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Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #8) clinical records reviewed for utilization of restraints for violent behavior, the Hospital failed to ensure that written modification of the patient's plan of care was completed.

Findings include:

1. On 7/15/2021, the clinical record of Pt. #8 was reviewed. Pt. #8 was admitted to the Hospital on 2/23/2021 due to alcohol abuse. The clinical record indicated that Pt. #8 was placed in restraints for violent behavior on 3/1/2021. The clinical record lacked written modification of Pt. #8's care plan regarding utilization of restraints.

2. On 7/15/2021, the Hospital's policy titled, "Restraints Use - Violent/Self-Destructive Behavior and Nonviolent/Non-Self Destructive Behavior Policy" (effective 1/2021) was reviewed and included, "This policy applies to any patient in either restraint or seclusion at (Name of the Hospital)... Procedure... 7. Documentation of Restraint in the patient's medical record includes the following... k. Revision to the plan of care..."

3. On 7/15/2021 at approximately 9:30 AM, findings were discussed with E #1 (Manager for Quality and Safety). E #1 stated that the care plan for Pt. #8 should have been modified following utilization of restraints.

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #8) clinical records reviewed for utilization of restraints for violent behavior, the Hospital failed to provide the "Notice Regarding Restricted Rights," to ensure use of restraints was implemented in accordance with safe and appropriate technique, as determined by hospital policy.

Findings include:

1. On 7/15/2021, the clinical record of Pt. #8 was reviewed. Pt. #8 was admitted to the Hospital on 2/23/2021 due to alcohol abuse. The clinical record indicated that Pt. #8 was placed in restraints for violent behavior on 3/1/2021. The clinical record lacked documentation that Pt. #8 was provided a copy of the Notice Regarding Restricted Rights.

2. On 7/15/2021, the Hospital's policy titled, "Restraints Use - Violent/Self-Destructive Behavior and Nonviolent/Non-Self Destructive Behavior Policy" (effective 1/2021) was reviewed and included, "This policy applies to any patient in either restraint or seclusion at (Name of the Hospital)... Procedure... 2... Violent/Self-Destructive Behavioral Order...j. The patient is... Provided with a copy of the Notice Regarding Restricted Rights of Individuals..."

3. On 7/15/2021 at approximately 9:30 AM, findings were discussed with E #1 (Manager for Quality and Safety). E #1 could not provide documentation nor evidence that Pt. #8 was given a copy of the Notice Regarding Restricted Rights.

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #8) clinical records reviewed for utilization of restraints for violent behavior, the Hospital failed to obtain a new order, to ensure use of restraints was in accordance with the order of a physician or licensed practitioner responsible for the care of the patient.

Findings include:

1. On 7/15/2021, the clinical record of Pt. #8 was reviewed. Pt. #8 was a 24 year-old patient admitted to the Hospital on 2/23/2021 due to alcohol abuse. The clinical record indicated that Pt. #8 was placed in restraints for violent behavior on 3/1/2021 from 11:00 AM through 1:30 PM (two hours and thirty minutes). The clinical record included a physician's order for Pt. #8's restraint for two hours. The clinical record lacked a physician's order for continued utilization of restraints for violent behaviors from 1:00 PM through 1:30 PM.

2. On 7/15/2021, the Hospital's policy titled, "Restraints Use - Violent/Self-Destructive Behavior and Nonviolent/Non-Self Destructive Behavior Policy" (effective 1/2021) was reviewed and included, "This policy applies to any patient in either restraint or seclusion at (Name of the Hospital)... Procedure... 2... Violent/Self-Destructive Behavioral Order...e. Orders may not exceed the following time limits: Every 2 hours - adults (18 year and older)... f. If the patient requires restraint beyond the initial order, a new order must be obtained from the attending, along with a physician or LIP in-person...face to face evaluation..."

3. On 7/15/2021 at approximately 9:30 AM, findings were discussed with E #1 (Manager for Quality and Safety). E #1 stated that another order from the physician should have been obtained.