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Based on a review of 10 open and closed patient records, patient #1's record reveals three omissions of restraint orders while patient #1 was restrained.

Based on medical records review, Patient #1 is a late-adolescent male who presented on emergency petition via police to hospital #1 emergency department, twice in as many weeks. Patient #1 required multiple restraint events for aggression during his stay. Review of the orders for those restraint events revealed:


- On 5/3/14, an order for violent restraints was placed at 2200 for up to 4 hours. Though patient #1 continued beyond the 4-hour order limit ending on 5/4 at 0220, there was no new order for continued restraint. Patient #1 remained in restraint to 0550, more than 3 hours without a physician order.


-On 5/4/14, an order for violent restraints was placed at 1050 for one point wrist restraint for up to 2 hours. Though the physician wrote the order for one point wrist restraints, nursing documentation reflects that patient #1 was placed in 4-point restraint; an intervention for which he had no order. Additionally, while the order for restraint ended at 1250, patient #1 was continued in restraint until 1659 with no new order although documentation indicates that the restraint was "Discontinued." However, other record documentation reveals that restraint continued through 1850 when patient #1 agreed not to harm others. Therefore, patient #1 was in restrained for up to 6 hours with no physician's order.


-On 5/5, an order for violent 4-point restraints was ordered at 0750 for up to 4 hours due to aggressive behaviors. Patient #1 was restrained beyond the 4 hours ending at 1150, and remained in restraint until 2152. One other continuation order is found which was written at 1924. It is a verbal order which reads "Continuous x 4 hours 5/5/14 1200 - 4-hours." This order is written 8 hours after the fact, which is not consistent federal regulations. Therefore, patient #1 was restrained for up to 8 hours between 1150 and 2152, without a valid physicians order; a period of approximately 10 hours.


Based on these findings, the hospital failed to obtain physician orders for some restraint events for patient #1.

Based on a review of 10 open and closed patient records, patient#1 who had multiple restraint events on 5/4/2014, was not released at the earliest possible time.

Patient #1 is a late-adolescent male who presented on emergency petition via police to hospital #1 emergency department, twice in as many weeks. Patient #1 required multiple restraint events for aggression during his stay.

On 5/3, patient #1 was restrained at 2200. The restraint continued until 5/4 at 0550. Per behavioral documentation, patient #1 was asleep and quiet for more than two hours between 0307 through 0550. However, staff did not release him from restraint.
On 5/4, during a 4-point restraint, RN documentation from 1229 to 1850 indicates every 15 minutes that patient #1 was "agitated, restless, yelling" yet he was released at 1850 without a noted change in behavior. Based on this lack of a change in behavior, documentation is either inaccurate, or patient #1 should have released at 1229 when he began demonstrating the same behaviors for which he was released at 1850. In either case, patient #1 was not released at the earliest possible time.

Based on a review of 10 open and closed patient records, patient #1's record revealed: 1) an order for violent restraint using only one point; and 2) Staff failure to assign one staff to continuously to monitor the patient in 4-point restraints; and 3), 15-minute monitoring of patient #1 was inconsistently documented.


Per the medical records , Patient #1 is a late-adolescent male who presented on emergency petition via police to hospital #1's emergency department twice in as many weeks. The first presentation was in late April 2014 due to aggression at his placement where he broke a window, threatened staff, and stated that he wants to live at another placement where he had lived at a prior time. While patient #1 has a diagnosis of Mood Disorder, Autism, and is intellectually disabled, he does understand that if he acts-up, he will be moved out of his current placement.

On day two of his ED stay, patient #1 crushed a pulse oximeter in his hand, then became aggressive with staff. An order written at 1050 for violent restraint stated to restrain patient #1's "Right wrist" for up to 2 hours. The use of a one point restraint does not meet standards for safe restraint practices for patients with psychiatric disorders. And while an order for one point was made, subsequent nursing documentation reveals that staff actually placed patient #1 in 4-point restraint.

Review of the Emergency Department Behavioral Health Unit reveals that staff utilizes video cameras to monitor patients in 4-point restraint instead of using continuously assigned staff, also known as a 1:1. Documentation on the fifteen-minute flowsheets of 5/5/14 were inconsistently documented where no documentation appears between 0842-0915, 0958-1105, 1350-1446,1508-1541, 1611-1650, 1652-1757, and 1759-1840. Additionally, under Maryland regulations COMAR 10.21.12.08 staff must be continuously assigned to monitor patients in 4-point restraint. However, lapses in monitoring documentation suggests that no staff was monitored patient #1 by video either during those times or immediately present with this patient who was in four point. patients in four point restraints are extremely vulnerable and require continuous observation.

Based on a review of 10 open and closed patient records, it is determined that patient #1 received partial or no face to face assessments over the course of multiple restraint events.

Patient #1 is a late-adolescent male who presented on emergency petition via police to hospital #1 emergency department, twice in as many weeks. Patient #1 required multiple restraint events for aggression during his stay.

On 5/4/2014, patient #1 was restrained beginning at 1050. No physician face to face evaluation was noted in the record.

On 5/5 at 0045, patient #1 required 4-point restraints. It is clear the physician saw patient #1 as the physician wrote a note stating " Patient seen in the BHU (behavioral health unit) because he required, and continues o (sic) require physical and chemical restraints." However, this note failed to address elements of the face to face such as the patient response to the restraint, and the patient's medical and behavioral condition.