HospitalInspections.org

Based on review of medical records, staff interviews, and facility policies, it was determined that the facility failed to appropriately monitor and document on patients while in restraints for three patients (P) (P#1, P#4, P#5) of five (P#1, P#2, P#3, P#4, P#5) sampled patients. Specifically, the facility failed to reveal either documentation of restraint charting for the time interval per the type of restraint, circulation assessment charting, assessment of needs by clinical staff, such as hygiene, elimination, or food and fluids, or documentation and assessment for the discontinuation of restraints.

Findings Included:

1. A review of the medical record revealed that P#1 was ordered non-violent restraints for 8/20/24 at 6:35 a.m., 8/20/24 at 8:41 a.m., and 8/21/24 at 8:23 a.m. A review of "Flowsheet - Restraints Information" dated 8/20/24 through 8/21/24 failed to reveal that P#1 was offered food or fluids, hygiene care, and assistance with elimination needs. Continued review failed to reveal documentation that restraints were discontinued by staff.

2. A review of P#4's medical record revealed that P#4 presented to the facility's ED on 8/20/24 due to suicidal ideations (SI) and paranoia. Continued review of the medical record revealed that violent restraints were ordered for P#4 on 8/20/24 at 7:55 a.m., 3:24 p.m., 4:36 p.m. A review of "Flowsheets - Restraints Information" dated 8/20/24 through 8/20/24 failed to reveal documentation of the discontinuation of restraints.

3. A review of P#5's medical record revealed that P#5 presented to the facility and was admitted on 8/20/24 at 8:19 p.m. Continued review of the medical record revealed that non-violent restraints were ordered for P#5 on 8/21/24 at 12:09 a.m., 8/21/24 at 1:36 p.m., 8/22/24 at 7:40 a.m., 8/23/24 at 6:53 a.m., 8/24/24 at 12:02 p.m., 8/25/24 at 1:29 p.m., 8/26/24 at 12:19 p.m., 8.27/24 at 11:57 a.m., 8/28/24 at 4:14 p.m.,8/29/24 at 6:39 p.m., 8/30/24 at 7:09 p.m., 9/2/24 at 2:30 p.m., and 9/2/24 at 2:55 a.m.
Continued review of P#5's "Flowsheets - Restraints Information" dated 8/20/24 through 9/3/24 failed to reveal appropriate two-hour restraint documentation from 8/23/24 at 8:00 p.m. through 8/24/24 at 12:00 a.m., 8/24/25 at 4:00 a.m. through 8/24/25 at 12:15 p.m., 8/25/24 at 7:00 a.m. through 8/25/24 at 7:00 p.m., 8/26/24 at 4:00 p.m. through 8/26/24 at 7:00 p.m., 8/27/24 at 5:00 a.m. through 8/27/24 at 8:00 a.m., 8/28/24 at 7:00 a.m. through 8/28/24 at 10:00 a.m., 8/28/24 at 6:00 p.m. through 8/28/24 at 8:15 p.m., 8/29/24 at 8:00 p.m. through 8/30/24 at 6:16 p.m., 8/31/24 at 7:00 a.m. through 9/1/24 at 1:00 p.m., and 9/1/24 3:00 p.m. through 9/2/24 at 8:00 a.m.
Continued review of the medical record failed to reveal appropriate documentation of offering fluids, food, hygiene care, and elimination needs at appropriate intervals for P#5.

A review of the facility's policy titled "Acute Care Restraint and Seclusion Policy," policy #942, last reviewed 10/25/22, revealed that the purpose of the policy was to detail that all patients have the right to be free from physical or mental abuse, and corporal punishment.
Continued review revealed, II, Restraint of The Non-Violent/Non-Self-Destructive Patient:
a. Monitoring and documentation of monitoring and interventions will occur at least every two hours and may include but is not limited to:
i. Patient's behavior, mental status with reorientation as needed
ii. Restraint observations and interventions
iii. Decrease in sensory stimuli
iv. Placement of call light and personal items within reach/remove unsafe objects from reach
v. Readiness for release from restraints whenever possible.
vi. Temperature, pulse, respiration, and blood pressure checks as ordered or clinically indicated
vii. Skin condition and reposition checks if needed to prevent skin breakdown
viii. Circulation, motor, and sensory function checks below the level of restraint.
ix. Needs:
1. Nutritional
2. Hydration
3. Elimination
4. Hygiene
5. Exercise and Range of Motion
x. Reinforcement of teaching of behaviors needed for early release
I. Requirements of documentation for when the restraints are released:
4. Associated interventions, patient's condition, changes in the patient's condition, and removal of the devices must be documented in the medical record.
5. Document the time when the patient met release criteria and was released from restraints.
6. Update plan of care to reflect restraints are removed.
Continued review revealed, III, Restraint or Seclusion of The Violent/Self Destructive Patient:
B. Requirements of documentation for the restraint or seclusion event:
1. The care plan must be individualized to address the restraint or seclusion usage.
4. Documentation by the physician includes the one-hour face-to-face medical and behavioral evaluation.
6. Monitor and document a minimum of every 15 minutes:
a. Patients' behavior, mental status, and readiness for release
b. Reinforcement of teaching of behaviors needed for early release as applicable and if practical and safe to do so.
c. Check circulation, motor, and sensory function below the level of restraint.
2. Information that should be documented approximately every two hours:
a. If deemed unsafe to be up and about, then each individual limb is released from restraint and active or passive range of motion is given.
b. Airway and respiratory status
c. Check of Circulation, motor, and sensory function below the level of the restraint as applicable.
d. Check of skin condition and any skin care provided.
e. Needs assessed:
i. Hydration
ii. Elimination
iii. Hygiene
8. Food should be offered to the patient at least every four hours or sooner when requested by the patient.

During a telephone interview on 9/4/24 at 9:07 a.m., Registered Nurse (RN) FF said that documentation by nursing staff included indications for the restraint usage, alternative measures taken aside from the restraint, how long the patient has been in restraint for, and the patient's response while in restraints. RN FF said that staff chart on non-violent restraints every two hours, and for violent restraints every 15 minutes. RN FF said that staff also chart that the patient was offered fluids, hygiene care, assistance with elimination, and nutrition for the patient.

During a telephone interview on 9/4/24 at 10:05 a.m., RN GG said that before a patient is placed in any type of restraints, staff should ensure that alternative methods have been attempted. RN GG said that if a non-violent restraint is applied, then staff should chart every two hours versus charting every 15 minutes for a violent restraint. RN GG said that while a patient is in restraints, she would assess the patient's need to be in it, circulation, range of motion, and if the patient has received food/fluids, and toileting.

During a telephone interview on 9/4/24 at 1:18 p.m., RN DD said that the commonly used restraint is the non-violent soft restraint that requires documentation every two hours. RN DD explained that patients in restraints are assessed for skin integrity, alternative measures to restraints and behavior.
RN DD said that she was not sure if fluid, foods, and elimination had to be charted for a patient in restraints. RN DD said that when a patient is ready to come out of restraints, staff should document the time it was removed and how the patient tolerated it.