HospitalInspections.org

Based on interview and record review the facility failed to follow their policies and procedures for restraint use in the non-psychiatric healthcare setting for three (#'s 8, 9 and 10) of three patients reviewed for restraints, requiring a safe environment, resulting in the potential for three patients (#'s 8, 9 and 10) losing their rights.

(See A-169)
1. The facility failed to ensure physician orders were obtained each calendar day for each episode of restraints for 3 (#8, #9 and #10) of 3 patients reviewed for restraints.

(See A- 175)
1. The facility failed to follow their policy for monitoring patients while in restraints for 2 (#8 and #10) of 3 patients reviewed for restraints out of a total of 10 sampled patients.

(See A-179)
1. The facility failed to complete timely face-to-face assessments for 3 of 3 patients (#8, #9 and #10) requiring restraint application.

Based on record review and interview, the facility failed to ensure that physician orders were obtained daily for each episode of restraints for three of three patients (#8, #9 and #10) reviewed for restraints out of a total of 10 sampled patients, resulting in the potential for patient #8, #9 and #10 loss of rights. Findings include:

A review of the medical record for patient #8 was conducted with Staff W (Director of Quality and Informatics) on 1/8/20 at 1400. Medical record review revealed patient #8 was a 49 year old female who presented to the Emergency Department (ED) on 9/1/19 at 2021. The patient's admitting diagnosis was hypertensive emergency.

A review of physician orders for non-violent restraints for patient #8 documented the following:
1. On 9/1/19 at 2024, "Soft limb x2, To keep Life Sustaining Devices in Place...)."
2. On 9/3/19 at 0001, "Soft limb x2, To keep Life Sustaining Devices in Place...)."
3. On 9/3/19 at 0424, "Soft limb x1, Restrict movements to facilitate healing, pain relief/comfort measures."
4. On 9/4/19 at 0001, "Soft limb x2, Unable to follow safety instructions, Re-orientation, Verbal reminders."

A review of restraint flow sheets revealed patient #8 was restrained with restraints on the following dates and times:
1. On 9/1/19 between the hours of 2024 and 2359.
2. On 9/2/19 between the hours of 0824 and 2224.
3. On 9/3/19 between the hours of 0024 and 1824.
4. On 9/4/19 between the hours of 0024 and 2224.

Further review of the medical record revealed there was no evidence that documented physician's orders were obtained for 9/2/19 when the patient (#8) was still restrained. At that time Staff W confirmed there were no orders for the restraints for patient #8 on the aforementioned date. He said I looked. There aren't any.


A review of the electronic medical record for patient #9 was conducted with Staff W on 1/8/20 at 1430. Medical record review revealed patient #9 was a 78 year old male who presented to the Emergency Department (ED) on 8/29/19 at 0218. The patient's admitting diagnosis was unwitnessed fall.

A review of restraint flow sheets revealed patient #9 was restrained with restraints on the following dates and times:
1. On 8/31/19 between the hours of 0055 and 2255.
2. On 9/3/19 between the hours of 0038 and 1038.

Further record review revealed:
1. There were no orders for the use of restraints for patient #9 documented in the medical record that corresponded with the restraint flow sheets dated on 9/3/19 between the hours of 0038 and 1038. At that time Staff W confirmed there were no orders for the restraints for patient #9 on the aforementioned date. He said I looked. There aren't any.



A review of the electronic medical record for patient #10 was conducted with Staff W on 1/8/20 at 1500. Medical record review revealed patient #10 was a 70 year old female who presented to the Emergency Department (ED) on 8/28/19 at 1930. The patient's admitting diagnosis was failure to thrive.

A review of restraint flow sheets revealed patient #10 was restrained on 9/15/19 between the hours of 0113 and 2313. However, there were no physician orders dated 9/15/19 for the restraints documented in the medical record for patient #10. At that time Staff W confirmed there were no orders for the restraints for patient #10 on the aforementioned date. He said I looked. There aren't any.

An interview was conducted with the Chief Nursing Officer on 1/9/2020 at 1120. At that time she confirmed that there should have been orders for each application of restraints for all patients that were restrained.

Review of facility policy titled, "Restraint in the Non-Psychiatric Healthcare Setting", with an Effective date of 4/30/18 documented:
IV Policy:
D. Restraint orders are never written on a "as needed" basis or as PRN orders or standing orders.
W. Non-Violent/Medical Support Restraint
4. a). A restraint order is good for a maximum of one calendar day.

Based on interview and record review, the facility failed to follow their policy for monitoring patients while in restraints for 2 (#8 and #10) of 3 patients reviewed for restraints out of a total of 10 sampled patients, resulting in the increased potential for less than optimal outcomes for patient #8 and #10.
Findings include:

A review of the electronic medical record for patient #8 was conducted with Staff W (Director of Quality and Informatics) on 1/8/20 at 1400. Medical record review revealed patient #8 was a 49 year old female who presented to the Emergency Department (ED) on 9/1/19 at 2021. The patient's admitting diagnosis was hypertensive emergency.

A review of restraint flow sheets revealed patient #8 was restrained on the following dates and times:
1. On 9/1/19 between the hours of 2024 through 2359. However, there were no flow sheets that documented the patient was assessed nor monitored during those times. The flow sheet was marked "discontinued".
At that time Staff W stated, "If the task (monitoring) was not performed it's recorded as discontinued (not done). Additionally, Staff W further explained there were no orders to discontinue the restraints during that time frame.
2. On 9/2/19 between the hours of 0824 and 2224. However, there were no flow sheets that documented the patient was assessed or monitored at 1624 nor at 2224.
3. On 9/3/19 between the hours of 0024 and 1824. However, there were no flow sheets that documented the patient was assessed or monitored at 1624.
4. On 9/4/19 between the hours of 0024 and 2224. However, there were no flow sheets that documented the patient was assessed or monitored at 1824. At that time Staff W confirmed there were no evidence that documented the patient #8 was monitored every 2 hours as required.

A review of the electronic medical record for patient #10 was conducted with Staff W (Director of Quality and Informatics on 1/8/20 at 1500. Medical record review revealed patient #10 was a 70 year old female who presented to the Emergency Department (ED) on 8/28/19 at 1930. The patient's admitting diagnosis was failure to thrive.

A review of restraint flow sheets revealed patient #10 was restrained on the following dates and times:
1. On 9/2/19 between the hours of 0114 and 2314. However, there were no flow sheets that documented the patient was assessed or monitored between the hours of 0714 through 2314.
2. On 9/4/19 between the hours of 0114 and 1114. However, there were no flow sheets that documented the patient was assessed or monitored between the hours of 0414 and 0914.

At that time Staff W confirmed there were no evidence that documented the patient #10 was monitored every 2 hours as required.

Review of facility policy titled, "Restraint in the Non-Psychiatric Healthcare Setting", with an Effective date of 4/30/18 documented:
"X. Patient Care During Restraint
5. When the restraint is in place, the patient is assessed, monitored and re-evaluated based on the patient's care needs, at a minimum of every two (2) hours."

Based on interview and record review the facility failed to complete timely face-to-face assessments for 3 of 3 patients (#8, #9 and #10) requiring restraint application placing patient's #8, #9 and #10 at risk for poor clinical outcomes. Findings include:


On 1/9/2020 at 1400 a review of Patient #8's restraint record was completed with Staff W (Director of Quality and Informatics). The review revealed the following information:

1. On 9/1/19 at 2024 per physician order, Patient #8 was placed into bilateral soft limb restraints (x2) to keep life sustaining devices in place.

2. A second physician order was written on 9/3/19 at 0001 for Patient #8 to continue in restraints. Review of the record revealed no documented evidence that the face-to-face assessment was completed by a qualified practitioner within one hour of the order. The documentation indicated the face-to-face assessment was completed on 9/3/19 at 2036.
8 hours and 36 minutes after the order.

3. A third physician order was written on 9/3/19 at 0424 to decrease the soft limb restraints from 1 to 2.

4. A fourth physician order was written on 9/4/19 at 0100. Review of the record revealed no documented evidence that the face-to-face assessment was completed by a qualified practitioner within one hour of the order. The documentation indicated the face-to-face assessment was completed on 9/4/19 at 0501. 5 hours after the order.
At that time Staff W acknowledged the face-to-face assessment times for Patient #8 were untimely.

A review of the restraint record for patient #9 was conducted with Staff W on 1/8/20 at 1430. The review revealed the following information:

1. On 8/31/19 at 0055 per physician order. "Soft limb x 2, Pulling at Tubes/Dressings, Visual supervision." The documentation indicated the face-to-face assessment was completed on 8/31/19 at 1854. 7 hours after the order.
2. A second order was written on 9/2/19 at 2238. "Soft limb x 2, Pulling at Tubes/Dressings, Visual supervision." The documentation indicated the face-to-face assessment was completed on 9/3/19 at 1224. 12 hours after the order. At that time Staff W acknowledged the face-to-face assessment times for Patient #8 were untimely.

A review of the electronic medical record for patient #10 was conducted with Staff W on 1/8/20 at 1500. Medical record review revealed patient #10 was a 70 year old female who presented to the Emergency Department (ED) on 8/28/19 at 1930. The patient's admitting diagnosis was failure to thrive. The review revealed the following information:

1. On 9/4/19 at 0010 per physician order, Patient #10 was placed into bilateral soft limb restraints (x2), unable to follow safety instructions. Reorientation, Verbal reminders. The documentation indicated the face-to-face assessment was completed on 9/4/19 at 0459. 4 hours after the order.
2. On 9/16/19 at 0001 per physician order, soft limb restraints x2 for pulling at tubes/dressings, Re-orientation, verbal reminders. The documentation indicated the face-to-face assessment was completed on 9/16/19 at 0246. 2 hours and 45 minutes after the order.
At the time of discovery Staff W acknowledged the face-to-face assessment times for Patient #10 were untimely.

An interview was conducted with the Chief Nursing Officer on 1/9/2020 at 1100 at that time she explained that she was still reviewing the facility's policy/procedures.

Review of facility policy titled, "Restraint in the Non-Psychiatric Healthcare Setting", with an Effective date of 4/30/18 documented:
V. Procedure And/Or Provisions:
C. A physician/MLP designee face-to-face comprehensive, clinical assessment must be performed.