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Based on record review, staff interview and review of the facility policies and procedures, the facility failed to included the use of a restraint on the care plan for 1 of 2 behavioral patients who were restrained (Patient 7). The facility census was 64. This deficient practice had the potential to affect any patients with restraints at the facility.

Findings are:

A. A review of Patient 7's medical record revealed the patient was admitted to the Intensive Care Unit on 7/2/18 for intentional drug overdose and on 7/5/18 was transferred to the Behavioral Care Unit. Patient 7's diagnoses included: depression; a history of suicidal ideations; intentional overdose; and borderline personality disorder.

A review of Patient 7's Nursing Progress Note (dated 7/6/18 at 1344 (1:44 PM), revealed that Patient 7 became aggressive with self-destructive behaviors and was unable to be redirected. "(Psychiatrist) notified, order received for restraint". Patient 7 was placed in 4 point restraints (ankles and wrists) due to "attempting to fight security staff, kicking, yelling, threatening to kill staff when is out." Patient 7 remained in restraints until 1532 (3:10PM) at which time, the patient was able to verbalize criteria for release of the restraint and walked to (gender) room.

An interview with Registered Nurse (RN) S on 7/9/18 at 1:30 PM, confirmed that Patient 7's medical record lacked a restraint plan of care.

A review of the Facility Policy 8210-0306 effective 9/86 titled, "Restraints/Seclusion for Violent or Self Destructive Patients" revealed, "The use of restraint/seclusion must be added to the patient's interdisciplinary plan of care; it needs to reflect the assessment, interventions, evaluations, and re-intervention. The patient's interdisciplinary plan of care will also include the patient's goal and desired outcome."