HospitalInspections.org

Based on medical record review and facility document review, it was determined the facility failed to modify the patient's plan of care after the use of seclusion for one (1) of seven (7) sampled medical records (MR) reviewed.

The findings include:

On July 28, 2025, a review of MR7 was conducted. MR7's record indicated that MR7 was placed in seclusion on July 1, 2025. The medical record did not contain documentation that the patient's plan of care was modified to reflect that the patient was placed in seclusion for their violent/destructive behavior.

A review of the facility's policy "Patient Restraint/Seclusion", effective 7/1/2023, indicated in part: "...10. Care of the Patient/Plan of Care. a. The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications...12. Documentation requirements. The medical record contains documentation of...n. Modifications of the plan of care...".

Based on medical record review and facility document review, it was determined the facility failed to use a restraint in accordance with the order from a physician for two (2) of seven (7) medical records (MR) reviewed.

The findings include:

On June 23, 2025 at 11:57 PM, MR5's medical record documented a physician order for "non-violent, soft, bilateral upper extremity restraints" for MR5 attempting to remove devices. At the same time and date, a Registered Nurse (RN) documented that violent/self destructive, soft bilateral wrist and ankle restraints were applied to MR5. There was no documentation that the physician canceled the non-violent order nor that the RN replaced the violent, 4-point restraints with non-violent, 2-point restraints per the physician's order.

On June 29, 2025 at 10:45 PM, MR6's medical record documented that MR6 was placed in a physical hold and transported to seclusion for presenting as a danger to others. There was no physician order found for MR6's physical hold.

A review of the facility's policy "Patient Restraint/Seclusion", effective 7/1/2023, indicated in part: "...5. Order for Restraint or Seclusion. a. An order for restraint or seclusion must be obtained from a physician or other licensed practitioner...E. Physical Holds...Holding a patient in a manner that restricts the patient's movement against the patient's will is considered restraint...".

Based on medical record and facility document review, it was determined the facility failed to conduct face-to-face assessments of patients after initiating violent restraints and/or seclusion for three (3) of seven (7) medical records (MR) reviewed.

The findings include:

On June 23, 2025, MR5 was placed in violent, 4-point restraints at 11:57 PM. There was no documentation found in MR5's medical record that a face-to-face assessment was completed by a physician, licensed practitioner, Registered Nurse (RN) or physician assistant within one (1) hour of initiating the restraints.

On June 29, 2025, MR6 was placed in seclusion at 8:36 PM. There was no documentation found in MR6's medical record that a face-to-face assessment was completed by a physician, licensed practitioner, registered nurse (RN) or physician assistant within one (1) hour of initiating the seclusion.

On July 1, 2025, MR7 was placed in seclusion at 5:24 PM. There was no documentation found in MR7's medical record that a face-to-face assessment was completed by a physician, licensed practitioner, registered nurse (RN) or physician assistant within one (1) hour of initiating the seclusion.

A review of the facility's policy "Patient Restraint/Seclusion", effective 7/1/2023, indicated in part: "...9. Face-to-face assessment by a Physician or Licensed Practitioner. a. A face-to-face assessment by a physician, licensed practitioner, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation...".