HospitalInspections.org

This condition has not been met

Based on review of hospital policies, procedures and documentation, clinical record reviews for ten of ten patients (Patients #101, 102, 103, 104, 105, 106, 108, 109, 110, and 111), and interviews, the department of in-patient psychiatry's medical staff failed to ensure accountability to the governing body for the quality of care provided to patients when it was known that physician's on the adolescent psychiatric unit were ordering to restrain patients with a restraint net or both a restraint net and 4 point restraints despite staff being instructed not to use both restraints at the same time, and failed to ensure that the restraint net was used in accordance with manufacturer's recommendations.

Please see A49

Based on review of hospital policies, procedures and documentation, clinical record review, and interviews, the department of in-patient psychiatry's medical staff failed to ensure accountability to the governing body for the quality of care provided to patients when it was known that physician's on the adolescent psychiatric unit were ordering to restraint patients with a restraint net or both a restraint net and 4 point restraints despite staff being instructed not to use both restraints at the same time, and failed to ensure that the restraint net was used in accordance with manufacturer's recommendations. The findings include:

Review of the hospital's physical restraint record (compilation of restraint episodes) between August 2014 and June 2015 identified that Patient's #101-111 had a total of twelve restraint episodes where 4 point leather restraints were used in conjunction with a restraint net. All restraint episodes involving the use of a restraint net occurred on the child/adolescent behavioral health unit. Observations on 06/23/15 at 11:30 AM, 6/25/15 and 6/29/15 identified that all patient beds were wood platform beds and not standard hospital type beds as directed in the manufacturer instructions for the use of restraint nets.

a. Patient #101 was admitted on 08/18/14 with diagnoses of mood disorder and ADHD. Review of a behavioral health progress note documented by RN #107 on 08/20/15 at 4:11 PM identified that Patient #101 was agitated and oppositional, threw things at the staff, clenched his/her fists, refused to walk to the bedroom, and kicked 2 Mental Health Workers (MHW's). Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg and Benadryl 25 mg intramuscularly (IM). A physician's order dated 08/20/14 at 1:50 PM directed application of 4 point restraints for verbal aggression towards self or others. An additional order at 1:51 PM directed application of a body net for verbal aggression towards self or others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation for behaviors necessitating the second restraint net and or less restrictive interventions attempted per hospital policy. The restraints were applied at 1:45 PM and discontinued at 2:45 PM.

b. Patient #102 was admitted on 08/13/14 with diagnoses of mood disorder. Review of a behavioral health progress note documented by RN #107 on 08/23/15 at 1:23 PM identified that, Patient #102 had become agitated, threw things at the staff, threatened to kill the staff, hit the wall and glass emergency door with a chair, refused oral medications, and attempted to barricade him/herself in the bathroom and bite staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg and Benadryl 25 mg, IM. A physician's order dated 08/23/14 at 11:45 AM directed application of 4 point restraints for violent behavior including injury to self. Review of an electronic restraint evaluation and a physician note dated 08/23/14 at 2:07 PM identified that both 4 point restraints and a restraint net were applied. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation for behaviors necessitating the secondary restraint net and/or less restrictive interventions attempted per hospital policy. The restraints were applied at 11:35 AM and discontinued at 1:01 PM.

c. Patient #103 was admitted on 08/26/14 with a diagnosis of psychosis. Review of a behavioral health progress note documented by RN #102 on 08/28/15 at 5:31 PM identified that, Patient #103 was disorganized, responding to internal stimuli, exhibiting intrusive behavior that was agitating peers, refusing oral medications, constantly changing TV channels, increasingly agitated when redirected by staff and refused to remain in his/her room. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg IM. A physician's order dated 08/28/14 at 9:45 AM directed application of 4 point restraints for verbal aggression towards self and others. Additionally a physician's order at 10:45 AM directed to apply a body net for verbal aggression towards self and others. The behavioral health progress note further identified that, following application of the 4 point restraint, Patient #2 continued to thrash and bit the leather restraint off his/her arm necessitating the placement of restraint net. An additional 25 mg of Thorazine and 1 mg of Ativan were administered. The patient remained agitated, screaming, crying, thrashing, and constantly tried to get out of both restraints. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 9:45 AM and the net restraint was applied at 10:14 AM. Restraints were discontinued at 11:34 AM.

d. Patient #104 was admitted on 10/07/14 with a diagnosis of bipolar disorder, most recent episode, manic. Review of a behavioral health progress note documented by RN #107 on 10/09/15 at 5:31 PM identified that, Patient #104 attempted to eat plaster, bang his/her head, refused oral medications, pulled a screw from the wall, and struck 3 staff members. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Ativan 1 mg and Benadryl 25 mg IM. A physician's order dated 10/09/14 at 11:43 AM directed application of 4 point restraints with restraint net for violent behaviors including physical abuse towards others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 11:25 AM. Patient #104 began thrashing and screaming that he/she wanted to die and the restraint net was applied at 11:30 AM. Restraints were discontinued at 11:55 AM.

e. Patient #105 was admitted on 10/14/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #102 on 10/20/15 at 1:23 PM identified that, Patient #105 was verbally and physically threatening to staff, refused oral medications, hit his/her head on the wall, and threatened to strangle RN #102. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg IM. A physician's order dated 10/20/14 at 10:23 AM directed application of 4 point restraints for violent behaviors including self injury. Review of the clinical record lacked documentation of a physician's order for the application of a restraint net, however, the behavioral health progress note and the electronic restraint flow sheet identified that a restraint net was applied as the patient began to thrash and scream after the application of the 4 point restraint. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 10:20 AM followed by the restraint net. Restraints were discontinued at 11:30 AM.

f. Patient #106 was admitted on 9/08/14 with a diagnosis of bipolar disorder, type 2, most recent episode, depressed with psychotic features. Review of a behavioral health progress note documented by RN #108 on 09/12/15 at 08:15 AM identified that, Patient #106 was repeatedly scratching his/her sternum, physically aggressive, clenching fists, and attempting to hit staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 09/12/14 at 4:06 AM directed application of 4 point restraints for violent behaviors including self injury. Additionally, a physician's order dated 09/12/14 at 04:53 AM directed application of a restraint net for self injury. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 3:50 AM and Benadryl 50 mg IM was administered at 4:07 AM. The patient attempted to bite off the restraints and the restraint net was applied at 4:25 AM. Restraints were discontinued at 5:50 AM.

g. Patient #108 was admitted on 10/30/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #109 on 11/16/14 at 12:13 AM identified that Patient #108 became agitated when redirected to his/her room following a conflict with a peer, refused oral medications, threatened to harm staff and self and attempted to climb on shelving in an attempt to jump. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 11/15/14 at 5:50 PM directed application of a body net for self injury. Further review of the behavioral health progress note identified that both 4 point restraints and a restraint net were placed at 8:55 PM. The patient was further assessed due to increased agitation, and Thorazine 50 mg and Benadryl 50 mg were administered IM at 9:00 PM. Documentation failed to identify that an order for the 4 point restraint was obtained. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. Restraints were discontinued at 9:40 PM.

h. Patient #109 was admitted on 11/16/14 with a diagnosis of depressive disorder. Review of a behavioral health progress note documented by RN #110 on 11/21/14 at 10:26 AM identified that Patient #109 was repeatedly using profanity, agitated, screaming, threatening self harm, refusing to stay in room when redirected, slamming doors, punching the wall, head banging, attempting to lock self in bathroom, and assaultive towards staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 25 mg PO. The patient continued to be agitated and Thorazine 25 mg IM was also administered. A physician's order dated 11/20/14 at 8:58 PM directed application of 4 point restraints for violent behaviors including self injury. Review of the behavioral health progress note documented on 11/20/14 at 9:03 PM by MD #104 identified that Patient #109 was placed in 4 point restraints with a restraint net for safety. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 8:50 PM. Restraints were discontinued at 9:30 PM.

i. Patient #110 was admitted on 03/20/15 with a diagnosis of autism spectrum disorder. Review of a behavioral health progress note documented by RN #108 on 04/07/15 at 06:18 AM identified that Patient #110 made sexual gestures towards an RN, physically assaulted a MHW, spit at staff, and yelled. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Benadryl 50 mg IM at 11:40 PM. A physician's order dated 04/06/15 at 11:46 PM directed application of 4 point restraints for violent behaviors including physical abuse to others. An additional physician's order at 11:49 PM directed to apply a body net for violent behaviors. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 11:45 PM. Following application, the patient attempted to remove the restraint, thrashed in the bed, and yelled to be let out. The restraint net was subsequently applied at 11:50 PM. Restraints were discontinued on 04/08/15 at 12:10 AM.

j. Patient #111 was admitted on 06/05/15 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #101 on 06/11/15 at 05:01 PM identified that, Patient #110 reached over the desk and grabbed 2 telephones, refused to go to his/her room, attempted to punch and kick staff, refused oral medications, and was unable to regain control. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg IM at 11:10 AM. A physician's order dated 06/11/15 at 11:21 AM directed application of 4 point restraints for violent behaviors including verbal aggression towards others. An additional physician's order at 11:23 AM directed application of a body net for violent behaviors including verbal aggression towards self or others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net and/or behaviors necessitating use per hospital policy. The 4 point restraints and restraint net were applied at 11:10 AM and discontinued at 11:30 AM.

Interview with the chief of the Adolescent Unit, MD #102 on 06/25/15 at 11:00 AM identified that he/she understood that the least restrictive device necessary to maintain patient safety was to be utilized and assumed that the 4 point leather restraints were removed prior to the application of the restraint net and was unaware that the restraint net was being utilized in conjunction with four point restraints.

Interview with the Chief of Psychiatry on 06/24/15 at 1:20 PM identified that some patients remain dangerous in four point restraints alone and require an additional restraint. An additional interview on 6/25/15 indicated that he/she was not sure, but may have signed off on the policy indicating that both the restraint net and 4 point restraints could be used together. MD #103 indicated that the practice for the 4 point and net restraint application was present prior to MD #103's hire date in 2004. MD #103 and the Quality and Patient Safety Director indicated that the Behavioral Health Quality Manager was transferred to the hospital's Quality Department in 2013 and had not been replaced until 2014. Documentation and interviews failed to reflect that the 4 point and net restraint usage for the adolescent psychiatric patient population was monitored in the hospital's performance improvement plan and ultimately not reported to the governing body.

Interviews and demonstration of application of the restraint net with Clinical Nurse Leader #1, MHW #1, and the DNS on 06/29/15 at 10:30 AM identified that when the restraint net is being used to stabilize the upper body with a patient already in 4-point leather restraints, the lower extremities are left in the leather restraints.


Interview with restraint net manufacturer's representative #1 on 06/24/15 at 2:00 PM identified that the restraint net was designed to be an alternative to other physical limb restraints and should not be used in combination with another physical restraint.


Despite the manufacturer instructions identifying that the restraint net was only for use with a hospital bed and that it was to be used as the least restrictive device, a hospital policy and procedure titled Physical Restraints and Seclusion identified that a full body restraint net can be used in conjunction with 4-point restraints.


Interview with the DNS on 06/25/15 at 1:10 PM identified that the staff was instructed to discontinue the practice of using two restraints, however, sometimes it was necessary to maintain patient safety and he/she concurred with the use despite the knowledge that the restraint net was not being attached to the bed in accordance with manufacturer's application instructions. The DNS further identified that the restraint net was utilized as a fifth point to secure a patient's upper body from twisting, turning, and sitting up, and to prevent removal of the leather restraint cuffs, and/or scratching themselves. Additionally, the DNS identified that, although he/she had not been trained to use the restraints together, the practice evolved due to the difficulties managing extremely violent behaviors. The DNS identified that although all restraint episodes were discussed and evaluated during debriefing sessions and, with the Chair of the Department of Psychiatry, MD #103, during regular restraint review meetings, the use of the restraint net in conjunction with the 4 point leather restraits was discussed outside of these meetings and a consensus could not be reached.

Interview with Clinical Nurse Leader #1 on 06/24/15 at 1:30 PM identified that in 2009, it was a common practice to restrain a patient using both four point leather restraints and a restraint net, however, by 2012, the staff were instructed to use either 4 point restraints or a restraint net. Staff compliance was limited, and in 2013, Clinical Leader #1 was directed by the DNS to educate all staff on the correct application of each restraint. Staff training was conducted for all newly hired staff as well as annually for all staff. Clinical Leader #1 identified that although the staff had been trained in the proper application of each restraint, the staff on the adolescent unit continued to restrain patients with both 4 point leather restraints and a restraint net, per physician's order.

The condition of Patient Rights has not been met.

Based on review of clinical records, hospital restraint documentation, hospital policies and procedures, interviews and review of manufacturer recommendations, for ten of ten patients (Patients #101, 102, 103, 104, 105, 106, 108, 109, 110, and 111), the hospital failed to promote and protect patient rights when all ten adolescents were restrained with both 4-point leather restraints and a full body restraint net, failed to ensure that patients received care in a safe setting when the restraint net was used in an unsafe manner that was not in accordance with the manufacturer recommendations, failed to assess for the least restrictive restraint option prior to applying a restraint net, failed to ensure physician orders were obtained for the restraints, failed to ensure that a face to face evaluation occurred once restraints were applied, failed to ensure that the plan of care included the restraint episodes, and despite being educated by the Clinical Nurse Leader on using only one or the other restraint, staff on the adolescent unit continued to use the restraint net and 4-point restraints together.


Please see A144, A154, A165, A166, A167, A168, A178, A179 and A194

Based on review of clinical records, hospital restraint documentation, hospital policies and procedures, interviews and review of manufacturer recommendations, for ten of ten patients (Patients #101, 102, 103, 104, 105, 106, 108, 109, 110, and 111) restrained with both 4-point leather restraints and a restraint net, the hospital failed to ensure that patients received care in a safe setting when the restraint net was used in an unsafe manner and not in accordance with the manufacturer's recommendation. The findings include:


Tour of all in-patient units at the hospital's off-site campus psychiatric units on 6/23/15 between 9:30 AM and 11:30 AM identified that restraint nets and leather wrist and ankle restraints were located in supply closets on each unit. Interview with RN #104, Nurse Manager of the adult unit on 6/23/15 at 9:30 AM identified that she did not know what the restraint net was and stated that she had never seen it used. Interview with RN #106, Nurse Manager of the adolescent unit) on 6/23/15 at 11:30 AM identified when a child or adolescent's behavior warranted, they were offered oral medication and if they refused, they were administered medication via injection. The patient was then placed in 4-point leather restraints. If the patient "bucked" in the bed or tried to "bite" the wrist restraints, a restraint net was applied to prevent the patient's movement in the bed. Once the medications took effect, the net is removed.


Review of the hospital's physical restraint record (compilation of restraint episodes) between August 2014 and June 2015 identified that Patient's #101-111 had a total of twelve restraint episodes where 4 point leather restraints were used in conjunction with a restraint net. All restraint episodes involving the use of a restraint net occurred on the child/adolescent behavioral health unit. Observations on 06/23/15 at 11:30 AM, 6/25/15 and 6/29/15 identified that all patient beds were wood platform beds and not standard hospital type beds as directed in the manufacturer instructions for the use of restraint nets. Each bed was fitted with wooden restraint brackets along the outer sides of the bed. Two of fifteen beds on the child/adolescent unit had only 4 spaces on each side of the bed for placement of restraint net straps (which required 5) and the remainder of the beds had 5 on each side of the bed. All beds lacked a bracket at the foot of the bed for attaching the restraint net end-strap. It was unable to be determined which patients may have been in a bed with only 4 spaces for securing the restraint net.


Interview and demonstration of restraint net placement with Clinical Nurse Leader #1 on 06/29/15 at 10:30 AM identified that if a bed lacked the necessary slots for securing of the 5 cross straps, staff would place 2 straps into one slot. Additional interviews and demonstration of application of the restraint net with Clinical Nurse Leader #1, MHW #1, and the DNS on 06/29/15 at 10:30 AM identified that when the restraint net is being used to stabilize the upper body with a patient already in 4-point leather restraints, the lower extremities are left in the leather restraints. The restraint net's Velcro ankle/calf restraints and the end-strap are not used (inconsistent with manufacturer instructions).


Interview with the DNS on 06/25/15 at 1:10 PM identified that the staff was instructed to discontinue the practice of using two restraints, however, sometimes it was necessary to maintain patient safety and he/she concurred with the use despite the knowledge that the restraint net was not being attached to the bed in accordance with manufacturer's application instructions. The DNS further identified that the restraint net was utilized as a fifth point to secure a patient's upper body from twisting, turning, and sitting up, and to prevent removal of the leather restraint cuffs, and/or scratching themselves.


Interview with restraint net manufacturer's representative on 06/24/15 at 2:00 PM identified that the restraint net was designed to be an alternative to other physical limb restraints and should not be used in combination with another physical restraint.


Despite the manufacturer instructions identifying that the restraint net was only for use with a hospital bed and that it was to be used as the least restrictive device, a hospital policy and procedure titled Physical Restraints and Seclusion identified that a full body restraint net can be used in conjunction with 4-point restraints.

Based on review of clinical records, hospital physical restraint log, hospital policies and procedures, and interviews for ten of ten adolescent patients who were placed in a restraint net in conjunction with four point leather restraints, Patients #101, 102, 103, 104, 105, 106, 108, 109, 110, and 111, the hospital failed to document that patients were assessed for less restrictive alternatives prior to placing a second eleven point restraint net on the patient. The findings include:

Review of clinical records for Patients #101, 102, 103, 104, 105, 106, 108, 109, 110, and 111 identified that each patient exhibited ongoing aggressive, self-injurious, and/or dangerous behaviors despite assessment and implementation of multiple less restrictive interventions resulting in the need for four point physical restraints. Following placement of the 4 point restraints, the patients exhibited behaviors that included slipping out of the restraint, sitting up, twisting, biting themselves, and or scratching themselves on the restraint and staff applied a restraint net in conjunction with the four point restraint creating a total of 13 to 15 point restraints on the patients.

a. Patient #101 was admitted on 08/18/14 with diagnoses of mood disorder and ADHD. Review of a behavioral health progress note documented by RN #107 on 08/20/15 at 4:11 PM identified that Patient #101 was agitated and oppositional, threw things at the staff, clenched his/her fists, refused to walk to the bedroom, and kicked 2 Mental Health Workers (MHW's). Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg and Benadryl 25 mg intramuscularly (IM). A physician's order dated 08/20/14 at 1:50 PM directed application of 4 point restraints for verbal aggression towards self or others. An additional order at 1:51 PM directed application of a body net for verbal aggression towards self or others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation for behaviors necessitating the second restraint net and or less restrictive interventions attempted per hospital policy. The restraints were applied at 1:45 PM and discontinued at 2:45 PM.

b. Patient #102 was admitted on 08/13/14 with diagnoses of mood disorder. Review of a behavioral health progress note documented by RN #107 on 08/23/15 at 1:23 PM identified that, Patient #102 had become agitated, threw things at the staff, threatened to kill the staff, hit the wall and glass emergency door with a chair, refused oral medications, and attempted to barricade him/herself in the bathroom and bite staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg and Benadryl 25 mg, IM. A physician's order dated 08/23/14 at 11:45 AM directed application of 4 point restraints for violent behavior including injury to self. Review of an electronic restraint evaluation and a physician note dated 08/23/14 at 2:07 PM identified that both 4 point restraints and a restraint net were applied. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation for behaviors necessitating the secondary restraint net and/or less restrictive interventions attempted per hospital policy. The restraints were applied at 11:35 AM and discontinued at 1:01 PM.

c. Patient #103 was admitted on 08/26/14 with a diagnosis of psychosis. Review of a behavioral health progress note documented by RN #102 on 08/28/15 at 5:31 PM identified that, Patient #103 was disorganized, responding to internal stimuli, exhibiting intrusive behavior that was agitating peers, refusing oral medications, constantly changing TV channels, increasingly agitated when redirected by staff and refused to remain in his/her room. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg IM. A physician's order dated 08/28/14 at 9:45 AM directed application of 4 point restraints for verbal aggression towards self and others. Additionally a physician's order at 10:45 AM directed to apply a body net for verbal aggression towards self and others. The behavioral health progress note further identified that, following application of the 4 point restraint, Patient #2 continued to thrash and bit the leather restraint off his/her arm necessitating the placement of restraint net. An additional 25 mg of Thorazine and 1 mg of Ativan were administered. The patient remained agitated, screaming, crying, thrashing, and constantly tried to get out of both restraints. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 9:45 AM and the net restraint was applied at 10:14 AM. Restraints were discontinued at 11:34 AM.

d. Patient #104 was admitted on 10/07/14 with a diagnosis of bipolar disorder, most recent episode, manic. Review of a behavioral health progress note documented by RN #107 on 10/09/15 at 5:31 PM identified that, Patient #104 attempted to eat plaster, bang his/her head, refused oral medications, pulled a screw from the wall, and struck 3 staff members. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Ativan 1 mg and Benadryl 25 mg IM. A physician's order dated 10/09/14 at 11:43 AM directed application of 4 point restraints with restraint net for violent behaviors including physical abuse towards others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 11:25 AM. Patient #104 began thrashing and screaming that he/she wanted to die and the restraint net was applied at 11:30 AM. Restraints were discontinued at 11:55 AM.

e. Patient #105 was admitted on 10/14/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #102 on 10/20/15 at 1:23 PM identified that, Patient #105 was verbally and physically threatening to staff, refused oral medications, hit his/her head on the wall, and threatened to strangle RN #102. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg IM. A physician's order dated 10/20/14 at 10:23 AM directed application of 4 point restraints for violent behaviors including self injury. Review of the clinical record lacked documentation of a physician's order for the application of a restraint net, however, the behavioral health progress note and the electronic restraint flow sheet identified that a restraint net was applied as the patient began to thrash and scream after the application of the 4 point restraint. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 10:20 AM followed by the restraint net. Restraints were discontinued at 11:30 AM.

f. Patient #106 was admitted on 9/08/14 with a diagnosis of bipolar disorder, type 2, most recent episode, depressed with psychotic features. Review of a behavioral health progress note documented by RN #108 on 09/12/15 at 08:15 AM identified that, Patient #106 was repeatedly scratching his/her sternum, physically aggressive, clenching fists, and attempting to hit staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 09/12/14 at 4:06 AM directed application of 4 point restraints for violent behaviors including self injury. Additionally, a physician's order dated 09/12/14 at 04:53 AM directed application of a restraint net for self injury. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 3:50 AM and Benadryl 50 mg IM was administered at 4:07 AM. The patient attempted to bite off the restraints and the restraint net was applied at 4:25 AM. Restraints were discontinued at 5:50 AM.

g. Patient #108 was admitted on 10/30/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #109 on 11/16/14 at 12:13 AM identified that Patient #108 became agitated when redirected to his/her room following a conflict with a peer, refused oral medications, threatened to harm staff and self and attempted to climb on shelving in an attempt to jump. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 11/15/14 at 5:50 PM directed application of a body net for self injury. Further review of the behavioral health progress note identified that both 4 point restraints and a restraint net were placed at 8:55 PM. The patient was further assessed due to increased agitation, and Thorazine 50 mg and Benadryl 50 mg were administered IM at 9:00 PM. Documentation failed to identify that an order for the 4 point restraint was obtained. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. Restraints were discontinued at 9:40 PM.

h. Patient #109 was admitted on 11/16/14 with a diagnosis of depressive disorder. Review of a behavioral health progress note documented by RN #110 on 11/21/14 at 10:26 AM identified that Patient #109 was repeatedly using profanity, agitated, screaming, threatening self harm, refusing to stay in room when redirected, slamming doors, punching the wall, head banging, attempting to lock self in bathroom, and assaultive towards staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 25 mg PO. The patient continued to be agitated and Thorazine 25 mg IM was also administered. A physician's order dated 11/20/14 at 8:58 PM directed application of 4 point restraints for violent behaviors including self injury. Review of the behavioral health progress note documented on 11/20/14 at 9:03 PM by MD #104 identified that Patient #109 was placed in 4 point restraints with a restraint net for safety. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 8:50 PM. Restraints were discontinued at 9:30 PM.

i. Patient #110 was admitted on 03/20/15 with a diagnosis of autism spectrum disorder. Review of a behavioral health progress note documented by RN #108 on 04/07/15 at 06:18 AM identified that Patient #110 made sexual gestures towards an RN, physically assaulted a MHW, spit at staff, and yelled. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Benadryl 50 mg IM at 11:40 PM. A physician's order dated 04/06/15 at 11:46 PM directed application of 4 point restraints for violent behaviors including physical abuse to others. An additional physician's order at 11:49 PM directed to apply a body net for violent behaviors. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 11:45 PM. Following application, the patient attempted to remove the restraint, thrashed in the bed, and yelled to be let out. The restraint net was subsequently applied at 11:50 PM. Restraints were discontinued on 04/08/15 at 12:10 AM.

j. Patient #111 was admitted on 06/05/15 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #101 on 06/11/15 at 05:01 PM identified that, Patient #110 reached over the desk and grabbed 2 telephones, refused to go to his/her room, attempted to punch and kick staff, refused oral medications, and was unable to regain control. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg IM at 11:10 AM. A physician's order dated 06/11/15 at 11:21 AM directed application of 4 point restraints for violent behaviors including verbal aggression towards others. An additional physician's order at 11:23 AM directed application of a body net for violent behaviors including verbal aggression towards self or others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net and/or behaviors necessitating use per hospital policy. The 4 point restraints and restraint net were applied at 11:10 AM and discontinued at 11:30 AM.

Interview with Clinical Nurse Leader #1 on 06/24/15 at 1:30 PM identified that in 2009, it was a common practice to restrain a patient using both four point leather restraints and a restraint net, however, by 2012, the staff were instructed to use either one or the other restraint (restraint net or 4 point restraint). Staff compliance was limited, and in 2013, Clinical Leader #1 was directed by the DNS to educate all staff on the correct application of each restraint. Staff training was conducted for all newly hired staff as well as annually for all staff. Clinical Leader #1 identified that although the staff has been trained in the proper application of each restraint, the staff on the adolescent unit continued to restrain with both the restraint net and 4 point restraints, per physician's order.

Interview with the Chair of the Department of Psychiatry on 06/24/15 at 1:20 PM identified that some patients continue to remain a danger to themselves or others while in four point restraints and need an additional physical restraint to remain safe.

A hospital policy titled Physical Restraints and Seclusion identified, in part, Principles of Restraint: stepwise progression should always be attempted starting with the least restrictive non-physical intervention; restraint may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, staff, or others; and the type or technique must be the least restrictive necessary that will achieve safety and security. The need for restraint is determined by a Licensed Independent Practitioner's comprehensive assessment in which the risks of using the restraint are outweighed by the risks of not using it. The assessment must be documented in the medical record.

Based on observation, review of clinical records, hospital policies and procedures, and interviews for ten of ten patients (Patients #101, 102, 103, 104, 105, 106, 108, 109, 110, and 111) restrained with a restraint net, the hospital failed to ensure that the least restrictive intervention was utilized to protect the patient from harm. The findings include:

a. Patient #101 was admitted on 08/18/14 with diagnoses of mood disorder and ADHD. Review of a behavioral health progress note documented by RN #107 on 08/20/15 at 4:11 PM identified that, Patient #101 was agitated and oppositional, threw things at the staff, clenched his/her fists, refused to walk to the bedroom, and kicked 2 MHW's. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 08/20/14 at 1:50 PM directed application of 4 point restraints for verbal aggression towards self or others. An additional order at 1:51 PM directed application of a body net for verbal aggression towards self or others. The clinical record lacked documentation for behaviors necessitating the secondary net restraint and or less restrictive interventions attempted per hospital policy.

b. Patient #102 was admitted on 08/13/14 with diagnoses of mood disorder. Review of a behavioral health progress note documented by RN #107 on 08/23/15 at 1:23 PM identified that, Patient #102 had become agitated, threw things at the staff, threatened to kill the staff, hit the wall and glass emergency door with a chair, refused oral medications, and attempted to barricade him/herself in the bathroom and bite staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 08/23/14 at 11:45 AM directed application of 4 point restraints for violent behavior including injury to self. Review of an electronic restraint evaluation and a physician note dated 08/23/14 at 2:07 PM identified that both 4 point restraints and a restraint net were applied. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation for behaviors necessitating the secondary net restraint and/or less restrictive interventions attempted per hospital policy.

c. Patient #103 was admitted on 08/26/14 with a diagnosis of psychosis. Review of a behavioral health progress note documented by RN #102 on 08/28/15 at 5:31 PM identified that, Patient #103 was disorganized, responding to internal stimuli, exhibiting intrusive behavior that was agitating peers, refusing oral medications, constantly changing TV channels, increasingly agitated when redirected by staff and refused to remain in his/her room. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 08/28/14 at 9:45 AM directed application of 4 point restraints for verbal aggression towards self and others. Additionally a physician's order at 10:45 AM directed to apply a body net for verbal aggression towards self and others. The behavioral health progress note further identified that, following application of the 4 point restraint, Patient #2 continued to thrash and bit the leather restraint off his/her arm necessitating the placement of restraint net. The patient remained agitated, screaming, crying, thrashing, and constantly tried to get out of both restraints. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 9:45 AM and the net restraint was applied at 10:14 AM.

d. Patient #104 was admitted on 10/07/14 with a diagnosis of bipolar disorder, most recent episode, manic. Review of a behavioral health progress note documented by RN #107 on 10/09/15 at 5:31 PM identified that, Patient #104 attempted to eat plaster, bang his/her head, refused oral medications, pulled a screw from the wall, and struck 3 staff members. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 10/09/14 at 11:43 AM directed application of 4 point restraints with restraint net for violent behaviors including physical abuse towards others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 11:25 AM. Patient #104 began thrashing and screaming that he/she wanted to die and the restraint net was applied at 11:30 AM.

e. Patient #105 was admitted on 10/14/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #102 on 10/20/15 at 1:23 PM identified that, Patient #105 was verbally and physically threatening to staff, refused oral medications, hit his/her head on the wall, and threatened to strangle RN #102. Multiple, documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 10/20/14 at 10:23 AM directed application of 4 point restraints for violent behaviors including self injury. Review of the clinical record lacked documentation of a physician's order for the application of a restraint net, however, the behavioral health progress note and the electronic restraint flow sheet identified that a restraint net was applied as the patient began to thrash and scream after the application of the 4 point restraint. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 10:20 AM followed by the restraint net.

f. Patient #106 was admitted on 9/08/14 with a diagnosis of bipolar disorder. Review of a behavioral health progress note documented by RN #108 on 09/12/15 at 08:15 AM identified that, Patient #106 was repeatedly scratching his/her sternum, physically aggressive, clenching fists, and attempting to hit staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 09/12/14 at 4:06 AM directed application of 4 point restraints for violent behaviors including self injury. Additionally, a physician's order dated 09/12/14 at 04:53 AM directed application of a body net for self injury. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 3:50 AM. The patient attempted to bite off the restraints and the restraint net was applied at 4:25 AM.

g. Patient #108 was admitted on 10/30/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #109 on 11/16/14 at 12:13 AM identified that, Patient #108 became agitated when redirected to his/her room following conflict with a peer, refused oral medications, threatened to harm staff and self and attempted to climb on shelving in an attempt to jump. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 11/15/14 at 5:50 PM directed application of a body net for self injury. Further review of the behavioral health progress note identified that both 4 point restraints and a restraint net were placed at 8:55 PM. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy.

h. Patient #109 was admitted on 11/16/14 with a diagnosis of depressive disorder. Review of a behavioral health progress note documented by RN #110 on 11/21/14 at 10:26 AM identified that, Patient #109 was repeatedly using profanity, agitated, screaming, threatening self harm, refusing to stay in room when redirected, slamming doors, punching the wall, head banging, attempting to lock self in bathroom, and assaultive towards staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 11/20/14 at 8:58 PM directed application of 4 point restraints for violent behaviors including self injury. Review of the behavioral health progress note documented on 11/20/14 at 9:03 PM by MD #104 identified that that Patient #109 was placed in 4 point restraints with a net for safety. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 8:50 PM and discontinued at 9:30 PM.

i. Patient #110 was admitted on 03/20/15 with a diagnosis of autism spectrum disorder. Review of a behavioral health progress note documented by RN #108 on 04/07/15 at 06:18 AM identified that Patient #110 made sexual gestures towards an RN, physically assaulted a MHW, spit at staff, and yelled. Multiple documented interventions were unsuccessful at de-escalating the patient ' s behavior. A physician's order dated 04/06/15 at 11:46 PM directed application of 4 point restraints for violent behaviors including physical abuse to others. An additional physician ' s order at 11:49 PM directed to apply a body net for violent behaviors. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 11:45 PM. Following application, the patient attempted to remove the restraint, thrashed in the bed, and, yelled to be let out and the restraint net was subsequently applied at 11:50 PM.

j. Patient #111 was admitted on 06/05/15 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #101 on 06/11/15 at 05:01 PM identified that, Patient #111 reached over the desk and grabbed 2 telephones, refused to go to his/her room, attempted to punch and kick staff, refused oral medications, and was unable to regain control. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 06/11/15 at 11:21 AM directed application of 4 point restraints for violent behaviors including verbal aggression towards others. An additional physician's order at 11:23 AM directed application of a body net for violent behaviors including verbal aggression towards self or others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net and/or behaviors necessitating use per hospital policy. The 4 point restraints and restraint net were applied at 11:10 AM and discontinued at 11:30 AM.

Interview with Clinical Nurse Leader #1 on 06/24/15 at 1:30 PM identified that in 2009, it was a common practice to restrain a patient using both four point leather restraints and a restraint net, however, by 2012, the staff were instructed to use either one or the other restraint. Staff compliance was limited, and in 2013, Clinical Leader #1 was directed by the DNS to educate all staff on the correct application of each restraint. Staff training was conducted for all newly hired staff as well as annually for all staff. Clinical Leader #1 identified that although the staff has been trained in the proper application of each restraint, the staff on the adolescent unit continued to restrain with both the restraint net and 4 point restraints per physician's order.

A hospital policy titled Physical Restraints and Seclusion identified, in part, Principles of Restraint: stepwise progression should always be attempted starting with the least restrictive non-physical intervention; restraint may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, staff, or others; and the type or technique must be the least restrictive necessary that will achieve safety and security. The need for restraint is determined by an LIP comprehensive assessment by an RN in which the risks of using the restraint are outweighed by the risks of not using it. The assessment must be documented in the medical record.

Based on review of clinical records, hospital policies and procedures, and interviews for eleven of eleven patients (Patients #101, 102, 103, 104, 105, 106, 108, 109, 110, and 111) who were restrained with a restraint net and/or four point restraints, the hospital failed to ensure that the use of restraint was in accordance with a written modification to the patient's plan of care. The findings include:

a. Patient #101 was admitted on 08/18/14 with diagnoses of mood disorder and ADHD. A physician's order dated 08/20/14 at 1:50 PM directed application of 4 point restraints for verbal aggression towards self or others. An additional order at 1:51 PM directed application of a body net for verbal aggression towards self or others. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans failed to ensure that the plan of care was updated to included the restraint episodes.

b. Patient #102 was admitted on 08/13/14 with diagnoses of mood disorder. A physician's order dated 08/23/14 at 11:45 AM directed application of 4 point restraints for violent behavior including injury to self. Review of an electronic restraint evaluation and a physician note dated 08/23/14 at 2:07 PM identified that both 4 point restraints and a restraint net were applied. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

c. Patient #103 was admitted on 08/26/14 with a diagnosis of psychosis. A physician's order dated 08/28/14 at 9:45 AM directed application of 4 point restraints for verbal aggression towards self and others. Additionally a physician ' s order at 10:45 AM directed to apply a body net for verbal aggression towards self and others. The behavioral health progress note further identified that, following application of the 4 point restraint, Patient #2 continued to thrash and bit the leather restraint off his/her arm necessitating the placement of restraint net. The patient remained agitated, screaming, crying, thrashing, and constantly tried to get out of both restraints. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

d. Patient #104 was admitted on 10/07/14 with a diagnosis of bipolar disorder. A physician's order dated 10/09/14 at 11:43 AM directed application of 4 point restraints with restraint net for violent behaviors including physical abuse towards others. The 4 point restraints were applied at 11:25 AM. Patient #104 began thrashing and screaming that he/she wanted to die and the restraint net was applied at 11:30 AM. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

e. Patient #105 was admitted on 10/14/14 with a diagnosis of mood disorder. A physician's order dated 10/20/14 at 10:23 AM directed application of 4 point restraints for violent behaviors including self injury. Review of the clinical record lacked documentation of a physician's order for the application of a restraint net, however, the behavioral health progress note and the electronic restraint flow sheet identified that a restraint net was applied as the patient began to thrash and scream after the application of the 4 point restraint. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

f. Patient #106 was admitted on 9/08/14 with a diagnosis of bipolar disorder. A physician's order dated 09/12/14 at 4:06 AM directed application of 4 point restraints for violent behaviors including self injury. Additionally, a physician's order dated 09/12/14 at 04:53 AM directed application of a body net for self injury. The 4 point restraints were applied at 3:50 AM. The patient attempted to bite off the restraints and the restraint net was applied at 4:25 AM. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

g. Patient #108 was admitted on 10/30/14 with a diagnosis of mood disorder. A physician's order dated 11/15/14 at 5:50 PM directed application of a body net for self injury. Further review of the behavioral health progress note identified that both 4 point restraints and a restraint net were placed at 8:55 PM. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

h. Patient #109 was admitted on 11/16/14 with a diagnosis of depressive disorder. A physician's order dated 11/20/14 at 8:58 PM directed application of 4 point restraints for violent behaviors including self injury. Review of the behavioral health progress note documented on 11/20/14 at 9:03 PM by MD #104 identified that that Patient #109 was placed in 4 point restraints with a net for safety. The 4 point restraints were applied at 8:50 PM and discontinued at 9:30 PM. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

i. Patient #110 was admitted on 03/20/15 with a diagnosis of autism spectrum disorder. A physician's order dated 04/06/15 at 11:46 PM directed application of 4 point restraints for violent behaviors including physical abuse to others. An additional physician's order at 11:49 PM directed to apply a body net for violent behaviors. The 4 point restraints were applied at 11:45 PM. Following application, the patient attempted to remove the restraint, thrashed in the bed, and, yelled to be let out and the restraint net was subsequently applied at 11:50 PM. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

j. Patient #111 was admitted on 06/05/15 with a diagnosis of mood disorder. A physician's order dated 06/11/15 at 11:21 AM directed application of 4 point restraints for violent behaviors including verbal aggression towards others. An additional physician's order at 11:23 AM directed application of a body net for violent behaviors including verbal aggression towards self or others. The 4 point restraints and restraint net were applied at 11:10 AM and discontinued at 11:30 AM. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

k. Patient #108 was admitted on 10/19/14 with a diagnosis of ADHD, impulsive type. A behavioral health progress note documented by RN #110 on 11/04/14 at 7:55 PM identified that the patient became agitated, spiting at staff, kicking walls, threatening to punch staff, and throwing chairs. A physician's order dated 11/03/14 at 7:10 PM directed application of 4 point restraint for violent behavior as evidenced by physical abuse to others. The restraint was applied at 6:55 PM and discontinued at 7:55 PM. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

Interview with the manager of the adolescent unit, RN #106 on 06/24/15 at 10:00 AM identified that each restraint episode was reviewed by the interdisciplinary team and a debriefing was conducted. And that a care plan revision should have been completed at that time of the restraint episode.

A hospital policy titled Physical Restraints and Seclusion identified, in part, Principles of Restraint: The use of restraint must be in accordance with a written modification to the patient plan of care/treatment plan which is updated with each new episode of restraint/seclusion.

Based on observation, review of clinical records, hospital policies and procedures, and interviews for ten of ten patients (Patients #101, 102, 103, 104, 105, 106, 108, 109, 110, and 111, ) who were restrained with a restraint net in conjunction with four point restraints, the hospital failed to ensure that the use of a combination of restraints reflected the least restrictive intervention to maintain safety and/or that the restraints were utilized in accordance with manufacturer's recommendations. The findings include:

Review of clinical records for Patients #101, 102, 103, 104, 105, 106, 108, 109, 110, and 111 identified that each patient exhibited ongoing aggressive, self-injurious, and/or dangerous behaviors despite assessment and implementation of multiple less restrictive interventions resulting in the need for four point physical restraints. Following placement of the 4 point restraint, the patients exhibited behaviors that included slipping out of the restraint, sitting up, twisting, biting themselves, and or scratching themselves on the restraint and a restraint net was applied in conjunction with the four point restraint.

a. Patient #101 was admitted on 08/18/14 with diagnoses of mood disorder and ADHD. Review of a behavioral health progress note documented by RN #107 on 08/20/15 at 4:11 PM identified that, Patient #101 was agitated and oppositional, threw things at the staff, clenched his/her fists, refused to walk to the bedroom, and kicked 2 MHW's. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 08/20/14 at 1:50 PM directed application of 4 point restraints for verbal aggression towards self or others. An additional order at 1:51 PM directed application of a body net for verbal aggression towards self or others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation for behaviors necessitating the secondary net restraint and or less restrictive interventions attempted per hospital policy. The restraints were applied at 1:45 PM and discontinued at 2:45 PM.

b. Patient #102 was admitted on 08/13/14 with diagnoses of mood disorder. Review of a behavioral health progress note documented by RN #107 on 08/23/15 at 1:23 PM identified that, Patient #102 had become agitated, threw things at the staff, threatened to kill the staff, hit the wall and glass emergency door with a chair, refused oral medications, and attempted to barricade him/herself in the bathroom and bite staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 08/23/14 at 11:45 AM directed application of 4 point restraints for violent behavior including injury to self. Review of an electronic restraint evaluation and a physician note dated 08/23/14 at 2:07 PM identified that both 4 point restraints and a restraint net were applied. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation for behaviors necessitating the secondary net restraint and/or less restrictive interventions attempted per hospital policy. The restraints were applied at 11:35 AM and discontinued at 1:01 PM.

c. Patient #103 was admitted on 08/26/14 with a diagnosis of psychosis. Review of a behavioral health progress note documented by RN #102 on 08/28/15 at 5:31 PM identified that, Patient #103 was disorganized, responding to internal stimuli, exhibiting intrusive behavior that was agitating peers, refusing oral medications, constantly changing TV channels, increasingly agitated when redirected by staff and refused to remain in his/her room. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 08/28/14 at 9:45 AM directed application of 4 point restraints for verbal aggression towards self and others. Additionally, a physician's order at 10:45 AM directed to apply a body net for verbal aggression towards self and others. The behavioral health progress note further identified that, following application of the 4 point restraint, Patient #2 continued to thrash and bit the leather restraint off his/her arm necessitating the placement of restraint net. The patient remained agitated, screaming, crying, thrashing, and constantly tried to get out of both restraints. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 9:45 AM and the net restraint was applied at 10:14 AM. Restraints were discontinued at 11:34 AM.

d. Patient #104 was admitted on 10/07/14 with a diagnosis of bipolar disorder, most recent episode, manic. Review of a behavioral health progress note documented by RN #107 on 10/09/15 at 5:31 PM identified that, Patient #104 attempted to eat plaster, bang his/her head, refused oral medications, pulled a screw from the wall, and struck 3 staff members. Multiple documented interventions were unsuccessful at de-escalating the patient ' s behavior. A physician's order dated 10/09/14 at 11:43 AM directed application of 4 point restraints with restraint net for violent behaviors including physical abuse towards others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 11:25 AM. Patient #104 began thrashing and screaming that he/she wanted to die and the restraint net was applied at 11:30 AM. Restraints were discontinued at 11:55 AM.

e. Patient #105 was admitted on 10/14/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #102 on 10/20/15 at 1:23 PM identified that, Patient #105 was verbally and physically threatening to staff, refused oral medications, hit his/her head on the wall, and threatened to strangle RN #102. Multiple, documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 10/20/14 at 10:23 AM directed application of 4 point restraints for violent behaviors including self injury. Review of the clinical record lacked documentation of a physician ' s order for the application of a restraint net, however, the behavioral health progress note and the electronic restraint flow sheet identified that a restraint net was applied as the patient began to thrash and scream after the application of the 4 point restraint. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 10:20 AM followed by the restraint net. Restraints were discontinued at 11:30 AM.

f. Patient #106 was admitted on 9/08/14 with a diagnosis of bipolar disorder, type 2, most recent episode, depressed with psychotic features. Review of a behavioral health progress note documented by RN #108 on 09/12/15 at 08:15 AM identified that, Patient #106 was repeatedly scratching his/her sternum, physically aggressive, clenching fists, and attempting to hit staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 09/12/14 at 4:06 AM directed application of 4 point restraints for violent behaviors including self injury. Additionally, a physician's order dated 09/12/14 at 04:53 AM directed application of a body net for self injury. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 3:50 AM. The patient attempted to bite off the restraints and the restraint net was applied at 4:25 AM. Restraints were discontinued at 5:50 AM.

g. Patient #108 was admitted on 10/30/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #109 on 11/16/14 at 12:13 AM identified that, Patient #108 became agitated when redirected to his/her room following conflict with a peer, refused oral medications, threatened to harm staff and self and attempted to climb on shelving in an attempt to jump. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 11/15/14 at 5:50 PM directed application of a body net for self injury. Further review of the behavioral health progress note identified that both 4 point restraints and a restraint net were placed at 8:55 PM. Documentation failed to identify that an order for the 4 point restraint was obtained. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. Restraints were discontinued at 9:40 PM.

h. Patient #109 was admitted on 11/16/14 with a diagnosis of depressive disorder. Review of a behavioral health progress note documented by RN #110 on 11/21/14 at 10:26 AM identified that, Patient #109 was repeatedly using profanity, agitated, screaming, threatening self harm, refusing to stay in room when redirected, slamming doors, punching the wall, head banging, attempting to lock self in bathroom, and assaultive towards staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 11/20/14 at 8:58 PM directed application of 4 point restraints for violent behaviors including self injury. Review of the behavioral health progress note documented on 11/20/14 at 9:03 PM by MD #104 identified that that Patient #109 was placed in 4 point restraints with a net for safety. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 8:50 PM. Restraints were discontinued at 9:30 PM.

i. Patient #110 was admitted on 03/20/15 with a diagnosis of autism spectrum disorder. Review of a behavioral health progress note documented by RN #108 on 04/07/15 at 06:18 AM identified that, Patient #110 made sexual gestures towards an RN, physically assaulted a MHW, spit at staff, and yelled. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 04/06/15 at 11:46 PM directed application of 4 point restraints for violent behaviors including physical abuse to others. An additional physician's order at 11:49 PM directed to apply a body net for violent behaviors. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 11:45 PM. Following application, the patient attempted to remove the restraint, thrashed in the bed, and, yelled to be let out and the restraint net was subsequently applied at 11:50 PM. Restraints were discontinued at 12:10 AM.

j. Patient #111 was admitted on 06/05/15 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #101 on 06/11/15 at 05:01 PM identified that, Patient #110 reached over the desk and grabbed 2 telephones, refused to go to his/her room, attempted to punch and kick staff, refused oral medications, and was unable to regain control. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 06/11/15 at 11:21 AM directed application of 4 point restraints for violent behaviors including verbal aggression towards others. An additional physician's order at 11:23 AM directed application of a body net for violent behaviors including verbal aggression towards self or others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net and/or behaviors necessitating use per hospital policy. The 4 point restraints and restraint net were applied at 11:10 AM and discontinued at 11:30 AM.

Interview and review of application instructions and safety instructions for the 4 point leather restraints and the restraint net with a customer service representative for the manufacturer on 06/24/15 at 2:00 PM and 07/06/15 at 10:30 AM identified that, although the application instructions for the 4 point restraints identify that additional or different body or limb restraints may be needed to prevent the patient from flailing or bucking up and down and causing self injury, the restraint net was not designed or recommended for that purpose. According to the customer service representative, other safe, appropriate alternatives are available. Additionally, the restraint net was designed to be used as an alternative to 4 point restraint when used in accordance with application instructions and should not be used in addition to four point restraints. Safety is compromised when the restraints are not applied in accordance with manufacturer's recommendations.
Interview with Clinical Nurse Leader #1 on 06/24/15 at 1:30 PM identified that in 2009, it was a common practice to restrain a patient using both four point leather restraints and a restraint net, however, by 2012, the staff were instructed to use either the restraint net or 4 point restraint. Staff compliance was limited, and in 2013, Clinical Leader #1 was directed by the DNS to educate all staff on the correct application of each restraint. Staff training was conducted for all newly hired staff as well as annually for all staff. Clinical Leader #1 identified that although the staff has been trained in the proper application of each restraint, the staff on the adolescent unit continued to restrain with both the restraint net or 4 point restraint per physician's order.

Interview with restraint net manufacturer's representative on 06/24/15 at 2:00 PM identified that the restraint net was designed to be an alternative to other physical limb restraints and should not be used in combination with another physical restraint.


Despite the manufacturer instructions identifying that the restraint net was only for use with a hospital bed and that it was to be used as the least restrictive device, a hospital policy and procedure titled Physical Restraints and Seclusion identified that a full body restraint net can be used in conjunction with 4-point restraints.

General Statutes of Connecticut Sec. 46a-152-154. Physical restraints, identified in part, that restraints are not used as a substitute for less restrictive alternatives, used as necessary and appropriate as determined on an individual basis, documented in the medical record, monitoring and internal reporting of the use of physical restraint, and develop policies and procedures.

Based on review of clinical records, hospital policies and procedures, and interviews for three of ten patients (Patients #102, 105, and 108) who were restrained with a restraint net in combination with four point restraints, the hospital failed to ensure that the restraints were implemented in accordance with a physician's order and/or hospital policy. The findings include:

a. Patient #102 was admitted on 08/13/14 with diagnoses of mood disorder. Review of a behavioral health progress note documented by RN #107 on 08/23/15 at 1:23 PM identified that, Patient #102 had become agitated, threw things at the staff, threatened to kill the staff, hit the wall and glass emergency door with a chair, refused oral medications, and attempted to barricade him/herself in the bathroom and bite staff. A physician's order dated 08/23/14 at 11:45 AM directed application of 4 point restraints for violent behavior including injury to self. Review of an electronic restraint evaluation and a physician note dated 08/23/14 at 2:07 PM identified that both 4 point restraints and a restraint net were applied. Documentation failed to identify an order for the application of the restraint net. The restraints were applied at 11:35 AM and discontinued at 1:01 PM.

b. Patient #105 was admitted on 10/14/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #102 on 10/20/15 at 1:23 PM identified that, Patient #105 was verbally and physically threatening to staff, refused oral medications, hit his/her head on the wall, and threatened to strangle RN #102. A physician's order dated 10/20/14 at 10:23 AM directed application of 4 point restraints for violent behaviors including self injury. Review of the clinical record lacked documentation of a physician's order for the application of a restraint net, however, the behavioral health progress note and the electronic restraint flow sheet identified that a restraint net was applied as the patient began to thrash and scream after the application of the 4 point restraint. The 4 point restraints were applied at 10:20 AM followed by the restraint net. Restraints were discontinued at 11:30 AM.

c. Patient #108 was admitted on 10/30/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #109 on 11/16/14 at 12:13 AM identified that, Patient #108 became agitated when redirected to his/her room following conflict with a peer, refused oral medications, threatened to harm staff and self and climbed on shelving in an attempt to jump. A physician's order dated 11/15/14 at 5:50 PM directed application of a body net for self injury. Further review of the behavioral health progress note identified that both 4 point restraints and a restraint net were placed at 8:55 PM. Documentation failed to identify that an order for the 4 point restraint was obtained. Restraints were discontinued at 9:40 PM.

Interview with MD #102 on 7/23/15 at 1:30 PM identified that the physician orders the 4 point restraints, and if the patient fights the restraints, another order is written for the restraint net.

A hospital policy titled Physical Restraints and Seclusion identified, in part, obtaining orders for restraint: The use of a restraint must be in accordance with the order of a physician or other licensed independent practitioner (LIP) who is responsible for the care of the patient and must be obtained within one hour of applying the restraint.

Based on review of hospital policies and procedures, clinical record review, and interviews for two of ten patients (Patients #103 and #108) who were restrained with a restraint net in conjunction with four point restraints, the hospital failed to ensure that the patient was seen face-to-face within 1 hour after initiation of the restraints. The findings include:

a. Patient #103 was admitted on 08/26/14 with a diagnosis of psychosis. Review of a behavioral health progress note documented by RN #102 on 08/28/15 at 5:31 PM identified that, Patient #103 was disorganized, responding to internal stimuli, exhibiting intrusive behavior that was agitating peers, refusing oral medications, constantly changing TV channels, increasingly agitated when redirected by staff and refused to remain in his/her room. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 08/28/14 at 9:45 AM directed application of 4 point restraints for verbal aggression towards self and others. Additionally a physician's order at 10:45 AM directed to apply a body net for verbal aggression towards self and others. The behavioral health progress note further identified that, following application of the 4 point restraint, Patient #2 continued to thrash and bit the leather restraint off his/her arm necessitating the placement of a restraint net. The 4 point restraints were applied at 9:45 AM and the net restraint was applied at 10:14 AM. Restraints were discontinued at 11:34 AM. A Behavioral Health Progress note (face-to-face) was documented by MD #102 at 5:14 PM (7.5 hours later) and did not include the required elements of the patient's immediate situation, reaction to the intervention, medical and behavioral condition, and need to continue or terminate the restraint.

b. Patient #108 was admitted on 10/30/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #109 on 11/16/14 at 12:13 AM identified that, Patient #108 became agitated when redirected to his/her room following conflict with a peer, refused oral medications, threatened to harm staff and self and attempted to climb on shelving in an attempt to jump. A physician's order dated 11/15/14 at 8:50 PM directed application of a body net for self injury. Further review of the behavioral health progress note identified that both 4 point restraints and a restraint net were placed at 8:55 PM. Restraints were discontinued at 9:40 PM. The clinical record lacked documentation of a face-to-face evaluation by a physician and/or LIP within 1 hour of initiation of restraints.

Interview with MD #102 on 7/23/15 at 1:30 PM identified that the physician documents restraint related information in daily notes.

A hospital policy titled Physical Restraints and Seclusion: Violent or Self Destructive Behavior: identified if an emergency restraint is initiated the LIP must assess the patient face to face within 1 hour of the application of restraints and document.

Based on review of hospital policies and procedures, clinical record review, and interviews for eight of ten patients (Patients #101, 102, 104, 106, 108, 109, 110, and 111) who were restrained with a restraint net in conjunction with four point restraints, the hospital failed to ensure that the physician or LIP saw the patient face-to-face within 1 hour after initiation of the restraints to evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral condition, and need to continue or terminate the restraint. The findings include:

a. Patient #101 was admitted on 08/18/14 with diagnoses of mood disorder and ADHD. Review of a behavioral health progress note documented by RN #107 on 08/20/15 at 4:11 PM identified that, Patient #101 was agitated and oppositional, threw things at the staff, clenched his/her fists, refused to walk to the bedroom, and kicked 2 MHW's. A physician's order dated 08/20/14 at 1:50 PM directed application of 4 point restraints for verbal aggression towards self or others. An additional order at 1:51 PM directed application of a body net for verbal aggression towards self or others. The restraints were applied at 1:45 PM and discontinued at 2:45 PM. Although MD #102 evaluated the patient (face-to-face), a corresponding behavioral health progress note dated 08/20/14 at 1:59 PM lacked the 4 required elements.

b. Patient #102 was admitted on 08/13/14 with diagnoses of mood disorder. Review of a behavioral health progress note documented by RN #107 on 08/23/15 at 1:23 PM identified that, Patient #102 had become agitated, threw things at the staff, threatened to kill the staff, hit the wall and glass emergency door with a chair, refused oral medications, and attempted to barricade him/herself in the bathroom and bite staff. A physician's order dated 08/23/14 at 11:45 AM directed application of 4 point restraints for violent behavior including injury to self. Review of an electronic restraint evaluation and a physician note dated 08/23/14 at 2:07 PM identified that both 4 point restraints and a restraint net were applied. The restraints were applied at 11:35 AM and discontinued at 1:01 PM. Although MD #101 documented a behavioral health progress note on 08/23/14 at 3:16 PM, the evaluation lacked the 4 required elements.

c. Patient #103 was admitted on 08/26/14 with a diagnosis of psychosis. Review of a behavioral health progress note documented by RN #102 on 08/28/15 at 5:31 PM identified that, Patient #103 was disorganized, responding to internal stimuli, exhibiting intrusive behavior that was agitating peers, refusing oral medications, constantly changing TV channels, increasingly agitated when redirected by staff and refused to remain in his/her room. A physician's order dated 08/28/14 at 9:45 AM directed application of 4 point restraints for verbal aggression towards self and others. Additionally a physician's order at 10:45 AM directed to apply a body net for verbal aggression towards self and others. The behavioral health progress note further identified that, following application of the 4 point restraint, Patient #2 continued to thrash and bit the leather restraint off his/her arm necessitating the placement of a restraint net. The 4 point restraints were applied at 9:45 AM and the net restraint was applied at 10:14 AM. Restraints were discontinued at 11:34 AM. A Behavioral Health Progress note (face-to-face) was documented by MD #102 on 08/28/14 at 5:14 PM the evaluation lacked the 4 required elements.

d. Patient #104 was admitted on 10/07/14 with a diagnosis of bipolar disorder, most recent episode, manic. Review of a behavioral health progress note documented by RN #107 on 10/09/15 at 5:31 PM identified that, Patient #104 attempted to eat plaster, bang his/her head, refused oral medications, pulled a screw from the wall, and struck 3 staff members. A physician ' s order dated 10/09/14 at 11:43 AM directed application of 4 point restraints with restraint net for violent behaviors including physical abuse towards others. The 4 point restraints were applied at 11:25 AM and the restraint net was applied at 11:30 AM. Restraints were discontinued at 11:55 AM. A physician's progress note (face-to-face) documented by MD #102 at 11:52 AM failed to include an evaluation of the 4 required elements.

e. Patient #105 was admitted on 10/14/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #102 on 10/20/15 at 1:23 PM identified that, Patient #105 was verbally and physically threatening to staff, refused oral medications, hit his/her head on the wall, and threatened to strangle RN #102. A physician's order dated 10/20/14 at 10:23 AM directed application of 4 point restraints for violent behaviors including self injury. The 4 point restraints were applied at 10:20 AM followed by the restraint net. Restraints were discontinued at 11:30 AM. A behavioral health progress note (face-to-face) documented by MD #105 at 10:45 AM failed to include an evaluation of the 4 required elements.

f. Patient #106 was admitted on 9/08/14 with a diagnosis of bipolar disorder, type 2, most recent episode, depressed with psychotic features. Review of a behavioral health progress note documented by RN #108 on 09/12/15 at 08:15 AM identified that, Patient #106 was repeatedly scratching his/her sternum, physically aggressive, clenching fists, and attempting to hit staff. A physician's order dated 09/12/14 at 4:06 AM directed application of 4 point restraints for violent behaviors including self injury. Additionally, a physician's order dated 09/12/14 at 04:53 AM directed application of a body net for self injury. The 4 point restraints were applied at 3:50 AM. The patient attempted to bite off the restraints and the restraint net was applied at 4:25 AM. Restraints were discontinued at 5:50 AM. A physician's progress note (face-to-face) documented by MD #104 at 10:45 AM failed to include an evaluation of the 4 required elements.

g. Patient #108 was admitted on 10/30/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #109 on 11/16/14 at 12:13 AM identified that, Patient #108 became agitated when redirected to his/her room following conflict with a peer, refused oral medications, threatened to harm staff and self and attempted to climb on shelving in an attempt to jump. A physician's order dated 11/15/14 at 5:50 PM directed application of a body net for self injury. Further review of the behavioral health progress note identified that both 4 point restraints and a restraint net were placed at 8:55 PM. Restraints were discontinued at 9:40 PM. A physician's progress note (face-to-face) documented by MD #104 on 11/16/14 at 10:01 AM failed to include an evaluation of the 4 required elements.

h. Patient #109 was admitted on 11/16/14 with a diagnosis of depressive disorder. Review of a behavioral health progress note documented by RN #110 on 11/21/14 at 10:26 AM identified that, Patient #109 was repeatedly using profanity, agitated, screaming, threatening self harm, refusing to stay in room when redirected, slamming doors, punching the wall, head banging, attempting to lock self in bathroom, and assaultive towards staff. A physician's order dated 11/20/14 at 8:58 PM directed application of 4 point restraints for violent behaviors including self injury. Review of the behavioral health progress note documented on 11/20/14 at 9:03 PM by MD #104 identified that that Patient #109 was placed in 4 point restraints with a net for safety. The 4 point restraints were applied at 8:50 PM. Restraints were discontinued at 9:30 PM. A physician's progress note (face-to-face) documented by MD #104 at 9:03 PM failed to include an evaluation of the 4 required elements.

i. Patient #110 was admitted on 03/20/15 with a diagnosis of autism spectrum disorder. Review of a behavioral health progress note documented by RN #108 on 04/07/15 at 06:18 AM identified that, Patient #110 made sexual gestures towards an RN, physically assaulted a MHW, spit at staff, and yelled. An additional physician's order at 11:49 PM directed to apply a body net for violent behaviors. The 4 point restraints were applied at 11:45 PM. and the restraint net was subsequently applied at 11:50 PM. Restraints were discontinued at 12:10 AM. A physician's progress note (face-to-face) documented by MD #106 at 11:48 PM failed to include an evaluation of the 4 required elements.

j. Patient #111 was admitted on 06/05/15 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #101 on 06/11/15 at 05:01 PM identified that, Patient #110 reached over the desk and grabbed 2 telephones, refused to go to his/her room, attempted to punch and kick staff, refused oral medications, and was unable to regain control. A physician's order dated 06/11/15 at 11:21 AM directed application of 4 point restraints for violent behaviors including verbal aggression towards others. An additional physician's order at 11:23 AM directed application of a body net for violent behaviors including verbal aggression towards self or others. The 4 point restraints and restraint net were applied at 11:10 AM and discontinued at 11:30 AM. A physician's progress note (face-to-face) documented by MD #102 at 12:47 PM failed to include an evaluation of the 4 required elements.

Interview with MD #102 on 7/23/15 at 1:30 PM identified that the physician documents restraint related information in daily notes.

A hospital policy titled Physical Restraints and Seclusion: Violent or Self Destructive Behavior: identified if an emergency restraint is initiated the LIP must assess the patient face to face within 1 hour of the application of restraints and document: patient's immediate situation, reaction to the intervention, medical and behavioral condition, and need to continue or terminate the restraint.

Based on review of hospital policies and procedures, clinical record review, and interviews the hospital failed to ensure safe implementation of restraints for patients restrained with a restraint net or both a restraint net and 4 point restraints when staff continued to use both the restraint net and 4 point restraints together despite being instructed not to do so by the nurse educator. The findings include:

Review of hospital skills check lists dated multiple dates in November 2013 identified training in restraint usage for clinical staff that included indication for use, proper placement of restraints (including 4 point and restraint net), and documentation of restraints. Skills were observed and validated for 10 staff members. Restraint documentation refresher training was conducted for all RN's and MHW's in June of 2014. A Safety Fair was conducted on 07/14/14 that included a restraint refresher attended by 19 staff members. A mandatory skills review was conducted on multiple dates in November 2014 and included review of the restraint policy, oral competency for indications for restraints, and staff demonstration of application of restraints. Additionally, non-violent crisis intervention training was conducted in 2015 for RN's, MHW's, and Security, is ongoing and includes restraint usage.

Interview with Clinical Nurse Leader #1 on 06/24/15 at 1:30 PM identified that in 2009, it was a common practice to restrain a patient using both four point leather restraints and a restraint net, however, by 2012, the staff were instructed to use either 4 point restraints or a restraint net. Staff compliance was limited, and in 2013, Clinical Leader #1 was directed by the DNS to educate all staff on the correct application of each restraint. Staff training was conducted for all newly hired staff as well as annually for all staff. Clinical Leader #1 identified that although the staff had been trained in the proper application of each restraint, the staff on the adolescent unit continued to restrain patients with both 4 point leather restraints and a restraint net, per physician's order.

Interview with the chief of the Adolescent Unit, MD #102 on 06/25/15 at 11:00 AM identified that he/she understood that the least restrictive device necessary to maintain patient safety was to be utilized and assumed that the 4 point leather restraints were removed prior to the application of the restraint net and was unaware that the restraint net was being utilized in conjunction with four point restraints.

Interview with the Chief of Psychiatry on 06/24/15 at 1:20 PM identified that some patients remain dangerous in four point restraints alone and require an additional restraint. An additional interview on 6/25/15 indicated that he/she was not sure, but may have signed off on the policy indicating that both the restraint net and 4 point restraints could be used together. MD #103 indicated that the practice for the 4 point and net restraint application was present prior to MD #103's hire date in 2004.

Interview with the DNS on 06/25/15 at 1:10 PM identified that the staff was instructed to discontinue the practice of using two restraints, however, sometimes it was necessary to maintain patient safety and he/she concurred with the use despite the knowledge that the restraint net was not being attached to the bed in accordance with manufacturer's application instructions. The DNS further identified that the restraint net was utilized as a fifth point to secure a patient's upper body from twisting, turning, and sitting up, and to prevent removal of the leather restraint cuffs, and/or scratching themselves.

Interview with the nursing supervisor/unit manager of the adolescent unit, RN #106, on 06/24/15 at 1:20 PM, identified that staff on the adolescent unit require re-education and, currently, monitoring of compliance for safe application of restraints was random.

Interview with MHW #2 on 06/24/15 at 9:20 AM identified that he/she had worked on the child/adolescent unit for 14 years and received restraint training annually during a skills check. According to MHW #2 the restraint net is used in conjunction with the four point restraints as a last resort when patients in leather restraints continue to be agitated, sit up, wiggle their hand out of the restraint, bang their head, thrash, bite the restraint, spit, or bite themselves. The restraint net is applied to the side of the bed and tightened enough so that the patient is not able to sit up or thrash. Generally, the legs are left in the leather restraints and sometimes, the arms are left in the leather restraints also.

Interview with MHW #3, a Crisis Prevention Institute (CPI) trainer, on 06/24/15 at 10:45 AM, identified that during restraint training he/she discusses the need to use the restraint net in conjunction with four point restraints and demonstrates application including leaving the 4 point restrain in place, removal of the four point restraint, and removal of the upper extremity leather restraint and leaving the lower extremity leather restrain in place. According to MHW #3, it is rare that the restraint net is used alone.

Interview with RN #102 on 06/24/15 at 9:30 AM identified that he/she had worked on the adolescent unit for 4.5 years and had been trained in restraint usage during the annual skills check. According to RN #102, use of the restraint net in conjunction with the four point restraints was a last resort and, in general, the leather ankle restraints remain on wile the upper extremity leather restraints might be released and the upper extremities placed through the holes in the restraint net and placed in the Velcro restraints on the exterior of the net. Sometimes, all 4 leather restraints will remain in place.

Interview with MHW #1 on 06/25/15 at 11:25 AM identified that he/she had been working on the adolescent unit for 4 years and had been trained that the restraits were to be utilized separately. When an emergency occurrs where a restraint is ordered, prior to application, MWH #1 asks the nurse coordinating the code if there will be a single restraint or double restraint. When a double restraint is applied, sometimes four point restraints remain in place, sometimes the upper extremities are removed from the leather restraints, placed through the holes in the net and secured in the upper extremity restraints that are part of the net. In some situations, all 4 leather restraints are removed as the restraint net is applied. However, the end-strap of the restraint net can not be cinched up and we attempt to make the other straps as snug as possible.

Interview with RN #101 on 06/25/15 at 11:45 AM identified that he/she had worked on the child/adolescent unit for 3 years and had been trained in restraint application during a skills check where both restraint net and 4 point restraint were discussed but not demonstrated. According to RN #101, the staff was aware that the restaints are not to be used together however, the restraint net is being used inconjunction with the 4 point leather restraints. The patient's upper extremities are placed in the restraint net velcro restraints however, the ankles remain in the leather restraints as they are too difficult to attach to the net restraints.

Interview with RN #103 on 06/25/15 at 12:00 PM identified that he/she had worked on the child/adolescent unit for 4.5 years and had been trained in restraint application by a nurse educator upon hire with a demonstration and return demontration but was unable to recall if application of the restraint net was included. The decision to place the secondary restraint net is based upon patient behavior while in 4 point restraints including struggling, sitting up, biting, trhashing. the use of the net is an attempt to restiricy the patient's movement. The clinical team and the physician make the decision. According to RN #103, the leather restraints remain in place when the net is placed and the net arm and leg retraints are not used except in the 2 most recent episodes (Patient #110 and #111). RN #103 did not recall being instructed that only one restraint was to be used at a time. Review of the most recent restraint episode of Patient #111, RN #103 identified that following assessment, multiple interventions, and administration of IM medications, Patient #111 was placed in 4 point restraint and further attempts were made to verbally de-escalate the patient but he/she continued to scream and the net was placed, however, the upper extremities were removed from the leather restrints and placed in the velcro net restraints. Attempts to place the lower extremities in the restraint net velcro ankle restraints were unsuccessful, so the lower extremities remained in the leather restraints.

Interview and demonstration of application of the restraint net with RN #106, MHW #1, Clinical Nurse Leader #1, and the DNS on 06/29/15 at 10:30 AM identified that when the restrain net was placed in conjunction with 4 point restraints, the net was placed over the patient and as each strap is affixed to the side of the bed, the corresponding extremity is released from the leather restrint and placed in the appropriate velcro restraint on the restraint net. The restraint net is used as a fifth point of restraint to stabilize the upper body and the lower extremities are frequently left in the leather restraints an estimated 99% of the time. The 5 straps are secured in the five slots on each side of the bed unless the bed has 4 slots, in which case, the lower two straps are secured in the lowest slot on each side of the bed. The end strap is not used as there is no slot and/or bracket on the end of any of the beds. The restraint net is not used as an exclusive restraint as the patient's lower extremities present a danger to patient and staff safety. The physician's and RN's collaborate to assess the need for a double restraint. Clinical Nurse Leader #1 identifed that he/she had been trained not to use the restraint net in conjunction with the 4 point restraints and trained the staff on how to use each restraint separately. MHW #1 and RN #106 identified that they were trained to use the restraints separately. The DNS identified that, although he/she had not been trained to use the restraints together, the practice evolved due to the difficulties managing extremely violent behaviors. The DNS identified that although all restraint episodes were discussed and evaluated during debriefing sessions and, with the Chair of the Department of Psychiatry, MD #103, during regular restaint review meetings, the use of the restraint net in conjunction with the 4 point leather restraits was discussed outside of these meetings and a consensus could not be reached.

Interview with the unit manager of the adult, detox and dual diagnosis unit RN #104 on 06/24/15 at 10:25 AM identified that the restraint net did not need to be used on the adult unit as the combination of medications and encouragement was usually effective in maintaining patient safety.

Interview with restraint net manufacturer's representative on 06/24/15 at 2:00 PM identified that the restraint net was designed to be an alternative to other physical limb restraints and should not be used in combination with another physical restraint.


Despite the manufacturer instructions identifying that the restraint net was only for use with a hospital bed and that it was to be used as the least restrictive device, a hospital policy and procedure titled Physical Restraints and Seclusion identified that a full body restraint net can be used in conjunction with 4-point restraints.

Based on review of clinical records, review of hospital policies, review of hospital documentation and interviews with hospital personnel for 10 of 10 adolescent psychiatric patients with 4 point/net restraint application, the hospital failed to ensure a continuous, ongoing program for quality improvement and patient safety for restraints. The findings include:
Review of the hospital's Performance Improvement Plan indicated for Restraint Use: Use of restraints shall be measured according to the requirements set forth by regulatory requirements or the Center for Medicare and Medicaid Services. Review of the hospital restraint log (FY 2014-2015) identified that 10 of 10 adolescent psychiatric patients were restrained for aggressive/combative behavior that included 4 point restraints and the full body restraint net applied together at the same time. Review of the Rights and Responsibilities of Patient and Medical Center Staff identified in part, that restraint or seclusion must be carried out in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with Connecticut law. Review of the hospital's Physical Restraint and Seclusion Policy (revised and approved March 20, 2014) indicated that Full Body Restraint/Net can be used in conjunction with 4-point restraint when there is considerable struggling and there is need to further secure the patient.

Interview with the Psychiatry Chairman, MD #103 on 6/25/15 indicated that he/she was not sure, but may have signed off on the policy. MD #103 indicated that the practice for the 4 point/net restraint application was present prior to MD #103's hire date in 2004.

Review of hospital documentation and interview with the Quality and Patient Safety Director on 6/25/15 identified that the restraint rate was monitored and had declined from 2012 to present. However, the types of restraints that included the 4 point/net restraints had not been and were not monitored. Review of the Behavioral Quality Council documentation identified minutes for 2014-2015, but failed to reflect minutes for 2013-2014.

Interview with the Behavioral Health VP, MD #103 and the Quality and Patient Safety Director indicated that the Behavioral Health Quality Manager was transferred to the hospital's Quality Department in 2013 and had not been replaced until 2014. Documentation and interviews failed to reflect that the 4 point and net restraint usage for the adolescent psychiatric patient population was monitored in the hospital's performance improvement plan.

Based on review of hospital policies, procedures and documentation, clinical record review, and interviews, the department of in-patient psychiatry's medical staff failed to ensure accountability to the governing body for the quality of care provided to patients when it was known that physician's on the adolescent psychiatric unit were ordering to restraint patients with a restraint net or both a restraint net and 4 point restraints despite staff being instructed not to use both restraints at the same time, and failed to ensure that the restraint net was used in accordance with manufacturer's recommendations. The findings include:

Review of the hospital's physical restraint record (compilation of restraint episodes) between August 2014 and June 2015 identified that Patient's #101-111 had a total of twelve restraint episodes where 4 point leather restraints were used in conjunction with a restraint net. All restraint episodes involving the use of a restraint net occurred on the child/adolescent behavioral health unit. Observations on 06/23/15 at 11:30 AM, 6/25/15 and 6/29/15 identified that all patient beds were wood platform beds and not standard hospital type beds as directed in the manufacturer instructions for the use of restraint nets.

a. Patient #101 was admitted on 08/18/14 with diagnoses of mood disorder and ADHD. Review of a behavioral health progress note documented by RN #107 on 08/20/15 at 4:11 PM identified that Patient #101 was agitated and oppositional, threw things at the staff, clenched his/her fists, refused to walk to the bedroom, and kicked 2 Mental Health Workers (MHW's). Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg and Benadryl 25 mg intramuscularly (IM). A physician's order dated 08/20/14 at 1:50 PM directed application of 4 point restraints for verbal aggression towards self or others. An additional order at 1:51 PM directed application of a body net for verbal aggression towards self or others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation for behaviors necessitating the second restraint net and or less restrictive interventions attempted per hospital policy. The restraints were applied at 1:45 PM and discontinued at 2:45 PM.

b. Patient #102 was admitted on 08/13/14 with diagnoses of mood disorder. Review of a behavioral health progress note documented by RN #107 on 08/23/15 at 1:23 PM identified that, Patient #102 had become agitated, threw things at the staff, threatened to kill the staff, hit the wall and glass emergency door with a chair, refused oral medications, and attempted to barricade him/herself in the bathroom and bite staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg and Benadryl 25 mg, IM. A physician's order dated 08/23/14 at 11:45 AM directed application of 4 point restraints for violent behavior including injury to self. Review of an electronic restraint evaluation and a physician note dated 08/23/14 at 2:07 PM identified that both 4 point restraints and a restraint net were applied. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation for behaviors necessitating the secondary restraint net and/or less restrictive interventions attempted per hospital policy. The restraints were applied at 11:35 AM and discontinued at 1:01 PM.

c. Patient #103 was admitted on 08/26/14 with a diagnosis of psychosis. Review of a behavioral health progress note documented by RN #102 on 08/28/15 at 5:31 PM identified that, Patient #103 was disorganized, responding to internal stimuli, exhibiting intrusive behavior that was agitating peers, refusing oral medications, constantly changing TV channels, increasingly agitated when redirected by staff and refused to remain in his/her room. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg IM. A physician's order dated 08/28/14 at 9:45 AM directed application of 4 point restraints for verbal aggression towards self and others. Additionally a physician's order at 10:45 AM directed to apply a body net for verbal aggression towards self and others. The behavioral health progress note further identified that, following application of the 4 point restraint, Patient #2 continued to thrash and bit the leather restraint off his/her arm necessitating the placement of restraint net. An additional 25 mg of Thorazine and 1 mg of Ativan were administered. The patient remained agitated, screaming, crying, thrashing, and constantly tried to get out of both restraints. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 9:45 AM and the net restraint was applied at 10:14 AM. Restraints were discontinued at 11:34 AM.

d. Patient #104 was admitted on 10/07/14 with a diagnosis of bipolar disorder, most recent episode, manic. Review of a behavioral health progress note documented by RN #107 on 10/09/15 at 5:31 PM identified that, Patient #104 attempted to eat plaster, bang his/her head, refused oral medications, pulled a screw from the wall, and struck 3 staff members. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Ativan 1 mg and Benadryl 25 mg IM. A physician's order dated 10/09/14 at 11:43 AM directed application of 4 point restraints with restraint net for violent behaviors including physical abuse towards others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 11:25 AM. Patient #104 began thrashing and screaming that he/she wanted to die and the restraint net was applied at 11:30 AM. Restraints were discontinued at 11:55 AM.

e. Patient #105 was admitted on 10/14/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #102 on 10/20/15 at 1:23 PM identified that, Patient #105 was verbally and physically threatening to staff, refused oral medications, hit his/her head on the wall, and threatened to strangle RN #102. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg IM. A physician's order dated 10/20/14 at 10:23 AM directed application of 4 point restraints for violent behaviors including self injury. Review of the clinical record lacked documentation of a physician's order for the application of a restraint net, however, the behavioral health progress note and the electronic restraint flow sheet identified that a restraint net was applied as the patient began to thrash and scream after the application of the 4 point restraint. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 10:20 AM followed by the restraint net. Restraints were discontinued at 11:30 AM.

f. Patient #106 was admitted on 9/08/14 with a diagnosis of bipolar disorder, type 2, most recent episode, depressed with psychotic features. Review of a behavioral health progress note documented by RN #108 on 09/12

Based on review of clinical records, hospital physical restraint log, hospital policies and procedures, and interviews for ten of ten adolescent patients who were placed in a restraint net in conjunction with four point leather restraints, Patients #101, 102, 103, 104, 105, 106, 108, 109, 110, and 111, the hospital failed to document that patients were assessed for less restrictive alternatives prior to placing a second eleven point restraint net on the patient. The findings include:

Review of clinical records for Patients #101, 102, 103, 104, 105, 106, 108, 109, 110, and 111 identified that each patient exhibited ongoing aggressive, self-injurious, and/or dangerous behaviors despite assessment and implementation of multiple less restrictive interventions resulting in the need for four point physical restraints. Following placement of the 4 point restraints, the patients exhibited behaviors that included slipping out of the restraint, sitting up, twisting, biting themselves, and or scratching themselves on the restraint and staff applied a restraint net in conjunction with the four point restraint creating a total of 13 to 15 point restraints on the patients.

a. Patient #101 was admitted on 08/18/14 with diagnoses of mood disorder and ADHD. Review of a behavioral health progress note documented by RN #107 on 08/20/15 at 4:11 PM identified that Patient #101 was agitated and oppositional, threw things at the staff, clenched his/her fists, refused to walk to the bedroom, and kicked 2 Mental Health Workers (MHW's). Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg and Benadryl 25 mg intramuscularly (IM). A physician's order dated 08/20/14 at 1:50 PM directed application of 4 point restraints for verbal aggression towards self or others. An additional order at 1:51 PM directed application of a body net for verbal aggression towards self or others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation for behaviors necessitating the second restraint net and or less restrictive interventions attempted per hospital policy. The restraints were applied at 1:45 PM and discontinued at 2:45 PM.

b. Patient #102 was admitted on 08/13/14 with diagnoses of mood disorder. Review of a behavioral health progress note documented by RN #107 on 08/23/15 at 1:23 PM identified that, Patient #102 had become agitated, threw things at the staff, threatened to kill the staff, hit the wall and glass emergency door with a chair, refused oral medications, and attempted to barricade him/herself in the bathroom and bite staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg and Benadryl 25 mg, IM. A physician's order dated 08/23/14 at 11:45 AM directed application of 4 point restraints for violent behavior including injury to self. Review of an electronic restraint evaluation and a physician note dated 08/23/14 at 2:07 PM identified that both 4 point restraints and a restraint net were applied. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation for behaviors necessitating the secondary restraint net and/or less restrictive interventions attempted per hospital policy. The restraints were applied at 11:35 AM and discontinued at 1:01 PM.

c. Patient #103 was admitted on 08/26/14 with a diagnosis of psychosis. Review of a behavioral health progress note documented by RN #102 on 08/28/15 at 5:31 PM identified that, Patient #103 was disorganized, responding to internal stimuli, exhibiting intrusive behavior that was agitating peers, refusing oral medications, constantly changing TV channels, increasingly agitated when redirected by staff and refused to remain in his/her room. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg IM. A physician's order dated 08/28/14 at 9:45 AM directed application of 4 point restraints for verbal aggression towards self and others. Additionally a physician's order at 10:45 AM directed to apply a body net for verbal aggression towards self and others. The behavioral health progress note further identified that, following application of the 4 point restraint, Patient #2 continued to thrash and bit the leather restraint off his/her arm necessitating the placement of restraint net. An additional 25 mg of Thorazine and 1 mg of Ativan were administered. The patient remained agitated, screaming, crying, thrashing, and constantly tried to get out of both restraints. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 9:45 AM and the net restraint was applied at 10:14 AM. Restraints were discontinued at 11:34 AM.

d. Patient #104 was admitted on 10/07/14 with a diagnosis of bipolar disorder, most recent episode, manic. Review of a behavioral health progress note documented by RN #107 on 10/09/15 at 5:31 PM identified that, Patient #104 attempted to eat plaster, bang his/her head, refused oral medications, pulled a screw from the wall, and struck 3 staff members. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Ativan 1 mg and Benadryl 25 mg IM. A physician's order dated 10/09/14 at 11:43 AM directed application of 4 point restraints with restraint net for violent behaviors including physical abuse towards others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 11:25 AM. Patient #104 began thrashing and screaming that he/she wanted to die and the restraint net was applied at 11:30 AM. Restraints were discontinued at 11:55 AM.

e. Patient #105 was admitted on 10/14/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #102 on 10/20/15 at 1:23 PM identified that, Patient #105 was verbally and physically threatening to staff, refused oral medications, hit his/her head on the wall, and threatened to strangle RN #102. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior including administration of Thorazine 50 mg IM. A physician's order dated 10/20/14 at 10:23 AM directed application of 4 point restraints for violent behaviors including self injury. Review of the clinical record lacked documentation of a physician's order for the application of a restraint net, however, the behavioral health progress note and the electronic restraint flow sheet identified that a restraint net was applied as the patient began to thrash and scream after the application of the 4 point restraint. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 10:20 AM followed by the restraint net. Restraints were discontinued at 11:30 AM.

f. Patient #106 was admitted on 9/08/14 with a diagnosis of bipolar disorder, type 2, most recent episode, depressed with psychotic features. Review of a behavioral health progress note documented by RN #108 on 09/12/15 at 08:15 AM identified that, Patient #106 was repeatedly scratching his/her stern

Based on observation, review of clinical records, hospital policies and procedures, and interviews for ten of ten patients (Patients #101, 102, 103, 104, 105, 106, 108, 109, 110, and 111) restrained with a restraint net, the hospital failed to ensure that the least restrictive intervention was utilized to protect the patient from harm. The findings include:

a. Patient #101 was admitted on 08/18/14 with diagnoses of mood disorder and ADHD. Review of a behavioral health progress note documented by RN #107 on 08/20/15 at 4:11 PM identified that, Patient #101 was agitated and oppositional, threw things at the staff, clenched his/her fists, refused to walk to the bedroom, and kicked 2 MHW's. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 08/20/14 at 1:50 PM directed application of 4 point restraints for verbal aggression towards self or others. An additional order at 1:51 PM directed application of a body net for verbal aggression towards self or others. The clinical record lacked documentation for behaviors necessitating the secondary net restraint and or less restrictive interventions attempted per hospital policy.

b. Patient #102 was admitted on 08/13/14 with diagnoses of mood disorder. Review of a behavioral health progress note documented by RN #107 on 08/23/15 at 1:23 PM identified that, Patient #102 had become agitated, threw things at the staff, threatened to kill the staff, hit the wall and glass emergency door with a chair, refused oral medications, and attempted to barricade him/herself in the bathroom and bite staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 08/23/14 at 11:45 AM directed application of 4 point restraints for violent behavior including injury to self. Review of an electronic restraint evaluation and a physician note dated 08/23/14 at 2:07 PM identified that both 4 point restraints and a restraint net were applied. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation for behaviors necessitating the secondary net restraint and/or less restrictive interventions attempted per hospital policy.

c. Patient #103 was admitted on 08/26/14 with a diagnosis of psychosis. Review of a behavioral health progress note documented by RN #102 on 08/28/15 at 5:31 PM identified that, Patient #103 was disorganized, responding to internal stimuli, exhibiting intrusive behavior that was agitating peers, refusing oral medications, constantly changing TV channels, increasingly agitated when redirected by staff and refused to remain in his/her room. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 08/28/14 at 9:45 AM directed application of 4 point restraints for verbal aggression towards self and others. Additionally a physician's order at 10:45 AM directed to apply a body net for verbal aggression towards self and others. The behavioral health progress note further identified that, following application of the 4 point restraint, Patient #2 continued to thrash and bit the leather restraint off his/her arm necessitating the placement of restraint net. The patient remained agitated, screaming, crying, thrashing, and constantly tried to get out of both restraints. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 9:45 AM and the net restraint was applied at 10:14 AM.

d. Patient #104 was admitted on 10/07/14 with a diagnosis of bipolar disorder, most recent episode, manic. Review of a behavioral health progress note documented by RN #107 on 10/09/15 at 5:31 PM identified that, Patient #104 attempted to eat plaster, bang his/her head, refused oral medications, pulled a screw from the wall, and struck 3 staff members. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 10/09/14 at 11:43 AM directed application of 4 point restraints with restraint net for violent behaviors including physical abuse towards others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 11:25 AM. Patient #104 began thrashing and screaming that he/she wanted to die and the restraint net was applied at 11:30 AM.

e. Patient #105 was admitted on 10/14/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #102 on 10/20/15 at 1:23 PM identified that, Patient #105 was verbally and physically threatening to staff, refused oral medications, hit his/her head on the wall, and threatened to strangle RN #102. Multiple, documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 10/20/14 at 10:23 AM directed application of 4 point restraints for violent behaviors including self injury. Review of the clinical record lacked documentation of a physician's order for the application of a restraint net, however, the behavioral health progress note and the electronic restraint flow sheet identified that a restraint net was applied as the patient began to thrash and scream after the application of the 4 point restraint. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 10:20 AM followed by the restraint net.

f. Patient #106 was admitted on 9/08/14 with a diagnosis of bipolar disorder. Review of a behavioral health progress note documented by RN #108 on 09/12/15 at 08:15 AM identified that, Patient #106 was repeatedly scratching his/her sternum, physically aggressive, clenching fists, and attempting to hit staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 09/12/14 at 4:06 AM directed application of 4 point restraints for violent behaviors including self injury. Additionally, a physician's order dated 09/12/14 at 04:53 AM directed application of a body net for self injury. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 3:50 AM. The patient attempted to bite off the restraints and the restraint net was applied at 4:25 AM.

g. Patient #108 was admitted on 10/30/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #109 on 11/16/14 at 12:13 AM identified that, Patient #108 became agitated when redirected to his/her room following conflict with a peer, refused oral medications, threatened to harm staff and self and attempted to climb on shelving in an attempt to jump. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 11/15/14 at 5:50 PM directed application of a body net for self injury. Further review of the behavioral health progress note identified that both 4 point restraints and a restraint net were placed at 8:55 PM. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the appli

Based on review of clinical records, hospital policies and procedures, and interviews for eleven of eleven patients (Patients #101, 102, 103, 104, 105, 106, 108, 109, 110, and 111) who were restrained with a restraint net and/or four point restraints, the hospital failed to ensure that the use of restraint was in accordance with a written modification to the patient's plan of care. The findings include:

a. Patient #101 was admitted on 08/18/14 with diagnoses of mood disorder and ADHD. A physician's order dated 08/20/14 at 1:50 PM directed application of 4 point restraints for verbal aggression towards self or others. An additional order at 1:51 PM directed application of a body net for verbal aggression towards self or others. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans failed to ensure that the plan of care was updated to included the restraint episodes.

b. Patient #102 was admitted on 08/13/14 with diagnoses of mood disorder. A physician's order dated 08/23/14 at 11:45 AM directed application of 4 point restraints for violent behavior including injury to self. Review of an electronic restraint evaluation and a physician note dated 08/23/14 at 2:07 PM identified that both 4 point restraints and a restraint net were applied. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

c. Patient #103 was admitted on 08/26/14 with a diagnosis of psychosis. A physician's order dated 08/28/14 at 9:45 AM directed application of 4 point restraints for verbal aggression towards self and others. Additionally a physician ' s order at 10:45 AM directed to apply a body net for verbal aggression towards self and others. The behavioral health progress note further identified that, following application of the 4 point restraint, Patient #2 continued to thrash and bit the leather restraint off his/her arm necessitating the placement of restraint net. The patient remained agitated, screaming, crying, thrashing, and constantly tried to get out of both restraints. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

d. Patient #104 was admitted on 10/07/14 with a diagnosis of bipolar disorder. A physician's order dated 10/09/14 at 11:43 AM directed application of 4 point restraints with restraint net for violent behaviors including physical abuse towards others. The 4 point restraints were applied at 11:25 AM. Patient #104 began thrashing and screaming that he/she wanted to die and the restraint net was applied at 11:30 AM. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

e. Patient #105 was admitted on 10/14/14 with a diagnosis of mood disorder. A physician's order dated 10/20/14 at 10:23 AM directed application of 4 point restraints for violent behaviors including self injury. Review of the clinical record lacked documentation of a physician's order for the application of a restraint net, however, the behavioral health progress note and the electronic restraint flow sheet identified that a restraint net was applied as the patient began to thrash and scream after the application of the 4 point restraint. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

f. Patient #106 was admitted on 9/08/14 with a diagnosis of bipolar disorder. A physician's order dated 09/12/14 at 4:06 AM directed application of 4 point restraints for violent behaviors including self injury. Additionally, a physician's order dated 09/12/14 at 04:53 AM directed application of a body net for self injury. The 4 point restraints were applied at 3:50 AM. The patient attempted to bite off the restraints and the restraint net was applied at 4:25 AM. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

g. Patient #108 was admitted on 10/30/14 with a diagnosis of mood disorder. A physician's order dated 11/15/14 at 5:50 PM directed application of a body net for self injury. Further review of the behavioral health progress note identified that both 4 point restraints and a restraint net were placed at 8:55 PM. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

h. Patient #109 was admitted on 11/16/14 with a diagnosis of depressive disorder. A physician's order dated 11/20/14 at 8:58 PM directed application of 4 point restraints for violent behaviors including self injury. Review of the behavioral health progress note documented on 11/20/14 at 9:03 PM by MD #104 identified that that Patient #109 was placed in 4 point restraints with a net for safety. The 4 point restraints were applied at 8:50 PM and discontinued at 9:30 PM. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

i. Patient #110 was admitted on 03/20/15 with a diagnosis of autism spectrum disorder. A physician's order dated 04/06/15 at 11:46 PM directed application of 4 point restraints for violent behaviors including physical abuse to others. An additional physician's order at 11:49 PM directed to apply a body net for violent behaviors. The 4 point restraints were applied at 11:45 PM. Following application, the patient attempted to remove the restraint, thrashed in the bed, and, yelled to be let out and the restraint net was subsequently applied at 11:50 PM. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

j. Patient #111 was admitted on 06/05/15 with a diagnosis of mood disorder. A physician's order dated 06/11/15 at 11:21 AM directed application of 4 point restraints for violent behaviors including verbal aggression towards others. An additional physician's order at 11:23 AM directed application of a body net for violent behaviors including verbal aggression towards self or others. The 4 point restraints and restraint net were applied at 11:10 AM and discontinued at 11:30 AM. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

k. Patient #108 was admitted on 10/19/14 with a diagnosis of ADHD, impulsive type. A behavioral health progress note documented by RN #110 on 11/04/14 at 7:55 PM identified that the patient became agitated, spiting at staff, kicking walls, threatening to punch staff, and throwing chairs. A physician's order dated 11/03/14 at 7:10 PM directed application of 4 point restraint for violent behavior as evidenced by physical abuse to others. The restraint was applied at 6:55 PM and discontinued at 7:55 PM. Review of the clinical record including MD treatment plans, master treatment plans, problem lists, and nursing care plans lacked documentation of the assessments, interventions, and evaluation of the restraint episode.

Interview with the manager of the adolescent unit, RN #106 on 06/24/15 at 10:00 AM identified that each restraint episode was reviewed by the interdisciplinary team and a debriefing was conducted. And that a care plan revisi

Based on observation, review of clinical records, hospital policies and procedures, and interviews for ten of ten patients (Patients #101, 102, 103, 104, 105, 106, 108, 109, 110, and 111, ) who were restrained with a restraint net in conjunction with four point restraints, the hospital failed to ensure that the use of a combination of restraints reflected the least restrictive intervention to maintain safety and/or that the restraints were utilized in accordance with manufacturer's recommendations. The findings include:

Review of clinical records for Patients #101, 102, 103, 104, 105, 106, 108, 109, 110, and 111 identified that each patient exhibited ongoing aggressive, self-injurious, and/or dangerous behaviors despite assessment and implementation of multiple less restrictive interventions resulting in the need for four point physical restraints. Following placement of the 4 point restraint, the patients exhibited behaviors that included slipping out of the restraint, sitting up, twisting, biting themselves, and or scratching themselves on the restraint and a restraint net was applied in conjunction with the four point restraint.

a. Patient #101 was admitted on 08/18/14 with diagnoses of mood disorder and ADHD. Review of a behavioral health progress note documented by RN #107 on 08/20/15 at 4:11 PM identified that, Patient #101 was agitated and oppositional, threw things at the staff, clenched his/her fists, refused to walk to the bedroom, and kicked 2 MHW's. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 08/20/14 at 1:50 PM directed application of 4 point restraints for verbal aggression towards self or others. An additional order at 1:51 PM directed application of a body net for verbal aggression towards self or others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation for behaviors necessitating the secondary net restraint and or less restrictive interventions attempted per hospital policy. The restraints were applied at 1:45 PM and discontinued at 2:45 PM.

b. Patient #102 was admitted on 08/13/14 with diagnoses of mood disorder. Review of a behavioral health progress note documented by RN #107 on 08/23/15 at 1:23 PM identified that, Patient #102 had become agitated, threw things at the staff, threatened to kill the staff, hit the wall and glass emergency door with a chair, refused oral medications, and attempted to barricade him/herself in the bathroom and bite staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 08/23/14 at 11:45 AM directed application of 4 point restraints for violent behavior including injury to self. Review of an electronic restraint evaluation and a physician note dated 08/23/14 at 2:07 PM identified that both 4 point restraints and a restraint net were applied. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation for behaviors necessitating the secondary net restraint and/or less restrictive interventions attempted per hospital policy. The restraints were applied at 11:35 AM and discontinued at 1:01 PM.

c. Patient #103 was admitted on 08/26/14 with a diagnosis of psychosis. Review of a behavioral health progress note documented by RN #102 on 08/28/15 at 5:31 PM identified that, Patient #103 was disorganized, responding to internal stimuli, exhibiting intrusive behavior that was agitating peers, refusing oral medications, constantly changing TV channels, increasingly agitated when redirected by staff and refused to remain in his/her room. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 08/28/14 at 9:45 AM directed application of 4 point restraints for verbal aggression towards self and others. Additionally, a physician's order at 10:45 AM directed to apply a body net for verbal aggression towards self and others. The behavioral health progress note further identified that, following application of the 4 point restraint, Patient #2 continued to thrash and bit the leather restraint off his/her arm necessitating the placement of restraint net. The patient remained agitated, screaming, crying, thrashing, and constantly tried to get out of both restraints. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 9:45 AM and the net restraint was applied at 10:14 AM. Restraints were discontinued at 11:34 AM.

d. Patient #104 was admitted on 10/07/14 with a diagnosis of bipolar disorder, most recent episode, manic. Review of a behavioral health progress note documented by RN #107 on 10/09/15 at 5:31 PM identified that, Patient #104 attempted to eat plaster, bang his/her head, refused oral medications, pulled a screw from the wall, and struck 3 staff members. Multiple documented interventions were unsuccessful at de-escalating the patient ' s behavior. A physician's order dated 10/09/14 at 11:43 AM directed application of 4 point restraints with restraint net for violent behaviors including physical abuse towards others. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 11:25 AM. Patient #104 began thrashing and screaming that he/she wanted to die and the restraint net was applied at 11:30 AM. Restraints were discontinued at 11:55 AM.

e. Patient #105 was admitted on 10/14/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #102 on 10/20/15 at 1:23 PM identified that, Patient #105 was verbally and physically threatening to staff, refused oral medications, hit his/her head on the wall, and threatened to strangle RN #102. Multiple, documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 10/20/14 at 10:23 AM directed application of 4 point restraints for violent behaviors including self injury. Review of the clinical record lacked documentation of a physician ' s order for the application of a restraint net, however, the behavioral health progress note and the electronic restraint flow sheet identified that a restraint net was applied as the patient began to thrash and scream after the application of the 4 point restraint. Documentation failed to identify that the order for the 4 point restraint was discontinued prior to the application of the restraint net. Additionally, the clinical record lacked documentation of less restrictive interventions attempted prior to the application of the restraint net per hospital policy. The 4 point restraints were applied at 10:20 AM followed by the restraint net. Restraints were discontinued at 11:30 AM.

f. Patient #106 was admitted on 9/08/14 with a diagnosis of bipolar disorder, type 2, most recent episode, depressed with psychotic features. Review of a behavioral health progress note documented by RN #108 on 09/12/15 at 08:15 AM identified that, Patient #106 was repeatedly scratching his/her sternum, physically aggressive, clenching fists, and attempting to hit staff. Multiple documented interventions were unsuccessful at de-escalating the patient's behavior. A physician's order dated 09/12/14 at 4:06 AM directed application of 4 point restraints for violent behaviors including self injury. Additionally, a physician's order dated 09/12/14 at 04:53 AM directed application of a body net for self injury. Documentati

Based on review of hospital policies and procedures, clinical record review, and interviews for eight of ten patients (Patients #101, 102, 104, 106, 108, 109, 110, and 111) who were restrained with a restraint net in conjunction with four point restraints, the hospital failed to ensure that the physician or LIP saw the patient face-to-face within 1 hour after initiation of the restraints to evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral condition, and need to continue or terminate the restraint. The findings include:

a. Patient #101 was admitted on 08/18/14 with diagnoses of mood disorder and ADHD. Review of a behavioral health progress note documented by RN #107 on 08/20/15 at 4:11 PM identified that, Patient #101 was agitated and oppositional, threw things at the staff, clenched his/her fists, refused to walk to the bedroom, and kicked 2 MHW's. A physician's order dated 08/20/14 at 1:50 PM directed application of 4 point restraints for verbal aggression towards self or others. An additional order at 1:51 PM directed application of a body net for verbal aggression towards self or others. The restraints were applied at 1:45 PM and discontinued at 2:45 PM. Although MD #102 evaluated the patient (face-to-face), a corresponding behavioral health progress note dated 08/20/14 at 1:59 PM lacked the 4 required elements.

b. Patient #102 was admitted on 08/13/14 with diagnoses of mood disorder. Review of a behavioral health progress note documented by RN #107 on 08/23/15 at 1:23 PM identified that, Patient #102 had become agitated, threw things at the staff, threatened to kill the staff, hit the wall and glass emergency door with a chair, refused oral medications, and attempted to barricade him/herself in the bathroom and bite staff. A physician's order dated 08/23/14 at 11:45 AM directed application of 4 point restraints for violent behavior including injury to self. Review of an electronic restraint evaluation and a physician note dated 08/23/14 at 2:07 PM identified that both 4 point restraints and a restraint net were applied. The restraints were applied at 11:35 AM and discontinued at 1:01 PM. Although MD #101 documented a behavioral health progress note on 08/23/14 at 3:16 PM, the evaluation lacked the 4 required elements.

c. Patient #103 was admitted on 08/26/14 with a diagnosis of psychosis. Review of a behavioral health progress note documented by RN #102 on 08/28/15 at 5:31 PM identified that, Patient #103 was disorganized, responding to internal stimuli, exhibiting intrusive behavior that was agitating peers, refusing oral medications, constantly changing TV channels, increasingly agitated when redirected by staff and refused to remain in his/her room. A physician's order dated 08/28/14 at 9:45 AM directed application of 4 point restraints for verbal aggression towards self and others. Additionally a physician's order at 10:45 AM directed to apply a body net for verbal aggression towards self and others. The behavioral health progress note further identified that, following application of the 4 point restraint, Patient #2 continued to thrash and bit the leather restraint off his/her arm necessitating the placement of a restraint net. The 4 point restraints were applied at 9:45 AM and the net restraint was applied at 10:14 AM. Restraints were discontinued at 11:34 AM. A Behavioral Health Progress note (face-to-face) was documented by MD #102 on 08/28/14 at 5:14 PM the evaluation lacked the 4 required elements.

d. Patient #104 was admitted on 10/07/14 with a diagnosis of bipolar disorder, most recent episode, manic. Review of a behavioral health progress note documented by RN #107 on 10/09/15 at 5:31 PM identified that, Patient #104 attempted to eat plaster, bang his/her head, refused oral medications, pulled a screw from the wall, and struck 3 staff members. A physician ' s order dated 10/09/14 at 11:43 AM directed application of 4 point restraints with restraint net for violent behaviors including physical abuse towards others. The 4 point restraints were applied at 11:25 AM and the restraint net was applied at 11:30 AM. Restraints were discontinued at 11:55 AM. A physician's progress note (face-to-face) documented by MD #102 at 11:52 AM failed to include an evaluation of the 4 required elements.

e. Patient #105 was admitted on 10/14/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #102 on 10/20/15 at 1:23 PM identified that, Patient #105 was verbally and physically threatening to staff, refused oral medications, hit his/her head on the wall, and threatened to strangle RN #102. A physician's order dated 10/20/14 at 10:23 AM directed application of 4 point restraints for violent behaviors including self injury. The 4 point restraints were applied at 10:20 AM followed by the restraint net. Restraints were discontinued at 11:30 AM. A behavioral health progress note (face-to-face) documented by MD #105 at 10:45 AM failed to include an evaluation of the 4 required elements.

f. Patient #106 was admitted on 9/08/14 with a diagnosis of bipolar disorder, type 2, most recent episode, depressed with psychotic features. Review of a behavioral health progress note documented by RN #108 on 09/12/15 at 08:15 AM identified that, Patient #106 was repeatedly scratching his/her sternum, physically aggressive, clenching fists, and attempting to hit staff. A physician's order dated 09/12/14 at 4:06 AM directed application of 4 point restraints for violent behaviors including self injury. Additionally, a physician's order dated 09/12/14 at 04:53 AM directed application of a body net for self injury. The 4 point restraints were applied at 3:50 AM. The patient attempted to bite off the restraints and the restraint net was applied at 4:25 AM. Restraints were discontinued at 5:50 AM. A physician's progress note (face-to-face) documented by MD #104 at 10:45 AM failed to include an evaluation of the 4 required elements.

g. Patient #108 was admitted on 10/30/14 with a diagnosis of mood disorder. Review of a behavioral health progress note documented by RN #109 on 11/16/14 at 12:13 AM identified that, Patient #108 became agitated when redirected to his/her room following conflict with a peer, refused oral medications, threatened to harm staff and self and attempted to climb on shelving in an attempt to jump. A physician's order dated 11/15/14 at 5:50 PM directed application of a body net for self injury. Further review of the behavioral health progress note identified that both 4 point restraints and a restraint net were placed at 8:55 PM. Restraints were discontinued at 9:40 PM. A physician's progress note (face-to-face) documented by MD #104 on 11/16/14 at 10:01 AM failed to include an evaluation of the 4 required elements.

h. Patient #109 was admitted on 11/16/14 with a diagnosis of depressive disorder. Review of a behavioral health progress note documented by RN #110 on 11/21/14 at 10:26 AM identified that, Patient #109 was repeatedly using profanity, agitated, screaming, threatening self harm, refusing to stay in room when redirected, slamming doors, punching the wall, head banging, attempting to lock self in bathroom, and assaultive towards staff. A physician's order dated 11/20/14 at 8:58 PM directed application of 4 point restraints for violent behaviors including self injury. Review of the behavioral health progress note documented on 11/20/14 at 9:03 PM by MD #104 identified that that Patient #109 was placed in 4 point restraints with a net for safety. The 4 point restraints were applied at 8:50 PM. Restraints were discontinued at 9:30 PM. A physician's progress note (face-to-face) documented by MD #104 at 9:03 PM failed to include an evaluation of the 4 required elements.

i. Patient #110 was admitted on 03/20/15 with a diagnosis of autism spectrum disorder. Review of a behavioral health progress note documented by RN #108 on 04/07/15 at 06:18 AM identified that, Patient #110 made sexual gestures towards an RN, physically assaulted a MHW, spit at staff, and yelled. An additional physician's order at 11:49 PM directe

Based on review of hospital policies and procedures, clinical record review, and interviews the hospital failed to ensure safe implementation of restraints for patients restrained with a restraint net or both a restraint net and 4 point restraints when staff continued to use both the restraint net and 4 point restraints together despite being instructed not to do so by the nurse educator. The findings include:

Review of hospital skills check lists dated multiple dates in November 2013 identified training in restraint usage for clinical staff that included indication for use, proper placement of restraints (including 4 point and restraint net), and documentation of restraints. Skills were observed and validated for 10 staff members. Restraint documentation refresher training was conducted for all RN's and MHW's in June of 2014. A Safety Fair was conducted on 07/14/14 that included a restraint refresher attended by 19 staff members. A mandatory skills review was conducted on multiple dates in November 2014 and included review of the restraint policy, oral competency for indications for restraints, and staff demonstration of application of restraints. Additionally, non-violent crisis intervention training was conducted in 2015 for RN's, MHW's, and Security, is ongoing and includes restraint usage.

Interview with Clinical Nurse Leader #1 on 06/24/15 at 1:30 PM identified that in 2009, it was a common practice to restrain a patient using both four point leather restraints and a restraint net, however, by 2012, the staff were instructed to use either 4 point restraints or a restraint net. Staff compliance was limited, and in 2013, Clinical Leader #1 was directed by the DNS to educate all staff on the correct application of each restraint. Staff training was conducted for all newly hired staff as well as annually for all staff. Clinical Leader #1 identified that although the staff had been trained in the proper application of each restraint, the staff on the adolescent unit continued to restrain patients with both 4 point leather restraints and a restraint net, per physician's order.

Interview with the chief of the Adolescent Unit, MD #102 on 06/25/15 at 11:00 AM identified that he/she understood that the least restrictive device necessary to maintain patient safety was to be utilized and assumed that the 4 point leather restraints were removed prior to the application of the restraint net and was unaware that the restraint net was being utilized in conjunction with four point restraints.

Interview with the Chief of Psychiatry on 06/24/15 at 1:20 PM identified that some patients remain dangerous in four point restraints alone and require an additional restraint. An additional interview on 6/25/15 indicated that he/she was not sure, but may have signed off on the policy indicating that both the restraint net and 4 point restraints could be used together. MD #103 indicated that the practice for the 4 point and net restraint application was present prior to MD #103's hire date in 2004.

Interview with the DNS on 06/25/15 at 1:10 PM identified that the staff was instructed to discontinue the practice of using two restraints, however, sometimes it was necessary to maintain patient safety and he/she concurred with the use despite the knowledge that the restraint net was not being attached to the bed in accordance with manufacturer's application instructions. The DNS further identified that the restraint net was utilized as a fifth point to secure a patient's upper body from twisting, turning, and sitting up, and to prevent removal of the leather restraint cuffs, and/or scratching themselves.

Interview with the nursing supervisor/unit manager of the adolescent unit, RN #106, on 06/24/15 at 1:20 PM, identified that staff on the adolescent unit require re-education and, currently, monitoring of compliance for safe application of restraints was random.

Interview with MHW #2 on 06/24/15 at 9:20 AM identified that he/she had worked on the child/adolescent unit for 14 years and received restraint training annually during a skills check. According to MHW #2 the restraint net is used in conjunction with the four point restraints as a last resort when patients in leather restraints continue to be agitated, sit up, wiggle their hand out of the restraint, bang their head, thrash, bite the restraint, spit, or bite themselves. The restraint net is applied to the side of the bed and tightened enough so that the patient is not able to sit up or thrash. Generally, the legs are left in the leather restraints and sometimes, the arms are left in the leather restraints also.

Interview with MHW #3, a Crisis Prevention Institute (CPI) trainer, on 06/24/15 at 10:45 AM, identified that during restraint training he/she discusses the need to use the restraint net in conjunction with four point restraints and demonstrates application including leaving the 4 point restrain in place, removal of the four point restraint, and removal of the upper extremity leather restraint and leaving the lower extremity leather restrain in place. According to MHW #3, it is rare that the restraint net is used alone.

Interview with RN #102 on 06/24/15 at 9:30 AM identified that he/she had worked on the adolescent unit for 4.5 years and had been trained in restraint usage during the annual skills check. According to RN #102, use of the restraint net in conjunction with the four point restraints was a last resort and, in general, the leather ankle restraints remain on wile the upper extremity leather restraints might be released and the upper extremities placed through the holes in the restraint net and placed in the Velcro restraints on the exterior of the net. Sometimes, all 4 leather restraints will remain in place.

Interview with MHW #1 on 06/25/15 at 11:25 AM identified that he/she had been working on the adolescent unit for 4 years and had been trained that the restraits were to be utilized separately. When an emergency occurrs where a restraint is ordered, prior to application, MWH #1 asks the nurse coordinating the code if there will be a single restraint or double restraint. When a double restraint is applied, sometimes four point restraints remain in place, sometimes the upper extremities are removed from the leather restraints, placed through the holes in the net and secured in the upper extremity restraints that are part of the net. In some situations, all 4 leather restraints are removed as the restraint net is applied. However, the end-strap of the restraint net can not be cinched up and we attempt to make the other straps as snug as possible.

Interview with RN #101 on 06/25/15 at 11:45 AM identified that he/she had worked on the child/adolescent unit for 3 years and had been trained in restraint application during a skills check where both restraint net and 4 point restraint were discussed but not demonstrated. According to RN #101, the staff was aware that the restaints are not to be used together however, the restraint net is being used inconjunction with the 4 point leather restraints. The patient's upper extremities are placed in the restraint net velcro restraints however, the ankles remain in the leather restraints as they are too difficult to attach to the net restraints.

Interview with RN #103 on 06/25/15 at 12:00 PM identified that he/she had worked on the child/adolescent unit for 4.5 years and had been trained in restraint application by a nurse educator upon hire with a demonstration and return demontration but was unable to recall if application of the restraint net was included. The decision to place the secondary restraint net is based upon patient behavior while in 4 point restraints including struggling, sitting up, biting, trhashing. the use of the net is an attempt to restiricy the patient's movement. The clinical team and the physician make the decision. According to RN #103, the leather restraints remain in place when the net is placed and the net arm and leg retraints are not used except in the 2 most recent episodes (Patient #110 and #111). RN #103 did not recall being instructed that only one restraint was to be used at a time. Review of the m