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A. Based on review of facility policy, patient medical records, and confirmed in interviews, the facility failed to ensure patient rights were protected and promoted in accordance with the facility's restraint policies and procedures for two of eight patients reviewed (Patient #A, B).

Refer to A 0167, 0171, 0174, 0175

B. Based on review of facility policy, patient medical records, and confirmed in interviews, the facility failed to ensure patient rights were protected and promoted in accordance with the facility's restraint policies and procedures, and in accordance with State law when chemical restraints/emergency behavioral medications were administered for the management of behaviors for four of four patients reviewed (Patient #A, B, E, G) with medication restraints identified.

Refer to A0160


The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Based on review of the facility, medical records, and confirmed in interview, the facility failed to ensure chemical restraints/emergency behavioral medications (EBM) administered Intramuscular (IM) and or (IV) for behavioral emergencies were identified and monitored as a restraint for four of eight patient ' s reviewed (Patient's #A, #B, #E, #G).

Failure to identify and monitor emergency medications used as restraints could result in the improper ordering and administration of medication by unauthorized staff, improper monitoring of the patient after the medication was given, and improper oversight by the facility which posed significant risks to patient safety.

Findings included:

Review of the facility Restraints and Seclusion Procedure (Version 4, 02/13/2024), it stated "Chemical Restraint: A drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement.

1. It is not a standard treatment or dosage for the patient's condition.
2. Drugs or medications that are used as part of a patient's standard medical or psychiatric treatment and are administered within the standard dosage for the patient's condition, are not considered to be chemical restraints. Criteria used to determine whether the use of a drug or medication, or combination of drugs or mediations is a standard treatment or dosage for the patient's condition includes all of the following:
a) The drug or medication issued within the pharmaceutical parameters approved by the Food and Drug Administration
(FDA) and the manufacturer for the indications that it is manufactured and labeled to address, including listed dosage parameters.
b) The use of the drug or medication follows national practice standards established or recognized by the medical community, or professional medical associations or organizations.
c) The use of the drug or medication to treat a specific patient's clinical condition is based on the patient's symptoms, overall clinical situation, and on the physician's knowledge of that patient's expected and actual response to the medication."

Review of the available policies revealed no policy to ensure safe and appropriate administration and monitoring of an emergency psychoactive medication that shall:
(1) identify the staff members authorized to administer an emergency psychoactive medication;
(2) identify the psychoactive medications permitted and approved by the hospital for administration in a psychiatric emergency;
(3) prescribe how and with what frequency and duration a staff member shall monitor a patient who has received an emergency psychoactive medication to ensure the health and safety of the patient, in addition to the in-person evaluation conducted as required by subsection (f) of this section;
(4) identify the licensed practitioners authorized to examine the patient as required by subsection (f) of this section; and
(5) ensure staff members follow all monitoring and evaluation requirements under this section and all hospital policies and procedures regarding administration of an emergency psychoactive medication each time a patient receives a separate dose of an emergency psychoactive medication.


Review of four of eight medical charts (Patient #A, #B, #E, #G) revealed four patients who received drugs or medication to restrict the patient's behavior and was not a standard treatment for the patient's condition.

Patient #A

Review of Patient #A's medical chart revealed she is a 12 year old female with a history of depression and anxiety and ADHD who presented to the ED for suicidal ideation on 05/12/2025. Review of her medical history from her previous psychiatric hospitalization revealed she did not routinely take Benadryl, Ativan, and/or Zyprexa for her mental health.

Staff #16's nursing notes on 05/14/2025 at 3:08 PM revealed "patient moved bed against wall and was hiding between the bed in the wall refusing to come out, security called to bedside. Explained to patient we need to be able to see her at all times, patient screaming and cussing and lunging at staff. Patient trying to pull bed against wall again and bed was removed from the room. At that time, patient punched the computer screen shattering it. Patient attempting to hit staff, bed brought back in room and patient placed on it, patient continues to attempt to hit and kick staff. Patient restrained at this time for self-destructive behavior."

Further review of Patient #A's chart revealed chemical restraints/emegency behavioral medication were administered on 05/14/2025 at 2:30 PM (benadryl 25 mg IM); 2:45 PM (Zyprexa 5 mg IM); and 3:00 PM (Ativan 2 mg IM).

The documentation reviewed did NOT include a face to face evaluation to determine the patient's immediate situation, patient's reaction to the medication nor patient's medical and behavioral conditions after administering the above emergency behavioral medications.

Patient #B

Review of Patient #B medical record revealed she is an 18 year old female who was seen at the ED with complaints of SI with plan to harm herself with a piece of glass on 04/04/2025 via police EDO (emergency detention order).

Further review of her chart revealed Haldol 5 mg IM; Ativan 2mg IM; Benadryl 50 mg, IM were administered on 04/05/2025 at 02:25 AM.

The documentation reviewed did NOT include a face to face evaluation to determine the patient's immediate situation, patient's reaction to the medication nor patient's medical and behavioral conditions after administering the above emergency behavioral medications.

Patient #E

Review of Patient #E's chart revealed she is a "15-year-old female brought in by her mom and sisters and grandmother for the past few weeks she has been acting up possibly been smoking marijuana she is beginning to fight she tried to cut her wrists she tried to jump out of windows the family's concern she may be a danger to herself and brought her in for evaluation. On exam
patient is not cooperative very aggressive try to run out not provide any history for us." She arrived in the ED via an EDO on 05/15/2025 at 2:24 PM.

Review of the nursing notes (staff #28) on 05/15/2025 at 3:30 PM, it stated "Pt very agitated and uncooperative. Pt screaming that she wants to leave and states she does not know what she is here for. Will not comply with instruction and refuses to do anything anyone asks her to do but continues to scream very loudly and very high-pitched. Security, RN staff, sitters and MD all at bedside. Pt fighting and swatting at any staff that comes near her."

Review of the physician notes (staff #27) on 05/15/2025 at 7:26 PM it stated "Patient still pending evaluation but we had to sedate patient earlier due to her aggressive behavior."

Further review of Patient #E's chart revealed emergency behavioral medications given on 05/15/2025 at 4:15 PM for Haldol 5 mg IM, Ativan 2 mg IM, Benadryl 25 mg IM. Review of records revealed no face to face assessment as required in the facility policy.

The documentation reviewed did NOT include change in condition impacting need for restraint, pulse, respiratory status, vital signs, mental status, or readiness for discontinuation of restraints or justification for continued use.

Patient #G

Patient #G is a 47 year old female with history of schizophrenia and multiple sclerosis brought to the ED via EMS and police on 05/04/2025 for erratic behavior.

Review of her medical record revealed she had five chemical restraints on 05/04/2025 at 3:40 AM; 05/05/2025 1:07 AM; 05/05/2025 at 05:31 AM; 05/05/2025 at 09:29 AM; 05/05/2025 at 11:12 AM with no face to face assessment as required in the facility policy.

The documentation reviewed did NOT include change in condition impacting need for restraint, pulse, respiratory status, vital signs, mental status, or readiness for discontinuation of restraints or justification for continued use.

Staff #21 notes on 05/04/2025 at 0324, "Given patient was threatening to grab the police's gun and she has been a little bit aggressive with staff, will chemically sedate her for now."

03:40 AM haloperidol lactate 5 mg IM; lorazepam 2mg IM; diphenhydramine 50 mg, IM
Staff # 22 notes on 05/05/2025 1:07 AM Patient woke up and wanted to be discharged. Patient walked towards the door of the room. This nurse and the sitter attempted to redirect the patient back into bed. The staff was not able to redirect the patient. The patient became irritated and aggressive and pulled up her pants while advancing towards nurse and sitter. Security was called to assist with keeping the patient in the room while chemical restraints were prepared. Droperidol 5mg and Ativan 2mg were given IM. The patient is unwilling to cooperate and repeatedly stated that she did not want to go to an inpatient facility and wanted to go home. The patient is asleep in bed at this time. Will continue to monitor the patient.

01:00 AM Ativan 2 mg IM given
01:01 AM Droperidol (Inapsine) 5 mg IM given

Staff #22 notes on 05/05/2025 at 05:31 AM "Patient woke up after given doperidol and lorazepam. The patient wasn't redirectable back to her bed and wanted to leave. The patient was given another dose of doperidol and lorazepam to reduce her anxiety. Will continue to the patient. The patient is now asleep in bed. Rise and fall of chest 16 breaths/min. The patient is not showing any signs of distress."

05:31 AM Ativan 2 mg IV given, Droperidol (Inapsine) 5 mg IV given

Staff #23 notes on 05/05/2025 at 09:20 AM "Pt started to be aggressive and pulling computer lines and throwing things. Tried talking and reorienting the patient but wouldn't listen. MD informed."

09:29 AM Zyprexa 5 mg IM; Benadryl 50 mg IV; Ativan 1 mg IV given

11:12 AM Ativan 1 mg IV given

Based on observation of facility video surveillance, review of facility policy, record reviews, and interviews, the facility failed to ensure physical restraints were implemented in accordance with safe and appropriate restraint techniques as determined by the hospital's restraint policy, training program and in accordance with State law during the implementation of a physical restraint for one of eight patients reviewed (Patient #A).

Findings included:

Review of the facility Restraints and Seclusion Policy (Version 4, 02/13/2024), it stated under Policy Statements "restraints must have a physician's order, appropriate clinical justification for the restraint, a start time and a time limit."

Review of the facility Restraints and Seclusion Procedure (Version 4, 02/13/2024), it stated under types of restraints "physical/therapeutic Hold: a manual method to restrict patient movement. a) a grasp on a patient that the patient cannot easily escape from, in order to escort the patient to another location. b) physically holding a patient for forced medications. This will require a physician order and the 1 hour face to face evaluation."

Video review of 05/14/2025 revealed the following observations from the body cam videos from Staff #7, #8, #9 from 2:51 PM to 3:03 PM, in part:
Staff #9 looking into the room talking with Patient #A (patient is visibly agitated)
Patient #A is observed punching a computer monitor
Staff #9 walks up to Patient #A and physically holds her by her wrists/arms behind her back with face against the wall
Medical bed is brought back in and Staff #7 and Staff #9 assist in holding patient onto the bed
2:52 PM The provider Staff #11 observed entering the room and assists by physically holding Patient #A's forehead with a stiff arm onto the bed with his hand. Staff #9 is also seen holding the patient's forehead with a stiff arm onto the bed as patient tries to bite staff. Several other clinical staff assist in placing the physical 4 point restraints.
2:54 PM The provider Staff #11 used 2 hands around sides of Patient #A's face to prevent her from thrashing and spitting.
2:56 PM Staff #15 observed talking with patient (patient crying and thrashing)
2:58 PM The provider Staff #11 observed by the head of the bed and he is heard stating "the more you fight it, the longer you'll be in it"
Lights are turned off and music from the tv is turned on
3:00 PM Staff #14 and #15 are heard explaining the restraints and IM meds given at 3:03 PM.

Review of the facility training for techniques for effective aggression management provided via email on 05/29/2025 did NOT include physical holds with both arms behind the patients back with face against the wall or a stiff arm technique to the forehead. It also did not include making threats of prolonging restraints if patient is uncooperative.

In an email on 05/30/2025 from Staff #3, she stated "Staff members complete a total of 3 hours of TEAM training (Essentials is online module for 1 hour, Advanced is hand on in person 2 hour training). For our Security Officers, their commission license course spends 16 hours on holds and defensive tactics."

Based on review of facility policy, review of medical records and confirmed in interview, the facility failed to ensure each restraint used for the management of violent or self-destructive behavior was in accordance with the 2 hour time limit for adolescents in one of two patients with restraints reviewed (Patient #A).

Findings included:

Review of the facility Restraints and Seclusion Procedure (Version 4, 02/13/2024), it stated "Obtain and renew restraint orders with the following limits for up to 24-hours for continued need: a. Every four (4) hours for adults age 18 or older b. Every two (2) hours for children and adolescents ages 9 to 17 years C. Every one (1) hour for patients under age 9 years Obtain a new order for the restraint if the restraint use is discontinued prior to the expiration of the original order and re-initiation of restraint is deemed necessary. Prior to expiration of the order, the RN will contact the provider with the results of the most recent patient assessment and request that the provider renew the original order for another period of time not to exceed the time limits established above. A face-to-face assessment is left to the discretion of the provider. "

Review of Patient #A's medical chart revealed she is a 12 year old female with a history of depression and anxiety and ADHD who presented to the ED for suicidal ideation on 05/12/2025.

Further review of her chart revealed physical restraints were used on 05/14/2025. Staff #16's nursing notes included:

3:08 PM "patient moved bed against wall and was hiding between the bed in the wall refusing to come out, security called to bedside. Explained to patient we need to be able to see her at all times, patient screaming and cussing and lunging at staff. Patient trying to pull bed against wall again and bed was removed from the room. At that time, patient punched the computer screen shattering it. Patient attempting to hit staff, bed brought back in room and patient placed on it, patient continues to attempt to hit and kick staff. Patient restrained at this time for self-destructive behavior."

5:30 PM "All restraints discontinued, patient tearful but cooperative. Skin is clean, dry, and intact. Patient given crayons to color with per request."

Review of Patient #A's medical chart revealed the following orders for restraints:

3:10 PM Restraints violent or self-destructive adolescent
5:08 PM Restraints discontinued (user system defaulted)
5:17 PM Restraints discontinued order acknowledged by RN (Staff #16)

Restraints were kept on for over 2 hours (2 hours 20 minutes) with no documentation of a new order to continue.

In an interview with Staff #1, she acknowledged that the restraints were kept on longer than the 2 hour limit for patient's age.

Based on review of facility policy, patient medical records, and confirmed in interview, the facility failed to ensure restraints were discontinued at the earliest possible time according to the physician orders and facility policy for one of eight Patients (Patient #A) reviewed for restraints.

Specifically, Patient #A remained in 4 point restraints while nursing documentation indicated she was sleeping, indicating she was no longer a threat to herself or others.

Findings included:

Review of the facility Restraints and Seclusion Procedure (Version 4, 02/13/2024), it stated "within 1 hour of the application of restraints, a face to face evaluation must be completed by physician or other provider. Telephonic or telemedicine methods of evaluation are not permitted. Should a patient's violent or self-destructive behavior be resolved and the restraint intervention is discontinued before the practitioner arrives, a face-to-face evaluation must be completed within one (1) hour after the initiation of the intervention. The face-to-face evaluation should include: a. An evaluation of the patient's immediate situation b. Factors that may have contributed to the violent or destructive behavior c. Whether the intervention was appropriate to address the violent of destructive behavior d. The patient's reaction to the intervention e. The patient's medical and behavioral condition f. The need to continue or terminate the restraint. g. The need for other interventions or treatments. The attending physician or provider responsible for the care of the patient must be consulted if the face-to-face evaluation is conducted by someone other than the attending physician or other provider responsible for the care of the patient. Obtain and renew restraint orders with the following limits for up to 24-hours for continued need: a. Every four (4) hours for adults age 18 or older b. Every two (2) hours for children and adolescents ages 9 to 17 years C. Every one (1) hour for patients under age 9 years Obtain a new order for the restraint if the restraint use is discontinued prior to the expiration of the original order and re-initiation of restraint is deemed necessary. Prior to expiration of the order, the RN will contact the provider with the results of the most recent patient assessment and request that the provider renew the original order for another period of time not to exceed the time limits established above. A face-to-face assessment is left to the discretion of the provider. The provider must conduct a face-to-face reevaluation before writing a new order for the continued use of restraint, if the patient remains in restraint 24-hours after the original order. Violent patients must be monitored for safe application at least every 30 minutes. Monitor the patient: a. Observe patients older than 9 at least every two (2) hours (patients under the age of 9 years must be assessed every (1) hour) for: i. change in condition impacting the need for restraint (such as level of distress or agitation) ii. circulation (pulse) distal to the restraint iii. skin integrity distal to the restraint (restraint may be removed to assess skin) iv. respiratory status v. vital signs - which include at a minimum the measurement of blood pressure, heart rate, respiratory rate, and 02 saturation vi. mental status vii. nutritional and hydration needs vili. elimination and toileting needs ix. range of motion and position change x. readiness for discontinuation of restraints xi. justification for continued use of restraints. Staff are expected to assess and monitor the patient's condition on an ongoing basis to determine whether restraint can safely be discontinued as quickly as possible."

Review of Patient # A's records revealed the following restraint orders:
MD Notified: Yes
Security Called: Yes
Injuries During Intervention: No
Incident Note Filed: Yes
Assessment
Alternatives to Restraints Tried/Judged to be Ineffective Prior to Application:
Repositioning; Reorientation to surrounds; Increased frequency of nursing
rounds; Verbal redirection; Decrease stimulation; Diversionary activities
Risk Factors: History of physical abuse
Justification
Clinical Justification: Imminent risk of harm to self and others
Restraint Type
4 Point Restraints (V): START
Both Upper Extremities Wrist Restraints (V): START
Both Lower Extremities Ankle Restraints (V): START
Education
Discontinuation Criteria: Contracts not to harm self; Absence of behavior
that required restraint; Contracts not to harm others
Criteria Explained: Yes
Patient's Response: Verbalized understanding
Family Notification: Guardian
ED Restraint Care Plan
ED Restraint Care Plan: Assess for continued need for
restraints/discontinuation of restraints; Release restraints every two hours for
ten minutes; Exercise and maintain range of motion; Assess and assist with
toileting needs; Administer medications as ordered for agitation/restlessness;
Observe for urinary incontinence, constipation; Circulation checks; Monitor
Vital Signs; Cover/protect IV lines and tubes"

Patient #A remained in a 4-point restraint from 05/14/2025 at 3:00 PM until discontinued on 05/14/2025 at 5:30 PM (over 2 hours).

Nursing documentation (Staff #16) indicated she was sleeping, but aggressive and uncooperative on the Violent Restraints Monitoring Every 30 minutes at 3:25 PM and 3:55 PM; but tearful and uncooperative at 4:25 PM.

3:25 PM Physical Comfort: Patient asleep Continuous Observation: Yes
Psychological Status: Aggressive/Violent; Uncooperative
3:55 PM Physical Comfort: Patient asleep Continuous Observation: Yes
Psychological Status: Aggressive/Violent; Uncooperative
4:25 PM Physical Comfort: Reposition; Pillows
Continuous Observation: Yes
Psychological Status: Tearful; Uncooperative

Review of Patient #A's medical chart revealed the following Q15 checks. Prior to and during restraints on 5/14/25, Staff #19 documented the Q15 minute checks:

2:30 PM Patient Location: In room
Patient Activity: Awake
Visual Check: Agitated/restless Physical Comfort: Reposition
15 Minute Sitter Check Observation Complete: Yes
2:45 PM Patient Location: In room
Patient Activity: Awake
Visual Check: Agitated/restless Physical Comfort: Reposition
15 Minute Sitter Check Observation Complete: Yes
3:00 PM Patient Location: In room
Patient Activity: Awake
Visual Check: Agitated/restless Physical Comfort: Reposition
15 Minute Sitter Check Observation Complete: Yes
3:15 PM Patient Location: In room
Patient Activity: Awake
Visual Check: Agitated/restless Physical Comfort: Reposition
15 Minute Sitter Check Observation Complete: Yes
3:30 PM Patient Location: In room
Patient Activity: Sleeping Visual Check: Asleep
Physical Comfort: Patient asleep
15 Minute Sitter Check Observation Complete: Yes Fluids: Patient asleep
Food/Meal: Patient asleep
Elimination: Patient asleep
During restraints on 5/14/25, Staff #18 continued the Q15 minute checks
3:45 PM Patient Location: In room
Patient Activity: Sleeping Visual Check: Asleep
Physical Comfort: Patient asleep
15 Minute Sitter Check Observation Complete: Yes Fluids: Patient asleep
Food/Meal: Patient asleep
Elimination: Patient asleep
4:00 PM Patient Location: In room
Patient Activity: Sleeping Visual Check: Asleep
Physical Comfort: Patient asleep
15 Minute Sitter Check Observation Complete: Yes Fluids: Patient asleep
Food/Meal: Patient asleep
Elimination: Patient asleep
4:15 PM Patient Location: In room
Patient Activity: Awake
15 Minute Sitter Check Observation Complete: Yes
Elimination: Offered
4:30 PM Patient Location: In room
Patient Activity: Awake Visual Check: Tearful
15 Minute Sitter Check Observation Complete: Yes
4:45 PM Patient Location: In room
Patient Activity: Awake
Visual Check: Tearful (crying)
15 Minute Sitter Check Observation Complete: Yes
5:00 PM Patient Location: In room
Patient Activity: Watching TV
Visual Check: Tearful (crying wants nurse)
15 Minute Sitter Check Observation Complete: Yes
5:16 PM Patient Location: In room Visual Check: (crying)
15 Minute Sitter Check Observation Complete: Yes

The behavior requiring restraint was absent while Patient #A was sleeping as documented by both Staff #16 and Staff #19 on 05/14/2025 at 3:30 PM.

In an interview with Staff #6 on 5/27/25 at 1:20 PM in the small conference room, he stated that he believed that Staff #16 accidentally input 'patient asleep' in the chart. He stated that Patient #A couldn't have been aggressive/violent, uncooperative if she was asleep. He acknowledged that restraints could be kept on as a precaution but that it should be reassessed for need.

Based on review of facility policy, patient chart review and confirmed in interview, the facility failed to ensure the condition of the patient who was restrained was monitored at intervals determined by hospital policy for two of eight charts reviewed (Patient #A, B).

Findings included:


Review of the facility Restraints and Seclusion Procedure (Version 4, 02/13/2024), it stated "within 1 hour of the application of restraints, a face to face evaluation must be completed by physician or other provider. Telephonic or telemedicine methods of evaluation are not permitted. Should a patient's violent or self-destructive behavior be resolved and the restraint intervention is discontinued before the practitioner arrives, a face-to-face evaluation must be completed within one (1) hour after the initiation of the intervention. The face-to-face evaluation should include: a. An evaluation of the patient's immediate situation b. Factors that may have contributed to the violent or destructive behavior c. Whether the intervention was appropriate to address the violent of destructive behavior d. The patient's reaction to the intervention e. The patient's medical and behavioral condition f. The need to continue or terminate the restraint. g. The need for other interventions or treatments. The attending physician or provider responsible for the care of the patient must be consulted if the face-to-face evaluation is conducted by someone other than the attending physician or other provider responsible for the care of the patientViolent patients must be monitored for safe application at least every 30 minutes. Monitor the patient: a. Observe patients older than 9 at least every two (2) hours (patients under the age of 9 years must be assessed every (1) hour) for: i. change in condition impacting the need for restraint (such as level of distress or agitation) ii. circulation (pulse) distal to the restraint iii. skin integrity distal to the restraint (restraint may be removed to assess skin) iv. respiratory status v. vital signs - which include at a minimum the measurement of blood pressure, heart rate, respiratory rate, and 02 saturation vi. mental status vii. nutritional and hydration needs vili. elimination and toileting needs ix. range of motion and position change x. readiness for discontinuation of restraints xi. justification for continued use of restraints. Staff are expected to assess and monitor the patient's condition on an ongoing basis to determine whether restraint can safely be discontinued as quickly as possible."

Patient #A

Review of Patient #A's medical chart revealed she is a 12 year old female with a history of depression and anxiety and ADHD who presented to the ED for suicidal ideation on 05/12/2025.

Staff #16's nursing notes included:
3:08 PM "patient moved bed against wall and was hiding between the bed in the wall refusing to come out, security called to bedside. Explained to patient we need to be able to see her at all times, patient screaming and cussing and lunging at staff. Patient trying to pull bed against wall again and bed was removed from the room. At that time, patient punched the computer screen shattering it. Patient attempting to hit staff, bed brought back in room and patient placed on it, patient continues to attempt to hit and kick staff. Patient restrained at this time for self-destructive behavior."

Review of Patient #A's medical chart revealed physical restraints were used on 05/14/2025 from 3:00 PM to 5:30 PM.

Patient #A's medical chart included the 30 min Violent Restraints monitoring performed by Staff #16
3:25 PM Physical Comfort: Patient asleep Continuous Observation: Yes
Psychological Status: Aggressive/Violent; Uncooperative
3:55 PM Physical Comfort: Patient asleep Continuous Observation: Yes
Psychological Status: Aggressive/Violent; Uncooperative
4:25 PM Physical Comfort: Reposition; Pillows
Continuous Observation: Yes
Psychological Status: Tearful; Uncooperative

Review of Patient #A's medical chart revealed the following Q15 checks. Prior to and during restraints on 5/14/25, Staff #19 documented the Q15 minute checks:
2:30 PM Patient Location: In room
Patient Activity: Awake
Visual Check: Agitated/restless Physical Comfort: Reposition
15 Minute Sitter Check Observation Complete: Yes
2:45 PM Patient Location: In room
Patient Activity: Awake
Visual Check: Agitated/restless Physical Comfort: Reposition
15 Minute Sitter Check Observation Complete: Yes
3:00 PM Patient Location: In room
Patient Activity: Awake
Visual Check: Agitated/restless Physical Comfort: Reposition
15 Minute Sitter Check Observation Complete: Yes
3:15 PM Patient Location: In room
Patient Activity: Awake
Visual Check: Agitated/restless Physical Comfort: Reposition
15 Minute Sitter Check Observation Complete: Yes
3:30 PM Patient Location: In room
Patient Activity: Sleeping Visual Check: Asleep
Physical Comfort: Patient asleep
15 Minute Sitter Check Observation Complete: Yes Fluids: Patient asleep
Food/Meal: Patient asleep
Elimination: Patient asleep
During restraints on 5/14/25, Staff #18 continued the Q15 minute checks
3:45 PM Patient Location: In room
Patient Activity: Sleeping Visual Check: Asleep
Physical Comfort: Patient asleep
15 Minute Sitter Check Observation Complete: Yes Fluids: Patient asleep
Food/Meal: Patient asleep
Elimination: Patient asleep
4:00 PM Patient Location: In room
Patient Activity: Sleeping Visual Check: Asleep
Physical Comfort: Patient asleep
15 Minute Sitter Check Observation Complete: Yes Fluids: Patient asleep
Food/Meal: Patient asleep
Elimination: Patient asleep
4:15 PM Patient Location: In room
Patient Activity: Awake
15 Minute Sitter Check Observation Complete: Yes
Elimination: Offered
4:30 PM Patient Location: In room
Patient Activity: Awake Visual Check: Tearful
15 Minute Sitter Check Observation Complete: Yes
4:45 PM Patient Location: In room
Patient Activity: Awake
Visual Check: Tearful (crying)
15 Minute Sitter Check Observation Complete: Yes
5:00 PM Patient Location: In room
Patient Activity: Watching TV
Visual Check: Tearful (crying wants nurse)
15 Minute Sitter Check Observation Complete: Yes
5:16 PM Patient Location: In room Visual Check: (crying)
15 Minute Sitter Check Observation Complete: Yes

The documentation reviewed did NOT include pulse, skin integrity, respiratory status, vital signs, readiness for discontinuation of restraints or justification for continued use.

Patient #B

Review of Patient #B medical record revealed she is an 18 year old female who was seen at the ED with complaints of SI with plan to harm herself with a piece of glass on 04/04/2025 via police EDO.

Review of Staff #20 nursing notes on 04/05/2025, it stated "this RN explained to the patient that we were going to try and redraw the labs. Patient screamed 'no you are not going to take my blood' and became verbally aggressive. Security was called to the room and MD ordered medication. Patient became physically aggressive towards staff and was medicated and restrained at 0230 to obtain IV access to get the labs."

Review of orders revealed the 4 point physical restraints were ordered on 04/05/2025 at 2:30 AM and discontinued at 3:30 AM.

Review of Patient #B chart revealed the following restraint monitoring:
30 min Violent Restraints monitoring performed
3:00 AM Physical Comfort: Patient declined
Continuous Observation:Yes
Psychological Status: Uncooperative

Q15 min
2:15 AM Patient Location: In room
Patient Activity: Awake
Visual Check: Agitated/restless
15 Minute Sitter Check Observation Complete: Yes
2:30 AM Patient Location: In room
Patient Activity: Awake
Visual Check: Agitated/restless
15 Minute Sitter Check Observation Complete: Yes
2:45 AM Patient Location: In room Patient Activity: Sleeping
Visual Check: Asleep
15 Minute Sitter Check Observation Complete: Yes
3:00 AM Patient Location: In room Patient Activity: Sleeping Visual Check: Asleep
15 Minute Sitter Check Observation Complete: Yes
3:15 AM Patient Location: In room Patient Activity: Sleeping Visual Check: Asleep
15 Minute Sitter Check Observation Complete: Yes

Vital Signs were assessed at 03:55 AM:
Temp 36.7 C
Pulse 89
Resp 18
BP 106/65
No vitals assessed from 2:30 AM to 3:30 AM while patient was in restraints.

The documentation reviewed did NOT include pulse, skin integrity, respiratory status, vital signs, readiness for discontinuation of restraints or justification for continued use.

In an interview with Staff #1 on 05/27/2025 at 0940 AM in the small conference room, she acknowledged that staff did not monitor the patients per their protocol.