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Based on record review and interview, the hospital failed to ensure the use of restraint was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This deficient practice is evidenced by 1 (Patient #2) of 2 (Patient #2, #3) patients sampled being placed in soft restraints with no physician's order.

Findings:
Review of the hospital's policy titled "Restraint Initiation" revealed in part: A physician or Licensed Independent Practitioner (LIP) primarily responsible for the patient's ongoing care, orders the use of restraints.

Review of Patient #2's medical record revealed no physician's order for the use of restraints while Patient #2 was in the emergency department on 07/03/2022 - 07/04/2022.

In an interview on 08/01/2022 at 12:44 p.m. S3RN stated Patient #2 was placed in 4 point soft restraints while Patient #2 was in the emergency department.

In an interview on 08/02/2022 at 8:55 a.m. S5Tech stated Patient #2 was placed in 4 point soft restraints while Patient #2 was in the emergency department.

In an interview on 08/01/2022 at 9:05 a.m. S1Dir verified Patient #2's medical record did not contain a physician's order for the use of restraints while Patient #2 was in the emergency department on 07/03/2022 - 07/04/2022.

Based on record review and interview, the hospital failed to ensure medical records were accurate and complete. This deficient practice was evidenced by failing to document restraints in a patient's medical record for 1 (Patient #2) of 2 (Patient #2, #3) patients reviewed for restraints of a total sample of five.

Findings:

Review of the hospital's policy titled "Restraint Initiation" revealed in part: Documentation of restraint in the medical record includes:
-The face-to-face medical and behavioral evaluations
-A description of the patient's behavior and interventions used
-Any alternatives or other less restrictive interventions attempted
-The patient's condition or symptom(s) that warranted the use of the restraint or seclusion
-The patient's response to the intervention(s) used, including the rationale for continued use of the restraints or seclusion
-Individual patient assessments and reassessments
-The intervals for monitoring
-Plan of Care (Center for Medicare & Medicaid Services, 2012)
-Revisions to the plan of care
-The patient's behavior and staff concerns regarding safety risks to the patient, staff, and others that necessitated the use of restraint
-Injuries to the patient
-Death associated with the use of restraint
-The identity of the physician, clinical psychologist, or other licensed independent practitioner who ordered the restraint
-Orders for restraints according to the defined time
-Notification of the use of restraint or seclusion to the attending physician (if not the ordering provider)
-The RN is responsible for assessing the patient and documenting the assessment every 15 minutes using the Restraint Flowsheet
-Assessment flow sheet documentation should include:
-Behavior: sleep/quiet, yelling/threatening, restless/fighting restraints, kicking/hitting, attempt to dislodge tube/dressing/device, impulsive behavior
-Mental Status: confused/disoriented, delirious/hallucinating, alert, oriented
-Comfort: turn/change position, medicated, comfortable temperature: room/patient, nutritional needs, toileting, personal hygiene/PM care
-Circulation: peripheral pulses intact, capillary refill <2 seconds, proper application of restraints, quick release knot
-Skin Integrity: intact/no breaks, redness
-Vital Signs
-Maintain dignity, rights and modesty
-Least restrictive restraint possible
-Restraint Alternatives
-Continues to meet criteria for restraint
-Ready to discontinue
-Discontinued

Review of Patient #2's medical record revealed no documentation of Patient #2 being placed in restraints while Patient #2 was in the emergency department on 07/03/2022 - 07/04/2022.

In an interview on 08/01/2022 at 12:44 p.m. S3RN stated Patient #2 was placed in 4 point soft restraints while Patient #2 was in the emergency department.

In an interview on 08/02/2022 at 8:55 a.m. S5Tech stated Patient #2 was placed in 4 point soft restraints while Patient #2 was in the emergency department.

In an interview on 08/01/2022 at 9:05 a.m. S1Dir verified Patient #2's medical record did not contain any documentation of Patient #2 being placed in restraints while Patient #2 was in the emergency department on 07/03/2022-07/04/2022.