HospitalInspections.org

Based on document reviews and interviews, the hospital failed to ensure a restraint was discontinued at the earliest time possible for one (1) of five (5) patients (Patient 2R).

Findings:

St. Mary's Regional Medical Center's "Non-Violent, Non-Self Destructive Restraint Policy (Medical)" policy, last revised 09/2022 states, in part, "All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time." Under the policy requirements for documentation, it states, in part, "Release patient if application criteria no longer exists".

On 8/22/2023 at 2:54 PM, Patient 2R's medical record was reviewed with the Quality Manager.

1. Documentation in Patient 2R's record indicated the following:
- Nursing staff documented that on 5/8/2023 at 11:38 AM, Patient 2R had soft bilateral wrist restraints applied; and
- There was no documentation that the restraint order for the soft bilateral wrist restraints was discontinued; and therefore,
- It could not be determined if the restraint was discontinued at the earliest possible time.

On 8/22/2023 at 3:04 PM, this finding was confirmed by the Quality Manager at the time of the review.