HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 2 (Pt. #1) clinical records reviewed regarding use of violent restraints, the Hospital failed to discontinue the restraints at the earliest possible time.

Findings include:

1. On 8/29/2022, the clinical record for Pt. #1 was reviewed. Pt. #1 was brought to the Hospital on 7/6/2022 due to right leg pain from hip to ankle and headache. The clinical record included:

- Pt. #1 was placed in four-point restraints on 7/6/2022 from 6:13 AM through 8:30 AM due to self-injury. The every-15 minute observation record indicated that Pt. #1 was quiet and sleeping from 6:45 AM through 8:30 AM.
- Pt. #1 was placed in four-point restraints on 7/7/2022 from 1:50 AM through 5:15 AM for physical and verbal aggression. The every-15 minute observation record indicated that Pt. #1 was quiet and/or sleeping from 2:15 AM through 5:30 AM.
- The clinical record did not include justification for the continued use of the restraints.

2. On 8/29/2022, the Hospital's policy titled, "Restraint and/or Seclusion Use and Indications in the Acute Care Setting" (revised 9/2020) was reviewed and included, "... Policy... 9. Restraint use is minimized and removed at the earliest possible time when the patient's behavior assessment determines the need for restraint... is no longer needed... C. Violent/Self-Destructive Behavioral Restraint... 9. Patients are released from violent/self-destructive behavioral restraint when the criteria to discontinue restraints are achieved. Examples of this criteria are: a. patient is no longer violent... b. patient is calm..."

3. On 8/30/2022 at approximately 10:30 AM, findings were discussed with E #22 (Accreditation Officer). E #22 could not provide justification for the continued use of restraints while Pt. #1 was observed as quiet and sleeping.