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Based on medical record review, policy review and interview, the facility failed ensure patients were free from the threat of restraint imposed as a mean of discipline for one of three patients reviewed for restraints (Patient #9). The facility's census was 233.

Findings include:

Review of the facility's Restraint and/or Seclusion Use Policy (Version 6, Effective 11/01/23) revealed all patients have the right to be free from unnecessary restraint or seclusion of any form. The decision to use restraints or seclusion is not driven by diagnosis but by a comprehensive individual patient assessment. Restraints and/or seclusion are used temporarily to prevent the risk of therapy disruption, and/or to ensure the immediate physical safety of the patient, a staff member, or others.

Review of Patient #9's medical record revealed a nursing note by Staff K on 10/04/23 at 11:01 PM. The note read:
"Patient has been combative with the sitter and I tonight, has tried to hit multiple staff members several times as well as trying to remove his catheter. I have warned the patient that if he continues to be combative we may have to put him back in restraints and he responds by saying he "hasn't hit anyone." Will continue to monitor."

The findings were shared with Staff A and Staff B in an interview on 10/05/23 at 11:05 AM and confirmed.

Based on medical record review, policy review and interview, the facility failed to ensure the use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner for one of three patients reviewed of patients who were restrained (Patient #9). The facility's census was 233.

Findings include:

Review of the facility's Restraint and/or Seclusion Use Procedure for Violent/Self-Destructive Behavior (VSD) policy (Version 5, Effective 11/01/22) revealed a restraint is defined as a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely. A Chemical Restraint is a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement, and is not a standard treatment or dosage for the patient's condition.

Restraint Orders/Registered Nurse: If alternatives are unsuccessful, immediately notify the physician/LIP (licensed independent practitioner) who is primarily responsible for the patient to obtain an order for restraint or seclusion. If the physician/LIP cannot immediately enter the order, then the nurse will obtain a verbal order and enter the order into the electronic medical record. Apply the least restrictive restraint or place patient in seclusion room. In an emergent situation, apply the least restrictive restraint or place patient in a seclusion room. Immediately notify the physician/LIP who is primarily responsible for the patient to obtain an order for restraint or seclusion. If the physician/LIP cannot immediately enter the order, then the nurse will obtain a verbal order and enter the order into the electronic health record (EHR). The need for restraint or seclusion intervention may occur so quickly that an order cannot be obtained prior to the application of restraint or seclusion. In these emergency application situations, the order must be obtained either during the emergency application of the restraints or seclusion, or immediately after restraint or seclusion is applied. Content of notification to physician/LIP will include patient's behavior, patient's physical and psychological condition and alternatives considered and/or attempted.

- Electronic orders requirements: Identification as a verbal order (as applicable); Date and time patient placed in restraint/seclusion; Duration of restraint/seclusion use; Specific clinical justification/reason for restraint/seclusion; Type of restraint, extremity or body part to be restrained (as applicable); Type of seclusion: locked/unlocked.

Review of Patient #9's medical record revealed documentation by Staff M on 10/02/23 at 12:00 PM stating that the patient was thrashing in bed. Staff attempting to hold patient in bed. Constantly throwing legs over the rails, trying to pull himself up. Kicking staff. RN (registered nurse) called physician in request for medication. 1:1 with no effect. Patient very confused.

Further review revealed documentation by Staff M on 10/02/23 at 12:33 PM stating that the patient was given 5 milligrams (mg) of Zyprexa (antipsychotic) at this time IM (intramuscular) in left shoulder. The patient continued to grab and kick staff, attempting to get out of bed. 1:1 sitter at bedside. Patient's bladder scanned for 540 milliliters (ml) of urine. Two RN's attempted to straight cath patient without success.

The medical record for Patient #9 did not contain an order for restraints on 10/02/23 at 12:33 PM.

Further review of Patient #9's medical record revealed a progress note by Staff N on 10/02/23 at 1:15 PM. The note stated that the patient became again quite restless, assisted nursing staff as able to try to keep him in the bed. He was kicking, hitting, pulling hair, did kick myself as well as nurses aides multiple times as well as punching. Did attempt multiple times to calm the patient, talk with him, try to keep him from hurting himself or the other staff. Ended up needing soft restraints times four extremities. This took five staff members in order to get the secured safely. Even with this present, the patient continued to be very restless.

The medical record for Patient #9 contained an order for soft wrist bilateral and soft ankle bilateral restraints for non-violent or non-self destructive management on 10/02/23 at 1:30 PM.

The medical record did not contain an order for violent restraints on 10/02/23.

The above findings were shared with Staff A and B in an interview on 10/05/23 at 10:47 AM and confirmed.