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Based on policy review and interview, the facility's policies do not identify the types of mitts and wrist restraints used by the facility for purposes of restraints.

Findings Include:

Review on 09/09/22 of the policy "Restraints", last revision 08/22, revealed approved restraints as mitts (secured), wrist, four-point ankle and wrist, five-point restraint, all four side rails, Geri-chair (chair prevents patient from rising) with table, and freedom splints (splints that restrict movement. This policy does not delineate between mitts and soft mitts or soft hand protectors or describe wrist restraints. This policy does not include soft limb restraints or medication as a restraint as approved restraints. The policy does not indicate which restraints are Behavioral, violent, non-violent, and/or medical. Additionally, the policy does not indicate what restraints can be utilized on the Behavioral Health Unit, Acute Care Units, or the Psychiatric Emergency Department.

Telephone interview on 09/15/2022 at 03:15 PM with Staff (A), RN, VP Chief Nursing Officer, verified these findings..

Based on policy review, medical record review, and interview, the facility does not ensure there is a physician order for the use of restraints for 1 of 5 patients (Patient #14).

Findings Include:

Review on 09/07/2022 of policy "Restraints", last revised 08/2022 revealed patients are not placed in restraints without a time-limited order with duration of restraint and type of restraint specified. The order for Behavioral Restraints on a medical unit may not exceed 4 hours. The order may be renewed for up to 24 hours.

Review on 09/09/2022 of Patient #14's medical record dated 08/01-22-2022 revealed the following:
- On 08/15/2022 at 03:06 AM, Patient #14 placed in bilateral wrist restraints. At 03:26 AM, physician order: Restraint, Initiate violent 18-years and older, soft limb, for injury to self. Order valid for 4 hours. Evaluate patient and order Restraints Continue Violent if indicated.
- On 08/15/22 at 03:06 AM, 07:35 PM, and 11:43 PM, on 08/16/22 at 02:30 AM, 04:15 AM, 06:20 AM, 08:30 PM, and 10:30 PM, and on 08/17/22 at 12:40 AM, 04:30 AM, and 06:29 AM: Restraint Monitoring-Restraint Order Verification Documentation-handcuffs (wrist restraints), side rails full, bilateral hands, behavior related restraint.
- On 08/18/22 at 07:38 AM, restraint discontinued.
No evidence was found to indicate a physician reordered restraints after the initial restraint order.

Interview on 09/09/2022 at 10:18 AM with Staff (C), RN, Director of Emergency Services, verified these findings

Based on policy review, medical record review, and interview, the facility did not ensure nursing staff documented the removal/discontinuation of restraints for 1 out of 5 patients (Patient #14).

Findings Include:

Review on 09/07/2022 of policy "Restraints", last revised 08/2022 revealed there shall be documentation in the patient's medical record for the rationale for continued use of the intervention. The policy does not state that nursing staff are to document when a restraint is discontinued.

Review on 09/09/2022 of Patient #14's medical record dated 08/01-22-2022 revealed the following:
- On 08/15/2022 at 03:06 AM, Patient #14 placed in bilateral wrist restraints. At 03:26 AM, physician order: Restraint, Initiate violent 18-years and older, soft limb. Order valid for 4 hours. Restraint monitoring violent document restraint monitoring every 15 minutes. At 05:24 AM, RN progress note: restless, agitated, confused, disorientated, visual/auditory/tactile hallucinations, aggressive with staff, fell x2, medicated with little effects. Handcuff (soft wrist) restraints applied per order. Remains aggressive, trying to break restraints. At 09:56 AM, RN progress note: very combative, mitts placed bilaterally.
- On 08/16/22 at 06:24 AM, RN progress note: confusion, disorientated, and anxious. Continue with handcuff (soft wrist) restraints. Tried to release a couple of times, but patient tried to come out of bed. At 11:26, RN progress note: mittens to both arms. At 05:58 PM, RN progress note: appears anxious and agitated, mittens on both arms as ordered.
- On 08/15/22 at 03:06 AM, 07:35 PM, and 11:43 PM, on 08/16/22 at 02:30 AM, 04:15 AM, 06:20 AM, 08:30 PM, and 10:30 PM, and on 08/17/22 at 12:40 AM, 04:30 AM, and 06:29 AM: Restraint Monitoring-Restraint Order Verification Documentation-handcuffs (wrist restraints), side rails full, bilateral hands, behavior related restraint. On 08/15/22 at 11:43 PM, 08/16/22 at 02:30 AM, 04:15 AM, and 06:20 AM, there is no documented Restraint Monitoring Restraint Behavior Description.
- From 08/17/22 at 06:29 AM to discharge on 08/22/22, no documented Restraint Monitoring-Restraint Order Verification Documentation or Restraint Behavior Description.
These is no evidence of documentation when restraints were discontinued.

Interview on 09/12/2022 at 11:01 AM with Staff (AA), Registered Nurse (RN), revealed that English is her second language. When asked to describe the "handcuff" restraint she applied to Patient #14, she stated she used the soft kind of restraint to wrists, which were tied to the side of the bed. Staff (AA), RN, verbalized that she first used the handcuff restraints then mitts. Staff (AA), RN, retrieved the "handcuff" restraints she used on Patient #14 to show this surveyor. When she returned, she provided soft mitts and soft-tie wrist restraints. Staff (AA), RN, handed the soft-tie wrist restraints to this surveyor and stated "here are the handcuffs".

Interview on 09/12/2022 at 11:01 AM with Staff (BB), RN, verified these findings.

Based on policy review, medical record review and interview, the facility did not ensure that there was evidence of ongoing restraint assessment and monitoring for 1 of 5 patients (Patient #14) in accordance with facility policy.

Findings Include:

Review on 09/07/2022 of policy "Restraints", last revised 08/2022 revealed a Registered Professional Nurse (RN) will perform safety checks every fifteen (15) minutes and will document in the electronic medical record the reason for continued use of behavioral restraints on acute care units. A RN will perform safety checks every 30 minutes and document in the EMR. A RN will conduct every 2-hour checks and document the following: neurovascular checks, release of restraint, patient needs such as toileting, offering food or drink, as applicable.

Review on 09/09/2022 of Patient #14's medical record dated 08/01-22-2022 revealed the following:
- On 08/15/2022 at 03:06 AM, Patient #14 placed in bilateral wrist restraints. At 03:26 AM, physician order: Restraint, Initiate violent 18-years and older, soft limb. Order valid for 4 hours. Restraint monitoring violent document restraint monitoring every 15 minutes. At 05:24 AM, RN progress note: restless, agitated, confused, disorientated, visual/auditory/tactile hallucinations, aggressive with staff, fell x2, medicated with little effects. Handcuff (soft wrist) restraints applied per order. Remains aggressive, trying to break restraints. At 09:56 AM, RN progress note: very combative, mitts placed bilaterally.
- On 08/16/22 at 06:24 AM, RN progress note: confusion, disorientated, and anxious. Continue with handcuff (soft wrist) restraints. Tried to release a couple of times, but patient tried to come out of bed. At 11:26, RN progress note: mittens to both arms. At 05:58 PM, RN progress note: appears anxious and agitated, mittens on both arms as ordered.
- On 08/15/22 at 03:06 AM, 07:35 PM, and 11:43 PM, on 08/16/22 at 02:30 AM, 04:15 AM, 06:20 AM, 08:30 PM, and 10:30 PM, and on 08/17/22 at 12:40 AM, 04:30 AM, and 06:29 AM: Restraint Monitoring-Restraint Order Verification Documentation-handcuffs (wrist restraints), side rails full, bilateral hands, behavior related restraint. On 08/15/22 at 11:43 PM, 08/16/22 at 02:30 AM, 04:15 AM, and 06:20 AM, there is no documented Restraint Monitoring Restraint Behavior Description.
These is no evidence of documentation that the RN performed safety checks every 15 minutes and 30 minutes. Additionally, there is no evidence of documentation that the RN performed every 2-hour neurovascular checks, release of restraint, and/or patient needs as applicable.

Interview on 09/12/2022 at 11:01 AM with Staff (BB), Registered Nurse verified these findings.

Based on medical record review, document review and interview the facility did not ensure a physician face-to-face evaluation was completed within one (1) hour of behavioral restraint initiation for one (1) of five (5) patients (Patient #14).

Findings Include:

Review on 09/07/22 of policy "Restraints", last revised 08/2022 revealed for Acute Care Units, the patient shall be evaluated face-to-face with-in one (1) hour after the initiation of the intervention.

Review on 09/09/2022 of Patient #14's medical record revealed on 08/15/22 at 03:06 AM, Nursing Note: behavior combative, alert with auditory hallucinations. Restraint initiated: handcuffs (wrist restraints), side rails full bilateral hands. At 07:11 AM, provider progress note: overnight events noted. Lying in bed, restless with wrist restraints on. Agitated, anxious, restless, disoriented.
There is no evidence of documentation that a face-to-face evaluation was completed with-in one (1) hour.

Interview on 09/09/2022 at 02:00 PM with Staff (C), RN, Director of Emergency Services verified these findings.

Based on policy review, document review, personnel file review, medical record review, and interview, the facility does not ensure security officers, who assist with restraints and perform manual holds, are trained in the safe use of restraints for 4 of 4 Security Officer personnel files reviewed (Staffs (F), (O), (Y), and (Z)).

Findings Include:

Review on 09/08/2022 of the Security Sergeant job description, last revised 01/2019, revealed assists with clinical and behavioral staff in maintaining a safe environment, assists with the necessary physical restraint of persons by clinical and/ or law enforcement personnel with the minimum force required to accomplish this task.

Review on 09/08/2022 of the Security Guard job description, last revised 01/2019, revealed assists with clinical and behavioral staff in maintaining a safe environment, assists with the necessary physical restraint of persons by clinical and/ or law enforcement personnel with the minimum force required to accomplish this task.

Review on 09/07/2022 of policy "Restraints", last revised 08/2022 revealed staff training on use of restraints, including application/removal, will occur as part of orientation and with yearly competencies, Staff from behavioral health, psychiatric emergency department, intensive care unit, emergency department and security will attend the preventing and Managing Crisis Situations education.

Review on 09/07/2022 of policy "Patient Behavior Management/Assault", last revised 01/2022, revealed if additional help is required and/or violence is imminent, all unit staff will be paged to the site utilizing the emergency call device to activate the Rapid Response code. Staff from behavioral units and security are required to respond to a Rapid response code.

Interview on 09/07/2022 at 02:25 PM with Staff (F), Director of Public Safety and Emergency, and on 09/08/2022 at 09:55 AM with Staff (O), Director of Security, revealed the security staff do not apply restraints, although they do assist staff with manually holding patients. Both staff stated that Security is not provided restraint training or Managing Crisis Situations education at orientation or annually.

Interview on 09/08/2022 at 03:23 PM with Staff (L), Chief Operating Officer, verified the findings.

Based on interview, document review, and personnel record review, the hospital does not ensure that all staff who have direct care responsibilities, including contract/agency personnel, demonstrate competency for the use and care of the patient in restraint or seclusion for 3 out of 16 staff (Travel Nurses Staff (D), RN, Staff (P), EN, and Staff (Q), RN)

Findings Include:

Review on 09/09/2022 of policy "Restraints", last revised 08/2022 revealed all staff involved with restraints will be CPR certified, staff training on use of restraints, including application, /removal, will occur as part of orientation and with yearly competencies, Staff from behavioral health, psychiatric Emergency Department, intensive care unit, emergency department and security will attend Preventing and Managing Crisis Situations education.

Review on 09/09/2022 of the personnel files revealed Staff (D), RN-Travel Nurse, Staff (P), RN-Travel Nurse, and Staff (Q), RN-Travel Nurse did not have documentation for de-escalation and restraint training and competency.

Phone Interview on 09/15/2022 at 03:15 PM with Staff (A) RN, VP Chief Nursing Officer verified these findings.

Based on policy review, document review, medical record review, and interview, the emergency department clinical staff did not adhere to facility's policy related to patient elopement.

Findings Include:

Review on 09/07/22 of policy "Pursuit of Patient Leaving Without Permission (Elopement)", last reviewed 12/21 (existing policy at time incident) revealed when a patient is found missing from a patient care unit, an immediate search is initiated, along with enactment of Code Grey (Patient Missing). The staff should notify the Department Director, Administrative Coordinator or designee, the Attending Physician, and the responsible family member immediately. Documentation on the event report should include the time of the elopement, who was notified, and the condition of the patient upon return and final disposition.

Review on 09/07/22 of facility confidential Root Cause Report dated 08/10/22 revealed that the hospital elopement policy was not followed appropriately, as a "Code Grey" was not called, and the Administrative Coordinator was not notified by nursing staff.

Review on 09/07/22 of the Emergency Department (ED) medical record for Patient #2 dated 07/02/22 revealed he arrived at the facility at 06:38 PM via ambulance and was triaged. Patient #2 was found minimally responsive at an outpatient drug rehabilitation facility after snorting opiates while on a day pass. 2mg of Narcan was administered by EMS. The Patient Assessment was stable. The Medical Screening Exam (MSE) unremarkable. Patient #2 was diagnosis with an accidental overdose. Patient #2 will be on observation for 2 hours. If vital signs are stable, he will be discharged back to "rehab". At 08:40 PM, the Nursing Discharge Summary indicates Patient #2's condition on discharge is stable. At 08:51 PM, vital signs are stable. At 08:57 PM, the ED RN Elopement Note indicates that Patient #2 left without receiving discharge instructions. He was instructed to stay in his room and be monitored until he could be safely discharged back to the rehab facility. Patient #2 left the room and eloped. The RN called Patient #2's to cell phone, but no answer.

Review of Patient Contact Information revealed no emergency or next of kin contact information was provided by the patient.

There is no evidence of documentation in Patient #2 's ED record that a "Code Grey" was enacted or that the Administrative Coordinator was notified.

Interview on 09/07/22 at 11:00 AM with Staff (B), RN, VP of Quality and Compliance, revealed the Hospital Elopement Policy was not followed, as a Code Grey was not called, and the Administrative Coordinator was not notified.