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Based on staff interview and document review, it was determined the facility failed to implement less restrictive measures prior to placing a patient in restraints in one (1) of four (4) medical records reviewed in the survey sample (Medical record #4).

Findings:

The medical record for Patient #4 contained a physician's order for bilateral secured mitts to protect the integrity of lines and tubes at 3:23 PM on October 28, 2024. It was unclear from the medical record when the restraints were initiated. The first documentation of the restraints by nursing staff occurred on October 28, 2024 at 7:24 PM. This documentation revealed that restraints were "continued." The documentation did not indicate what if any less restrictive alternatives were considered prior to initiation of the restraints and at the start of each order as mandated by facility policy. Less restrictive measures were first documented at 11:25 AM on October 29, 2024 (the following day). Additionally, documentation indicated the restraints were discontinued at 2:54 PM on October 29, 2024. The last restraint monitoring was completed by nursing staff at 11:25 AM on October 29, 2024, approximately three and a half hours before the restraints were discontinued.

The hospital's policy, Restraint Policy was reviewed and reads in part: Nonviolent/Nondestructive patients in restraints shall have their behavior reassessed and documented....2. Description of alternatives or other less restrictive interventions attempted. Documented at the start of each order and as indicated....7. Patient monitoring: a. At least every two hours for all other non-behavioral patients. This assessment includes, as appropriate to the type of restraint employed: signs of any injury associated with the application of restraint; skin integrity; nutrition/hydration needs (while awake); circulation; elimination needs; physical and psychological status and comfort; readiness for discontinuation of restraint.

An interview was conducted with Staff Member #2 on December 3, 2024 who confirmed less restrictive alternatives and every two hour monitoring should be documented in all patients in restraints.