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Based on a review of hospital policy for restraints (revised 9/16/2016) and two restraint records, patient #2's record, it is revealed that staff failed to base release criteria on his/her behavior ,which may have impacted patient #2's release at the earliest possible time.

Hospital Restraint policy (effective 9/16/2016) revealed in part, "Release from Restraint A. Continuous assessment of behavior for early release is an expectation. As early as possible, the patient is made aware of the rationale for restraint and the release criteria for its discontinuation., i.e. patient no longer violent or self-destructive. Restraint should be discontinued as soon as the unsafe situation ends ..."

Patient #2 was an adult admitted to the psychiatric hospital. Approximately two weeks later, and according to an RN note of 1831 in part, " ...pt became extremely agitated, threw papers, from his pocket, kicked a chair, refused redirection and began aggressively posturing toward staff ..." On the pre-printed restraint form under "This criteria was explained to patient for discontinuation," the RN documented an appropriate criterion of, "Patient ceases danger to others." The form followed with " ...specific behaviors discussed for discontinuation:" The RN documented in part, " ...Pt must accept and follow redirection as soon as given." Based on this, the RN gave a criterion which failed to relate to imminent dangerousness, and may not have been a capability of patient #2 at baseline.

A face to face completed by the RN at 1837 revealed the RN inquiry as to whether patient #2 could come to staff if needed. Patient #2 responded, "No." On the preprinted face to face element for "Describe rationale or behavior for continuance:" The RN documented "Patient said he could not come to staff. Pt did not follow directions from staff. The RN failed to document how not coming to staff when needed continued imminent dangerousness." Additionally, the RN failed to document how not following directions given to the patient continued patient #2's imminent dangerousness. Patient #2 continued in restraint for a total of 4 hours.

Based on all documentation, staff educated patient #2 regarding appropriate criteria for release from restraint, and then applied non-behavioral, and subjective criterion which had no documented basis in imminently dangerous behaviors and may not have been a patient capability at a baseline. Consequently, patient #2 remained in restraint for the duration of the 4-hour restraint order, and may not have been released at the earliest possible time.

Based on a review of Hospital Restraint policy and two patient restraint records, it was revealed that staff failed to document actual care given to patient #3, and failed to obtain guidance of an licensed independent practitioner (LIP)or physician when a decision of whether to withhold care was needed.

Hospital Restraint policy (effective 9/16/2016) revealed in part, "At least every 15 minutes, staff shall perform the following tasks via contact with the patient and these will be documented in the medical record. These tasks include (in part): ...b. nutrition/hydration needs (inquiry or patient request); c. circulation ...; e. hygiene and elimination needs; f. physical and psychological status ...; g. vital signs ... The staff who performs these tasks shall immediately notify the RN if a further assessment is required or if he/she is unable to complete tasks due to the status of the patient."

Patient #3 was an adult admitted to the psychiatric hospital. Approximately one month following admission, patient #3 was placed into 4-point restraint at 2155 for aggressive behaviors. A Mental Health Worker (MHW) documented every fifteen minutes in part related to "Patient Care Completed." For the entries of 0029, 0045, 0100, 0115, 0130, 0145, and 1059, the MHW documented "Not Clinically Indicated due to Behavior ..." Additionally, for 0213, the MHW documented "Refused all staff attempts."

Based on this documentation, it is not possible to tell which care elements were not done for patient #3. Further, the decision not to render care was made by a non-clinical staff member who per policy and documentation, also failed to notify the RN. Finally, it is not within the scope of a MHW to decide to forego required care during restraint. It is only within the scope and responsibility of a physician, informed by the RN to forego any part of patient care based on a physician order. Therefore, the hospital failed to document actual care and maintain clinical elements of restraint care for patient #3.

Based on a review of geriatric patient #1's record, it was revealed that while nursing had multiple clinical care processes in place, nursing failed to evaluate and address patient #2's chronic insufficient fluid intake.

Patient #1 was a 70+ year old patient who was admitted due to increasingly aggressive behaviors. Patient #1 had a history of Dementia and Parkinson's disease. On admission, patient #1 was reported in part to have a poor intake with a 10 lbs weight loss in one month. No fluid intake deficit documentation was found.

The hospital monitored patient #1's weight, his food intake, and fluid (I&O) Intake and Output over a 45-day admission. During those 45 days, patient #1 averaged a fluid intake of 1076 per day, ranging from as little as 300ml intake to as high as high as 1800ml per day, with many days averaging between 1000-1100ml.

Patient #1 received an x-ray at the hospital. Pneumonia was diagnosed and an antibiotic was begun. A couple of days later, patient #1 was sent to an emergency department due to lethargy, worsening mental status and fever. Patient #1 was found to have a hypovolemic (low blood volume), and a dehydration (low body fluid volume) condition along with an acute kidney injury and high sodium level. Based on this, the nursing failed to evaluate andfully evaluate patient #1's insufficient fluid intake.