HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 5 (Pt #1, Pt#10) clinical records reviewed for restraints, the Hospital failed to ensure that the use of a restraints was in accordance with the order of a physician.

Findings include:

1. The Hospital's policy titled, "Restraint Policy" (revised 1/2019) was reviewed on 7/29/2020, and required, "...Each episode of restraint or seclusion must be ordered by a physician or an authorized LIP [Licensed Independent Practitioner] responsible for the patient's ongoing care..."

2. The clinical record for Pt #1 was reviewed on 7/29/2020. Pt #1 was admitted to the Hospital on 6/28/2020 with a diagnosis of Altered Mental Status. On 6/28/2020, Pt #1 was transferred to the Medical/Surgical/Telemetry Unit. Pt #1's Nursing Restraint Flowsheet was reviewed, and indicated that the Pt #1 was placed in non-violent restraints from 6/29/2020 at 1:00 PM through 7/1/2020 at 1:00 PM. Pt #1's clinical record lacked an order for the non-violent restraint that was initiated on 6/29/2020.

3. The clinical record for Pt #10 was reviewed on 7/30/2020. Pt #10 was admitted to the Hospital on 6/12/2020 with a diagnosis of overdose. Pt #10's "Restraint Monitoring Assessment" (dated 6/17/2020 at 10:45 AM) indicated that the patient was placed in non-violent restraints. However, the clinical record lacked an order for the non-violent restraint that was initiated on 6/17/2020.

4. On 7/30/2020 at 9:45 AM, an interview was conducted with the Director of Behavioral Health (E #10). E #10 stated that there should be an order each time a restraint is initiated.