HospitalInspections.org

Based on medical record review and staff interview, the facility failed to ensure restraint use was in accordance with the physician's order for one of one restraint record reviewed (Patient #8). Ten medical records were reviewed.

Findings include:

Review of the medical record for Patient #8 revealed arrival in the emergency department on 09/03/23. The patient's chief complaint was depression, anxiety, and alcohol abuse. The medical record contained an order dated 09/03/23 at 7:56 PM for bilateral soft wrist restraints for four hours due to violent behavior. The medical record contained documentation the patient was placed in four point locking restraints on 09/03/23 from 7:30 PM to 9:21 PM.

This finding was verified in an interview on 09/28/23 at 10:42 PM with Staff A and B.

On 09/28/23, Staff C was interviewed by phone. Staff C stated that four point locking restraints were ordered for Patient #8's violent outburst and were applied as ordered. Staff C stated the order must not have been documented correctly.

Based on policy review, medical record review and staff interview, the facility failed to ensure a face to face by a physician was completed within one hour of initiating restraints for violent behavior for one of one restraint record reviewed (Patient #8). Ten medical records were reviewed.

Findings include:

Review of the policy titled, "Use of Restraints," effective 3/10/22, revealed the licensed independent practitioner must evaluate the patient face to face within one hour of applying the restraints for violent or self destructive behaviors.

Review of the medical record for Patient #8 revealed arrival in the emergency department on 09/03/23. The patient's chief complaint was depression, anxiety, and alcohol abuse. The medical record contained an order dated 09/03/23 at 7:56 PM for bilateral soft wrist restraints for four hours due to violent behavior. The medical record contained documentation the patient was placed in four point locking restraints on 09/03/23 from 7:30 PM to 9:21 PM. The Face to Face Assessment was documented at 9:30 PM on 09/03/23. The Face to Face did not indicate it was completed at a different time. There was documentation in the medical record that the physician was present and interacting with the patient during the violent outburst at the nurses' station when the restraints were ordered.

This was verified in an interview on 09/28/23 at 10:42 PM with Staff A and B.

On 09/28/23, Staff C was interviewed by phone. Staff C stated that the Face to Face Assessment was done when the restraints were ordered and applied, but was documented later.