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Based on interview, record review, policy review, and video recording review, the hospital failed to follow their policy and complete a face-to-face assessment within one hour after four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) were placed on one discharged Emergency Department (ED) patient (#13) of one discharged ED patient reviewed. This had the potential to affect all patients when restraint or seclusion were used. The hospital census was 45. The hospital ED saw an average of 800 patients a month in the past six months, with 31 episodes where restraints were used.

Findings included:

Review of the hospital's policy titled, "Restraints or Seclusion," dated 03/2020, showed a physician, licensed independent practitioner (LIP), specifically trained Registered Nurse (RN), or a physician assistant (PA), must see the patient within one hour to assess:
- The patient's immediate situation.
- The patient's reaction to the intervention.
- The patient's medical and behavioral condition.
- The need to continue or terminate restraint and/or seclusion.

Review of the hospital's document titled, "ED Restraint Log," dated from 03/2020 to 08/2020, showed that there were 31 episodes where restraints were used.

Review of Patient #13's medical record showed that he was a 54-year-old male that was homeless and had a history of substance misuse and intoxication that came into the ED with a chief complaint of a puncture wound to his shin. After the patient was registered, he became verbally and physically aggressive towards staff. The patient was medicated and placed in four-point restraints in room, "Hallway1", which was located between the nurses' station and the ED psychiatric room 11. The patient remained in four-point restraints for approximately one hour and 15 minutes.

Review of the Restraint and Seclusion Face-to-Face Evaluation, dated 04/30/20, showed that Staff BB, Psychiatrist, was called on 04/30/20 at 1:00 AM, and a face-to-face assessment was documented as performed on 04/30/20 at 1:05 AM, by Staff BB. The assessment showed that Staff BB reviewed the patient's vital signs (one hour and 35 minutes before the first set was documented as taken). A physical and psychological assessment was documented, which indicated the patient had denied any complaints (the patient was documented as verbally abusive from 1:00 AM to 1:45 AM on the restraint flow sheet), there were no signs of injury, skin was intact, and the patient's emotional comfort was within normal limits (the patient was documented as verbally abusive from 1:00 AM to 1:45 AM on the restraint flow sheet), and the answer to the question for the need to have continued the restraint event was, "yes." There was no explanation documented, although the assessment required it with an answer of "yes." The face-to-face evaluation was signed on 04/30/20 at 4:45 AM.

Review of video of the North ED Hallway, dated 04/30/20, from 00:50:10 to 09:02:52, showed Patient #13 was placed in four-point restraints and left on the stretcher. The video showed that no face-to-face assessment was completed during the approximate one hour and 15 minute restraint episode. There was no face-to-face assessment viewed as completed the entire ED visit. The patient was discharged and assisted out of the ED at 09:02:50.

During an interview on 08/20/20 at 10:10 AM, Staff U, ED Registered Nurse (RN), stated that a face-to-face evaluation was to have been performed at the bedside by a physician or a specially trained nurse, within an hour from when restraints were applied.

During an interview on 09/01/20 at 2:45 PM, Staff G, ED RN, stated that a face-to-face evaluation was to have been performed by a physician at the bedside of the patient within one hour after restraints were applied.

During an interview on 08/26/20 at 1:35 PM, Staff V, ED RN, stated that a face-to-face evaluation was to have been performed by a physician at the bedside of the patient within one hour after restraints were applied.

During an interview on 08/20/20 at 10:25 AM, Staff S, ED Psychiatric Intake RN, stated that a face-to-face evaluation was performed at the bedside by a physician and by some nurses that were trained, no later than one hour after the placement of the restraints.

During an interview on 08/26/20 at 2:35 PM, Staff DD, ED RN, stated that:
- A face-to-face evaluation was to have been performed by a physician at the bedside of the patient within one hour.
- She was not sure if the physician actually completed a face-to-face evaluation.
- If she was not at the bedside at the time the face-to-face was performed, she had to take the physician's word that it was completed.

During an interview on 08/18/20 at 12:10 PM, Staff N, ED Manager, stated that:
- Any physician in the ED and any trained nurse could have completed a face-to-face evaluation.
- The healthcare provider that completed a face-to-face evaluation had to have done a physical assessment and had to talk to the patient in person.
- She reviewed the video and had not seen a face-to-face evaluation performed, but it was documented as if it was completed.
- Staff K, DQRM, and Staff O, ED Medical Director, were fully aware of the incident.

During an interview on 09/01/20 at 5:43 PM, Staff BB, Psychiatrist, stated that:
- According to the medical boards, a face-to-face evaluation should have occurred within a few minutes after the restraints were applied.
- A face-to-face evaluation was only considered completed if it was performed at the bedside.
- He always went to the bedside and performed the face-to-face evaluations.
- He had no recollection that he provided care for the patient.

During an interview on 08/25/20 at 11:00 AM, Staff O, ED Medical Director, stated that:
- A face-to-face evaluation was documented as completed, but was not viewed as completed on the video.
- A face-to-face evaluation was to have been performed within one hour of when medical or physical restraints were applied.
- In the ED, a face-to-face should have been performed within minutes after restraints were applied; any ED physician had the ability to complete a face-to-face evaluation.
- He reviewed the video with Staff BB, Psychiatrist, and discussed the face-to-face evaluation that was documented as completed.
- Staff BB was removed from the ED schedule, and his contract was terminated.

During an interview on 08/18/20 at 2:58 PM, Staff K, DQRM, stated that:
- Any physician and any nurse that was trained could have completed a face-to-face evaluation.
- Although there was documentation that showed a face-to-face evaluation was completed, when the video was reviewed, it was clear there had been no face-to-face evaluation.
- He requested that Staff O, ED Medical Director, speak with Staff BB, Psychiatrist, about the documentation completed and the care that was not provided per video review.