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Based on medical record review, policy review and interview, the facility failed to obtain orders for violent restraints in accordance with its policy for one, Patient #8, of one medical record reviewed for restraints.

Findings include:

The facility's Restraint and/or Seclusion Use Procedure for Violent/Self-Destructive Behavior (VSD) policy (Effective Date 05/10/22) stated:

3. Restraint Orders/Registered Nurse:
Orders requirements:
· Identification as a verbal/telephone order (as applicable)
· Date and time patient place in restraint/seclusion
· Duration of restraint/seclusion use
· Specific clinical justification/reason for restraint/seclusion
· Type of restraint, extremity or body part to be restrained (as applicable)
· Type of seclusion: locked/unlocked

4. Restraint Orders Physician/LIP (Licensed Independent Practitioner)

· The physician/LIP conducts an in-person evaluation within one hour of initiation of the restraints or seclusion and physical holding for forced medication even if the patient was released by the time the physician/LIP arrives.
· The physician/LIP signs the verbal/telephone order at time of in-person evaluation.
· Frequency of orders; every 1 hours (age less than 9 years), 2 hours (ages 9-17 years) or 4 hours (18 years or older) to assess if restraints or seclusion needs to be continued.

The medical record for Patient #8 contained orders on 06/01/22, 06/02/22, 06/03/22, 06/04/22, 06/05/22 and 06/06/22 for restraints for nonviolent behavior. The medical record did not contain an order for restraints for violent behavior. The medical record for Patient #8 contained the following entries:

On 06/03/22 restraints were removed; however patient was violent again on 06/04/22 and restraints were placed back.

Service Date 06/01/22 10:43 AM - Called by the nursing staff patient getting very agitated hitting the staff.

Service Date: 06/01 /22 11:48 AM- A family member was present in the room. The patient was in soft restraints. I was informed that the patient hit his son earlier today. Also the patient was out in the hallway and refused to come back and until security was called.

Service Date: 06/04/22 8:10 AM - Patient's condition changed to become more delirious confused agitated. Four-point restraints were placed.

Service Date: 06/05/22 10:34 AM - Patient's condition changed to become more delirious confused agitated. Four-point restraints were placed.

Service Date: 06/06/22 9:36 AM - One of his daughters was visiting. He was in soft restraints. He was oblivious to that. He had been out of restraints, but I was informed that he attacked a staff yesterday and was put back in restraints.

The findings were shared with Staff A on 06/08//2 at 9:34 AM and confirmed.

Based on medical record review, policy review and interview, the facility failed to ensure orders for restraints included the time the order was given for one (Patient #8) of one medical record reviewed for restraints.

Findings include:

The facility's Restraint Use Procedure for Non-Violent/Non-Self-Destructive Behavior procedure (Effective 05/10/22) was reviewed. It stated:
Order requirements:

· Identification as verbal /telephone (as applicable)
· Date and time patient was placed in restraint
· Specific clinical justification reason for restraint
· Type of restraint extremity or body part to be restrained (as applicable)

The medical record for Patient #8 contained orders from 06/01/22 through 06/06/22 for nonviolent restraints. The 06/01/22, 06/02/22, 06/03/22, 06/05/22 and 06/06/22 orders did not include the time the orders were written.

The findings were shared with Staff A on 06/08/22 at 9:43 AM and confirmed.

Based on observations, policy review and interview, the facility failed to discard of full sharps containers in accordance with its policy for one unit (Unit 8) out of four nursing units observed.

Findings include:

The facility's Bloodborne Pathogens Exposure Control Plan policy (Policy:3.00, Revised 02/2020) was reviewed. It stated:

4. Some examples of engineering and work practice controls currently used are listed below:

a. plastic capillary tubes in the Clinical Laboratory
b. needleless IV (intravenous) system
c. blunt suture needles
d. sharps disposal containers - These are reusable and are checked and replaced by an outside vendor weekly. EVS (environmental services) can also replace if noted to be ¾ full between service checks by the vendor.

On 06/06/22 at 1:20 PM, a Workstation on Wheels (WOW) located on the 8th floor nursing unit was observed with a sharps container filled to the top.

The findings were shared with Staff A on 06/06/22 at 1:20 PM and confirmed.