HospitalInspections.org

Based on observation, record review and interview the facility failed to ensure the medical staff wrote subsequent orders for restraints for one of three patients ( ID#9) in the cardiac care unit.

Findings Include:

Record review of the facility policy effective May 2022 titled "Restraint or Seclusion", stated on page 7 of 22 the following:
B. Renewal of Orders: Non-Violent Restraints
i. Each order for Restraint used to ensure the physical safety of the nonviolent or non-self-destructive patient may be renewed if Restraint use continues to be clinically justified.
ii. Initial and subsequent orders for non-violent restraint use are to be renewed within 1 calendar day.

Observation of patient (ID#9) on 07/07/2023 at 1215, revealed mittens on patient (ID# 9) hands. Nurse (ID#62) verified that patient (ID#9) was confused and was restrained for his safety.

Record review of three patient medical records on 07/07/2023 at 1225 with staff (ID#65) revealed patient (ID#9) was restrained from 07/03/2023-07/07/2023. Further review revealed patient (ID#9) had no restraint orders written for 07/04/2023.

Interview with staff (ID#65) during the review on 07/07/2023 verified that patient (ID#9) did not have subsequent orders for restraints on 07/04/2023 per hospital policy.