or unnecessary use of restraint or seclusion and to be safe when use of either intervention is necessary." Review of the section titled 'Lesson 3: Restraint as a Last Resort' revealed it states in part: "Restraint can only be used to ensure the immediate physical safety of the patient/resident, a staff member or other and may only be used as a last resort when less restrictive interventions have been determined to be ineffective... The type of restraint used must also be the least restrictive and applied in compliance with safe and appropriate techniques as defined by your organization." Review of the section titled 'Lesson 5: Restraint Order' revealed it states in part: "A restraint order cannot be written as needed (PRN) or as a standing order; instead the order must be time limited...A protocol cannot serve as a substitute for obtaining a physician or other (Licensed Independent Practitioner) LIP order before initiating restraint use...When implementing a protocol that includes the use of a restraint intervention, a separate order must be obtained for the restraint. The medical record must include documentation of the assessment, symptoms and diagnosis that triggered the protocol." Review of the section titled 'Lesson 9: Documentation' revealed it states in part: "When restraint is used, the following must be documented in the medical record. A description of the patient's/resident's behavior and the intervention used; Alternatives or less restrictive interventions attempted (as applicable)."