HospitalInspections.org

Based on a review of hospital record and interviews, it was determined that the hospital failed to ensure that a provider order was received when patient #11 required a physical restraint. This deficient practice poses the risk of patients being restrained unnecessarily, the use of restraint as a punishment, increased risk of injury to the patient being restrained, and the right of the patient to have an environment free from abuse.

Findings include:

The policy titled, "Restraint use for Non-violent and Violent situations revealed": Behavioral/Violent Restraint: Restraint or Seclusion used to manage violent or self-destructive behavior; i.e. danger to self (DTS) or danger to others (DTO) that poses an imminent danger to the physical safety of the patient, staff or others, regardless of the
patient ' s location...B. Physical Holding: Patients may be physically held for the purpose of conducting physical examinations or tests. However, patients do have the right to refuse treatment, including the right to refuse
physical examinations or tests. Holding a patient in a manner that restricts the patient ' s movement against the patient ' s will is considered a restraint. The use of force in order to medicate a patient against their will, even when court ordered, is considered a restraint. Staff may only use Banner approved physical hold techniques as taught per Workplace Violence Prevention training. C. A physician/LIP order is required prior to the initiation of Restraints or Seclusion. Exception: In emergency situations, Restraints and Seclusion may be applied prior to the Registered Nurse (RN) obtaining the order; however, an order must be obtained duringor immediately (within a few minutes) after the application of Restraints...."

During review of Patient #11 medical record was revealed that on 07/30/2025 at 2135 patient became confused agitated, and aggressive towards staff. Attempting to kick, bite and headbutt staff. Security staff was called to intervene. Further review of Patient #11 medical record revealed that patient was physically restrained to prevent injury or harm to patient #11 and staff. Further review of Patient #11 revealed that patient #11 did sustain skin tear to left and right arms during the physical hold. Further review of Patient #11 medical record revealed that there was no restraint order for the physical hold that occurred on 07/30/2025.

An interview with employee #4 on 08/19/2025 confirmed that the policy for restraint use was not followed and there was no order for restraint in Patient #11 medical record.