Uva Health Haymarket Medical Center

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient or others from harm. This Standard is not met as evidenced by: 46466 Based on interviews, medical record review and facility document review, the facility failed to use the least restrictive type of restraint for one (1) of three (3) restraint medical records (MR) reviewed. The findings include: A review of the facility’s policy “Restraints and Seclusion”, last revised 7/2025, indicated in part: “...B. Use of Restraints, 1. The type or technique of restraint must be the least restrictive intervention that will be effective to protect the patient, Team Member or others from harm...”. On July 1, 2026, at 6:41 AM, MR5’s medical record documented a physician order for “violent, soft, bilateral upper and lower extremity restraints” and “four side rails” for the patient jeopardizing the immediate physical safety to self. The nursing flowsheets documented monitoring every 15 minutes per policy but failed to clearly document the effective alternatives and the least restrictive restraint methods that were attempted and failed from 7:15 AM through 1:59 PM when the restraints were discontinued. On July 22, 2026, during restraint medical record reviews, EMP1 agreed that the restraint documentation was lacking more details to provide a better description.”

“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: 46466 Based on interviews, medical record reviews and facility document reviews, the facility failed to use a restraint in accordance with an order from a physician for one (1) of three (3) restraint medical records (MR5) reviewed. The findings include: A review of the facility’s policy “Restraints and Seclusion”, effective 7/2025, indicated in part: “...C. Time Limited Orders, 1. Orders are time-limited and expire as follows: a. 4 hours for adults 18 years of age or older...2. If restraint or seclusion needs to continue beyond the expiration of the time-limited order, a new order must be obtained...”. On July 1, 2026, at 6:41 AM, MR5 documented a physician order for “violent, soft, bilateral upper and lower extremity restraints” for MR5 jeopardizing the immediate physical safety to self. The order length was not to exceed four (4) hours. There was no renewed order placed until 1:10 PM on July 1, 2026. The nursing flowsheets revealed that the restraints were continued on the patient through 1:59 PM on July 1, 2026. On July 22, 2026, during restraint medical record reviews, EMP18 stated there was no physician order found.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 46466 Based on interviews, medical record reviews and facility document reviews, the facility failed to monitor patients who were restrained according to facility policy for one (1) of three (3) restraint medical records (MR) reviewed. The findings include: A review of the facility’s policy “Restraints and Seclusion”, last reviewed 7/2025, indicated in part: “...Non-Violent Restraints...5. Patients in 4-point restraints shall be observed every 15 minutes...”. On July 6, 2026, at 2:26 PM, a physician order was placed for MR6 to be placed in non-violent, bilateral upper and lower extremity restraints (4-point restraints). The nursing flowsheets revealed that the patient was monitored every two (2) hours rather than every 15 minutes per facility policy. On July 22, 2026, during restraint record review, EMP1 reviewed the facility policy and stated they were not aware that non-violent, 4-point restraints required 15-minute monitoring.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(i) When restraint or seclusion is used, there must be documentation in the patient’s medical record of the following: The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior. This Standard is not met as evidenced by: 46466 Based on interviews, medical record reviews and facility document reviews, the facility failed to provide evidence of documentation that a face-to-face assessment was conducted within one (1) hour of placing patients in restraints for one (1) of three (3) restraint medical records (MR) reviewed. The findings include: A review of the facility’s policy “Restraints and Seclusion” last reviewed 7/2025, indicated in part: “...D. Face-to-Face Evaluations, 1. The patient must be examined in person by a physician, physician assistant or nurse practitioner or specially trained Registered Nurse (RN) within 1 hour after the initiation of the intervention...”. On July 1, 2026, MR5’s medical record revealed that the patient was placed in “violent, soft, bilateral upper and lower extremity restraints” for jeopardizing the immediate physical safety to self at 7:00 AM. The order also documented “Are you a physician, APP or specially trained RN who can perform a face-to-face assessment? -Yes, Assessment of the patient includes Physical exam...”. There was no additional documentation found in the medical record or provided to indicate that the patient received a face-to-face evaluation within one (1) hour of the initiation of restraints. On July 22, 2026, during restraint record review, EMP18 stated that the wording in the physician order indicated above was documentation that a face-to-face assessment was completed. EMP18 could not provide additional documentation of a face-to-face evaluation.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(v) [there must be documentation in the patient’s medical record of the following:] The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention. This Standard is not met as evidenced by: 46466 Based on interviews, medical record reviews and facility document reviews, the facility failed to document the patient’s response to the intervention of a restraint and failed to document a description of the patient’s behavior that warranted the continued use of restraints for two (2) of three (3) restraint medical records (MR)reviewed. The findings include: A review of the facility’s policy “Restraints and Seclusion”, last reviewed 7/2025, indicated in part: “ ...Non-violent Restraints...D. Monitoring ...The following will be monitored and documented every 2 hours ...or more often as indicated by patient condition ...j. Readiness for discontinuation of restraint ...E. Discontinuation of Non-violent Restraints, 1. Restraint must be discontinued at the earliest possible time, regardless of the length of time identified in the order...Violent/Self-Destructive Restraint Requirements (in any area)...E. Monitoring and Assessments...3. Observations include the following as appropriate to the type of restraint on seclusion in use...j. Readiness for discontinuation of restraint or seclusion. 4. Trained Team Members will help patients meet behavior criteria for discontinuing restraint or seclusion...”. The facility’s “Restraints and Seclusion” policy did not contain a separate “Discontinuation of Violent Restraints” section. The policy did contain a section for the discontinuation of violent/self-destructive restraints in Behavioral Medicine (BM). On July 1, 2026, at 6:41 AM, MR5’s medical record documented a physician order for “violent, soft, bilateral upper and lower extremity restraints” and “four side rails” for MR5 jeopardizing immediate physical safety to self. The nursing flowsheets documented monitoring every 15 minutes per policy from 7:15 AM through 1:59 PM but did not document how the patient’s behavior was continuing to meet the criteria. On July 15, 2026, at 10:59 AM, a new order was placed for MR7 to continue in non-violent restraints to continue through July 16, 2026, at 11:59 PM. The nursing flow sheet failed to document the patient’s behavior that warranted the use of restraints from 9:00 PM through 11:00 PM, on July 15, 2026. On July 22, 2026, during restraint medical record reviews, EMP1 agreed that the restraint documentation was lacking more details to provide a better description.”