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Based on document review and interview, the facility failed to renew restraint order every 4 hours in 1 of 2 patient (Patient 6) medical records reviewed, failed to document patient assessment to determine renewal of restraint order within 4 hours of initial placement in 1 of 2 patient (Patient 6) medical records reviewed, failed to document 15-minute monitoring safety checks for 1 of 2 patient (Patient 6) medical records reviewed, failed to document the 1 hour face to face assessment after restraint placement for 1 of 2 patient (Patient 1) medical records reviewed, failed to document the patient's behavior response to the restraint intervention for 1 of 2 patients (Patient 6) medical records reviewed, failed to document reassessment and rationale for continued use after the initial restraint placement for 1 of 2 patients (Patient 6) medical records reviewed, and failed to ensure appropriate staff initiated application of restraints in 1 of 2 patient (Patient 6) medical records reviewed.

The cumulative effects of these systemic problems resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview, the facility failed to renew restraint order every 4 hours in 1 of 2 patient (Patient 6) medical records reviewed.

Findings include:

1. Facility Policy titled, Use of Restraints and Seclusion, Publication Date 05/26/2022, indicated under VI. Procedures, C. Use of Physical Restraints, Seclusion, Chemical Restraint, or Hold for Violent Behavior, 6. The need to continue or ability to discontinue restraints/seclusion renewal process: When the order is near age appropriate renewal, RN assesses patient for readiness to discontinue. a. If patient meets criteria for discontinuation, end restraint or seclusion intervention and document. b. If patient needs to remain in restraints/seclusion, contact LIP to share findings and request renewal. c. Repeat process as needed for up to 24 consecutive hours; Adults (18 or older), renew every 4 hours.

2. Review of Patient 6's medical record indicated on 04/05/2024 at 2:55 a.m. the provider ordered application of four point/four extremities restraints for violent behavior; restraints applied to patient at 3:06 a.m. On 04/05/2024 the medical record indicated the provider ordered four point/four extremities restraints at 7:55 a.m. Medical record lacked documentation the restraints were completely removed prior to and/or at the expiration time of 4 hours of the initial order. Medical record indicated the renewal order was 5 hours after the initial restraint order.

3. Interview with A3 (Clinical Nurse Specialist) on 07/08/2024 at approximately 1:20 p.m., confirmed that patient 6's medical record lacked documentation that the restraints were completely removed from patient after 4 hours of initial application and the restraint renewal order not completed within 4 hours of initial restraint placement.

Based on document review and interview, nursing services failed to document patient assessment to determine renewal of restraint order within 4 hours of initial placement in 1 of 2 patient (Patient 6) medical records reviewed and failed to document 15-minute monitoring safety checks for 1 of 2 patient (Patient 6) medical records reviewed.

Findings include:

1. Facility Policy titled, Use of Restraints and Seclusion, Publication Date 05/26/2022, indicated under VI. Procedures, C. Use of Physical Restraints, Seclusion, Chemical Restraint, or Hold for Violent Behavior, 6. The need to continue or ability to discontinue restraints/seclusion renewal process: When the order is near age appropriate renewal, RN assesses patient for readiness to discontinue. a. If patient meets criteria for discontinuation, end restraint or seclusion intervention and document. b. If patient needs to remain in restraints/seclusion, contact LIP to share findings and request renewal. c. Repeat process as needed for up to 24 consecutive hours; Adults (18 or older), renew every 4 hours; 8. Monitoring includes: d. Minimum documentation of on-going monitoring, i. Every fifteen (15) minutes team members documents elements focused on Patient Safety.

2. Review of Patient 6's medical record indicated on 04/05/2024 at 2:55 a.m. the provider ordered application of four point/four extremities restraints for violent behavior; restraints applied to patient at 3:06 a.m. On 04/05/2024 the medical record indicated the provider ordered four point/four extremities restraints at 7:55 a.m. Medical record lacked documentation of an assessment to determine the continuation of restraints within 4 hours after initial application; Medical record indicated on 04/05/2024 at 3:05 a.m. restraints were applied and removed on 04/05/2024 at 9:37 a.m and lacked documentation of the 15-minute monitoring safety checks for duration the restraints were applied.

3. Interview with A3 (Clinical Nurse Specialist) on 07/08/2024 at approximately 1:20 p.m., confirmed that patient 6's medical record lacked documentation of patient assessment to determine renewal of restraint order and lacked documentation of 15-minute monitoring patient safety checks for the duration the restraints were applied.

Based on document review and interview, the facility failed to document the 1 hour face to face assessment after restraint placement for 1 of 2 patient (Patient 1) medical records reviewed.

Findings include:

1. Facility Policy titled, Use of Restraints and Seclusion, Publication Date 05/26/2022, indicated under VI. Procedures, C. Use of Physical Restraints, Seclusion, Chemical Restraint, or Hold for Violent Behavior, 5. Perform Face to Face evaluation within 1 hour. b. The face-to-face evaluation shall be completed within 1 hour of the patient being restrained or secluded and include the following: i. The patient's immediate situation. ii. The patient's reaction to the intervention., iii. The patient's medical and behavioral condition including a review of systems assessment, behavioral assessment, and an assessment of the patient's history including drugs, medications, and recent lab results etc that may contribute to their violent or self-destructive behavior. (CMS), iv. The need to continue or terminate the restraint and/or seclusion.

2. Review of Patient 1's medical record indicated that the patient was placed in 4-way restraints on 04/05/2024 at 6:05 p.m., and the medical record lacked documentation of the 1-hour face to face assessment.

3. Interview with A3 (Clinical Nurse Specialist) on 07/08/2024 at approximately 11:15 a.m. confirmed that patient 1's MR lacked documentation of the 1-hour face to face assessment.

Based on document review and interview, the facility failed to document the patient's behavior response to the restraint intervention for 1 of 2 patients (Patient 6) medical records reviewed and failed to document reassessment and rationale for continued use after the initial restraint placement for 1 of 2 patients (Patient 6) medical records reviewed.

Findings include:

1. Facility Policy titled, Use of Restraints and Seclusion, Publication Date 05/26/2022, indicated under VI. Procedures, C. Use of Physical Restraints, Seclusion, Chemical Restraint, or Hold for Violent Behavior, 8. Monitoring includes: c. Decision to Continue or Discontinue; The need for continued restraint use is determined by assessing the presence or absence of the circumstance triggering the restraint use. Possible assessment include patient's mental status, cognitive functioning, level of distress or agitation and continued presence of the medical device that triggered restraint application. d. Minimum documentation of on-going monitoring, i. Every fifteen (15) minutes team members documents elements focused on Patient Safety; ii. Every one (1) hour staff assigned to the patient documents the above elements and additional Patient Comfort elements; iii. Every one (1) hour RN assigned to the patient documents decision to continue or discontinue

2. Review of Patient 6 medical record indicated that the patient was placed in 4-way restraints on 04/05/2024 at 3:05 a.m. and removed on 04/05/2024 at 9:37 a.m.; the medical record lacked documentation of the of the patient's response to the restraint intervention for the duration of the restraint were applied and lacked documentation of the reassessment to continue the restraints after the initial restraint placement.

3. Interview with A3 (Clinical Nurse Specialist) on 07/08/2024 at approximately 1:20 p.m., confirmed that patient 6's medical record lacked documentation of patient's response to the restraint intervention for the duration of the restraints were applied and lacked documentation of the reassessment to continue the restraints after the initial restraint placement.

Based on document review and interview, nursing services failed to ensure appropriate staff initiated application of restraints in 1 of 2 patient (Patient 6) medical records reviewed.

Findings include:

1. Facility Policy titled, Use of Restraints and Seclusion, Publication Date 05/26/2022, indicated under Forms/Appendices, Attachment, Role-Based Responsibilities, Column, Role: Attending MD, Licensed Independent Practitioner (LIP), RN, LPN, CAN, PCA, PCI, CTUS, EMT (at the direction of a RN), and Ancillary Therapy Roles (PT, RT, OT); Column, Initiate: Attending MD, Licensed Independent Practitioner (LIP), and RN.

2. Review of Patient 6's medical record indicated that S2 (Behavioral Health Technician) documented the initial placement of restraints on 04/05/2024 at 3:06 a.m.

3. Interview with A3 (Clinical Nurse Specialist) on 07/08/2024 at approximately 1:20 p.m., confirmed that patient 6's medical record indicated the initiation of the restraints was documented by S2 (Behavioral Health Therapist) who cannot initiate restraints.