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Based on document reviews and interviews, the hospital failed to ensure the hospital's policy for restraints and seclusion, related to the documenting of less restrictive measures tried before applying restraints, was implemented for three (3) of five (5) restrained patients (Patient #2R, #3R and #4R).

Findings:

The "Southern Region Use of Restraints" policy, last revised 05/19/2025, states in part, "Guidelines: Restraint for Violent, Self-Destructive Behavior/ Seclusion ... The trained RN documentation at the time of initiation of restraint will document the following on the Violent Self Destructive flow sheet in the EHR a. Assessment of the patient's behavior leading to restraint b. Less restrictive alternatives considered or used, as appropriate to the situation, and why these alternatives proved ineffective."

In addition, it also states "Guidelines: Restraint for Non-Violent, Non-Self-Destructive Behavior ... Assessment of the patient and the circumstances should be completed prior to the application of a restraint, if possible.
The assessment must include the following [In part]:
· Less restrictive alternatives considered or used, as appropriate to the situation, and why these alternatives proved ineffective.
· Least restrictive alternatives should be implemented first. If the alternatives prove to be ineffective. Document on the Non-Violent Non Self destructive flow sheet in the EHR."

On 06/18/2025 from 9:00 AM to 10:00 AM, five (5) patients' medical records that were restrained were reviewed with the Clinical Informatics Specialist.

1. Documentation in Patient #2R's record indicated that:
- On 03/19/2025 at 2:28 PM, Provider #2 ordered bilateral soft wrist restraints;
- On 03/19/2025 at 2:29 PM, Registered Nurse ("RN") #5 applied bilateral soft wrist restraints;
- RN #5 documented that Patient #2R had the restraints discontinued on 03/20/2025 at 8:29 AM; and
- There was no documented evidence in the medical record that would show that less restrictive measures were attempted prior to applying the restraints.

2. Documentation in Patient #3R's record indicated that:
- On 03/09/2025 at 2:07 PM, Provider #4 ordered a manual hold;
- On 03/09/2025 at 2:13 PM, RN #1 documented in part, "...Order obtained for IM [IntraMuscular] Zyprexa. Permission to give med against objection by spouse ... Security called to assist with giving the injection IM ... 5mg IM Zyprexa given at 1410 [2:10 PM] ... ."
- There was no restraint flowsheet documentation completed by an RN; and
- There was no documented evidence in the medical record that would show that less restrictive measures were attempted prior to applying the restraints.

3. Documentation in Patient #4R's record indicated that:
- On 05/27/2025 at 3:25 AM, RN #7 documented in part, "... pt [patient] to be placed in restraints and medicated for further eval."
- On 05/27/2025 at 3:34 AM, Provider #5 ordered four-point restraints;
- There was no restraint flowsheet documentation completed by an RN; and
- There was no documented evidence in the medical record that would show that less restrictive measures were attempted prior to applying the restraints.

On 06/18/2025, the above findings were confirmed at the time of the review by the Clinical Informatics Specialist.

Based on document reviews and interviews, the facility failed to ensure the use of restraint or seclusion was in accordance with the provider order for one (1) of five (5) patients reviewed (Patient #3R).

Finding:

The "Southern Region Use of Restraints" policy, last revised 05/19/2025, states in part, "Violent, self-destructive behaviors: Assessment for psychological status/behaviors/ circulation/ skin integrity, patients' dignity, privacy and comfort maintained and progress towards release is assessed and documented approximately every 15 minutes. 4. Non-violent, non-self-destructive behaviors: Assessed for safety and continued need at a minimum of approximately every 2 hours. Assessment includes patient dignity, privacy and comfort maintained, nutrition and hydration, elimination, circulation/ skin integrity, range of motion and progress towards release. 5. Violent, self-destructive behaviors a. Patients in violent, self-destructive restraints or seclusion always require direct observation by a trained staff member. b. Violent, self-destructive (including seclusion) requires a face-to-face assessment, where the trained provider or trained designee must complete an in person, face to face evaluation of the patient within 1 hour from the onset of restraint, even if the restraint has been discontinued, to evaluate: i. the patient's immediate situation, ii. the patient's reaction to the intervention, iii. the patient's medical and behavioral condition and iv. the need to continue or discontinue the restraint. c. Consultation with the Attending/covering Attending should occur as soon as possible and include: i. a discussion of the findings of the 1-hour face to face evaluation ii. the need for other interventions or treatments, and iii. the need to continue or discontinue the use of restraint or seclusion."

On 06/18/2025 from 9:00 AM to 10:00 AM, five (5) patients' medical records that were restrained were reviewed with the Clinical Informatics Specialist.

1. Documentation in Patient #3R's record indicated that:
- On 03/01/2025 from 10:22 AM, Provider #6 ordered non-violent restraint soft bilateral wrist restraints was ordered;
- On 03/01/2025 from 10:22 AM through 10:45 AM, Registered Nurse ("RN") #2 documented on the restraint flowsheet that soft bilateral wrist restraints were applied;
- On 03/01/2025 at 10:45 AM, RN #2 documented, "Temporary restraints for combative behavior, were not ordered as violent, discontinued approx.. 20 min once behavior improved";
- Based on the above, the intent of the restraint type, per the nursing documentation, did not match the order by the provider;
- There was no documented evidence that a violent restraint was ordered on 03/01/2025 for Patient #3R; and
- Therefore, the requirements for violent restraints were not followed, per hospital policy.

On 06/18/2025 from 9:00 AM to 10:00 AM, the above findings were confirmed at the time of the review by the Clinical Informatics Specialist.

Based on document reviews and interviews, the hospital failed to ensure a restraint was discontinued at the earliest time possible for two (2) of five (5) patients (Patient #1R and #3R).

Findings:

The "Southern Region Use of Restraints" policy, last revised 05/19/2025, states in part, "Guidelines: Restraint for Violent, Self-Destructive Behavior/ Seclusion ... Documentation of the termination of restraint will be documented on the Violent Self Destructive flowsheet in the EHR, and the trained RN must discontinue the order in the electronic documentation system. (Choose "no longer clinically indicated" from dropdown list). The plan of care should be completed."

On 06/18/2025 from 9:00 AM to 10:00 AM, five (5) patients' medical records that were restrained were reviewed with the Clinical Informatics Specialist.

1. Documentation in Patient #1R's record indicated that:
- On 02/04/2025 at 1:02 AM, Registered Nurse ("RN") #6 applied four-point restraints;
- On 02/04/2025 at 1:43 AM, Provider #1 ordered four-point restraints;
- On 02/04/2025 at 8:45 AM, RN #6 documented that "no progress" had been made towards the release of the four-point restraints with no further documentation; and therefore,
- It could not be determined if the restraint was discontinued at the earliest possible time.

2. Documentation in Patient #3R's record indicated that:
- On 03/09/2025 at 2:07 PM, Provider #4 ordered a manual hold;
- On 03/09/2025 at 2:13 PM, RN #1 documented in part, "...Order obtained for IM [IntraMuscular] Zyprexa. Permission to give med against objection by spouse ... Security called to assist with giving the injection IM ... 5mg IM Zyprexa given at 1410 [2:10 PM] ... ."
- There was no restraint flowsheet documentation completed by an RN; and
- Therefore, it could not be determined if the restraint was discontinued at the earliest possible time.

On 06/18/2025, the above findings were confirmed at the time of the review by the Clinical Informatics Specialist.

REPEAT DEFICIENCY

Based on document reviews and interviews, the hospital failed to ensure the condition of a patient, who was in restraints, was monitored in accordance with hospital policy for two (2) of five (5) patients reviewed (Patient #3R and #4R).

Findings:

During a recent complaint survey on 04/07/2025, the hospital was in substantial compliance with 42 Code of Federal Regulations, Part 482, Conditions of Participation: Patient Rights (§482.13). However, there was a following standard level requirement that was not met. Based on document reviews and interviews, the hospital failed to ensure the condition of a patient, who was in restraints, was monitored every two (2) hours in accordance with hospital policy for one (1) of five (5) patients reviewed (Patient #4R). On 4/07/2025 at approximately 1:00 PM, Patient 4R's medical record was reviewed with the Clinical Informatics Specialist. This review indicated the following: - On 2/12/2025 at 11:00 PM, Patient #4 had soft bilateral wrist restraints applied; - On 2/16/2025 from 2:37 PM until 8:57 PM (a duration of five (5) hours and twenty (20) minutes), there was no documentated evidence of the required monitoring; and - On 2/17/2025 at 6:49 PM, the restraints were discontinued. On 4/07/2025 at approximately 1:00 PM, this finding was confirmed by the Clinical Informatics Specialist at the time of the review.

The "Southern Region Use of Restraints" policy, last revised 05/19/2025, states in part, "1. The trained RN documentation at the time of initiation of restraint will document the following on the Violent Self Destructive flow sheet in the EHR a. Assessment of the patient's behavior leading to restraint b. Less restrictive alternatives considered or used, as appropriate to the situation, and why these alternatives proved ineffective. c. Date, time and type of restraint used. d. Request for a security officer, if circumstances are warranted. e. The patient's response to the use of restraint. f. Notification and education provided to the patient/family regarding the necessity. 2. The trained RN ongoing documentation will include the following at a minimum of approximately every 15 minutes on the Violent Self Destructive flow sheet in the EHR. 3. Criteria to determine if a restraint meets the requirements. 4. Documentation of the termination of restraint will be documented on the Violent Self Destructive flowsheet in the EHR, and the trained RN must discontinue the order in the electronic documentation system. (Choose "no longer clinically indicated" from dropdown list). The plan of care should be completed."

In addition, it states, "Holding a patient in a manner that restricts the patient's freedom of movement against the patient's will is considered a violent/self-destructive restraint. An example is the application of force to physically hold a patient, to administer a medication against the patient's wishes, is considered a restraint. This intervention should be a temporary measure; if a longer hold is necessary, alternative restraint types should be considered."

On 06/18/2025 from 9:00 AM to 10:00 AM, five (5) patients' medical records that were restrained were reviewed with the Clinical Informatics Specialist.

1. Documentation in Patient #3R's record indicated that:
- On 03/09/2025 at 2:07 PM, Provider #4 ordered a manual hold;
- On 03/09/2025 at 2:13 PM, Registered Nurse ("RN") #1 documented in part, "...Order obtained for IM [IntraMuscular] Zyprexa. Permission to give med against objection by spouse ... Security called to assist with giving the injection IM ... 5mg IM Zyprexa given at 1410 [2:10 PM] ... ."
- There was no restraint flowsheet documentation completed by an RN; and
- There was no documented evidence in the medical record that would show that the patient was monitured while being restrained.

2. Documentation in Patient #4R's record indicated that:
- On 05/27/2025 at 3:25 AM, RN #7 documented in part, "... pt [patient] to be placed in restraints and medicated for further eval."
- On 05/27/2025 at 3:34 AM, Provider #5 ordered four-point restraints;
- There was no restraint flowsheet documentation completed by an RN ; and
- There was no documented evidence in the medical record that would show that the patient was monitured while being restrained.

On 06/18/2025, the above findings were confirmed at the time of the review by the Clinical Informatics Specialist.

Based on document reviews and interviewed, the hospital failed to ensure that staff ordering and applying restraints had the required training per hospital policy for two (2) Registered Nurses ("RNs") and one (1) Provider involved in the ordering and applying of restraints (RN #4, RN #5 and Provider #6).

Findings:

The "Southern Region Use of Restraints" policy, last revised 05/19/2025, states in part, "All staff who are involved with the application of a restraint, implementation of seclusion, providing care for a patient in restraint or seclusion, or assessment and monitoring the condition of the violent self-destructive restrained or secluded patient, will receive training based on their duties and responsibilities. Training occurs prior to performing restraint application and on a periodic basis."

In addition, it states, "A trained licensed practitioner, trained provider or designee must issue the order to initiate restraint or seclusion. ... Apply restraints with a trained team of staff to prevent patient or staff injury."

On 06/18/2025 from 9:00 AM to 10:00 AM, five (5) patients' medical records that were restrained were reviewed with the Clinical Informatics Specialist.

The following was identified:
1. Documentation in Patient #2R's record indicated that:
- On 03/08/2025 at 4:34 AM, RN #5 applied bilateral soft limb restraints; and
- RN #5 had restraint training on 09/16/2021.

Based on the above finding, RN #5 did not meet the requirements to be involved with the restraint of Patient #2R.

2. Documentation in Patient #2R's record indicated that:
- On 03/12/2025 at 10:15 AM, RN #4 was involved with the discontinuation of restraints; and
- RN #4 last had restraint training on 01/17/2022, upon hire.

Based on the above finding, RN #4 did not meet the requirements to be involved with the restraint of Patient #2R.

3. Documentation in Patient #3R's record indicated that:
- On 03/01/2025 at 10:22 AM, Provider #6 ordered restraints; and
- Provider #6 had no documented training prior to 03/05/2025.

Based on the above finding, Provider #6 did not meet the requirements to be involved with the restraint of Patient #3R.

On 06/18/2025 at approximately 1:30 PM, the Senior Director, Regional Accreditation and Regulatory Affairs confirmed the above findings.

Based on document reviews and interviews, the hospital failed to ensure that staff member's personnel record contained documentation of the required training for three (3) of sixteen (16) staff who had been involved in the restraint of a patient (Registered Nurse ("RN") #4, RN #5 and Provider #4).

Findings:

The "Southern Region Use of Restraints" policy, last revised 05/19/2025, states in part, "All staff who are involved with the application of a restraint, implementation of seclusion, providing care for a patient in restraint or seclusion, or assessment and monitoring the condition of the violent self-destructive restrained or secluded patient, will receive training based on their duties and responsibilities. Training occurs prior to performing restraint application and on a periodic basis."

In addition, it states, "A trained licensed practitioner, trained provider or designee must issue the order to initiate restraint or seclusion. ... Apply restraints with a trained team of staff to prevent patient or staff injury."

1. RN #4:
- On 03/12/2025, RN #4 was involved in the care of Patient #2R when he/she was restrained;
- On 06/18/2025, RN #4's training records were reviewed and indicated that RN #4 had completed training on restraints on 01/17/2022; and
- As of 06/18/2025, there was no evidence provided to the surveyor that indicated RN #4 had completed training on restraints since 01/17/2022.

2. RN #5:
- On 03/08/2025, RN #5 was involved in the care of Patient #2R when he/she was restrained;
- On 06/18/2025, RN #5's training records were reviewed and indicated that RN #5 had completed training on restraints on 09/16/2021; and
- As of 06/18/2025, there was no evidence provided to the surveyor that indicated RN #5 had completed training on restraints since 09/16/2021.

3. Provider #6:
- On 03/01/2025, Provider #6 ordered restraints for Patient #3R;
- On 06/18/2025, Provider #6's training records were reviewed and indicated that Provider #6 had completed training on restraints on restraints on 03/05/2025, four (4) days after ordering restraints; and
- As of 06/18/2025, there was no evidence provided to the surveyor that indicated Provider #6 had completed training on restraints prior to 03/05/2025.

On 06/18/2025 at approximately 1:30 PM, the Senior Director, Regional Accreditation and Regulatory Affairs confirmed the above findings.