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Based on document review and interview, it was determined that for 2 of 2 patients' (Pt. #7 and Pt. #8) clinical records reviewed regarding use of violent and/or self-destructive restraints, the hospital failed to ensure that the care plan was modified to reflect use of restraint as an intervention.

Findings include:

1. On 5/30/2024, the hospital's policy titled, "Restraint Use of and Alternative Measures for Violent and/or Self-Destructive Patients" (7/2021) was reviewed and indicated, "... Assessment/Monitoring/Reassessment... 3. The Restraint... Order... Assessment... Alternative... to be part of the patient's plan of care..."

2. On 5/30/2024, the clinical record for Pt. #7 was reviewed. On 5/18/2024, Pt. #7 was admitted to the hospital with a diagnosis of bipolar disorder (type of mental illness) On 5/23/2024, Pt. #7 was placed in restraints due to violent and/or self-destructive behavior. The clinical record lacked documentation that the care plan was modified to reflect use of restraint as an intervention.

3. On 5/30/2024, the clinical record for Pt. #8 was reviewed. On 5/11/2024, Pt. #8 was admitted to the hospital due to suicidal ideation. On 5/14/2024, Pt. #8 was placed in restraints due to violent and/or self-destructive behavior. The clinical record lacked documentation that the care plan was modified to reflect use of restraint as an intervention.

4. On 5/31/2024 at approximately 10:30 AM, findings were discussed with E #6 (Director of Behavioral Health). E #6 could not provide documentation that the patients' care plans were modified to reflect use of restraints. E #6 did not know the modification of care plan was required after use of restraint.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #7) clinical records reviewed regarding use of violent and/or self-destructive (locked) restraints, the hospital failed to ensure that use of restraint was in accordance with the physician's order.

Findings include:

1. On 5/30/2024, the hospital's policy titled, "Restraint Use of and Alternative Measures for Violent and/or Self-Destructive Patients" (7/2021) was reviewed and indicated, "... Violent and/or Self-Destructive Restraint Use - When patient is currently exhibiting dangerous behavior that is harmful to him/herself/others and/or destructive to property... Policy... 7. A restraint order must be obtained from LIP (Licensed Independent Practitioner) for each restraint episode..."

2. On 5/30/2024, the clinical record for Pt. #7 was reviewed. On 5/18/2024, Pt. #7 was admitted to the hospital with a diagnosis of bipolar disorder (type of mental illness). On 5/23/2024, Pt. #7 was placed in locked restraints due to violent and/or self-destructive behavior from 11:15 AM through 1:15 PM (two hours). The LIP order lacked the type of restrained to be used for Pt. #7.

3. On 5/31/2024 at approximately 10:30 AM, findings were discussed with E #6 (Director of Behavioral Health). E #6 stated that the LIP restraint order should indicate the type of restraint to be used.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #7) clinical records reviewed regarding use of violent and/or self-destructive (locked) restraints, the hospital failed to ensure that the physician or trained personnel conducted a face-to-face evaluation 1 hour after initiation of the restraints.

Findings include:

1. On 5/30/2024, the hospital's policy titled, "Restraint Use of and Alternative Measures for Violent and/or Self Destructive Patients" (7/2021) was reviewed and indicated, "... Violent and/or Self-Destructive Restraint Use - When patient is currently exhibiting dangerous behavior that is harmful to him/herself/others and/or destructive to property... Policy... 11... d... the LIP (Licensed Independent Practitioner) or trained HOA (Hospital Operations Administrator)... must see the patient face-to-face to do the evaluation within 1 hour of initiation of restraints and document the specific need for restraints..."

2. On 5/30/2024, the clinical record for Pt. #7 was reviewed. On 5/18/2024, Pt. #7 was admitted to the hospital with a diagnosis of bipolar disorder (type of mental illness). On 5/23/2024, Pt. #7 was placed in locked restraints due to violent and/or self-destructive behavior from 11:15 AM through 1:15 PM (two hours). The clinical record lacked documentation that a face-to-face evaluation by or HOA was conducted within 1 hour of initiation of restraints.

3. On 5/31/2024 at approximately 10:30 AM, findings were discussed with E #6 (Director of Behavioral Health). E #6 could not provide documentation that a 1-hour face to face evaluation was conducted for Pt. #7. E #6 stated that one hour face to face should be conducted.

Based on document review and interview, it was determined that for 2 of 3 patients (Pt. #5 and Pt. #6) clincal records reviewed regarding discharge of ambulatory surgery patients, the hospital failed to ensure that the patients were discharged to a responsible adult, as required.

Findings include:

1. On 5/30/2024, the hospital's policy titled, "Admision and Discharge of Amublatory Surgery Patients" (5/2021) was reviewed and included, "... To... initiate an appropriate care plan for admission and discharge from the Ambulatory Surgery Unit... Discharge Procedure... l. Patient is dicharged to a responsible adult..."

2. On 5/30/2024, the clinical record for Pt. #5 was reviewed. On 5/28/2024, Pt. #5 underwent a colonoscopy (visualization of the large intestine and anus) procedure as an outpatient. The clinical record lacked documentation that Pt. #5 was discharged to a responsible adult.

3. On 5/30/2024, the clinical record for Pt. #6 was reviewed. On 5/29/2024, Pt. #6 underwent a colonoscopy procedure as an outpatient. The clinical record lacked documentation that Pt. #6 was discharged to a responsible adult.

4. On 5/30/2024 at approximately 1:00 PM, findings were discussed with E #2 (Director Surgical Services). E #2 stated that the practice is to discharge post-colonoscopy patients to a responsbile adult. E #2 could not provide documentation that Pt. #5 and Pt. #6 were discharged to a responsible adult after the procedure.

5. On 5/31/2024 at approximately 9:40 AM, a telephone interview was conducted with MD #2 (Gastro-Intestinal Specialist). MD #2 stated that patients should be accompanied by a responsible adult when discharged from the hospital.