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Based on deficiencies cited, the facility failed to protect and promote the rights of 5 (#s 9, 10, 11, 12, and 13) of 14 patients admitted to the facility. Findings include:

The facility staff did not receive an order after restraints were placed for 2 (#s 9 and 13) (See A168).

The facility staff did not follow the policy on PRN restraint orders for 1 (#12) of 5 restraint records reviewed (See A169).

The facility failed to document the earliest possible time for the restraint to be discontinued for 4 (#s 9, 10, 11, and 13) of 5 medical restraint records reviewed (See A174).

The facility failed to document the rationale for continued use of restraints/seclusion for 1 (#10) of 5 restraint records reviewed (See A188).

The facility staff did not call the Centers of Medicare and Medicaid about 1 (#9) patient who passed away within 24 hours of restraints being removed (See A214).

Based on record review, review of the facility's policy, and staff interview, the facility did not obtain an order from a physician or licensed independent practitioner prior to the use of restraints for 2 (#s 9 and 13) of 5 restraint records reviewed. Findings include:

1. Medical Record Review

a. Patient #9 was admitted to the facility on 11/24/10, with diagnoses of hyponatremia, swelling of left upper extremity, and immune deficiency related to being on immunosuppressant drugs.

On 1/26/10 at 7:35 p.m., the patient was intubated.

On 1/27/10 at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., and 7:53 p.m., the ICU nursing staff documented using soft wrist restraints on patient #9.

Patient #9's medical record lacked a physician order for the bilateral wrist restraints.

b. Patient #13 was admitted to the facility on 9/26/10, with diagnoses of respiratory failure of questionable etiology, severe metabolic acidosis, hypertension, renal failure, and malnutrition.

On 9/26/10 patient #13 was intubated in the emergency room and admitted to ICU at 8:15 p.m.

On 9/26/10 at 8:15 p.m. and 10:00 p.m., the ICU staff documented using bilateral soft wrist restraints on patient #13.

Patient #13's medical record lacked a physician order for the bilateral soft wrist restraints.

2. Staff interviews

a. On 2/1/11 at 2:00 p.m., the manager of the ICU and ER, staff member F, stated she would get an order for the restraint before implementing, or immediately after implementing, the restraint or seclusion. Staff member F stated she would also look the facility's restraint policy up to make sure she was in compliance.

b. On 2/2/11 at 6:55 a.m., 7:10 a.m., 1:13 p.m., and 2:45 p.m., facility nursing staff were interviewed about restraints. The staff stated they needed to call the physician and obtain an order for restraints or seclusion before implementing, or immediately after implementing, the restraints or seclusion.

3. Facility's Restraint Policy

a. The surveyor reviewed the facility's policy labeled "Restraint and Seclusion." The surveyor noted the following statements documented under C. Medical Restraint, "1. Indications
Medical Restraint may be used for the following indications when less restrictive means would not be effective in protecting the patient:
a. The patient is pulling at tubes, lines or dressings [sic]
b. The confused patient is interfering with the provision of care.
c. The patient's actions are endangering themselves: for example if the patient is thrashing around in bed or attempting to get out of bed in a way or under conditions where it might cause harm (including when such behavior is related to acute withdrawal syndrome).
d. The patient's diagnosis or condition is such that they may unpredictably and suddenly awaken and harm themselves: for example, a) When an intubated patient is being weaned from Propofol; or b) When an intubated patient has a neurological condition that may cause them to unpredictably and suddenly awaken with a significant risk of self-extubation before staff have an opportunity to intervene.
2. Physician Orders:
a. If the attending physician is not available, a registered nurse may initiate restraint in advance of a physician's order (form NUR 8660e).
i. If restraint was necessary due to a significant change in the patient's condition, the attending physician shall be contacted immediately for an order.
ii. Otherwise, the attending physician must be notified and a restraint order requested within 12 hours of it initiation..."

b. On 2/2/11 at 11:30 a.m., the vice president of patient care services, staff member B, talked about section 2. a. ii. of the facility's restraint policy. Staff member B stated the facility's restraint policy discussed notifying the patient's own physician if the on-call physician had ordered the restraints. The nursing staff had 12 hours to notify the patient's physician that the physician's patient was in restraints.

Based on medical record review and staff interview, the facility failed to ensure orders for the use of restraints were not written as an as needed (PRN) basis for 1 (#12) of 5 restraint records reviewed. Finding include:

1. The facility's restraint policy had the following documented under Section B. General Provisions, "1. Orders:...b. 'As Needed' (PRN) restraint orders are not acceptable and the ordering physician will be contacted to clarify or discontinue the order..."

2. Patient #12 was admitted to the facility on 1/13/11 with diagnoses of hypothermia and hypertension.

On 1/17/11, no time noted, the physician wrote transfer orders with the following: "...Restrain prn..."

3. On 2/2/11 at 11:30 a.m., the manager of ER and ICU, staff member F, and the vice president of patient care services, staff member B, stated the facility expectation would be for the nurse to call the provider and clarify the PRN restraint order. The facility would not want the nurse to accept and transcribe the restraint order or ignore the restraint order.

Based on medical record review, facility's policy review, and staff interview, the facility failed to document the earliest possible time for the restraint to be discontinued for 4 (#s 9, 10, 11, and 13) of 5 medical restraint records reviewed. Finding include:

1. Facility Policy

The facility's restraint policy had documented under Section B. General Provisions the following, "...4. Early Release: Restraints shall be discontinued when the behavior or condition, which was the basis for the restraint order is resolved, regardless of the duration of the enabling order."

The facility's restraint policy had documented under Section C. Medical Restraint 3. Patient Monitoring the following, "a. Type and location of the restraining device(s) shall be documented at least once per shift and when changed. b. Rationale for restraint (observed condition or behavior) shall be assessed on an ongoing basis and documented at least once per shift..."

2. Record Review

a. Patient #9 was admitted to the facility on 11/24/10 with diagnoses of hyponatremia, swelling of left upper extremity, and immune deficiency related to being on immunosuppressant drugs.

On 1/26/10 at 7:35 p.m., the patient was intubated.

On 1/27/10 at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., and 7:53 p.m., the ICU nursing staff documented using soft wrist restraints on patient #9.

On 11/28/10 at 8:15 a.m., patient #9 was extubated due to the request of family to let him die peacefully.

On 11/28/10 at 1:42 p.m., patient #9 expired.

Patient #9's medical record lacked documentation of when the restraints were discontinued.

b. Patient #10 was admitted to the facility on 1/18/11 with diagnoses of psychosis and scalp laceration.

On 1/23/11 at 5:30 a.m., per the computerized Observation Checklist document, patient #10 was in his room shouting. The nurse charted, "PT. states 'Casting out Demons.'''

On 1/23/11 at 5:34 a.m., per the computerized Patient Notes, the patient was yelling out repeatedly, "In the name of Jesus Christ, will all demons leave this room now!"

On 1/23/11 at 5:45 a.m., per the computerized Patient Notes, the patient was yelling out louder. The patient was given 2 mg of Ativan intramuscular for agitation.

On 1/23/11 at 5:48 a.m., per the computerized Observation Checklist document, patient #10 was in his room shouting.

On 1/23/11 at 5:53 a.m., per the computerized Patient Notes, the patient continued to yell out, with hands in "prayer attitude" down kneeling by the bed.

On 1/23/11 at 6:00 a.m., per the computerized Observation Checklist document, the patient was agitated and being escorted to seclusion.

On 1/23/11 at 6:15 a.m., per the computerized Observation Checklist document, the patient was agitated in the seclusion room.

On 1/23/11 at 6:30 a.m., per the computerized Observation Checklist document, the patient was quietly standing in front of the door in the seclusion room.

On 1/23/11 at 6:45 a.m., per the computerized Observation Checklist document, the patient was acting out in the seclusion room the nurses did a take down.

On 1/23/11 at 7:00 a.m., per the computerized Observation Checklist document, the patient was acting out in the seclusion room. The activity was a take down and the patient was in restraints.

On 1/23/11 at 7:05 a.m., per the computerized Patient Notes, the nurse documented the following, "D: PT. into bathroom to get water, out to bedside and yelling again and threw water at window. PT. escorted to seclusion room by [nurse's name], RN and [nurse's name], RN. [Physician's name] called and informed of situation. Order received for seclusion for safety and to change Haldol to 5 mg po BID at 0800 [8:00 a.m.] and 1400 [2:00 p.m.]. A: PT. being monitored with 1:1 observation. R: PT. standing in seclusion room, occasionally [sic] yelling out. D: RN in to take PT's blood pressure and PT. took swing at [nurse's name] with fist. Code Grey called and PT. placed in restraints. [Physician's name] called and informed of situation, order received to place PT. in restraints. R: PT. lying on bed in restraints with eyes closed."

On 1/23/11 at 7:15 a.m., per the computerized Observation Checklist document, the patient was in restraints in the seclusion room being quiet.

On 1/23/11 at 7:30 a.m., per the computerized Observation Checklist document, the patient was in restraints in the seclusion room being quiet.

On 1/23/11 at 7:41 a.m., per the computerized Observation Checklist document, the patient was in the seclusion room being quiet and resting, by himself. The nurse charted, "Open eyes & looks around room intermittently. Rests calmly on back."

On 1/23/11 at 8:00 a.m., per the computerized Observation Checklist document, the patient was in the seclusion room, being cooperative with the RN. The nurse charted, "Communicated with delayed verbal response. Asks why he is 'tied up'. Reoriented. Takes sips H2O. C/O 'being cold' given extra blanket for comfort."

On 1/23/11 at 8:15 a.m., per the computerized Observation Checklist document, the patient was in the seclusion room being quiet and resting, by himself.

On 1/23/11 at 8:30 a.m., per the computerized Observation Checklist document, the patient was in the seclusion room being quiet. The nurse charted, "Restraint removed right hand. PT assisted to sitting position. Assisted with meal."

On 1/23/11 at 8:45 a.m., per the computerized Observation Checklist document, the patient was in the seclusion room being quiet. The nurse charted, "PT assisted with menu choices. PT feel [sic] asleep while choosing lunch."

On 1/23/11 at 8:58 a.m., per the computerized Patient Notes, the nurse documented the following, "Focus: Restraint Monitoring/Mental Status D/A: Pt physical assessment done this AM. Pt denies any C/O pain, HA, discomfort. PT pleasant, cooperative with care, however is very slow to offer response to questions, and appears guarded when answering, as though he is thinking of how to respond, and responds very carefully. Stated he was hungry for breakfast. After informing PT that as long as nurses did not feel threatened by PT, restraints would slowly be removed. Restraint to RUE released so that PT may feed himself breakfast. PT assisted with breakfast by [nurse's name], RN, ate 100%, tolerated well. Fell asleep while being assisted in filling out his menu for tomorrow's meals. [Physician's name] in to see PT at this time. A: Will continue close monitoring per restraint policy. Maintain PT and nurse safety with goal to have restraints removed within several hours."

On 1/23/11 at 9:00 a.m., per the computerized Observation Checklist document, the patient was in the seclusion room with his physician, being cooperative.

On 1/23/11 at 9:15 a.m., per the computerized Observation Checklist document, the patient was in the seclusion resting quietly.

On 1/23/11 at 9:30 a.m., per the computerized Observation Checklist document, the patient was in the seclusion resting quietly. The nurse released the right leg restraint.

On 1/23/11 at 9:44 a.m., per the computerized Observation Checklist document, the patient was in the seclusion resting quietly. The nurse charted, "PT on left side appears to be sleeping."

On 1/23/11 at 10:00 a.m., per the computerized Observation Checklist document, the patient was restless in seclusion. The nurse charted, "Incontinent urine, Restraints off. Linen & gown changed. Offered urinal."

On 1/23/11 at 10:28 a.m., per the computerized Patient Notes, the nurse documented the following, "Focus: Restraints/Safety Contract D: PT has remained cooperative throughout the AM, though slightly restless. Incontinent of urine x1 between 1000 [a.m.] and 1015 [a.m.]. PT provided with urinal and voided an additional 150 cc clear amber urine. Denies any dysuria. Restraints have been released and PT moved from seclusion room to room [number]. PT has signed new safety contract, agreeing to not harm himself, others or hospital property through his entire length of stay in this facility. PT restless in room, medicated with scheduled Risperidal and PRN Haldol. PT continues to deny C/O pain or other discomfort. CMS to all extremities WNL. A: Will continue close observation of PT, monitor for signs of psychosis, provided PT safety, reorient as indicated, address PT questions. PRN meds as indicated."

Patient #10's medical record lacked documentation of why seclusion was started at 6:00 a.m. The patient was not harming himself, other patients, or staff.

Patient #10's medical record lacked documentation from 7:00 a.m., why he was in four point restraints and seclusion. The patient was quiet, resting, or cooperative while in restraints and the seclusion room. The patient was not harming himself, other patients, or the staff.

Patient #10 was not removed from restraints at the earliest possible time.

c. Patient #11 was admitted to the facility on 12/19/10 with diagnoses of lower gastrointestinal bleed, acute and chronic anemia, dementia, depression, and chronic kidney disease.

On 12/20/10 at 3:45 p.m., the nurse received a verbal order for soft wrist restraints due to the high potential for removing tubes.

On 12/20/10 at 4:30 p.m., 6:21 p.m., and 8:31 p.m., and on 12/21/10 at 1:00 a.m., the nurse documented the use of the bilateral wrist restraints.

Patient#11's nasogastric tube was removed on 12/22/10 at 9:24 a.m.

Patient #11's medical record lacked documentation of when the restraints were discontinued.

d. Patient #13 was admitted to the facility on 9/26/10 with diagnoses of respiratory failure of questionable etiology, severe metabolic acidosis, hypertension, renal failure, and malnutrition.

On 9/26/10 patient #13 was intubated in the emergency room and admitted to the ICU at 8:15 p.m.

On 9/26/10 at 8:15 p.m. and 10:00 p.m., the ICU staff documented using bilateral soft wrist restraints on patient #13.

On 9/27/10 at 8:15 a.m., patient #13 was extubated.

Patient #13's medical record lacked documentation of when the restraints were discontinued.

3. Staff interview

a. On 2/1/11 at 2:00 p.m., the manager of ICU and ER, staff member F, stated the staff should be charting when the restraints were discontinued.

b. On 2/2/11 at 6:55 a.m., a registered nurse, staff member D, stated the criteria for releasing a patient from restraints was the patient's safety.

c. On 2/2/11 at 7:10 a.m., a registered nurse, staff member E, stated the criteria for releasing a patient form restraints was the patient's cooperation. The patient was not a risk of harming self, other patients, or staff.

d. On 2/2/11 at 1:13 p.m., a registered nurse, staff member G, stated the patient would need to be cooperative to be removed from restraints. Also, the patient was not a risk of harming self, other patients, or staff.

e. On 2/2/11 at 2:45 p.m., a registered nurse, staff member H, stated how the patient was behaving would play into the removal of the patient's restraints.

Based on medical record review, facility's policy review, and staff interviews, the facility failed to document the rationale for continued use of restraints/seclusion for 1 (#10) of 5 restraint records reviewed. Finding include:

1. Facility Policy

a. The facility's restraint policy had documented under Section B. General Provisions the following, "...4. Early Release: Restraints shall be discontinued when the behavior or condition, which was the basis for the restraint order is resolved, regardless of the duration of the enabling order."

b. The facility's restraint policy had documented under section D. Behavioral Health Care Restraint and Seclusion, "e. Monitoring: i. A competent registered nurse shall assess the patient at the initiation of restraint or seclusion and every 15 minutes for one hour. RN may assign trained medical personnel to monitor patient every 15 minutes or per physician order. ii. The assessment shall include the following, unless it is inappropriate for the type of restraint or seclusion employed. Documentation via Meditech intervention.
*Signs of any injury associated with applying restraint or seclusion
*Nutrition and hydration
*Circulation and range of motion in the extremities
*Vital signs as defined by the patient's care plan in relevance to the physical safety of the patient.
*Hygiene and elimination
*Physical and psychological status and comfort
*Readiness for discontinuation of restraint or seclusion."

2. Record Review

Patient #10 was admitted to the facility on 1/18/11 with diagnoses of psychosis and scalp laceration.

On 1/23/11 at 5:30 a.m., per the computerized Observation Checklist document, patient #10 was in his room shouting. The nurse charted, "PT. states 'Casting out Demons.'''

On 1/23/11 at 5:34 a.m., per the computerized Patient Notes, the patient was yelling out repeatedly, "In the name of Jesus Christ, will all demons leave this room now!"

On 1/23/11 at 5:45 a.m., per the computerized Patient Notes, the patient was yelling was louder. The patient was given 2 mg of Ativan intramuscularly for agitation.

On 1/23/11 at 5:48 a.m., per the computerized Observation Checklist document, patient #10 was in his room shouting.

On 1/23/11 at 5:53 a.m., per the computerized Patient Notes, the patient continued to yell out, with hands in "prayer attitude" down kneeling by the bed.

On 1/23/11 at 6:00 a.m., per the computerized Observation Checklist document, the patient was "agitated" and being escorted to seclusion.

On 1/23/11 at 6:15 a.m., per the computerized Observation Checklist document, the patient was "agitated" in the seclusion room.

On 1/23/11 at 6:30 a.m., per the computerized Observation Checklist document, the patient was quietly standing in front of the door in the seclusion room.

On 1/23/11 at 6:45 a.m., per the computerized Observation Checklist document, the patient was acting out in the seclusion room the nurses did a take down.

On 1/23/11 at 7:00 a.m., per the computerized Observation Checklist document, the patient was acting out in the seclusion room. The activity was a take down and the patient was in restraints.

On 1/23/11 at 7:05 a.m., per the computerized Patient Notes, the nurse documented the following, "D: PT. into bathroom to get water, out to bedside and yelling again and threw water at window. PT. escorted to seclusion room by [nurse's name], RN and [nurse's name], RN. [Physician's name] called and informed of situation. Order received for seclusion for safety and to change Haldol to 5 mg po BID at 0800 [8:00 a.m.] and 1400 [2:00 p.m.]. A: PT. being monitored with 1:1 observation. R: PT. standing in seclusion room, occasionally [sic] yelling out. D: RN in to take PT's blood pressure and PT. took swing at [nurse's name] with fist. Code Grey called and PT. placed in restraints. [Physician's name] called
On 1/23/11 at 7:00 a.m., per the computerized Observation Checklist document, the patient was acting out in the seclusion room. The activity was a take down and the patient was in restraints.

On 1/23/11 at 7:15 a.m., per the computerized Observation Checklist document, the patient was in restraints in the seclusion room being quiet.

On 1/23/11 at 7:30 a.m., per the computerized Observation Checklist document, the patient was in restraints in the seclusion room being quiet.

On 1/23/11 at 7:41 a.m., per the computerized Observation Checklist document, the patient was in the seclusion room being quiet and resting, by himself. The nurse charted, "Open eyes & looks around room intermittently. Rests calmly on back."

On 1/23/11 at 8:00 a.m., per the computerized Observation Checklist document, the patient was in the seclusion room, being cooperative with the RN. The nurse charted, "Communicated with delayed verbal response. Asks why he is "tied up". Reoriented. Takes sips H2O. C/O "being cold" given extra blanket for comfort."

On 1/23/11 at 8:15 a.m., per the computerized Observation Checklist document, the patient was in the seclusion room being quiet and resting, by himself.

On 1/23/11 at 8:30 a.m., per the computerized Observation Checklist document, the patient was in the seclusion room being quiet. The nurse charted, "Restraint removed right hand. PT assisted to sitting position. Assisted with meal."

On 1/23/11 at 8:45 a.m., per the computerized Observation Checklist document, the patient was in the seclusion room being quiet. The nurse charted, "PT assisted with menu choices. PT feel [sic] asleep while choosing lunch."

On 1/23/11 at 8:58 a.m., per the computerized Patient Notes the nurse documented the following, "Focus: Restraint Monitoring/Mental Status D/A: Pt physical assessment done this AM. Pt denies any C/O pain, HA, discomfort. PT pleasant, cooperative with care, however is very slow to offer response to questions, and appears guarded when answering, as though he is thinking of how to respond, and responds very carefully. Stated he was hungry for breakfast. After informing PT that as long as nurses did not feel threatened by PT, restraints would slowly be removed. Restraint to RUE released so that PT may feed himself breakfast. PT assisted with breakfast by [nurse's name], RN, ate 100%, tolerated well. Fell asleep while being assisted in filling out his menu for tomorrow's meals. [Physician's name] in see PT at this time. A: Will continue close monitoring per restraint policy. Maintain PT and nurse safety with goal to have restraints removed within several hours."

On 1/23/11 at 9:00 a.m., per the computerized Observation Checklist document, the patient was in the seclusion room with his physician being cooperative.

On 1/23/11 at 9:15 a.m., per the computerized Observation Checklist document, the patient was in the seclusion resting quietly.

On 1/23/11 at 9:30 a.m., per the computerized Observation Checklist document, the patient was in the seclusion resting quietly. The nurse released the right leg restraint.

On 1/23/11 at 9:44 a.m., per the computerized Observation Checklist document, the patient was in the seclusion resting quietly. The nurse charted, "PT on left side appears to be sleeping."

On 1/23/11 at 10:00 a.m., per the computerized Observation Checklist document, the patient was in the seclusion restless. The nurse charted, "Incontinent urine, Restraints off. Linen & gown changed. Offered urinal."

On 1/23/11 at 10:28 a.m., per the computerized Patient Notes the nurse documented the following, "Focus: Restraints/Safety Contract D: PT has remained cooperative throughout the AM, though slightly restless. Incontinent of urine x1 between 1000 [a.m.] and 1015 [a.m.]. PT provided with urinal and voided an additional 150cc clear amber urine. Denies any dysuria. Restraints have been released and PT moved from seclusion room to room [number]. PT has signed new safety contract, agreeing to not harm himself, others or hospital property through his entire length of stay in this facility. PT restless in room, medicated with scheduled Risperidal and PRN Haldol. PT continues to deny C/O pain or other discomfort. CMS to all extremities WNL. A: Will continue close observation of PT, monitor for signs of psychosis, provided PT safety, reorient as indicated, address PT questions. PRN meds as indicated."

Patient #10's medical record lacked documentation of why the patient was put in seclusion at 6:00 a.m. The patient was not harming himself, other patients, or the staff.

Patient #10's medical record lacked documentation from 7:00 a.m., why he was in four point restraints and seclusion. The patient was quiet, resting, or cooperative while in restraints and the seclusion room. The patient was not harming himself, other patients, or the staff.

3. Staff interview

a. On 2/1/11 at 2:00 p.m., the manager of ICU and ER, staff member F, stated the staff should be charting the reasons for the patient to be in the restraints.

b. On 2/2/11 at 6:55 a.m., a registered nurse, staff member D, stated restraints are used when the patient was harming himself or other patients or staff.

c. On 2/2/11 at 7:10 a.m., a registered nurse, staff member E, stated restraints are used to protect the patient from harming themselves other patients or the staff .

d. On 2/2/11 at 1:13 p.m., a registered nurse, staff member G, stated restraints are to be used to protect the patient from harming themselves, other patients, or the staff.

Based on record review and staff interview, the facility failed to report on restraint/seclusion death by the close of business the next day following the death of 1 (#9) of 5 restraint records reviewed. Findings include:

1. Patient #9 was admitted to the facility on 11/24/10 with diagnoses of hyponatremia, swelling of left upper extremity, and immune deficiency related to being on immunosuppressant drugs.

On 1/27/10 at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., and 7:53 p.m., the ICU nursing staff documented using soft wrist restraints on patient #9.

Patient #9's medical record lacked documentation of the restraints being removed from the patient.

On 11/28/10 at 8:15 a.m., patient #9 was extubated due to the request of family to let him die peacefully.

On 11/28/10 at 1:42 p.m., patient #9 expired.

2. The facility's restraint policy stated, "...7. Reporting of Death: Hospital personnel shall promptly contact hospital administration whenever:
a. A patient dies while restrained
b. A patient dies within on [sic] hour of the removal of restraints
c. When hospital personnel become aware of a death within one week of the conclusion of restraint due to a condition or illness that may be related to the restraint episode. Hospital administration shall notify the Centers for Medicare and Medicaid Services of the death within one business day."

The facility's policy was inaccurate. The facility must report each death that occurs within 24 hours (not one hour) after restraints are removed from a patient or after a patient is removed from seclusion.

3. On 2/2/11 at 11:30 a.m., the vice president of patient care services, staff member B, talked about the regulation dealing with deaths in restraint/seclusion. Staff member B stated the regulation stated the facility must report patient death when the death is associated with the use of seclusion or restraints. The physician documented patient #9's death was anticipated due to his declining health. Staff member B stated the facility had reread the policy several times and had not noticed the one hour after restraint removal issue.