HospitalInspections.org

Based on interviews and document review, the facility failed to ensure care provided to patients was verified from a provider order when a patient was placed into restraints for one of six records reviewed of patients placed in restraints. (Patients #1)

Findings Include:

Facility policy:

According to the Restraint or Seclusion: Behavioral Policy, each episode of restraint or seclusion required an order by a physician or clinical psychologist primarily responsible for the patient's ongoing care.

1. The facility failed to ensure a provider order was provided when patients were placed in restraints.

a. Record review of Patient #1's medical record revealed she was admitted on 8/22/22 and was treated for leg swelling and syncope. A provider progress note from 8/22/22 at 3:08 p.m. stated Patient #1 required restraints for being combative. Further review of the medical record revealed registered nurse (RN) #3 failed to document Patient #1 was restrained or document an assessment of Patient #1 while in restraints. In addition, there was no provider order for the episode of restraints on 8/22/22.

The medical record review was in contrast to Restraint or Seclusion: Behavioral Policy which stated each episode of restraint or seclusion required an order by a physician or clinical psychologist primarily responsible for the patient's ongoing care.

b. On 10/12/22 at 6:50 a.m., an interview with Physician #5 was conducted. Physician #5 stated a provider order was always required when placing a patient into restraints. Physician #5 further stated sometimes an order was missed, but the provider was expected to place the order in the medical record as soon as possible after the patient was placed into restraints. Physician #5 reviewed the medical record for Patient #1 and stated the patient was in soft restraints, and a provider order was not in the medical record. Physician #5 further stated a restraint was inappropriate without a provider notification and order.

c. On 10/10/22 at 2:01 p.m., an interview with RN #3 was conducted. RN #3 stated when a patient was placed into restraints, a provider order was always required.

i. During a follow-up interview with RN #3 on 10/11/22 at 3:35 p.m., RN #3 stated she provided care for Patient #1 and she stated the patient was placed into restraints while receiving care.

d. On 10/10/22 at 2:35 p.m., an interview with RN #1 was conducted. RN #1 stated a provider order was always required when a patient was placed into restraints.