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Based on document review and interview, it was determined that for 2 of 3 patients' (Pt. #1 and Pt. #10) clinical records reviewed for restraint use, the hospital failed to ensure that least restrictive measures/alternatives were attempted prior to placing the patient in restraints.

Findings include:

1. On 3/25/2025, the hospital's policy titled, "Restraint and Seclusion" (Last Revision 04/23/2024), was reviewed and required, "...Use of Restraints for Acute Medical and Post-Surgical Care - Nonviolent/Non-self-destructive...Restraint Orders...Be implemented at the least restrictive level possible while maintaining the patient's safety and well-being...Documentation. The RN (registered nurse) documents in the patient's EHR (electronic health record)..."

2. On 3/25/2025, the clinical record for Pt. #1 was reviewed. On 10/13/2024, Pt. #1 was admitted to the ICU (intensive care unit) due to hypotension (low blood pressure). While in the ICU from 10/13/2024 through 10/24/2024, there was no documentation that least restrictive measure was attempted prior to application of restraints.

3. The clinical record of Pt. #10 was reviewed on 03/25/2025 at 10:30 AM. The ED (Emergency Department) Progress Note by ED Physician (MD#3) on 10/13/2024 at 11:51 PM, indicated that Pt.#10 presented to the ED with delirium, vomiting and yawning and diagnosed with Acute Hyperactive Opioid Withdrawal Delirium. Pt.#10 was found restless on the ground by Pt.#10's child. The ED Triage Note by ED Registered Nurse (E#9) on 10/13/2024 at 11:23 PM, included - "Patient arrives via EMS (Emergency Medical Service) from home for drug withdrawal...[Pt.#10's child] called 911 when patient was thrashing around & vomiting..." A physician's order was placed on 10/13/2024 at 11:56 PM for non-violent or non-self destructive restraints. Restraint flowsheets indicated that Pt. #10 was placed in violent/locked restraints on 10/13/2024 at 11:56 PM. The record lacked documentation that the least restrictive measures/alternatives were attempted prior to using restraints as required.

4. On 3/25/2025 at approximately 12:03 PM, an interview was conducted with Registered Nurse (E#7). E#7 stated that prior to using restraints on a patient, attempts should be made at utilizing less restrictive interventions and such attempts should be documented. E#7 stated that prior to application of restraints, a physician's order should be obtained.

5. On 3/25/2025 3:01 PM, a telephone interview was conducted with E #6 (ICU RN/Pt. #1's RN). Regarding application of restraints, E #6 stated, "I placed soft wrist restraints on (Pt. #1) because (Pt. #1) was pulling tubes."

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #1) clinical records used regarding use of restraints, the hospital failed to ensure that the care plan was modified.

Findings include:

1. On 3/25/2025, the hospital's policy titled, "Restraint and Seclusion" (4/23/2024) was reviewed and included, "... Use of Restraints for Acute Medical and Post-Surgical Care... Be accompanied by modification to the patient's plan of care..."

2. On 3/25/2025, the clinical record for Pt. #1 was reviewed. On 10/13/2024, Pt. #1 was admitted to the ICU (intensive care unit) due to hypotension (low blood pressure). While in the ICU from 10/13/2024 through 10/24/2024, there was no documentation that the care plan was modified when restraints were used.

3. On 3/25/2025 3:01 PM, a telephone interview was conducted with E #6 (ICU RN/Pt. #1's RN). Regarding application of restraints, E #6 stated, "I placed soft wrist restraints on (Pt. #1) because (Pt. #1) was pulling tubes." E #6 stated that the care plan is modified when restraints are used.

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #1) clinical records used regarding use of restraints, the hospital failed to ensure that a physician's order was obtained.

Findings include:

1. On 3/25/2025, the hospital's policy titled, "Restraint and Seclusion" (4/23/2024) was reviewed and included, "... Use of Restraints for Acute Medical and Post-Surgical Care... Restraints orders are documented in the EHR (electronic health record)... "

2. On 3/25/2025, the clinical record for Pt. #1 was reviewed. On 10/13/2024, Pt. #1 was admitted to the ICU (intensive care unit) due to hypotension (low blood pressure). While in the ICU from 10/13/2024 through 10/24/2024, there was no documentation that a physician's order was obtained when restraints were used.

3. On 3/25/2025 3:01 PM, a telephone interview was conducted with E #6 (ICU RN/Pt. #1's RN). Regarding application of restraints, E #6 stated, "I placed soft wrist restraints on (Pt. #1) because (Pt. #1) was pulling tubes." E #6 stated that a physician's order should be obtained when restraints are used.

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #1) clinical records used regarding use of restraints, the hospital failed to document that the patient was monitored while in restraints.

Findings include:

1. On 3/25/2025, the hospital's policy titled, "Restraint and Seclusion" (4/23/2024) was reviewed and included, "... Use of Restraints for Acute Medical and Post-Surgical Care... The following monitoring and activities are performed... Every 2 hours: Signs of injury... Adequate nutrition and hydration. Circulation, skin integrity and range of motion..."

2. On 3/25/2025, the clinical record for Pt. #1 was reviewed. On 10/13/2024, Pt. #1 was admitted to the ICU (intensive care unit) due to hypotension (low blood pressure). While in the ICU from 10/13/2024 through 10/24/2024, there was no documentation that Pt. #1 was monitored while in restraints, as required.

3. On 3/25/2025 3:01 PM, a telephone interview was conducted with E #6 (ICU RN/Pt. #1's RN). Regarding application of restraints, E #6 stated, "I placed soft wrist restraints on (Pt. #1) because (Pt. #1) was pulling tubes." E #6 stated that when in restraints, patients should be monitored every two hours for signs of injury, hydration, type of restraint use, and range of motion.

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #1) clinical records reviewed for nursing assessment/reassessment, the hospital failed to ensure that reassessment was documented, as required.

Findings include:

1. On 3/25/2025, the hospital's document titled, "Attachment A: Nursing Assessment Standards by Patient Venue" (3/4/2024) was reviewed and indicated, " ... ICU (Intensive Care Unit) ... Reassessment: Head to Toe reassessments will be completed/documented every 4 hours ..."

2. On 3/25/2025, the clinical record for Pt. #1 was reviewed. On 10/13/2024, Pt. #1 was admitted to the ICU (intensive care unit) due to hypotension (low blood pressure). While in the ICU from 10/13/2024 through 10/24/2024, there was no documentation that Pt. #1 was monitored while in restraints, as required.

3. On 3/25/2025 at approximately 10:45 AM, interviews were conducted with E #10 (ICU Assistant Manager) and E #11 (ICU Manager). E #10 and E #11 stated a head to toe nursing assessment should be completed every four hours.