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Based on medical record review, policy review and staff interview, the facility failed to document the release of restraints in accordance with the facility policy for two (#1 and #10) of two patients reviewed for restraint release. The facility's active census was 77.

Findings include:

Review of the facility policy titled "Restraints and Seclusion," Number R02-N, last revised 07/01/21, revealed
modification of the patient's treatment plan related to restraint use, patient's response to restraint, and plan for reduction/elimination is included in the patient's medical record. Interdisciplinary team member documentation must state observations/interventions/findings from periodic observations to include: safety, comfort, mobility, skin integrity, food/hydration, and toileting - to include removal of restraints at least 10 minutes every two hours or more often (observations every two hours for medical restraints and every 15 minutes for behavioral restraints)

1. Review of the medical record revealed Patient #1 was ordered bilateral soft wrist restraints on 12/19/21. On 12/19/21 the medical record contained documentation of the restraints being released at 12:00 AM, 2:00 AM, 4:00 AM and 10:00 AM. The restraints were discontinued at 2:10 PM on 12/19/21. The medical record did not contain evidence of the restraints being released at 6:00 AM, 8:00 AM or 12:00 PM.

Interview on 02/14/22 at 9:00 AM, Staff AA confirmed the findings.

2. Review of the medical record revealed Patient #10 was in restraints on 01/10/22 and 01/11/22. The medical record contained documentation of restraint release on 01/10/22 at 12:00 AM, 2:00 AM, 4:00 AM, 5:49 AM, 10:00 AM, 12:00 PM, 2:00 PM, and 6:00 PM. On 01/11/22, facility staff documented restraint release at 8:00 AM, 10:00 AM, 12:00 PM and 8:00 PM. The restraints were discontinued on 01/13/22. The medical record did not contain evidence of the restraints being released on 01/10/22 at 8:00 AM and 4:00 PM. The medical record did not contain evidence the restraints were removed from 01/10/22 at 8:00 PM through 01/11/22 at 6:00 AM. The medical record did not contain evidence of the restraints being released on 01/11/22 at 2:00 PM, 4:00 PM, 6:00 PM, or 10:00 PM.

Interview on on 02/14/22 at 11:40 AM, Staff L confirmed the findings.

This deficiency substantiates Substantial Allegation OH00128738