HospitalInspections.org

Based on document review and interview the facility failed to obtain a provider order for restraint and/or seclusion use for 2 of 11 patient medical records reviewed (Patient 4 and Patient 5); and failed to update/revise patient's plan of care related to restraint use for 1 of 11 medical records reviewed (Patient 4).

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview the facility failed to update/revise patient's plan of care realted to restraint use for 1 of 11 medical records reviewed (Patient 4).

Findings include:

1. The facility did not follow their policy titled: Scope of Service/Provision of Patient Care Plan, Policy Number: LD 1, last revised 3/2025, under Treatment Planning: The program has an interdisciplinary approach to treatment planning. Those involved in the treatment planning process include the patient's physician, nursing, therapists, activity therapists and mental health technicians. Dietitian and pharmacist are included as indicated. The team is responsible for development of the individualized treatment planned review and evaluation of ongoing treatment. The Interdisciplinary Treatment Plan is developed within 72 hours of admission. Treatment plans are reassessed by the team at regular intervals and revised as needed. The patient, and family when appropriate, is encouraged to participate in the treatment planning process by providing input and acknowledging agreement with the plan in writing. Patient progress in meeting the treatment plan goals is documented in the progress notes.

2. Review of P4's MR (Medical Record) lacked documentation of patient's care plan reviewed/revised/updated after a restraint was used on patient on 6/5/25.

3. In interview on 8/22/25 at approximately 4:00 pm, A3 (Director of Risk Management) confirmed P4's MR lacked documenation of treatment plan reviewed/revised after a restraint was used on the patient, on 6/5/25.

Based on document review and interview the facility failed to obtain a provider order for restraint and/or seclusion use for 2 of 11 patient medical records reviewed (Patient 4 and Patient 5).

1. Facility policy titled: Restraint, No Policy Number, last revised 9/2024, under Procedure: 2. The order shall indicate the reason and maximum duration of restraint, and under Policy: 4. Restraint may only be ordered by the attending physician or covering practitioner.

2. Facility policy titled: Seclusion, No Policy Number, last revised 9/2024, under Policy: 3. Seclusion may only be ordered by a psychiatrist and only for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others after less restrictive interventions are ineffective or ruled-out, and under Procedure: 2. The order shall indicate the reason and maximum duration of the seclusion.

3. Review of P4's MR indicated on 6/05/25 at approximately 3:02 pm to 3:19 pm, a physical restraint was initiated by staff as patient was self-harming by biting oneself intentionally causing bleeding. P4's MR lacked an order for physical restraint use and/or duration.

4. Review of P5's MR indicated on 6/30/25 at approximately 8:27 am staff initiated a protective restraint technique as patient attempted to elope between unit doors. P5's MR indicated patient was restrained from 8:26 am to 8:27 am and then the patient was placed in seclusion until 10:03 am. P5's MR lacked documentation of an order for restraint/seclusion, reason, and/or maximum duration on 6/30/25.

5. Facility Incident/Event Report dated 6/05/25 indicated P4 was restrained at approximately 3:02 pm until 3:19 pm. The report lacked documentation of provider notification and/or order for the restraint.

6. Facility Incident/Event Report dated 6/30/25 indicated P5 attempted to elope through a door between the 500 and 600 Unit. The report indicated staff used a protective restraint technique to prevent patient from leaving the unit and patient was then placed in seclusion for patient's safety from 8:27 am until 10:03 am. The Incident/Event report lacked documentation of provider notification and/or order for restraint or seclusion.

7. In interview on 8/22/25 at approximately 4:00 pm, A3 (Director of Risk Management) confirmed MRs lacked documented physician orders for patient's (P4) restraint on 6/5/25, and patient (P5) restraint/seclusion on 6/30/25.