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Based on a review of six open and five closed medical records, including two restraint records, it was determined the hospital failed to discontinue the use of restraints for patient #7 at the earliest possible time.

Patient #7 was brought to the emergency department via an emergency petition for a mental health evaluation. Per patient #7's medical record, patient #7 was justifiably placed in 4 point violent restraints at 1220. Review of restraint documentation titled "Section #2. Justification Record" the RN documented for time of restraint release: "By 1300 (right) upper extremity was free. At 1345 (left) hand freed. Both lower extremities discontinued at 1615."

A nursing note at 1630 which referred to the nursing restraint documentation of 1345, stated; "Pt is calm, so the 2nd upper extremity will be free from restraints." Patient # 7 was described as "calm" at the release of the second upper extremity restraint yet remained in bilateral lower extremity restraints for 2 hours and 30 minutes. Per a provider note at 1339, patient was also described as "better more calm." No justification was provided to keep patient in bilateral lower restraints for that time.

In summary, no regulatory provision allows for incremental release of a patient who has met behavioral criterion for release from restraint. Further, no documentation revealed justification for the continuance of patient #7's restraint between the hours of 1300 and 1615. Therefore, the hospital failed to discontinue restraint at the earliest possible time.

Based on a review of six open and five closed medical records, including two restraint records, and hospital policy it was determined the hospital failed to document monitoring of patient #7 while in violent restraints.

Per hospital policy titled, "Use of Restraint and Seclusion, 901-037" (last reviewed 07/2017) for the section titled "Seclusion and Restraint for Violent/ Self Destructive Behavior" under "Observation, Assessment and Monitoring" it stated "1. Asses the patient and document at least evert 15 minutes." Subcategories included: "Rational for continuation (assessment done by the RN every hour)" and "An RN must assess the patient hourly for the continued need for restraint or seclusion."

Patient #7 was brought to the emergency department via an emergency petition for a mental health evaluation. Per patient #7's medical record, patient #7 was placed in 4 point violent restraints at 1220 and released at 1615.

Review of patient #7 medical record revealed no documentation for the 15 minute monitoring as per policy. Patient was on 1:1 observation during the restraint episode until 1445 per comment on the face-to-face form that stated. "pt was on 1:1 care from arrival until 1445." Additionally, a nursing assessment was documented at 1333 but there were no further RN assessments or a rationale for continuation of the restraints for every hour patient was in restraints. Vitals were documented three times during the restraint episode.

Based on a review of six open and five closed medical records, including two restraint records, it was determined the hospital failed to document a complete face-to-face evaluation within one hour of initiation of restraints for violent behavior for patient #7.

Patient #7 was brought to the emergency department via an emergency petition for a mental health evaluation. Per patient #7's medical record, patient #7 had an order and was placed in 4 point violent restraints at 1220.

While patient had a review of systems and physical exam documented by an emergency department provider at 1236 no provider documentation referenced the fact that patient #7 was in restraints. Patient #7 was re-evaluated by the provider around 1339 and was described to be "better more calm ...." however, the provider failed again to reference the fact that patient #7 was in restraint, and failed to document whether patient #7 should be continued or terminated from restraint.

Further review of patient #7's record revealed a blank form titled "Section #3 Face to Face Evaluation Note by Trained Nurse/Nurse Manager/Nursing Supervisor." Except for the Registered Nurse signature, date, and comment next to "Time Patient Seen". None of the four elements of the face-to-face were documented on the sheet. A "Nursing Assessment: Head-To-Toe" was documented at 13:33 that justified the reason for use of restraints however it did not address whether patient #7 should be continued or terminated from restraint.

In Summary, while patient #7 was seen and evaluated by a provider after the initiation of restraints, no provider assessment related to the fact that patient #7 was in restraints. Finally, neither the provider nor the nurse assessed for the requirement if patient #7 should be continued or terminated from restraints and the patient's reaction to the intervention.

Based on a review of six open and five closed medical records, including two restraint records, and hospital policy it was determined the hospital failed to continue restraints in a safe manner for patient #7.

Patient #7 was brought to the emergency department via an emergency petition for a mental health evaluation. Per patient #7's medical record, patient #7 was justifiably placed in 4 point violent restraints at 1220. Review of restraint documentation titled "Section #2. Justification Record" the RN documented for time of restraint release: "By 1300 (right) upper extremity was free. At 1345 (left) hand freed. Both lower extremities discontinued at 1615."

Based on documentation, nursing continued patient #7 in two-point ankle restraints from 1345 until 1615, a period of 2.5 hours. Additionally, per the face-to-face document, 1:1 observation was only continued till 1445. The sequence of release made it more likely that if the patient had become agitated or attempted to leave the bed, patient #7 could have injured themselves while being monitored and especially when 1:1 observation was discontinued at 1445. Therefore, the hospital failed to continue restraints in a safe manner.

Based on a review of six open and five closed medical records, including two restraint records, it was determined the hospital failed to keep accurate documentation for patient #7.

Patient #7 was brought to the emergency department via an emergency petition for a mental health evaluation. Per patient #7's medical record, patient #7 was justifiably placed in 4 point violent restraints at 1220.

An order at 1226 by the provider read "Insert Foley Catheter I&O (in and out, or one time insertion of a urinary catheter to get a urine specimen with immediate removal of the catheter) cath if needed for tox (toxicology) and u/a (urinalysis)." Per the nursing assessment note at 1333 for the assessment of "Genitourinary ....:" it was documented "Pt was in/cath." The results of the urinalysis (u/a) and urine toxicology screen were noted at 1317.

Because the documentation was so poor, it was not possible to determine how long the catheter was in place and if in fact it was an indwelling catheter versus an in-out catheterization. For instance, the RN assessment note stated "in/cath" with no explanation. No documentation was found regarding a urine output, or whether the patient was able to urinate voluntarily at that time.