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Based on record review and staff interview, the hospital failed to ensure restraint orders for the management of violent or self-destructive behavior included the required time limits based on age in accordance with federal regulations for 5 of 5 patients reviewed whose records contained restraint orders that did not specify the maximum duration of the restraint, (Patient ID #s 1, 2, 3, 4, and 5).

Findings are as follows:

1. Record review revealed that on 5/6/2025, Patient ID #1 was placed in 4-point restraint (used to restrain both arms and both legs) after becoming agitated and combative.

The record failed to reveal evidence that the physician's order for the use of restraints included a time limit in accordance with federal regulations.

2. Record review revealed that on 6/1/2025, Patient ID #2 was placed in 4-point restraints after becoming combative toward staff.

The record failed to reveal evidence that the physician's order for the use of restraints included a time limit in accordance with federal regulations.

3. Record review revealed that on 5/26/2025, Patient ID #3 was physically restrained and subsequently placed in a restraint chair after becoming agitated, assaultive, combative, and unable to be de-escalated.

The record failed to reveal evidence that the physician's order for the use of restraints included a time limit in accordance with federal regulations.

4. Record review revealed that on 4/8/2025, Patient ID #4 was placed in 4-point restraints after becoming combative toward staff.

The record failed to reveal evidence that the physician's order for the use of restraints included a time limit in accordance with federal regulations.

5. Record review revealed that on 6/1/2025, Patient ID #5 was placed in 4-point restraints after becoming agitated, aggressive, verbally threatening and unable to be redirected or verbally de-escalated.

The record failed to reveal evidence that the physician's order for the use of restraints included a time limit in accordance with federal regulations.

During a surveyor interview on 6/3/2025 at approximately 3:30 PM with the Risk Manager, she acknowledged that all of the physician orders entered in the medical record for the use of restraints for the above-mentioned patients, did not include a time limit.

Based on record review and staff interview, the hospital failed to ensure that documentation of restraint use included a complete description of the intervention used as a result of the patient's behavior as required by federal regulations relative to a physical intervention applied by security personnel during a restraint episode for 1 of 5 patients reviewed who were applied restraints while in the hospital, (Patient ID #1).

Findings are as follows:

On 5/29/2025, the Rhode Island Department of Health received a complaint in which Patient ID #1 alleged that while being restrained at the hospital, staff held his/her face down and asked him/her if she liked it while using profanity and when she/he spit at them, staff held his/her face down "harder."

Record review for Patient ID #1 revealed she/he arrived at the hospital in May of 2025 with only a sheet covering him/her and no clothes underneath. The record indicated that staff attempted to dress the patient in a hospital gown, but the patient became agitated. When staff attempted to transfer the patient from a stretcher onto a hospital bed, the patient became combative and 4-point restraints (used to restrain both arms and both legs) were applied.

Record review of nursing progress notes dated 5/6/2025 authored by Employee A, Licensed Practical Nurse (LPN), indicated that after 4-point restraints were applied on the patient, the patient was able to remove both wrist restraints. When staff attempted to reapply the restraints, the patient attempted to swing and grab staff, and then spit on a security guard and a code gray was initiated.

During a surveyor interview on 6/3/2025 at 9:20 AM with Employee B, Lead Security Officer, he stated that the patient had "slipped out" of both wrist restraints and so he entered the patient's room, "grabbed" the patient's hands, "controlled" the patient's arms, and the patient then spit on his left cheek. He explained that he was able to control one of the patient's arms while the nurse controlled the other arm and at that time, he applied a "safety hold" on the patient by placing the palm of his right gloved hand on the patient's jawline for approximately 30 seconds, turning the patient's face away from him to prevent the patient from spitting at him, until other staff arrived to help restrain the patient.

Further review of nursing progress notes and restraint documentation failed to reveal evidence describing the physical intervention used by Employee B to prevent the patient from spitting at him.

During a surveyor interview on 6/3/2025 at approximately 9:30 AM with Employee A, LPN, she was unable to explain why Employee B's physical intervention was not documented in the medical record.

During a surveyor interview on 6/3/2025 at approximately 3:15 PM with Employee C, Educator, he indicated that he would hope there would be documentation in the medical record reflective of the restraints applied to the patient during a restraint episode.