HospitalInspections.org

Based on a review of documentation and interview, the facility failed to ensure that the condition of the patients who were restrained were monitored at an interval determined by hospital policy.

Findings included:

Facility policy PC-063 titled "Restraint" states, in part:
"Scope:
This policy and procedure applies to healthcare professionals with direct responsibility in the ordering, assessment, care planning and application and/or implementation of restraints, monitoring and care of the restrained patient. This policy is applicable to in-patients and out-patients in which restraint is used. This policy is applicable to all age groups of patients, from the neonate to the geriatric population in the acute hospital, excluding patients in the designated behavioral health units.

Purpose:
To provide guidance for the use and management of restraints. Patients in the acute care hospital are never placed in seclusion ...

Policy: ...

J. Orders ...

2. Non-Violent/Non-Self-destructive:
a. Physician orders for non-violent restraints shall remain in effect until:
(1) The patient's behavior or situation no longer requires a restraint
(2) If the order includes discontinuation criteria, when such criteria are met
(3) If the order does not include discontinuation criteria, at the end of the calendar day following the order.

K. Ongoing Monitoring: ...

2. Non-Violent/Non-Self Destructive:
a. Restraint not used for the management of violent behavior shall be subject to ongoing monitoring and assessment as specified in the patient's plan of care. Monitoring is expected to occur a minimum of every two (2) hours ...

M. Documentation related to restraint includes:
1. The initial assessment of the patient related to restraint;
2. Documentation of each episode of restraint includes:
a. The circumstances that led to the use of restraint
(1) Specific behaviors
(2) Description of events leading up to the incident and other pertinent information
b. Consideration or failure of non-physical interventions
c. The rationale for use and continued use of restraint
d. Notification of the patient's family when appropriate
e. Orders for use-including each order for continuation
f. Any injuries sustained and treatment received for these injuries
g. Time of initiation and termination of restraint
h. Treatment plan (Interdisciplinary Plan of Care) review/revision"

Review of medical records revealed that 6 of 6 patients with non-violent restraint applications were not monitored appropriately per the facility policy (every 2 hours).
* Patient #1 was placed in a non-violent restraint on 05/12/22 at 6:50 pm. Monitoring was documented on 05/14/22 at 6:00 am, 7:08 am, 7:35 pm, 05/15/22 at 8:00 am, 2:00 pm, 7:30 pm, 11:15 pm, 05/16/22 at 3:15 am, 7:15 am, 11:00 am, and 3:00 pm. The restraint was discontinued on 05/16/22 at 7:30 pm.
* Patient #2 was placed in a non-violent restraint on 08/04/22 at 6:50 pm. Monitoring/assessment was documented on 08/04/22 at 8:00 pm and 11:00 pm, 08/05/22 at 3:00 am, 7:00 am, 11:00 am, and 3:00 pm. The restraint was discontinued on 08/04/22 at 5:19 pm.
* Patient #3 was placed in a non-violent restraint on 08/01/22 at 1:03 am. Monitoring/assessment was documented at 1:04 a.m. and 2:18 am. The restraint was discontinued at 7:00 pm on 08/01/22.
* Patient #4 was placed in a non-violent restraint on 08/06/22 at 10:15 pm. Monitoring/assessment was documented on 08/07/22 at 2:15 am, 6:15 am, 7:30 am, 11:30 am, 3:30 pm, 7:00 pm and 11:00 pm, 08/08/22 at 3:00 am, 7:00 am, 9:54 am, 11:00 am, 2:23 pm, 3:00 pm, 7:00 pm, 11:00 pm, 08/09/22 at 2:09 am, 3:00 am, 7:00 pm, 11:00 pm, 08/10/22 at 3:00 am, 7:00 am, 9:44 am, 11:32 am, 3:05 pm, 3:52 pm, 7:15 pm, and 11:00 pm, 08/11/22 at 3:00 am, 7:00 am, 8:53 am, 11:14 am, 2:23 pm, 5:26 pm, and 5:27 pm, 08/12/22 at 7:24 am. The restraint was discontinued on 08/25/22 at 7:25 am.
* Patient #5 was placed in a non-violent restraint on 08/13/22 at 3:00 am. Monitoring/assessment was documented on 08/13/22 at 7:00 am, 11:00 am, 3:00 pm, 7:00 pm, and 11:00 pm. Per documentation a second non-violent restraint was initiated on 08/14/22 at 6:57 am. Monitoring/assessment was documented on 08/14/22 at 7:00 am. The restraint was discontinued on 08/14/22 at 10:08 am.
* Patient #6 was placed in a non-violent restraint on 07/29/22 at 9:19 pm. Monitoring/assessment was documented on 07/30/22 at 5:33 am, 7:00 am, 7:30 am, 9:56 am, 11:00 am, 1:56 pm, 3:00 pm, 6:10 pm, and 7:37 pm. The restraint was discontinued on 07/30/22 at 11:10 am. A second non-violent restraint was initiated on 08/01/22 at 3:13 am. Monitoring/assessment was documented on 08/01/22 at 3:26 pm and 5:21 pm, 08/02/22 at 1:45 am, 7:00 am, 10:00 am, 2:00 pm, and 4:44 pm, 08/03/22 10:00 am. It appears the restraint was discontinued around 10:00 am on 08/03/22.

The above 6 patients all had large gaps (over 2 hours) in their documented monitoring and assessments while in non-violent restraints. The lack of documented monitoring of patients while in restraint per facility policy was verified in interview on 08/23/22 with staff members #3 and 5.