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Based on hospital policy review, medical record review and staff interviews, the nursing staff failed to ensure there was a physician order for a non-violent restraint in 1 of 2 non-violent restraint patient records reviewed (Patient # 14).

The findings include:

Review on 08/28/2025 of hospital policy, "Restraints and Seclusion," effective 02/26/2024, revealed, "... The use of restraints/seclusion is in accordance with the order of a physician, physician assistant (PA) or nurse practitioner (NP) who is responsible for the care of the patient ... "

Closed medical record review on 08/28/2025 for Patient #14 (Pt) revealed a 62-year-old patient that was admitted on 08/06/2025 at 0046 with a diagnosis of encephalopathy (a disease that alters brain function, often caused by infection) and shock (a life-threatening condition where the internal organs do not receive adequate blood flow) with unclear etiology (cause). Record review revealed an arterial line (a catheter that is inserted into the artery to continuously monitor blood pressure and obtain blood samples) was placed on 08/25/2025 at 0325. Review of the Restraint Record on 08/25/2025 at 0700 revealed a left-sided soft wrist restraint and a right-sided unsecured mitt (a soft padded glove) were "continued." Review failed to reveal the date and time restraints were applied. Review of the Provider Order on 08/25/2025 at 0726 revealed an order for "Restraints non-violent or non-self destructive: Restraint type: Mitt secured; Mitt Secured Laterality: Right, Left." Review of the Provider Orders failed to reveal an order for a left soft wrist restraint or an order for a right-sided unsecured mitt. Review of the Restraint Record revealed the left-sided soft wrist restraint and the right-sided unsecured mitt were "continued" at 0900 and discontinued at 1030. Review of the Death Discharge Summary on 08/25/2025 at 1409 revealed Pt #14 passed away at 1359 with a diagnosis of septic shock (a wide-spread, life-threatening infection that causes organ failure).

Telephone interview on 08/28/2025 at 1240 with Registered Nurse #1 (RN) revealed the patient had a right-sided unsecured mitt and a left-sided soft wrist restraint applied when RN #1 first entered the patient's room on the morning of 08/25/2025 at 0700. RN #1 revealed the restraints were applied by the patient's previous nurse (RN #2). RN #1 thought RN #2 had requested an order from the provider when the restraints were applied. Interview revealed the RN was responsible for ensuring the applied restraints matched the provider order. Interview revealed RN #1 could not recall why the order was not verified.

Telephone interview on 08/28/2025 at 1306 with RN #2 revealed a right-sided unsecured mitt and a left-sided soft wrist restraint were applied within 30 minutes of an arterial line being placed, at approximately 0400 on 08/25/2025. Interview revealed RN #2 requested an order for the restraints from the two providers that were at the bedside when the restraints were placed on the patient. RN #2 did not verify the order was placed in the patient's medical record.

Telephone interview on 08/28/2025 at 1255 with RN Manager #3 revealed restraint orders were typically entered into the medical record soon after the restraint was applied. Providers sometimes remained at the bedside until the patient was calm, then placed the order. The nurse should check the restraint order as soon as possible. Nursing staff should verify that the restraints that were ordered matched the restraints that were applied. If the restraints did not match the order, the restraints should have been removed or the order should have been changed to match the necessary restraints.

In summary, the investigation revealed non-violent restraints were applied on 08/25/2025 at approximately 0400. Review failed to reveal a Provider Order for restraints until 0726 (approximately 3 hours and 26 minutes after restraints were applied). Review of the Provider Order revealed an order for bilateral secured mitts. The patient was restrained from approximately 0400 until 1030 with a right-sided unsecured mitt and a left-sided soft wrist restraint (6 hours and 30 minutes) without a provider order.

Based on hospital policy review, medical record reviews and staff interviews, the nursing staff failed to monitor a restraint patient per the hospital policy in 2 of 5 restraint patient records reviewed (Patient # 10, Patient #14).

The findings include:

Review on 08/28/2025 of hospital policy, "Restraints and Seclusion," effective 02/26/2024, revealed, "... Non-Violent/Non Self-Destructive Restraints ... Initiation/Order Entry ... RN (Registered Nurse) to assess and document on initiation: * patient affect/behavior * mental status * device in use * clinical justification * less restrictive methods/alternative strategies attempted ... Ongoing Assessment & (and) Monitoring RN or LPN (Licensed Practical Nurse) assess and document every 2 hours: * mental status * strategies to reduce or remove restraint * if less restrictive alternatives are available * criteria for continued restraint use ... RN, LPN, or trained clinical teammate monitor and document every 2 hours: * patient affect/behavior * safety check *circulation status * skin integrity * signs of injury related to restraints * range of motion ... * assistance with food, hydration, elimination, and/or hygiene while awake ... Violent/ Self-Destructive Restraint and Seclusion ... Ongoing Assessment & Monitoring ... RN or LPN to assess and document every 15 minutes: * mental status * strategies to reduce or remove restraint * if less restrictive alternatives are available * meets criteria to continue restraint/seclusion ... RN, LPN, or trained clinical teammate to monitor and document every 15 minutes: * patient affect/behavior * signs of injury related to restraints * respiratory status * safety check * circulation status * skin integrity ..."

1. Open medical record review on 08/27/2025 for Patient #10 (Pt) revealed a 35-year-old patient that arrived in the Emergency Department (ED) on 08/20/2025 at 1305 with a chief complaint of suicidal ideation (thoughts). Record review revealed violent 4-point restraints (restraints to all 4 extremities) were applied on 08/21/2025 at 0130 for "Attempting self harm." Review of the Restraint Record failed to reveal evidence that restraints were monitored every 15 minutes from 0334 until 0534 (2 hours). Review of the Restraint Record at 0534 revealed the patient no longer met criteria to continue restraints. Record review failed to reveal evidence that violent 4-point restraints were discontinued at 0534. The patient was free if restraints and was a current patient in the ED during record review.

Telephone interview on 08/28/2025 at 0858 with RN #4 revealed violent restraints were typically monitored every 15 minutes. Monitoring included assessing tightness, skin integrity, circulation, and breathing. RN #4 took over care for Pt #10 from another nurse on 08/21/2025 at 0334. Interview revealed the type of restraints were not stated during nursing handoff. RN #4 thought the patient was in non-violent restraints and was documenting under the non-violent restraint flowsheet which required documentation every 2 hours rather than every 15 minutes. Interview revealed RN #4 did not monitor the patient every 15 minutes per the policy requirements. RN #4 did not check the restraint order when taking over care of the patient. RN #4 normally checked the restraint order when initiating restraints but not when taking over care. Interview revealed RN #4 started removing restraints, one at a time, at 0534. A restraint was removed every 15 minutes until all 4 restraints were discontinued at approximately 0615. Interview revealed RN #4 forgot to document the discontinuation of restraints in the medical record.

Interview on 08/28/2025 at 0930 with RN Manager #5 revealed violent restraints should be monitored and documented every 15 minutes in the medical record.

2. Closed medical record review on 08/28/2025 for Patient #14 (Pt) revealed a 62-year-old patient that was admitted on 08/06/2025 at 0046 with a diagnosis of encephalopathy (a disease that alters brain function, often caused by infection) and shock (a life-threatening condition where the internal organs do not receive adequate blood flow) with unclear etiology (cause). Record review revealed an arterial line (a catheter that is inserted into the artery to continuously monitor blood pressure and obtain blood samples) was placed on 08/25/2025 at 0325. Review of the Restraint Record on 08/25/2025 at 0700 revealed a left-sided soft wrist restraint and a right-sided unsecured mitt (a soft padded glove) were "continued." Review failed to reveal the date and time restraints were initiated or monitoring of restraints prior to 0700. Review of the Restraint Record revealed the left-sided soft wrist restraint and the right-sided unsecured mitt were "continued" at 0900 and restraints were discontinued on 08/25/2025 at 1030. Review of the Death Discharge Summary on 08/25/2025 at 1409 revealed Pt #14 passed away at 1359 with a diagnosis of septic shock (a wide-spread, life-threatening infection that causes organ failure).

Telephone interview on 08/28/2025 at 1240 with Registered Nurse #1 (RN) revealed the patient had a right-sided unsecured mitt and a left-sided soft wrist restraint applied when RN #1 first entered the patient's room on the morning of 08/25/2025 at 0700. RN #1 revealed the restraints were applied by the patient's previous nurse (RN #2).

Telephone interview on 08/28/2025 at 1306 with RN #2 revealed a right-sided unsecured mitt and a left-sided soft wrist restraint were applied within 30 minutes of an arterial line being placed, at approximately 0400 on 08/25/2025. Interview revealed RN #2 was not sure why restraint application and monitoring was not documented from 0400 until 0700 but stated it had been a "difficult morning" due to the patient's condition. Non-violent restraint monitoring was normally documented every 2 hours.

In summary, non-violent restraints were initiated for Pt #14 on 08/25/2025 at approximately 0400 per interview with RN #2. Record review failed to reveal evidence that Pt #14 was assessed upon initiation of restraints or monitored from 0400 until 0700 (approximately 3 hours and 26) per hospital policy.

NC00218644; NC00232116; NC00227886; NC00219757; NC00229902