HospitalInspections.org

Based on record review, review of policy and procedures, and staff interviews, the facility failed to ensure restraints were implemented appropriately in accordance with hospital policy for one Patient (P) P#5 of two sampled patients reviewed for restraints.


Findings included:


Review of a facility policy titled "Restraint/Seclusion," last revised 01/03/2024, indicated, "A. Each restraint episode will be ended at the earliest possible time." The policy specified, "D. Discontinuation of restraints should be documented by the Nurse in the patient's electronic health record." Per the policy, "E. Non-Violent - Assessment and monitoring documentation should take place every 2 hours in the patient's electronic health record and must include clinical justification, patient behavior, circulation/signs of injury, range of motion, skin assessment, fluid and foods offered, and hygiene/elimination needs addressed."


P#5's medical record included an order dated 10/11/2024 at 10:29 p.m., for bilateral secured mitts. Per the order, the order expired on 10/12/2024 at 11:59 PM.


P#5's "Non-Violent Restraint Type Documentation" flowsheet revealed that the right and left secured mitts were last continued on 10/12/2024 at 4:00 p.m. There was no documentation to indicate the bilateral mitts for the patient were discontinued or further assessed per the facility's policy.


P#5's "Nursing Notes," dated 10/12/2024 at 9:40 p.m., indicated the patient discharged from the facility.


During an interview on 01/09/2025 at 10:38 AM, Nurse Manager (NM) #8 stated it was unknown when P#5 was removed from restraints. She stated that the nurse last documented the mitts as continued 10/12/2024 at 4:00 PM.