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Based on medical record review, policy and document review and staff interview, it was determined that the hospital failed to ensure staff implemented restraints per hospital policy (refer to A 167); failed to obtain a physician's order for seclusion (refer to A 168); failed to include a time limit for restraint use (refer to A 171); and failed to ensure patients placed in physical restraint were monitored for respiratory rate and/or circulation checks (refer to A 175). The cumulative effect of these deficient practices resulted in the hospital's inability to protect patient rights and provide services in a safe setting.

Based on medical record review, policy review and staff interview, it was determined that for two (2) of two (2) (100%) restrained patients (Patients #3 and #5) in the sample, the restraint order failed to specify the information required by hospital policy. Findings include:


A. Hospital policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" stated, "...The physician's order for use of restraint or seclusion will...include the following...Behavioral criteria for discontinuation of/release from physical restraint/seclusion..."


B. Patient #3 Medical Record

Review of the "Seclusion/Restraint Order" forms:

1. Telephone verbal order, dated 12/31/22 with no time documented, for physical restraint. The order failed to include behavioral criteria for release. Review of "Interventions Utilized" section documented that physical restraint began at 10:29 AM.

2. Telephone verbal order, dated 1/10/23 at 9:05 PM, for physical restraint. The order failed to include behavioral criteria for release. Review of "Interventions Utilized" section documented that physical restraint began at 9:05 PM.

During an interview on 3/10/23 at 3:32 PM, Employee #4 confirmed that the restraint orders lacked behavioral criteria for release.


C. Patient #5 Medical Record

Review of Restraint/Seclusion packet:

1. Telephone verbal order, dated 2/6/23 at 1:03 PM, for physical restraint. The order failed to include behavioral criteria for release. Review of "Interventions Utilized" section documented that physical restraint began at 1:03 PM.

2. Telephone verbal order, dated 2/7/23 at 7:45 PM, for physical restraint. The order failed to include behavioral criteria for release. Review of "Date/Time of Intervention" section documented that physical restraint began at 7:46 PM.

3. Telephone verbal order, dated 2/25/23 at 9:55 PM, for physical restraint. The order failed to include behavioral criteria for release. Review of "Interventions Utilized" section documented that physical restraint began at 9:05 PM.

4. Telephone verbal order, dated 3/5/23 at 10:00 PM, for physical restraint. The order failed to include behavioral criteria for release. Review of "Interventions Utilized" section documented that physical restraint began at 10:00 PM.

During an interview on 3/10/23 at 2:54 PM, Employee #4 confirmed that the restraint orders lacked behavioral criteria for release.

Based on medical record review, policy review, and staff interview, it was determined that for one (1) of two (2) (50%) restrained or secluded patients in the sample (Patient #3), a seclusion intervention was utilized without a physician's order. Findings include:

A. Hospital policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" stated, "...Restraint or seclusion shall be used in emergency situations only and requires an order from a physician...A physician's order is required for each separate restraint and seclusion episode that is not considered one continuous episode..."


B. Patient #3 Medical Record:

1. Review of Restraint/Seclusion packet:

- Telephone verbal order for physical and medication/chemical restraint dated 1/6/23 at 7:30 PM
- "Nursing Summary and Notification" section of packet documented that physical restraint was from 7:25 to 7:35 PM.
- "Time of Termination" section stated, "Hands off 7:35 PM. Seclusion until 2100 (9:00 PM)..."
- "Summary section" stated, "Pt (patient) moved by police into seclusion..."
- No evidence of physician's order placed for seclusion on 1/6/23 from 7:35 to 9:30 (1 hour 25 minutes).

During an interview on 3/10/23 at 3:32 PM, Employee #4 confirmed the lack of physician's order for seclusion.

Based on medical record review, policy review, and staff interview, it was determined that the physician's orders for two (2) of two (2) (100%) restrained patients (Patient #3 and #5) in the sample, failed to include a time limit for restraint use. Findings include:


A. Hospital policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" stated, "...The physician's order for use of restraint or seclusion will...include the following...Time limits not to exceed 4 hours for adults, 2 hours for children and adolescents ages 9 to 17, and 1 hour for children under age 9..."


B. Patient #3 Medical Record:

Review of Seclusion/Restraint packet:

1. Telephone verbal order, dated 12/26/22 at 5:35 PM, for physical restraint. The order failed to include a duration of time. Review of "Interventions Utilized" section documented that physical restraint began at 5:36 PM.

2. Telephone verbal order, dated 12/31/22 with no time, for physical restraint. The restraint order failed to include a duration of time. Review of "Interventions Utilized" section documented that physical restraint began at 10:29 AM.

3. Telephone verbal order, dated 1/5/23 at 5:25 PM, for physical restraint. The restraint order failed to include a duration of time. Review of "Interventions Utilized" section documented that physical restraint began at 5:30 PM.

4. Telephone verbal order, dated 1/10/23 at 9:05 PM, for physical restraint. The restraint order failed to include a duration of time. Review of "Interventions Utilized" section documented that physical restraint began at 9:05 PM.

During an interview on 3/10/23 at 3:32 PM, Employee #4 confirmed that the restraint orders lacked a duration of time.


C. Patient #5 Medical Record:

Review of Seclusion/Restraint packet:

1. Telephone verbal order, dated 2/6/23 at 1:03 PM, for physical restraint. The order failed to include a duration of time. Review of "Interventions Utilized" section documented that physical restraint began at 1:03 PM.

2. Telephone verbal order, dated 2/7/23 at 7:45 PM, for physical restraint. The order failed to include a duration of time. Review of "Interventions Utilized" section documented that physical restraint began at 7:46 PM.

3. Telephone verbal order, dated 3/5/23 at 10:00 PM, for physical restraint. The order failed to include a duration of time. Review of "Interventions Utilized" section documented that physical restraint began at 10:00 PM.

During an interview on 3/10/23 at 2:54 PM, Employee #4 confirmed that the restraint orders lacked a duration of time.

Based on medical record review, staff interview, and review of hospital policy, the hospital failed to ensure patients placed in physical restraint were monitored for respiratory rate and/or circulation checks for two (2) of two (2) restrained patients (100%) in the sample (Patients #3 and #5). Findings include:


A. Hospital policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" stated, "...Patients in restraints/seclusion will be closely monitored and evaluated...the patient shall be assessed every 15 minutes while in restraint/seclusion...The assessment includes...Circulation and skin integrity...Vital signs shall be taken upon initiation and as clinically indicated..."


B. Patient #3 Medical Record Review:

Review of Seclusion/Restraint Packet:

1. Dated 12/21/22 at 9:35 PM, Seclusion/Restraint order for Physical Restraint. "Nursing Summary and Notifications" documented that physical restraint occurred from 9:30 to 10:30 PM (60 minutes). Vital signs portion of the packet documented as "Refused - physical aggression". Respiratory rate section was blank. No evidence that circulation checks were done every 15 minutes.

2. Dated 12/26/22 at 5:35 PM, Seclusion/Restraint order for Physical Restraint. "Nursing Summary and Notifications" documented that physical restraint occurred from 5:36 to 5:55 PM (19 minutes). Vital signs portion of the packet documented as "Refused". Respiratory rate section was blank. No evidence that circulation checks were done every 15 minutes.

3. Dated 12/30/22 at 3:55 PM, Seclusion/Restraint order for Physical Restraint. "Nursing Summary and Notifications" documented that physical restraint occurred from 3:55 to 4:18 PM (23 minutes). Vital signs portion of the packet is blank. Respiratory rate section was blank. No evidence that circulation checks were done every 15 minutes.

4. Dated 12/31/22 with no time, Seclusion/Restraint order for Physical Restraint. "Nursing Summary and Notifications" documented that physical restraint occurred from 10:29 to 10:40 AM (11 minutes). Vital signs portion of the packet is blank. Respiratory rate section was blank.

5. Dated 1/4/23 at 3:55 PM, Seclusion/Restraint order for Physical Restraint. "Nursing Summary and Notifications" documented that physical restraint occurred from 3:55 to 4:10 PM (15 minutes). Vital signs portion of the packet is blank. Respiratory rate section was blank.

6. Dated 1/5/23 at 5:25 PM, Seclusion/Restraint order for Physical Restraint. "Nursing Summary and Notifications" documented that physical restraint occurred from 5:30 to 5:50 PM (20 minutes). Vital signs portion of the packet documented as "Refused". Respiratory rate section was blank. No evidence that circulation checks were done every 15 minutes.

7. Dated 1/6/23 at 7:30 PM, Seclusion/Restraint order for Physical Restraint. "Nursing Summary and Notifications" documented that physical restraint occurred from 7:25 to 7:35 PM (10 minutes). Vital signs portion of the packet documented as "Refused". Respiratory rate section was blank.

8. Dated 1/10/23 at 9:05 PM, Seclusion/Restraint order for Physical Restraint. "Nursing Summary and Notifications" documented that physical restraint occurred from 9:05 to 9:32 PM (27 minutes). Vital signs portion of the packet documented as "Refused". Respiratory rate section was blank. No evidence that circulation checks were done every 15 minutes.

During an interview on 3/10/23 at 3:32 PM, Employee #4 confirmed that the restraint documentation lacked respiratory rate and/or circulation checks.


C. Patient #5 Medical Record:

Review of Seclusion/Restraint Packet:

1. Dated 2/5/23 at 8:25 PM, Seclusion/Restraint order for Physical Restraint. "Nursing Summary and Notifications" documented that physical restraint occurred from 8:37 to 8:40 PM (3 minutes). Vital signs portion of the packet documented as "Refused". Respiratory rate section was blank.

2. Dated 2/6/23 at 1:03 PM, Seclusion/Restraint order for Physical Restraint. "Nursing Summary and Notifications" documented that physical restraint occurred from 1:03 to 1:08 PM (5 minutes). Vital signs portion of the packet documented as "Refused". Respiratory rate section was blank.

3. Dated 2/7/23 at 7:45 PM, Seclusion/Restraint order for Physical Restraint. "Nursing Summary and Notifications" documented that physical restraint occurred from 7:46 to 7:55 PM (9 minutes). Vital signs portion of the packet was blank. Respiratory rate section was blank.

4. Dated 2/10/23 at 3:45 PM, Seclusion/Restraint order for Physical Restraint and Seclusion. "Nursing Summary and Notifications" documented that physical restraint occurred from 3:45 to 4:05 PM (20 minutes), and seclusion occurred from 4:05 to 4:25 PM (20 minutes). Vital signs portion of the packet documented as "Refused". Respiratory rate section was blank. No evidence that circulation checks were done every 15 minutes.

5. Dated 2/12/23 at 9:00 AM, Seclusion/Restraint order for Physical Restraint. "Nursing Summary and Notifications" documented that physical restraint occurred from 9:00 to 9:20 AM (20 minutes). Vital signs portion of the packet was blank. Respiratory rate section was blank. No evidence that circulation checks were done every 15 minutes.

6. Dated 2/23/23 at 6:55 PM, Seclusion/Restraint order for Physical Restraint. "Nursing Summary and Notifications" documented that physical restraint occurred from 7:02 to 7:03 PM (1 minute). Vital signs portion of the packet documented as "Refused".

7. Dated 2/25/23 at 9:55 PM, Seclusion/Restraint order for Physical Restraint. "Nursing Summary and Notifications" documented that physical restraint occurred from 9:05 to 9:30 PM (25 minutes). Vital signs portion of the packet documented as "Will not stay still". Respiratory rate section was blank. No evidence that circulation checks were done every 15 minutes.

8. Dated 3/2/23 at 5:30 PM, Seclusion/Restraint order for Physical Restraint. "Nursing Summary and Notifications" documented that physical restraint occurred from 5:30 to 5:32 PM (2 minutes). Vital signs portion of the packet documented as "Refused 'I'm fine' ". Respiratory rate section was blank.

9. Dated 3/5/23/23 at 10:00 PM, Seclusion/Restraint order for Physical Restraint. "Nursing Summary and Notifications" documented that physical restraint occurred from 10:00 to 10:15 PM (15 minutes). Vital signs portion of the packet documented as "Refused". Respiratory rate section was blank.

During an interview on 3/10/23 at 2:54 PM, Employee #4 confirmed that the restraint orders lacked respiratory rate and/or circulation checks.

Based on observation, staff interview, and hospital document and policy review, it was determined that the hospital failed to maintain a safe and functional environment for patients in 5 of 7 areas at this hospital. Findings include:


A. The hospital policy titled "Physical Environment Plan," stated, "Patient care areas are safe, clean, functional, and comfortable...All storage rooms and equipment rooms should remain free of clutter and unsafe conditions..."

The hospital policy titled "Occupied Room Cleaning," stated,"...Visual Inspection for safety and cleanliness of area..."


B. During an environmental tour on 3/10/23 between 10:06 AM and 12:02 PM, the following was observed:

1. Between 10:06 AM and 10:16 AM - West Unit Day Room:

- Missing floor tiles; three (3) floor tiles missing under sofa closet to TV.

- Dry brownish liquid stain under sofa closet to TV; approximately 1 foot by 2 foot stain.

These findings were confirmed at time of discovery by Employee # 1.

2. Between 10:17 AM and 10:30 AM - South Unit Day Room:

- Handprint in dry wall; approximately four (4) inches by two (2) inch indentation in wall

This finding was confirmed at time of discovery by Employee # 1.

3. Between 10:31 AM and 11:27 AM - Cafeteria:

- Floor tiles under snack machine in disrepair.

- Debris and discoloration on the floor of the soda syrup dispensing room:
-Approximately 5 to 10 pieces of ripped cardboard on floor.
-Brownish discoloration of the floor.
-Approximately ¼ full bag of unused soda syrup on floor.

This finding was confirmed at time of discovery by Employee # 1.

Based on observation, staff interview, and hospital document and policy review, it was determined that the hospital failed to maintain a safe and functional environment for patients. Findings include:


A. The hospital policy titled "Physical Environment Plan," stated, "... all items should be stored a minimum of 18" away from the ceiling..."

"2022, National Fire Protection Association 13, Standard for the installation of sprinkler systems," stated,"...9.5.5 obstruction to sprinkler discharge... 9.5.5.2.1... Continuous or non continuous obstructions less than or equal to 18 inches (450mm) below the sprinkler deflector that prevent the pattern from fully developing..."

B. During an environmental tour on 3/10/23 between 10:06 AM and 12:02 PM, the following was observed:

1. Between 11:39 and 11:44 AM - Linen supply room:

- Linen stored less than 18 inches from ceiling and fire sprinklers:
- 6 of 10 bundles of towels stored less than 18 inches from ceiling and fire sprinkler: ten (10) towels per bundle
- 6 of 14 bundles of blankets stored less than 18 inches from ceiling and fire sprinkler: two (2) blankets per bundle

These findings were confirmed at time of discovery by Employee #1.

2. Between 11:45 AM and 12:02 PM - Storage room:

- Supplies being stored less than 18 inches from ceiling: 4 of 9 boxes of large synthetic gloves, 1,000 pieces per case, SKU# V2243, Manufacture GVP9-LG-1-SYBL.

This finding was confirmed at time of discovery by Employee #1.

Based on observation, staff interview, and hospital document and policy review, it was determined that the hospital failed to ensure that the hospital facilities and supplies and equipment were maintained to ensure an acceptable level of safety and quality. Findings include:


A. The hospital policy titled "Supplies and Equipment Storage" stated,"... All bottles, containers should be properly labeled at all times...storage areas will comply with codes and regulations related to safety..."


The hospital policy titled "Physical Environment Plan," stated, "...All storage rooms...should remain free of unsafe conditions...No boxes, linen, or anything should be stored on the floor..."

The hospital policy titled "Hazardous Materials Management Plan," stated,"...Chemical materials are maintained in labeled containers...Chemical materials are labeled throughout their use...The label is on the container prior to receipt or is placed on containers when filled or mixed within the hospital..."

"2022, National Fire Protection Association 55, Compressed Gases and Cryogenic fluids code," stated,"...7.3.1.7.2 The cylinder, ...tank shall be secured ...7.1.8.1 compressed gas cylinders, container tanks ...shall be secured against accidental dislodgement..."

Document titled "Specimen Label: Gordon's Aqueous Fly Spray" stated, "...Harmful if swallowed. Wash hands thoroughly with soap and water after handling and before eating, drinking...or using the toilet...Remove or cover exposed food and drinking water before application..."

Document titled "Safety Data Sheet" stated, "...Steri-fab...Probable Routes of Exposure...Inhalation...Eye contact...Skin contact...Acute effects...Vapors have narcotic effect...Causes substantial but temporary eye injury. Do not get in eyes or on clothing. Harmful if absorbed through skin..."

Document titled "Peroxy Hdox Concentrate Earth Laboratories, Inc. Safety Data Sheet" stated, "...May cause nausea, vomiting, diarrhea. Skin irritation. May cause redness and pain and oxidation of skin surface. Direct contact with eyes may cause temporary irritation..."

Document titled "Aiken Chemical Company, Inc. Safety Data Sheet Purple Power Industrial Strength Cleaner Degreaser" stated, "...Hazard statement(s)...Causes serious eye irritation...Causes skin irritation...Wash hands thoroughly after handling...If eye irritation persists: Get medical advice/attention..."

B. During an environmental tour on 3/10/23 between 10:06 AM and 12:02 PM, the following was observed:

1. Between 10:31 AM and 11:27 AM - Cafeteria:

- Five (5) Carbon Dioxide tanks not secured inside of soda syrup dispensing room:
- One (1) in use blue tank
- Two (2) empty blue tanks without safety cap on tank
- Two (2) full blue tanks with safety cap on tank

These findings were confirmed at time of discovery by Employee #1.

2. Between 11:45 AM and 12:02 PM - Storage room:

- One (1) of eight (8) spray bottles on shelf not labeled with the name of the liquid inside.
- One (1) of seven (7) boxes of paper towels being stored directly on the floor: Multi fold towel, white, 175 sheets per box, reference # 27012, signature series, Manufacturer Cintas.
- Chemicals being stored over paper products:
- One (1) Aqueous Fly Spray for livestock, 1 Gallon, manufacturer Gordon's, stored over 3 rolls of brown paper hand towels
- One (1) Steri-Fab, 1 Gallon, manufacturer Noble Pine Products Company, stored over approximately 68 rolls of Angel Soft toilet paper; reference # 16880
- Two (2) Peroxy-Hdox, 1 Gallon, manufacturer Earth Lab. Inc, stored over approximately 68 rolls of Angel Soft toilet paper; reference # 16880
- One (1) Purple Power, 2.5 Gallon, Aiken Chemical Co Inc, stored over approximately 80 rolls of Angel Soft toilet paper; reference # 16880

These findings were confirmed at time of discovery by Employee #1.