HospitalInspections.org

Based on policy review, clinical record review and interview, it was determined the facility failed to ensure physicians orders were obtained for restraints for two (#18 and #19) of three (#18-#20) patients in restraints. Failure to obtain physician's orders for restraints did not allow the physician to be knowledgeable of the patient's need for restraints. The failed practice had the potential to affect any patient in restraints. Findings follow.

A. Review of policy titled "Restraint and Seclusion" showed "the order must ...specify the date, time of day, type of restraint, the specific behaviors that resulted in the need for restraint and the maximum length of time for the restraint, which shall not exceed twenty-four (24) hours ...The original order may only be renewed in accordance with these limits for up to a total of 24 hours for restraints and/or seclusion."
B. Review of the clinical record for Patient #18 showed the patient was in restraints from 6:11 PM on 10/10/17 through 6:00 AM on 10/25/17. The clinical record showed no evidence of a physician's order for restraints on 10/14/17 from 6:20 AM through 5:35 PM and on 10/22/17 at 6:47 AM through 10/23/17 at 7:22 AM.
C. Review of the clinical record for Patient #19 showed the patient was in restraints from 2:17 AM on 10/21/17 through 6:00 PM on 10/22/17. The clinical record showed no evidence of a physician's order for restraints on 10/22/17 from 2:27 AM through 6:00 PM.
D. During an interview on 10/25/17 at 10:39 AM, the PI (Performance Improvement) Coordinator confirmed the findings in B and C.

Based on policy review, clinical record review, and interview, it was determined the facility failed to ensure chemical restraint orders (Haldol) were not ordered PRN (as needed) for one of one (#19) Patients with chemical restraints. Ordering chemical restraints PRN did not ensure the physician had assessed the patient's behavior and assessed the immediate need for the restraint. Findings follow.

A. Review of policy titled "Restraints and Seclusion" defined a chemical restraint as "A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the freedom of movement and is not a standard treatment or dosage for the patient's condition." The policy also showed restraint orders must "NEVER be written or electronically entered as a standing order or an as needed basis (PRN)."
B. Review of Patient #19's clinical record revealed the following:
1) An order beginning on 10/20/17 at 9:29 AM for Haldol 2.5mg (milligrams) IM (intramuscular) Q4H (every four hours) PRN for agitation. The patient received the Haldol on 10/20/17 at 2:32 PM and at 8:26 PM
a. Review of Nurses Note on 10/20/17 at 2:32 PM showed "Pt (Patient) angry, yelling, states he wants to go home, and his family has had him "put in a nuthouse"- trying to pull at catheter and IV. PRN Haldol administered."
2) An order beginning on 10/21/17 at 12:45 PM for Haldol 5mg Q4H PRN for agitation. The patient received the Haldol on 10/22/17 at 11:26 PM.
3) Review of the plan of care showed one problem as "Aggressive Resistance to Care." Haldol was not listed as an intervention to this problem.
4) Review of Patient #19's home medications did not list Haldol.
C. During an interview on 10/25/17 at 10:39 AM, the PI Coordinator confirmed the findings in A and B.