HospitalInspections.org

Based on interview and record review, the hospital failed to ensure one of two sampled patients (Patient 1) was monitored during the use of restraints as per the hospital's P&P and Nursing Clinical Standards. This failure created a risk of unsafe care and poor clinical outcomes to the patient.

Findings:

During a review of the hospital's P&P titled Restraints/Seclusion dated 6/10/23, showed "The trained staff assess/monitor/perform at the initiation of restraints, prior to discontinuation, with every order obtained, or more frequently based on the patient's needs per the Restraints: Non-Violent or Non-Self- Destructive Behavior Nursing Clinical Standard and Restraints/Seclusion: Violent or Self-Destructive Behavior Nursing Clinical Standard protocols."

Review of the hospital's Nursing Clinical Standard titled Restraints/Seclusion: Violent or Self-Destructive Behavior dated July 2023 showed to monitor and document the following upon initiation of restraints or seclusion, every 15 minutes thereafter or more frequently based on patient's condition: BH Patient activity (e.g. awake, eye closed), restraint site evaluation (restraint type, location, and signs of injury related to restraints), and respiratory rate.

On 7/31/25 at 1310 hours, Patient 1's medical record was reviewed with the Licensing Coordinator.

Patient 1's medical record showed Patient 1 was admitted to the hospital on 7/16/25.

Review of the Orders showed an order dated 7/28/25 at 1315 hours, showing "Restraint Violent Initiate 9-17 Years". The reason was injury to self, physical abuse to others, verbally threatening to harm self/others.

Review of the Orders showed an order dated 7/28/25 at 1348 hours, showing "Restraint Violent Monitoring (RN)."

Review of the Face-to-Face Evaluation dated 7/28/25 at 1335 hours, showed the patient was informed this afternoon that he would not be able to attend game room this afternoon due to not following his behavioral plan this morning. The patient became agitated, arguing with staff, and then started banging his head. The patient asked to go to seclusion room for a time out. He refused and continued banging his head. The patient was attempting to bite the staff while being transported to seclusion room, continued to yell at staff. Patient required 4 points restraint initiation for safety of himself. He continued to try to hit himself while in restraints, was given PRN oral medication to help calm down. Patient reaction intervention was "Agitated."

Review of the nursing assessment under the restraint episode showed Patient 1 was on hard restraints to all four extremities on 7/28/25 from 1315 hours to 1350 hours.

Review of the Restraints Flowsheet dated 7/28/25, showed the following:

* The neurovascular checks were completed on 7/28/25 at 1315 and 1350 hours. The neurovascular checks were not completed between 1315 to 1350 hours.
* The respiratory rate assessment was documented on 7/28/25 at 1325 and 1350 hours. The respiratory rate assessment was not documented between 1315 to 1350 hours.
* The restraint mental status was assessed on 7/28/25 at 1315 and 1350 hours. The restraint mental status was not assessed between 1315 to 1350 hours.
* There was no documentation on BH patient activity, on 7/28/25 from 1315 to 1350 hours.

On 7/31/25 at 1310 hours, the Licensing Coordinator verified the above findings.