HospitalInspections.org

Based on medical record review, document review and interview, the use of restraints was not documented in the patient 's plan of care in 8 of 14 patients. (Patient #2, 5, 6, 9 - 13)

Findings include:

Review of medical records revealed the use of restraints was not documented in the the patient plan of care for Patient #2 on 5/21/19, Patient #5 on 5/3/19, Patient #6 on 5/18/19, Patient #9 on 5/4/19, Patient #10 and 13 on 4/30/19, Patient #11 on 4/16/19 and Patient #12 on 4/27/19.

Review of the facility restraint policy # GM 8 and GM 8A and review of the Annual Restraint Education documentation on 5/23/19 revealed no information regarding the need to document the use of restraints on the patients plan of care.

These findings were verified by Staff (E), Nursing Administration on 5/23/19.