Old Vineyard Behavioral Health was cited by the Centers for Medicare and Medicaid Services for placing minors in physician ordered restraints or seclusion without time limitations. In one case, a 9 year old was restrained or escorted to seclusion 7 times over a 3-day period, and her records did not document a time limitation for any of the 7 instances. Facility policy dictates that restraint and seclusion interventions must be time-limited. Old Vineyard was also cited because the facility failed to ensure that registered nurses consulted with the attending physician or other licensed independent practitioner (LIP) following the completion of 1-hour face-to-face evaluations of patients placed under restraint or seclusion. The 9-year-old patient’s records indicate that she was given face-to-face evaluations after each of the 7 times she was placed in restraints or seclusion, but there was no indication that the evaluation findings were shared with her attending physician as soon as they were completed.