Essentia Health St Joseph’s Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 43080 Based on interview and document review, the facility failed to order non-violent restraints based on specific comprehensively assessed patient need(s) for 4 of 10 patients (P4, P5, P6, P7), and obtain a restraint order prior to, during, or immediately (within a few minutes) following, each episode of violent restraint use for 1 of 1 patients (P3) reviewed for restraint use. This had the potential to affect all intubated (breathing tube) patients, and all patients who required restraints. See A-0168 for additional information. Based on interview and document review, the facility failed to ensure practitioners followed the hospital restraint policy related to renewal of restraint order patient assessment processes for 1 of 10 patients (P5) who were reviewed for restraints that were utilized longer than 24 hours. See A-173 for additional information. Based on interview and document review, the facility failed to ensure restraints were discontinued at the earliest possible time for 4 of 10 patients (P4, P5, P6, P7) who were reviewed for non-violent restraint use. This had the potential to affect all patients who utilized non-violent restraints. See A-174 for additional information. As a result, the hospital was found out of compliance with the Condition of Participation: Patient Rights at 42 CFR 482.13.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 43080 Based on interview and document review, the facility failed to order non-violent restraints based on specific comprehensively assessed patient need(s) for 4 of 10 patients (P4, P5, P6, P7), and obtain a restraint order prior to, during, or immediately (within a few minutes) following, each episode of violent restraint use for 1 of 1 patients (P3) reviewed for restraint use. This had the potential to affect all intubated (breathing tube) patients, and all patients who required restraints. Findings include: An Adult Ventilator (equipment to assist with breathing) Module, undated, identified a section labeled Nursing Assessments/Interventions. Under this section an order for “Restraints non-violent/non-self-destructive” was present. The order reflected a frequency of “Routine, Continuous x (for) 24 hours, Starting Today, for 24 Hours,” related to “Physical restraints for patient safety.” The order allowed the provider to designate which restraints they wished to order. “Soft Restraint Wrist and/or Ankle” was one option. P6’s medical record identified a 4/12/26 emergency department (ED) presentation, in response to a cardiac arrest. Upon arrival, P6 was intubated and sedated (calm, relaxed state due to effects of medication). P6’s Admission History and Physical, date of service 4/12/26, at 2:51 a.m., completed by medical provider (MD)-A, identified P6 was sedated and utilized a ventilator (equipment to assist with breathing). The note lacked evidence P6 attempted to remove and/or interfere with ventilator equipment and/or any other utilized medical equipment, nor did the note identify other interventions to decrease P6 from pulling at lines/tubes/etc. prior to a restraint order. P6’s 4/12/26 Restraint order, Restraint Non-Violent flowsheet, and nursing assessment flowsheets identified the following: -2:54 a.m., MD-A placed an order for “Soft Restraint Wrist and/or Ankle,” for patient safety. -4:00 a.m., soft Restraint to the right and left wrists started (approximately one hour after the order was placed). P6’s 4/12/26 Restraint Non-Violent flowsheet and medical record identified the following: -11:30 a.m., the restraints were discontinued as P6 was extubated (ventilator discontinued). P6’s medical record lacked evidence he was assessed for restraint use, prior to the application of non-violent restraints, and that this assessment process was based on his specific needs to ensure the restraint use was the least restrictive measure to ensure P6’s safety. P4’s medical record identified a 4/16/26 ED presentation for infectious diarrhea and alcohol withdrawal syndrome and associated delirium (sudden confusion/disorientation). P4’s Admission History and Physical, date of service 4/16/26, at 4:33 a.m., identified P4 was awake but confused with delirium. P4 displayed active tremors. The note lacked identification of any behavioral disturbances and/or attempts to remove medical equipment. Additionally, the note lacked information related to restraint use and/or restraint rationalization. P4’s 4/16/26 Restraint order, Restraint Non-Violent flowsheets, and nursing assessment flowsheets identified the following: -4:23 a.m., MD-B placed an order for “Soft Restraint Wrist and/or Ankle,” for patient safety. -4:40 a.m., a Restraint Face-to-Face identified soft restraints were applied in which P4 was disoriented and hallucinated, and his “behaviors demonstrated prior to restraints continued.” The face-to-face lacked additional information for the utilization of the restraint order. P4’s medical record lacked evidence of any demonstrated behaviors prior to restraints. -4:45 a.m., restraint flowsheets identified soft restraints to the right and left wrists started. P4’s medical record lacked evidence he was assessed for restraint use, prior to the application of non-violent restraints, and that this assessment process was based on his specific needs to ensure the restraint use was the less restrictive measure to ensure P4’s safety. P5’s medical record identified a 4/18/26 ED presentation for acute hypoxic respiratory failure. P5’s medical record identified the following: -4/19/26, at 3:36 p.m., MD-C placed an order for “Soft Restraint Wrist and/or Ankle,” for patient safety. Frequency was for 24 hours. -4/19/26, at 3:52 p.m., P5 was intubated. -4/19/26, 4:00 p.m., restraint flowsheet identified right and left soft wrist restraints were started. P5’s Admission History and Physical, date of service 4/20/26, at 10:47 a.m., completed by MD-D, identified P5 was intubated and sedated. Restraints were in place in which family reported P5 did move his arms and hands at times, despite quadriplegia, and had inadvertently dislodged his feeding tube in the past [prior to admission]. The note lacked additional restraint information. P5’s End of Shift Summary nursing progress note, date of service 4/22/26, at 6:11 p.m., identified P5 was extubated at 11:55 a.m. P5’s Restraint Non-Violent flowsheets identified that on 4/22/26, at 11:55 p.m., restraints were discontinued. P5’s medical record lacked evidence he was assessed for restraint use, prior to the application of non-violent restraints, and that this assessment process was based on his specific needs to ensure the restraint use was the least restrictive measure to ensure P5’s safety. P7’s medical record identified a 4/22/26 ED presentation for a small bowel obstruction. P7’s provider progress note, date of service 4/23/26, at 8:25 a.m., identified P7 required intubation. P7’s Restraint Non-Violent flowsheets, dated 4/23/26, at 8:45 a.m., identified right and left soft wrist restraints were started. P7’s Restraint order section, dated 4/23/26, at 3:29 p.m., identified MD-F placed an order for “Soft Restraint Wrist and/or Ankle” for patient safety (six hours and 45 minutes after the restraints started). P7’s medical record lacked evidence she was assessed for restraint use, prior to the application of non-violent restraints, and that this assessment process was based on her specific needs to ensure the restraint use was the less restrictive measure to ensure P7’s safety. P3’s medical record identified a 4/28/26 ED presentation for severely aggressive behavior. P3 was an autistic adolescent. P3’s provider note, date of service 4/28/26, at 9:52 a.m., identified while the provider gathered information, P3 started to kick, hit, and punch his father. P5’s behavior was uncooperative, agitated, and aggressive and his judgment was impulsive and inappropriate. The note identified P3 was provided intramuscular (IM) medication to help decrease aggressive behaviors. P3’s nursing notes, date of service 4/28/26, identified the following: -10:07 a.m.: P3 continued to be violent and aggressive. He kicked, scratched, and threw a scanner at staff’s face. -11:11 a.m.: P3 continued to hit his father and attempted “to go after” staff. -12:38 p.m.: P3 continued to have aggressive behaviors with attempts to grab and hit at staff. -4:00 p.m.: P3 attempted to leave and hit at staff. He was redirected back to room multiple times. -4:08 p.m.: P3 was aggressive and swung at staff. -4:54 p.m.: P3 was placed in restraints for both staff and family’s safety. Despite medications to help calm him, he still, at times, fought against the restraints. The note was signed by the provider on 4/29/26, at 12:16 a.m. [Restraint episode]. -7:15 p.m.: P3 charged at staff and father. He slapped, scratched, bit, and kicked. P3 “placed on bed by writer, security, and dad. Staff holding hands for safety at this time. [P3] continues to try to pull staff hair and pinching.” [Manual hold - restraint event]. P3’s medical record lacked evidence that the provider ordered restraint(s) based on the 4:54 p.m. provider note, and the 7:15 p.m. manual hold events. P3’s Restraint flowsheets, dated 4/28/26, at 8:05 p.m., identified “Velcro firm” restraint device, but the documentation was under locked restraints to bilateral wrists and ankles were started. P3’s Restraint order section, dated 4/28/26, at 9:52 p.m. (approximately one hour and 45 minutes after restraints were applied), identified MD-G placed an order for “Velcro Firm” restraints to ankles and wrists in response to imminent danger to self and others. The frequency was for two hours. When interviewed on 5/1/26, at 10:55 a.m., Doctor of Osteopathic Medicine (DO)-H stated restraints for behavioral situations was rare; however, non-violent restraints were utilized for intubated patients as standard practice as to decrease the risk of them pulling at lines/tubes, etc. DO-H stated he was expected to place restraint orders right away and restraints were expected to be discontinued as soon as the reason for use was no longer present. Additionally, any restraint event required an order, along with a face-to-face evaluation for violent restraints to ensure patient safety. When interviewed on 5/1/26, at 11:24 a.m., medical doctor (MD)-C stated he did not provide violent restraint orders and was unsure how to answer related questions; however, he explained he did order non-violent restraints for intubated patients in the intensive care unit (ICU). He explained an assessment was needed to determine any type of restraint need and then if deemed necessary, an order was required right away. When interviewed on 5/1/26, at 11:49 a.m., registered nurse (RN)-A stated restraint orders should be obtained right away as such orders cannot wait due to patient and staff safety; however, she had up to an hour to obtain the order. When interviewed on 5/1/26, at 12:06 p.m. RN-B stated it was expected the restraint order was obtained prior to restraint application; however, he may have from 15 minutes to one hour to obtain the order. He stated he would have to review the policy to ensure this information was correct. When interviewed on 5/1/26, at 12:33 p.m., RN-C stated that restraints are only used in the ICU, from what she was aware of. If restraints were required on her unit (medical floor), the patient was transferred to the ICU. Despite this, RN-C explained, before restraints were applied, the least restrictive interventions were required first. She indicated she would have to review the policy for specific restraint details and direction. When interviewed on 5/4/26, at 9:21 a.m., RN-D, a medical floor manager, stated anyone who required restraints were not kept on the medical floor. Those patients were transferred to the ICU for required monitoring. Due to this facility practice, RN-D was unaware of restraint expectations and would be required to reference the policy if needed. He expected staff to follow the restraint directions identified in the restraint policy. When interviewed on 5/4/26, at 9:54 a.m., the chief nursing officer (CNO), stated that an assessment and a practitioner order were expected prior to restraint application. In emergency behavioral situations, a nurse was able to apply restraints; however, the practitioner was required to enter a restraint order once the nurse called and they were updated on the situation. This ensured the practitioner could assess the patient to see if the need for the restraint were related to a medical condition, such as pain. The CNO stated, based on their policy, staff had up to one hour to procure a restraint order; however, due to practitioners always being there, this time extension really should be limited. During the abbreviated patient medical record review process on 5/4/26, at 1:08 p.m., with RN-D, RN-E (ED manager), and RN-F (critical care manager). All three stated orders were expected to be placed timely. Additionally, all restraints require an order. With review of P7’s medical record, RN-E and RN-F stated staff were expected to obtain a non-violent restraint order within four hours of application. This was to ensure the patient was assessed for restraint need. RN-F explained that routinely the nurse called the provider, as they were allowed to make restraint decisions “in the moment,” and once the provider provided a verbal order, the nurse was to enter a verbal restraint order. However, when it came to verbal orders for P6, RN-F stated verbal orders overall should be limited as there were always hospitalist (practitioner) coverage and verbal orders were more for emergency behavioral events. For P6, in relation to the timeframe from the order to application, RN-F could only speculate as to what occurred, but stated providers were not supposed to place as needed (just in case) restraint orders, and restraint orders were only supposed to be ordered when needed. She expected restraint orders and associated placement to occur in conjunction with each other, not an hour later. For P4, RN-F speculated this was a similar situation to P6. When interviewed on 5/4/26, at 3:47 p.m., MD-A stated patients would not be restrained if they lacked signs of concern as restraint use required a reason for application. She explained, for caution’s sake, when a patient was intubated, the first 24-hours after intubation, based on their protocols, all intubated patients were restrained with soft-restraints. She explained she wished to be more proactive in decreasing the risk of patients pulling at lines, tubing, etc., and due to each patient’s level of sedation and the potential unexpected ability to pull at tubes, she ultimately wanted to ensure safety and protection of the lines/tubing. MD-A explained that it was her practice to order non-violent soft restraints for intubated patients, based off the intubation protocols, for at least the first 24 hours. She identified she placed the order for the restraints when she placed the orders for the intubation as this was embedded in the order set. MD-A stated the restraint order must be placed after the restraint application; however, she just added it to this order set. After 24 hours of being restrained, if the patient continued to be intubated, the restraints were reordered; however, later in the interview MD-A stated if the patient was “well sedated” and showed no sign of pulling at lines, then the restraints would be discontinued. MD-A stated, when it came to violent restraints, she responded right away, as she was expected to assess the patient and order the restraints before they were applied. During a follow-up interview on 5/4/26, at 4:08 p.m., with the CNO, the CNO stated she would have to review the restraint policy related to non-violent restraint use. She stated she expected restraint needs to be assessed first to see if there were any underlying reasons for any patient presentations prompting restraint use before restraints were applied. She was unsure as to the time for completion of this process and again would have to review the policy. For intubated patients, the CNO did not think non-violent restraints were part of the order set. She stated staff were still required to make sure the restraints were needed as “no two intubated patients are the same.” She verbalized she did not like that providers were automatically putting in non-violent restraint orders if that indeed occurred. When it came to restraint order placement, she stated one hour seemed too long and she wanted providers to place restraint orders “right away” and for them to assess if there were other reasons for any displayed patient actions/behaviors to ensure restraint use was the least restrictive and not used unless necessary. The CNO stated the facility audited restraints and no recent restraint issues were identified; however, this was based on their policy, not the information provided to her because of the investigation. A Restraint and Seclusion policy, dated 5/17/24, identified a section Restraints for Violent or Self-Destructive Behavior that indicated restraints were only utilized when less restrictive interventions were determined to be ineffective to protect the patient, and others, from harm. Additionally, the least restrictive interventions were to be used. Restraint orders were only to be implemented by a practitioner order; however, in an emergency application situation, the order must be obtained “either during the emergency application of the restraint ...or within (1) hour,” even if the restraint was already discontinued. Restraint orders were to be “individualized,” and were not allowed to be “written as a standing order, as a preemptive order, as a protocol order, or as an as needed basis (e.g. a ‘prn order)’.” A second section, Restraints for Non-Violent / Non-Self-Destructive Behavior, identified a practitioner order “must be obtained within four (4) hours,” for a non-violent restraint.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy. This Standard is not met as evidenced by: 43080 Based on interview and document review, the facility failed to ensure practitioners followed the hospital restraint policy related to renewal of restraint order patient assessment processes for 1 of 10 patients (P5) who were reviewed for restraints that were utilized longer than 24 hours. Findings include: A Restraint and Seclusion policy, dated 5/17/24, identified a section labeled Restraints for Non-Violent / Non-Self-Destructive Behavior. This section directed orders for non-violent/non-self-destructive restraints must be renewed every calendar day based on assessment of continuing need unless the order was discontinued within 24 hours of initiation and the patient must be seen and assessed by the practitioner caring for the patient prior to a new order for the use of restraint after the initial 24 hours. P5’s medical record identified a 4/18/26 ED presentation for acute hypoxic respiratory failure. P5’s medical record identified the following: -4/19/26, at 3:36 p.m., MD-C placed an order for “Soft Restraint Wrist and/or Ankle,” for patient safety. Frequency was for 24 hours. -4/19/26, at 3:52 p.m., P5 was intubated. -4/19/26, 4:00 p.m., restraint flowsheet identified right and left soft wrist restraints were started. P5’s Admission History and Physical, date of service 4/20/26, at 10:47 a.m., completed by medical doctor (MD)-D, identified P5 was intubated and sedated. Restraints were in place in which family reported P5 did move his arms and hands at times, despite quadriplegia, and had inadvertently dislodged his feeding tube in the past. The note lacked information related to any restraint decision(s) at that time other than the current use and the history of feeding tube dislodgment. P5’s Restraint order section, dated 4/20/26, at 3:48 p.m. (approximately five hours after the history and physical), identified MD-D placed a [renewal] order for “Soft Restraint Wrist and/or Ankle,” for patient safety. Frequency was for 24 hours. P5’s medical record lacked evidence P5 was assessed/evaluated by MD-D in relation to the restraint renewal order. P5’s Restraint order section, dated 4/21/26, at 11:02 a.m., identified MD-E placed a [renewal] order for “Soft Restraint Wrist and/or Ankle,” for patient safety. Frequency was for 24 hours. P5’s Hospital Medicine Service provider note, dated 4/21/26, at 11:12 a.m., identified P5 was assessed by MD-E. P5 was sedated and intubated. The note lacked evidence P5 was restrained and/or information related to the continued need for restraints. P5’s Restraint order section, dated 4/22/26, at 11:04 a.m., identified an RN placed a verbal order for “Soft Restraint Wrist and/or Ankle,” for patient safety. Frequency was for 24 hours. P5’s medical record lacked evidence P5 was assessed by the practitioner on 4/22/26 prior to the provided verbal order at 11:04 a.m. P5’s respiratory therapy progress note, date of service 4/22/26, at 11:58 a.m., identified P5 was extubated at 11:55 a.m. P5’s Restraint Non-Violent flowsheets identified that on 4/22/26, at 11:55 p.m., restraints were discontinued. P5’s medical record identified that on 4/22/26, P5 was assessed by MD-D at 1:06 p.m. (two hours after the RN placed the restraint verbal order). When interviewed on 5/1/26, at 10:55 a.m., MD-H stated he was expected to assess a patient who continued to use restraints for more than 24-hours to determine if the restraint was required to continued. Once this was completed, and the restraint needed to continue, then he placed another order. When interviewed on 5/1/26, at 11:23 a.m., MD-C stated that he was expected to assess a patient who continued to use restraints for more than 24 hours to determine if continued need was present. If there was not a need, he was expected to discontinue the order. During the abbreviated patient medical record review process on 5/4/26, at 1:08 p.m., with RN-D, RN-E (ED manager), and RN-F (critical care manager). All three stated orders were expected to be placed timely. RN-F explained that routinely the nurse called the provider, as they were allowed to make restraint decisions “in the moment,” and once the provider provided a verbal order, the nurse was to enter a verbal restraint order. However, when it came to verbal orders, RN-F stated verbal orders overall should be limited as there were always hospitalist (practitioner) coverage and verbal orders were more for emergency behavioral events. RN-F stated restraint orders were only supposed to be ordered when needed. RN-F explained it was facility policy to obtain restraint renewal orders every 24 hours. She was unsure why a verbal order was provided for P5 as she expected the provider would have assessed the continued need as part of their daily P5 assessment. This was not an emergency restraint situation. When interviewed on 5/4/26, at 3:47 p.m., MD-A stated that it was her practice to order non-violent restraints for intubated patients. After 24 hours, if the restraint continued, she was expected to reassess the patient and determine if the restraint continued to be required, or if it could be discontinued. When interviewed on 5/4/26, at 4:08 p.m., the chief nursing officer (CNO) stated she would have to review the restraint policy related to non-violent restraint use for specific details on expectations and she expected the restraint policy to be followed. The CNO stated the facility audited restraints and no recent restraint issues were identified.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 43080 Based on interview and document review, the facility failed to ensure restraints were discontinued at the earliest possible time for 4 of 4 patients (P4, P5, P6, P7) who were reviewed for non-violent restraint use. This had the potential to affect all patients who utilized non-violent restraints. Findings include: P6’s medical record identified a 4/12/26 emergency department (ED) presentation, in response to a cardiac arrest. Upon arrival, P6 was intubated (breathing tube) and sedated (calm, relaxed state due to effects of medication). P6’s Admission History and Physical, date of service 4/12/26, at 2:51 a.m., completed by medical provider (MD)-A, identified P6 was sedated and utilized a ventilator (equipment to assist with breathing). The note lacked evidence P6 attempted to remove and/or interfere with ventilator equipment and/or any other utilized medical equipment, nor did the note identify other interventions to decrease P6 from pulling at lines/tubes/etc. prior to a restraint order. P6’s 4/12/26 Restraint order, Restraint Non-Violent flowsheet, and nursing assessment flowsheets identified the following: -4:00 a.m., soft Restraint to the right and left wrists started (approximately one hour after the order was placed). P6 was “Calm.” -5:45 a.m., during a pain assessment, P6 showed tense facial expressions, and his body movements were documented as “restlessness/agitation.” The medical record lacked additional information related to specific body movement features. -6:00 a.m., during the required two-hour restraint check, P5 remained “Calm.” P6’s End of Shift Summary nursing progress note, date of service 4/12/26, 6:17 a.m., identified P6 was restless at times and fought the ventilator. The note lacked details that provided additional information as to the restlessness and fighting the ventilator. P6’s 4/12/26 Restraint Non-Violent flowsheet and nursing assessment flowsheets identified the following: -8:00 a.m., during the vent assessment, P6 remained “Calm.” -10:00 a.m., during the vent assessment, P6 remained “Calm.” -11:30 a.m., the restraints were discontinued as P6 was extubated (ventilator discontinued). P6’s medical record lacked evidence P6 was behavioral or attempted to remove and/or interfere with medical equipment prior to, or during restraint utilization. P4’s medical record identified a 4/16/26 ED presentation for infectious diarrhea and alcohol withdrawal syndrome and associated delirium (sudden confusion/disorientation). P4’s Admission History and Physical, date of service 4/16/26, at 4:33 a.m., identified P4 was awake but confused with delirium. P4 displayed active tremors. The note lacked identification of any behavioral disturbances and/or attempts to remove medical equipment. Additionally, the note lacked information related to restraint use and/or restraint rationalization. P4’s 4/16/26 Restraint order, Restraint Non-Violent flowsheets, and nursing assessment flowsheets identified the following: -4:45 a.m., restraint flowsheets identified soft restraints to the right and left wrists started. P4 was “Asleep.” -4:49 a.m., a Daily Observation identified P4 was drowsy, with poor safety awareness. No additional details were provided. -4:50 a.m., a Pain Assessment identified P4 slept. -5:30 a.m., restraint flowsheets identified P4 was “Asleep.” P4’s End of Shift Summary nursing progress note, date of service 4/16/26, at 6:32 a.m., identified P4 was drowsy, a Foley catheter was in place, and intravenous (IV) medications were being administered. The note lacked identification of any behavioral disturbances and/or attempts to remove medical equipment which necessitated the use of restraints. P4’s 4/16/26 Restraint Non-Violent flowsheets and nursing assessment flowsheets identified the following: -7:28 a.m., a Daily Observation identified P4 was deeply sedated with no response to stimuli. -7:30 a.m., the restraints were discontinued. P4’s medical record lacked evidence P4 was behavioral or attempted to remove and/or interfere with medical equipment prior to, or during restraint utilization. P5’s medical record identified a 4/18/26 ED presentation for acute hypoxic respiratory failure. P5’s medical record identified the following: -4/19/26, at 1:30 p.m., Daily Observation flowsheet identified P5 had limited movement in his right and left upper arms due to contractures. -4/19/26, at 1:30 p.m., P5’s Pain Assessment flowsheet identified P5 squirmed, shifted back and forth and was tense. The assessment lacked evidence that P5 attempted to grab any medical equipment. -4/19/26, at 3:52 p.m., P5 was intubated. -4/19/26, 4:00 p.m., P5’s Pain Assessment flowsheet identified he was without movements, and his muscle tone was relaxed. -4/19/26, 4:00 p.m., restraint flowsheet identified right and left soft wrist restraints were started. P5 was calm. Staff repositioned tubes/lines out of P5’s reach. -4/19/26, at 5:17 p.m., RASS (Richmond Agitation and Sedation Scale) flowsheet identified P5 was restless and anxious, but his movements were not aggressively vigorous. The assessment lacked evidence that P5 attempted to grab any medical equipment. P5’s RASS (Richmond Agitation and Sedation Scale) flowsheet, dated 4/20/26, at 12:03 a.m., identified P5 was restless and anxious but his movements were not aggressively vigorous. The assessment lacked evidence that P5 attempted to grab any medical equipment. P5’s Admission History and Physical, date of service 4/20/26, at 10:47 a.m., completed by MD-D, identified P5 was intubated and sedated. Restraints were in place in which family reported P5 did move his arms and hands at times, despite quadriplegia, and had inadvertently dislodged his feeding tube in the past [prior to admission]. P5’s End of Shift Summary nursing progress note, date of service 4/20/26, at 4:24 a.m., identified P5 was intubated and sedated. Restraints continued. P5’s Pain Assessment flowsheet, dated 4/21/26, at 8:00 a.m., identified P5’s movements as slow, decreased, hesitant, cautious, with relaxed muscle tone. P5’s Pain Assessment flowsheet, dated 4/22/26, at 7:35 a.m., identified P5 was without movement and his muscle tone was relaxed. P5’s End of Shift Summary nursing progress note, date of service 4/22/26, at 6:11 p.m., identified P5 was extubated at 11:55 a.m. P5’s Restraint Non-Violent flowsheets identified that on 4/22/26, at 11:55 p.m., restraints were discontinued. P5’s Restraints Non-Violent flowsheets, from 4/19/26, at 4:00 p.m., through discontinuation on 4/22/26, at 11:55 p.m., identified P5 was either “Calm” or “Asleep” during the every two-hour RN assessment. This timeframe of assessment lacked evidence P5 was behavioral or attempted to remove and/or interfere with medical equipment prior to, or during restraint utilization. P7’s medical record identified a 4/22/26 ED presentation for a small bowel obstruction. P7’s provider progress note, date of service 4/23/26, at 8:25 a.m., identified P7 required intubation. P7’s Restraint Non-Violent flowsheets, dated 4/23/26, identified the following: -8:45 a.m., right and left soft wrist restraints started. P5 was “Asleep” at that time. -During the 11:00 a.m., 12:30 p.m., and 2:30 p.m., restraint visual checks, P5 continued to remain “Asleep.” -3:54 p.m., during the restraint visual check, P5 continued to remain “Asleep.” P7’s medical record, dated 4/23/26, at 4:52 p.m., identified P7 was transferred to another hospital. P7’s medical record lacked evidence P7 was behavioral or attempted to remove and/or interfere with medical equipment prior to, or during restraint utilization. When interviewed on 5/1/26, at 10:55 a.m., medical doctor (MD)-H stated restraints were expected to be discontinued as soon as possible when there was no longer evidence for continued need. This helped increase patient safety in relation to restraint use risks. When interviewed on 5/1/26, at 11:49 a.m., registered nurse (RN)-A stated restraints were expected to be removed when there were no longer any concerns for patient, and others ’ safety. She explained that soft restraints for intubated patients were typically removed when the patient was extubated. During the abbreviated patient medical record review process on 5/4/26, at 1:08 p.m., with RN-D, RN-E (ED manager), and RN-F (critical care manager). RN-F stated restraint orders were not supposed to be placed just in case they were needed. The order, and the application, were supposed to be for actual patient situations that placed a patient at risk for concerns, such as pulling at lines and tubing. If a patient was documented as not showing actions that increased their risk of harm and/or safety, restraints were expected to not be on as this restricted the patient’s rights. Ultimately, restraints were expected to be discontinued as soon as possible. When interviewed on 5/4/26, at 3:47 p.m., MD-A stated that it was her practice to order non-violent restraints for intubated patients; however, later in the interview MD-A stated if a patient lacked signs of concern while intubated, such as pulling at lines, tubes, etc., then the patient was not to be restrained. She explained, “for caution sake,” and to be “more proactive” and not waiting for the patient to start pulling at their medical equipment, restraints were automatically applied and then after 24 hours she was expected to reassess the patient and determine then if the restraint continued to be required, or if it could be discontinued. During that assessment, if the patient was well sedated, and lacked signs of pulling at medical equipment, the order was then discontinued and not renewed. When interviewed on 5/4/26, at 4:08 p.m., the chief nursing officer (CNO) stated she expected the restraint policy to be followed by staff where restraints were not utilized unless necessary and to utilize the least restrictive interventions necessary for any exhibited concerns. She explained that no two intubated patients were the same and thus ongoing restraint assessment processes were expected. If a patient lacked displayed behaviors that risked them and others injury, staff were expected to discontinue the restraints as soon as able, or to not even place the patients in restraints in the first place if the criteria were not met for use. The CNO explained, if a patient was placed in restraints without need, there were potential risks for injury, harm, or mobility issues. The CNO stated the facility audited restraints and no recent restraint issues were identified. A Restraint and Seclusion policy, dated 5/17/24, identified a non-violent restraint as a restraint that protected the patient’s physical safety and aided in medical healing of nonviolent or non-self-destructive patients, for example, to prevent the dislodgment of lines, drains or airways [medical equipment]. The policy directed restraints were to be discontinued as quickly as possible and at the earliest possible time, regardless of the ordered length of time, once “the unsafe situation ends and the patient’s behaviors is no longer a threat to self, staff members, or others.””