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Based on interview and record review, the facility failed to properly restrain 3 (P-4, P-20, P-25) of 5 patients reviewed for restraint resulting in the loss of patient rights and the potential for poor patient outcomes. Findings include:

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A-171 Failure to renew the restraint order every 4 hours while in restraint
A-179 Failure to conduct face-to-face assessment within one hour of restraint application

Based on interview and record review, the facility failed to renew a violent restraint order every four hours while the patient was in restraint for 2 (P-4, P-25) of 5 patients reviewed for restraint resulting in the loss of patient rights. Findings include:

Review of the medical record for P-4 revealed he was a 61-year-old male who presented to the Emergency Department (ED) 2/6/2025 at 1457 for alcohol intoxication. P-1 was highly agitated and was "swinging at security." As a result, an order was given for violent/behavioral 4-point locked restraint on 2/6/2025 at 1500 with a duration of four hours and the restraints were applied on 2/6/2025 at 1501. The restraints were discontinued 2/6/2025 at 2047, 5 hours and 47 minutes after the first order. There was no renewal of the order for the restraints. This was confirmed by Staff G 8/25/2025 at 1345.

Review of the medical record for P-25 revealed he was a 44-year-old male who presented to the ED 4/25/2025 at 1620 with paranoia and agitation. On 4/26/2025 at 0511, an order was given for violent restraint of the right wrist and left ankle. This order was modified 4/26/2025 at 0624 and 0629 to having all extremities restrained with a duration of 4 hours. A "reorder" of restraint was given on 4/26/2025 at 1104, 4 hours and 35 minutes after the modification order at 0629. This was confirmed by Staff G on 8/26/2025 at 1117.

Facility policy "Restraint (Non-violent and Violent)" last revised 2/2025 states, "A physician/LIP [licensed independent practitioner] restraint order to manage a patient's violent or self-destructive behavior must be renewed on the following scheduled [sic]: i. Adults 18 and older: every four (4) hours..."

Based on interview and record review, the facility failed to conduct a face-to-face assessment within one hour of initiation of violent/behavioral restraint for 3 (P-4, P-20, P-25) of 5 patients reviewed for restraint resulting in the potential for unidentified, unmet patient needs and poor patient outcomes. Findings include:

Review of the medical record for P-4 revealed he was a 61-year-old male who presented to the Emergency Department (ED) 2/6/2025 at 1457 with alcoholic intoxication and agitation. An order was given on 2/6/2025 at 1500 for P-4 to be placed in four-point locked restraint. The restraints were initiated at 1501. The face-to-face-evaluation was conducted at 1500. This was confirmed by Staff E on 8/25/2025 at 1345.

Review of the medical record for P-20 revealed he was a 30-year-old male who presented to the ED 7/30/2025 at 1142 with a drug overdose and agitation. An order was given 7/31/2025 at 0117 for 2-point locked restraint of the left wrist and right ankle. Restraint was initiated 7/31/2025 at 0105 and the face-to-face assessment was conducted at 0105. This was confirmed by Staff E on 8/26/2025 at 1042.

Review of the medical record for P-25 revealed he was a 44-year-old male who presented to the ED 4/25/2025 at 1620 with paranoia and agitation. On 4/25/2025 at physical hold was done at 1621 followed by P-25 being placed in four-point locked restraints at 1623. The face-to-face assessment was done 4/25/2025 at 1620. Additionally, on 4/26/2025 at 0511, an order was placed violent/behavioral restraint of the right wrist and left ankle. AT 0624 and 0629 the order was modified to include all extremities. The face-to-face assessment was conducted at 0529.

Facility policy "Restraint (Non-violent and Violent) last revised 2/2025 states, "For violent of self-destructive behavior, a face-to-face evaluation between the physician/LIP [licensed independent practitioner] and the patient will need to occur within one hour of the initiation of the restraint. The physician/LIP conducting a required evaluation must include an assessment of the following issues and document the evaluation findings in the patient's medical record: i. The patient's immediate situation ii. The patient's reaction to the intervention iii. The pateint's medical and behavioral condition iv. The need to continue or terminate the restraint or seclusion."