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Based on record review and interview, 1 of 10 patients (patient # 8) was placed in restraints without an order from the medical staff.

This is a 18 year old patient who presented to the Emergency Department (ED) on 4/28/2022 in the custody of police. The patient presented for evaluation of agitation, being combative and appearing acutely intoxicated. Serum ethanol level was 176 mg/dl (normal < 50 mg/dl). All other labs and drug screening were negative.
The patient remained physically and verbally aggressive, spitting and attempting to bite staff members in the ED. For patient and staff safety, patient was physically and pharmacologically restrained. Once calm, the patient was closely monitored, and a safety sit was in place. Once alert, oriented and cooperative, the patient was medically cleared and discharged on 4/29/2022

Findings:
-Review of the medical record on 8/5/2022 revealed staff placed this patient in four-point restraints on 4/28/2022 at 2315. There was not an order in the medical record from a physician or other medical provider for the application of restraints during this episode.

-Review of the facility policy entitled "Restraint Use for Violent/Self-Destructive Behavior Management in the Non-Behavioral Health Areas" dated 6/21/2018 identifies a physician's order is required for restraint application. In the absence of a physician, a Registered Professional Nurse (RPN) may initiate restraint use based on assessment and immediate needs of the patient. If this occurs, the order must be obtained either during the emergency application of the restraint or immediately (without time interval) after the restraints are applied.

-This patient record was reviewed with the Director of Hospital Regulatory Affairs on 7/13/2022. No physician order for restraint was noted in the chart. The Director requested additional time to evaluate this issue. On 7/20/2022, the Director reported no additional information or documentation after speaking with the Emergency Department Chair.