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Based on interview and record review, facility failed to properly assess and monitor 5 restrained patients (P-1, 2, 3, 5, and 6) of 10 reviewed patients resulting in the potential for adverse outcomes for all restrained patients. Findings include:

See Specific Tags:

A-166 Failure to document restraints in a plan of care
A-168 Failure to obtain provider's order for restraints
A-175 Failure to assess and monitor patients in restraints.
A-184 Failure to document face to face provider assessment in the patient's record

Based on interview and record review, the facility failed to document use of restraints in a plan of care for two patients (P-5 and P-6) of 10 patients reviewed, resulting in possible negative outcomes for these patients. Findings include:

P-5

Record review for P-5 on 10/21/25 revealed the following documentation:
P-5 was an 82-year-old female who was admitted to facility on 10/17/25 with a chief
complaint of right hip, low back and left lower leg pain post syncopal fall and subsequent head injury shortly after she stood up out of bed in the morsing on 10/15/25. P-5 had a history of syncopal falls, hypertension (elevated blood pressure), hyperlipidemia, chronic hyponatremia (low sodium levels in blood), IBS (irritable bowel syndrome), anemia, chronic low back pain, osteoarthritis, vitamin D deficiency, restless leg syndrome and skin cancer.

During the hospitalization P-5 experienced change in mental status on 10/18/25.
There was a provider order for "Restraints non-violent or non-self-destructive" dated 10/18/25 1200 for soft restraints left and right wrist, restraint etiology- acute delirium. Order for restraints was discontinued on 10/19/25 1012.

Further review of P-5 medical record did not reveal documentation for plan of care for restraints.

P-6

Record review for P-6 on 10/21/25 revealed the following documentation:
Patient was a 63-year-old male admitted to facility on 10/20/25 at 0329 with chief complaint of seizure and possible stroke. Patient had a medical history GERD (gastroesophageal reflux disease), hypercholesterolemia (high levels of cholesterol in the blood), hypertension, OSA (obstructive sleep apnea), and Raynaud disease (condition that causes spasms in small blood vessels in your fingers and toes).

Nursing note dated 10/20/25 0550 revealed: Patient very agitated, threatening to staff, verbally abusive; imminent harm to self & staff. Patient shouting out to sitter at bedside and staff. Multiple RN & security at bedside attempting to redirect patient back in bed; patient agitation increased. Patient placed in 4-point leather restraints. Notified Dr. [name]. Orders placed for restraints.

Further P-6 medical record review revealed that patient was in violent restraints on 10/20/25 from 0627 to 1640. Review of the emergency center nursing documentation did not reveal a care plan for restraints for P-6.

On 10/21/25 at approximately 1000 during interview with Director of Nursing, Staff G, she stated that nurses are required to document restraints in patients' plan of care.

Facility's policy titled "Restraints: Care of the Patients in Restraints", dated 07/21/2024, was reviewed and revealed:
"III. Use of Restraints
A. Ordering Requirements
1. Non-Violent Restraints
m. Restraints will be documented on the patient's plan of care."

Facility policy "Patient Plan of Care", effective 07/21/24, was reviewed and revealed:
C. Inpatient and Inpatient Rehab Plan of Care:
vi. Documentation of patient progress and an outcome/summary statement is recommended on change in patient condition and minimally twice per day for hospitalized patients."

Based on interview and record review, the facility failed to ensure there was a provider order for the restraints for two patients (P-1 and P-3) of 10 patients reviewed, resulting in possible negative outcomes for these patients. Findings include:

P-1
Record review for P-1 on 10/20/25 revealed the following documentation:
P-1 was an 80-year-old female admitted to facility on 10/07/24 with chief complaint of vertigo. Patient had a history of chronic neck pain and hypertension (elevated blood pressure).
There was a nursing note dated 10/07/24 2010: RN (registered nurse) at bedside to assess the patient. Patient became combative and paranoid feeling like she is going to "die" and wanting to call her family. RN wanted patient to be evaluated by physician due to sudden change in patient's status, so RRT (rapid response team) was called and came to bedside. Patient combative with RRT, RN's and confused. RRT PA (physician assistant) was called to bedside to also assess patient. Due to patient being combative and for safety reasons patient was placed in 4-point soft restraints so a full assessment could be completed. Epic camera was ordered for patient at this time as well for patient safety. Once cleared by RRT and PA patient was calm and RN left the patient resting in bed.

Physician's assistant (PA) note dated 10/7/2024 1735 revealed: RRT called to evaluate pt (patient) for suspected medication reaction. Pt admitted for BPPV (Benign paroxysmal positional vertigo- brief episodes of mild to intense dizziness that usually triggered by specific changes in the head's position) which has responded to Benadryl gtt (drip) in the past. Pt was evaluated by neurology who ordered Benadryl 100 mg intended to be administered over 4 hours, however it was administered as an IVP (intravenous push). Pt subsequently became agitated, combative, and anxious after administration. She was attempting to bite and hit staff. RN notified Dr. [name] (Neurology) who recommended monitoring the patient and waiting for Benadryl to wear off. I arrived to bedside to find pt agitated, paranoid, and in restraints".

Further record review for P-1 revealed no provider orders for application or discontinue of 4-point soft restraints on 10/07/25.

P-3
Record review for P-3 on 10/21/25 revealed the following documentation:
Patient was a 21-year-old female admitted to facility on 8/20/25 with suicidal ideations and attempted self-injury. Patient had a history of schizoaffective disorder and autism. P-3 had intermittent and unpredictable instances of agitation and verbal and physical aggression towards facility staff. Patient was in violent restraints intermittently through her stay in the facility.

There was a provider order for Violent 2-point keyed leather/fabric bilateral wrists restraints dated 09/01/25 1745 for 4 hours (till 2145).
Next order for Violent 2-point keyed leather/fabric bilateral wrists restraints was dated 09/02/25 0708 for 4 hours (till 1108).
There was no provider order for restraints between period of 09/01/25 2145 to 09/02/25 0708. Further record review revealed consistent nursing restraint assessment and documentation of P-3 who was continuing to be restrained for the above period of time (9 hours).

On 10/20/25 at approximately 1350 during interview with director of nursing, Staff F, regarding restraints policy and provider's orders he stated that restraints are initiated by the provider's order.

Facility policy "Restrains: Care of the Patient in Restraints", effective 07/21/24, was reviewed and revealed:
"II. Purpose of Restraints
A. Non-Violent Restraint: Restraints are used when needed to manage non-violent behavior that jeopardizes the immediate physical safety of the patient.
III. Use of Restraints.
1. Non-Violent Restraints
a. Restraints may be initiated by the order of the physician, NP or PA (Provider) responsible for the patient's care. When the order for restraints is initiated by a Resident, NP or PA, that provider will notify the Attending as soon as possible.
b. The provider will complete a comprehensive patient assessment to identify medical problems that may be causing the behavior requiring restraint use.
c. Restraint orders must include the type of restraint to be used and specify the location(s) that are to be restrained.
d. In emergent situations, when the need for intervention occurs so quickly that an order cannot be obtained prior to application of physical restraints, an RN may initiate physical restraint based on assessment of the patient. The RN will notify the Provider within minutes of restraint application once the patient is safe and obtain the appropriate order. The assessment and restraint intervention must be documented by the RN.
2. Violent Restraints
a. Restraints may be initiated by the order of the Physician, NP or PA (Provider) responsible for the patients care. When the order for restraints is initiated by a Resident, NP or PA, that provider will notify the Attending as soon as possible".

Based on interview and record review, the facility failed to properly assess and monitor two restrained patients (P-5 and P-6) of 10 reviewed patients resulting in possibility of patients' physiological needs not being met, incomplete restraint assessments, and risk for negative outcomes for these patients. Findings include:

P-5

Record review for P-5 on 10/21/25 revealed the following documentation:

P-5 was an 82-year-old female who was admitted to facility on 10/17/25 with a chief
complaint of right hip, low back and left lower leg pain post syncopal fall and subsequent head injury shortly after she stood up out of bed in the morning on 10/15/25. P-5 had a history of syncopal falls, hypertension (elevated blood pressure), hyperlipidemia, chronic hyponatremia (low sodium levels in blood), IBS (irritable bowel syndrome), anemia, chronic low back pain, osteoarthritis, vitamin D deficiency, restless leg syndrome and skin cancer.

During the hospitalization P-5 experienced change in mental status on 10/18/25.
There was a provider order for "Restraints non-violent or non-self-destructive" dated 10/18/25 1200 for soft restraints left and right wrist, restraint etiology- acute delirium. Order for restraints was discontinued on 10/19/25 1012.

Further review of P-5 medical record revealed nursing restraint assessment documentation dated 10/18/25 1100. Next nursing restraint assessment was dated 10/18/25 1430 and had documentation that restraints were "discontinued". No additional Q1h (every 1 hour) and Q2h (every 2 hours) restraint assessments were noted.

P-6

Record review for P-5 on 10/21/25 revealed the following documentation:
Patient was a 63-year-old male admitted to facility on 10/20/25 at 0329 with chief complaint of seizure and possible stroke. Patient had a medical history GERD (gastroesophageal reflux disease), hypercholesterolemia, hypertension, OSA (obstructive sleep apnea), and Raynaud disease (condition that causes spasms in small blood vessels in your fingers and toes).

Nursing note dated 10/20/25 0550 revealed: Patient very agitated, threatening to staff, verbally abusive; imminent harm to self & staff. Patient shouting out to sitter at bedside and staff. Multiple RN & security at bedside attempting to redirect patient back in bed; patient agitation increased. Patient placed in 4-point leather restraints. Notified Dr. [name]. Orders placed for restraints.

Further P-6 medical record review revealed the patient was in violent restraints on 10/20/25 from 0627 to 1640. Review of the emergency center nursing documentation revealed there was no Q1h (every one hour) violent restraint assessment for the time from 0627 to 0823, and from 1020 to 1220.

On 10/21/25 at approximately 1000 during interview with Director of nursing, Staff G, she confirmed that nurses are required to document their restraint assessment every 2 hours while patient in restraints and every 1 hour for violent restraints assessment.

Facility's policy titled "Restraints: Care of the Patients in Restraints", dated 07/21/2024, was reviewed and revealed:
III. Use of Restraints
B. Monitoring, Assessment, and Documentation of Patient Care.
1. General Standards
a. Patients will be monitored and reassessed. Minimal standards for assessment, intervention, evaluation and re-intervention for non-violent restraints and violent restraints are listed below. It is expected that if the patient's condition warrants, the monitoring will be more frequent or continuous.
2. Non-violent Restraint: Assessment and Documentation
a. On initiation and discontinuation, the RN will document that the restraint used is the least restrictive restraint intervention and that it was applied properly and safely.
b. Every 60 minutes, the RN will complete and document or delegate to an LPN or NSS.
i. Patient observation to ensure that the patient's safety is maintained
c. Every 2 hours, the RN will complete and document (or delegate to an LPN or NSS the:
i. Offering of nutrition, hydration, and toileting
ii. Repositioning of the patient
iii. Completion of range of motion as appropriate
iv. Release/reapplication of physical restraints
d. Every 2 hours, the RN will complete and document an assessment that includes:
i. Patient behavior continues to require restraints
ii. Current restraints continue to be appropriate for the behavior
iii. Condition of restrained area including circulation, evidence of edema and
skin condition
iv. Patient's behavior that places the patient or others at risk
v. Physical and psychological status
vi. Comfort
3. Violent Restraint: Assessment and Documentation
c. Patients will be continuously observed by a trained staff member, staff will notify the
RN immediately if there are any safety concerns.
d. On initiation and discontinuation, the RN will document that the restraint used is the least restrictive restraint intervention and that it was applied properly and safely.
e. Every 60 minutes, the RN will complete and document an assessment to ensure the patient's safety is maintained. The assessment will include the following as appropriate.
i. Patient behavior continues to require restraints
ii. Current restraints continue to be appropriate for the behavior
iii. Condition of restrained area including circulation, evidence of edema and skin condition
iv. Physical and psychological status
v. Comfort
vi. Readiness for discontinuation of restraint
vii. Range of motion in the extremities (release and reapply wrist/ankle restraints every two (2) hours)
viii. Nutrition, hydration, and toileting (minimally every 2 hours)
ix. Vital signs are obtained based on department assessment standards and provider orders.
f. An LPN or NSS may assist with care activities

Based on interview and record review, the facility failed to ensure there was a provider face to face assessment and documentation for violent restraints for two restrained patients (P-2 and P-6) of 10 patients reviewed, resulting in possible negative outcomes to these patients. Findings include:

P-2

Record review for P-2 on 10/20/25 revealed the following documentation:
P-2 was a 65-year-old female admitted to facility on 10/18/25 with chief complaint of shortness of breath, cough and nausea. Patient had a medical history of atrial fibrillation, anemia, chronic back pain, drug-seeking behavior, diabetes mellitus, chronic obstructive pulmonary disease, essential hypertension, dyslipidemia, peripheral neuropathy, spinal stenosis and severe recurrent major depression with suicidal ideations.

There was a provider order for initiation of violent 4-point restraints dated 10/19/25 1621 and discontinued at 1921.
There was a nursing note dated 10/19/25 1915: Patient in 4-point lockable restraints and sitter now at the bedside. At 1800, restraints removed, patient calm and cooperative.

Further review of P-2 record revealed no ordering provider violent restraint face to face assessment and documentation in flowsheets.

P-6

Record review for P-5 on 10/21/25 revealed the following documentation:
Patient was a 63-year-old male admitted to facility on 10/20/25 at 0329 with chief complaint of seizure and possible stroke. Patient had a medical history GERD
(gastroesophageal reflux disease), hypercholesterolemia, hypertension, OSA (obstructive sleep apnea), and Raynaud disease (condition that causes spasms in small blood vessels in your fingers and toes).

Nursing note dated 10/20/25 0550 revealed: Patient very agitated, threatening to staff, verbally abusive; imminent harm to self & staff. Pt shouting out to sitter at bedside and staff. Multiple RN & security at bedside attempting to redirect patient back in bed; patient agitation increased. Patient placed in 4-point leather restraints. Notified Dr. [name]. Orders placed for restraints.

Further P-6 medical record review revealed the patient was in violent restraints on 10/20/25 from 0627 to 1640. Review of the emergency center documentation did not reveal provider face to face violent restraint assessment and documentation for the initial order for violent restraints on 10/20/25 0627.

On 10/20/25 at approximately 1350 during interview with director of nursing, Staff F, regarding restraints policy and provider's orders he stated that restraints are initiated by the provider's order and face to face assessment needs to be completed by providers within 1 hour after initiation of violent restraints.

Facility's policy titled "Restraints: Care of the Patients in Restraints", dated 07/21/2024, was reviewed and revealed:
"2. Violent Restraints
a. Restraints may be initiated by the order of the Physician, NP or PA (Provider) responsible for the patient's care. When the order for restraints is initiated by a Resident, NP or PA, that provider will notify the Attending as soon as possible.
d. A face-to-face assessment is required by a Provider within one hour after restraint initiation."