HospitalInspections.org

Based on medical record review and facility document review, it was determined the facility failed to obtain an order for the use of restraints, according to facility policy, for one (1) of nine (9) medical records (MR) sampled.

The findings include:

A review of the facility's policy "Use of Patient Restraints or Seclusion", last revised 1/2025, indicated in part:
...3. Physical Hold Restraints: a. Order. 1. Obtain an order from Licensed Independent Practitioner (LIP) prior to initiation (exception: Emergency application). a. Emergency application: Nurse may initiate if LIP not available and nurse assesses need for immediate intervention to prevent the patient from harming self or others. The LIP must be notified and the order obtained either during the emergency application or immediately thereafter...".

Review of Patient #6's medical record revealed that Patient #6 was placed in a physical hold at approximately 6:00 AM on July 29, 2025. The medical record revealed that the LIP's order was not placed until 7:11 PM on the same day.

Based on medical record reviews and facility document reviews, it was determined the facility failed to discontinue the use of restraints at the earliest possible time for one (1) of nine (9) medical records (MR) sampled.

The findings include:

A review of the facility's policy "Use of Patient Restraints or Seclusion", last revised 1/2025, indicated in part: "...6. Discontinuation of Any Restraint, Seclusion, or Physical Hold - Restraint or seclusion must be removed at the earliest possible time...Restraints must be removed as soon as the patient demonstrates desired behaviors...".

A review of Patient #5's medical record revealed that Patient #5 was placed in non-violent restraints at approximately 8:00 AM on July 21, 2025 for pulling at lines. The Registered Nurse (RN) documented at 10:00 AM, 12:00 PM, 2:00 PM and 3:15 PM, that Patient #5 was "asleep". There was no other documentation to support that Patient #5 was displaying behaviors to meet the restraint criteria at those times.

Based on medical record and facility document review, it was determined the facility failed to monitor the condition of patients who were placed in physical holds, according to facility policy, for two (2) of nine (9) medical records (MR) reviewed (Patient #6 and Patient #8).

The findings include:

A review of the facility's policy "Use of Patient Restraints or Seclusion", last revised 1/2025, indicated in part: "...3. Physical Hold Restraints...b. Monitoring and Documentation...ii. Discontinuation Assessment - occurs at the time of discontinuation for the Physical Hold restraint, - Must be documented in the EMR or appropriate downtime flowsheet...".

Patient #6's medical record revealed that Patient #6 was placed in a physical hold on July 29, 2025 at 5:54 AM and released from the physical hold at 5:57 AM. The medical record didn't contain any documentation of Patient #6's assessment after the physical hold was discontinued.

Patient #8's medical record revealed that Patient #8 was placed in a physical hold on July 13, 2025 at 2:00 AM and released from the physical hold at 2:05 AM. The medical record didn't contain any documentation of Patient #8's assessment after the physical hold was discontinued.

Based on medical record reviews and facility document reviews, it was determined the facility failed to document a face-to-face assessment within one (1) hour of placing patients in restraint or seclusion for two (2) of nine (9) medical records (MR) reviewed (Patient #6 and patient #8).

The findings include:

A review of the facility's policy "Use of Patient Restraints or Seclusion", last revised 1/2025, indicated in part: "...3. Physical Hold Restraints...b. Monitoring and Documentation...iii. Face to Face Assessment - LIP must assess the patient face to face within 1 hour of application of restrains and/or use of seclusion - Must be documented in the MR or appropriate downtime flowsheet...".

Patient #6's medical record revealed that Patient #6 was placed in a physical hold on July 29, 2025 at 5:54 AM and released from the physical hold at 5:57 AM. The medical record didn't contain provider's documentation of an face-to-face assessment within one hour of placing Patient #6 in physical hold.

Patient #8's medical record revealed that Patient #8 was placed in a physical hold on July 13, 2025 at 2:00 AM and released from the physical hold at 2:05 AM. The medical record didn't contain provider's documentation of an face-to-face assessment within one hour of placing Patient #8 in physical hold.