HospitalInspections.org

Based on record review and interview, the facility failed to renew restraint orders at least every twenty-four hours for 1 of 1 patients (Index patient # 1) reviewed during the complaint investigation survey.

Findings:

-Review of the index patient's medical record conducted off site on 3-29-22 revealed that the patient was restrained intermittently in a vest restraint from 3-12-21 at 11:55 AM to 3-22-21 at 11:32 AM.

-An initial physician order for restraint was written on 3-12-21 at 11:55 AM for safety.

-The renewal order for 3-14-21 was timed 16:22, 5 hours past due.

-The vest restraint was discontinued on 3-15-21 at 11:12 AM; a new physician order for vest restraint was written at 5:37 PM for fall risk. This order was renewed on 3-16-21 at 2:10 PM.

-The patient then remained in the vest restraint from 3-16-21 at 2:10 PM until 3-22-21 at 11:32 AM without daily restraint renewal orders in place.

-Review of facility policy entitled: "Restraints", conducted on 3-29-22, indicates that the restraint order should have been renewed every 24 hrs. per the facility's policy.

-Interview with the facility Chief Operating Officer, on 7-7-22 at 10:15 AM confirmed the findings.

Based on record review and interview, facility nursing staff failed to document reassessments and safety checks in the patient's medical record in accordance with facility policy for 1 of 1 patients (Index patient # 1) reviewed during the complaint investigation survey.

Findings:

-Review of the index patient's medical record conducted off site on 3-29-22, revealed that the patient was restrained intermittently in a vest restraint from 3-12-21 at 11:55 AM to 3-22-21 at 11:32 AM. Nursing documentation of reassessments and safety checks were lacking on the following dates/times:



On 3-12-21-there was no documentation until 8 PM; the patient was placed in a vest restraint at 11:55 AM on 3-12-21.
On 3-13-21 documentation at 5:28 AM and not again until 08:15 AM.
On 3-13-21-there was documentation at 5:46 PM and not again until 9:16 PM and then not until midnight on 3-14-21.
On 3-14-21 documentation at 6:00 PM and not again until 10:32 PM.
On 3-15-21 documentation at 8:00 AM and not again until 5:47 PM.
On 3-21-21 documentation at 4:00 AM and not again until 08:00 AM.

-Review of facility policy entitled: Restraints, conducted on 3-29-22, indicates that for patients in restraints, nursing staff are required to reassess and document every 2 hours as well as conduct and document safety checks every 30 min which can be documented at the end of the shift.

-Interview with the facility Chief Operating Officer, on 7-7-22 at 10:15 AM confirmed the findings.