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Based on interview and record review, the facility failed to ensure its nursing staff used the less restrictive restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) intervention for one of nine sampled patients (Patient 5), in accordance with the facility's policy and procedure regarding restraints use, when Patient 5 was placed on 4-point (bilateral [both] wrists and bilateral ankles) restraints to prevent Patient 5 from getting out of bed in the Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) on 5/21/2025.

This deficient practice resulted in restraint overuse for Patient 5.

Findings:

During a review of Patient 5's "Emergency Department Notes (ED note, assessment notes completed by ED physician)," dated 5/21/2025, the ED note indicated, Patient 5 presented to ED with acute (new onset) head injury and acute psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality).

During a review of Patient 5's "Physician Order Restraints," dated 5/21/2025, the "Physician Order Restraints," indicated, non-violent or non-self-destructive restraint with soft bilateral (both) wrists and ankles (4-point restraint), was started on 5/21/2025 at 11:45 a.m. with indication for restraint: "observed trying to climb out of bed when instructed not to do so, and unsteady, will not ask for assistance."

During a concurrent interview and record review on 6/3/2025 at 10:28 a.m. with the Nurse Manager of Emergency Department (NM 1), Patient 5's "Clinical Assessment - Note (nursing note)," dated 5/21/2025, was reviewed. The nursing note indicated, "at 11:46 a.m. patient (Patient 5) wandering and stepping into patient rooms, requires constant redirection from Registered Nurse (RN), Certified Nursing Assistant (CNA) and security staff. Patient (Patient 1) unsteady, will not ask for assistance. Physician (MD 53) at bedside with security staff, CNA and RN. Received verbal order for non-behavioral restraints."

During the same interview on 6/3/2025 at 10:28 a.m. with the Nurse Manager of Emergency Department (NM 1), NM 1 stated the following: 4-point restraints were considered as behavioral/violent restraint use because it was restricting the patient's (Patient 5) all four extremities. For patient attempting to wander and getting out of bed, a lesser restrictive measure such as bilateral soft wrists restraints should be used first. NM 1 also stated there was no documented attempt of using other less restrictive restraints method prior to the 4-point restraint use for Patient 5.

During an interview on 6/3/2025 at 10:39 a.m. with the Director (DIR 1) of Emergency Department, DIR 1 stated the following: there was some confusion regarding 4-point restraints, but it was clarified. 4-point restraints should only be used for patients with violent behavior. For non-behavioral/non-violent restraints, nurse could only use up to 3-point restraints (restraining up to three of four extremities).

During an interview on 6/2/2025 at 10:51 a.m. with the ED Registered Nurse (RN 1), RN 1 stated a 4-point restraint would be considered as violent/behavioral restraints. Nurses should never use 4-point restraints as non-violent/behavioral restraints. Nurses should try to use 2-point (restraining up to two extremities) or 3-point restraints before using a 4-point restraint. Nurses should try the least restrictive method first.

During a review of the facility's policy and procedure (P&P) titled, "Non-Violent Behavior," dated 11/2024, the P&P indicated, "To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients' rights ... Policy ... 2. All patients have the right to be free from any form of abuse and neglect. All patients have the right to be free from restraint, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff ... 3. Restraints may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member or others from harm."

Based on interview and record review, the facility failed to ensure staff assessed, evaluated, and documented a patient's behavior to justify the continued use of restraints, when renewing a behavioral restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) order for one of nine sampled patients (Patient 4), in accordance with facility's policy and procedure regarding restraints use, when the physician restraint renewal order and the nursing assessment did not indicate what was Patient 4's behavior, which was indicative of immediate danger to self or others that warrants the use of restraints.

This deficient practice resulted in unnecessary restraints use on Patient 4 from 10 p.m. to 2:30 a.m. (total 4.5 hours) on 4/27/2025 and violated Patient 4's rights to be free from restraints.

Findings:

During a review of Patient 4's "Emergency Department Notes (ED note, assessment notes completed by ED physician)," dated 4/27/2025, the ED note indicated, Patient 4 presented to ED with suicidal (feeling of ending his/her own life) and homicidal (feeling of killing others) ideations. The ED note also indicated Patient 4 was medically cleared (a healthcare professional has assessed a person's health and determined they are fit to participate in a specific activity) and pending psychiatric (specializes in mental health) evaluation.

During a review of Patient 4's "Physician Order Restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body)," dated 4/27/2025, the "Physician Order Restraints," indicated, behavioral restraints with soft bilateral (both) wrists and ankles (4-point restraint) was started on 4/27/2025 at 8:30 p.m. with indication for restraint (must identify the specific behavior requiring restraints such as harming self, hitting, throwing objects): injury to self - hostile threatening self; injury to others - threatening staff, to be violent, pacing, walking towards staff. The "Physician Order Restraints" indicated, time limit for written order was four [4] hours.

During a concurrent interview and record review on 6/3/2025 at 9:36 a.m. with the Nurse Manager of Emergency Department (NM 1), Patient 4's "Restraint Flowsheet," dated 4/27/2025, was reviewed. The "Restraint Flowsheet" indicated, 4-point restraints started on 4/27/2025 at 8:30 p.m. and removed on 4/28/2025 at 2:30 a.m. NM 1 stated Patient 4 was on 4-point restraints for 6 hours.

During a concurrent interview and record review on 6/3/2025 at 9:47 a.m. with the Nurse Manager of Emergency Department (NM 1), Patient 4's "Restraint Flowsheet," dated 4/27/2025, was reviewed. The "Restraint Flowsheet" indicated, Patient 4 was sleeping at 10 p.m., at 12 a.m. and at 2 a.m. per documented assessment. NM 1 stated there was no indication for continuation for restraints. Nurse should have assessed and evaluated the patient and discontinued the restraints as Patient 4 was sleeping.

During a concurrent interview and record review on 6/3/2025 at 9:56 a.m. with the Nurse Manager of Emergency Department (NM 1), Patient 4's "Suicide Prevention Monitor Observation Flowsheet (sitter flowsheet, documentation of patient's behavior and location during 1:1 monitoring [the continuous, direct observation of a patient by a designated staff member])," dated 4/27/2025, was reviewed. The sitter flowsheet indicated Patient 4's behavior as follows:
-At 8:30 p.m.: awake and disruptive; at 9 p.m.: awake and calm; at 9:45 p.m.: awake and sitting quietly; at 10 p.m.: patient (Patient 4) was sleeping. The sitter flowsheet also indicated Patient 4 remained sleeping from 10 p.m. to 2:30 a.m. the next day. NM 1 stated there was no necessity to continue restraints for Patient 4 because Patient 4 was calm and sleeping. NM 1 said the Nurse did not discontinue Patient 4's restraints at the earliest time possible. NM 1 further stated, this (referring to the continued use of restraints even though Patient 4 was calm and sleeping) was a patient's rights violation.

During a concurrent interview and record review on 6/3/2025 at 5:10 p.m. with the Nurse Manager of Emergency Department (NM 1), Patient 4's "CPOE (Computerized Provider Order Entry) Order Report (physician order, orders entered by physician electronically)," dated 4/27/2025, was reviewed. The physician order indicated physician (MD 55) ordered bilateral (both) wrists and ankle restraints on 4/27/2025 at 10:41 p.m. The physician order did not indicate any reason for restraints. NM 1 stated the restraint renewal order did not have any indication for continuation of restraints. NM 1 also stated restraints was unnecessary because Patient 4 had been sleeping since 10 p.m.

During a review of the facility's policy and procedure (P&P) titled, "Restraints: Violent Behavior," dated 12/2021, the P&P indicated, "To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients' rights ... Policy ... 2. All patients have the right to be free from any form of abuse and neglect. All patients have the right to be free from restraint, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. 3. Restraint may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. 4. Restraint may only be imposed to ensure the immediate physical safety of the patient, a staff member or others and must be discontinued at the earliest possible time ... 14. Restraints are discontinued by a trained Registered Nurse (RN) or Licensed Independent Practitioner (LIP) at the earliest possible time, regardless of the length of time identified in the order. Procedure ... 3. Behavioral Health Care restraint use is limited to the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others ... Documentation ... use available electronic health records (EHR) flow sheets and order forms and narrative notes to document all pertinent information in the medical record including but not limited to ... assessment and care provided ... circumstances that led to use restraint."

Based on interview and record review, the facility to ensure that a full History and Physical (H&P, a formal and complete assessment of the patient and the problem) was completed within 30 days and a copy placed in the medical record for one of 10 sampled patients (Patient 1), prior to Patient 1 undergoing a surgical procedure.

This deficient practice had the potential for changes in Patient 1's condition to go undetected including potential risks such as allergies, pre-existing conditions like heart problems and also had the potential for unforeseen complications.

Findings:

During a review of a Patient 1's Face Sheet (a document summarizing a patient's key information in a hospital or clinic setting. It provides a quick overview of a patient's basic details, medical history, and current status), Patient 1's Face Sheet indicated Patient 1 was admitted to the facility on 5/29/2024 with complaints of fibroid (noncancerous growths in the uterus), and pelvic pain (discomfort in the lowest part of the abdomen).

During a review of Patient 1's "Current Physical Assessment," dated 5/29/2025, the Current Physical Assessment indicated the following: Heart: RRR (regular rate and rhythm), Lungs: CTAB (clear to auscultation [the act of listening to sounds within the body, typically using a stethoscope- a medical instrument, to assess the condition of organs like the heart, lungs, and intestines] bilaterally). Abdomen: distended. Genito-urinary (includes organs like the kidneys, bladder, urethra, and the male or female reproductive organs): deferred. Admitting diagnosis: fibroid uterus (non-cancerous growths in the uterus). Plan of treatment: TAH (total abdominal hysterectomy [removal of uterus and cervix])/BSO (bilateral salphingo-oophorectomy, removal of both fallopian tubes [a pair of tubes along which eggs travel from the ovaries to the uterus] and ovaries [One of a pair of female glands in which the eggs form and the female hormones estrogen and progesterone are made]). There were no physical assessments documented for the following: Eyes, ENT (ears, nose, throat), Head, Neck, Breast, Rectal/Pelvic, Muscle-Skeletal, Skin, Neurology (encompasses the brain, spinal cord [a cylinder-shaped tube of tissue that runs through the center of your spine, from your brainstem to your lower back], nerves, and muscles), Laboratory, EKG (electrocardiography, a recording of the heart's electrical activity through repeated cardiac cycles), X-rays (used in medical imaging to create pictures of the inside of the body, particularly bones and other dense structures).

During a review of Patient 1's "Interval History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/29/2025, the Interval H&P indicated "I have evaluated this patient and there is no significant change from the most current history and physical ..."

During a review of Patient 1's outpatient office visit titled, "History of Present Illness (HPI, a detailed chronological account of a patient's current symptoms)," dated 4/23/2025, the History of Present Illness indicated the following: Patient 1 presented for Consult. Patient 1 with enlarged fibroid uterus ...Past medical history of Diabetes (high blood sugar, hypertension (high blood pressure) and anxiety (a common human emotion, characterized by feelings of unease, worry, and apprehension, often accompanied by physical symptoms like increased heart rate and sweating) ...No known allergies ...Physical Exam of the body systems: Eyes, Respiratory, Cardiovascular (a general term for conditions affecting the heart and blood vessels), Genitourinary, Musculoskeletal, Extremity, Neurological, and Psychiatric (specializes in mental health) ...Patient Plan: The following procedures were recommended and described in full to the patient (Patient 1): Exploratory laparotomy (a surgical procedure where the abdomen is opened to examine the abdominal organs), total abdominal hysterectomy, bilateral salpingo-oophorectomy ...

During a review of Patient 1's "Operative Note," dated 5/29/2025, the Operative Note indicated an Exploratory Laparotomy, total abdominal hysterectomy, bilateral salphingo-oophorectomy and resection of umbilical hernia (intestine protrudes through the abdominal muscles at the belly button), were performed.

During a concurrent interview and record review on 6/3/2025 at 10:12 a.m. with the Nurse Manager (NM) 2, NM 2 stated the following: Patient 1 was admitted on 5/29/2025. Patient 1 underwent a surgical procedure on 5/29/2025. Patient 1's "History of Present Illness" was conducted over 30 days from admission, on 5/29/2025. A complete H&P was not documented in Patient 1's medical record within 24 hours of being admitted to the facility or at least updated from a full H&P within 30 days of admission or surgical procedure.

During a second interview on 6/3/2025 at 11:28 a.m. with the Nurse Manager (NM) 2, NM 2 verified that the facility's Medical Staff Bylaws (a set of rules and regulations that govern the structure, conduct, and responsibilities of the hospital's medical staff) indicated that a full H&P needed to be completed within 24 hours of admission or if a previous H&P existed, it should be within 30 days. NM 2 verified that Patient 1 had a surgical procedure without a current and full H&P to assess for any changes.

During a review of the facility's "Medical Staff Bylaws," dated 10/31/2000, the Medical Staff Bylaws indicated the following: Responsibilities of the Medical Staff Members ... Each staff member shall ... Complete a brief written admitting note and a dictated history and physical (H&P) examination on all patients within 24 hours of admission. All history and physicals performed by other than attending physician must be reviewed for completeness, corrected, and signed, when necessary, by the attending physician. A full H&P is required for all patients admitted for inpatient care ... It should address the following.
(a) A chief complaint
(b) Details of the present illness
(c) Past medical and surgical history
(d) Relevant past Psycho-Social History
(e) Family history
(f) Allergies
(g) Current medications
(h) A physical examination inventoried by body systems ...

An interval H&P may be used to update a full H&P in the following circumstances:
(a) There are no significant changes the findings contained in the full or abbreviated H&P since the time such H&P was performed.
(b) There are no significant changes and document what those changes are.
Time Frames for Completion of H&P Report.
(a) The H&P for each patient shall be completed and placed on the record up to 24 hours prior to the admission, or registration, but not more than 30 days, and no later than 24 hours after the patient's admission or registration, unless the patient will be taken to surgery requiring anesthesia services before that time, in which case the H&P report must be placed in the patient's chart before the patient is taken to surgery ...