HospitalInspections.org

Based on review of facility policy and procedures, medical record review and interview with staff (EMP), it was determined the facility failed to follow its policy to ensure restraint monitoring assessments were documented on one of six restraint charts reviewed (MR14).


Review of facility policy on March 7, 2024 revealed "Restraint for Non-Self Destructive Behavior, approval date May 03, 2022 I. Key Points: 4. A restrained patient is monitored every 2 hours... D. Application of Restraints 1. Posey Limb Holders F. Reassessment and Monitoring: 1. A restrained patient is monitored every 2 hours... G. Documentation 2. Patient care (providing comfort measures and observation) under the direction of an RN is addressed every two hours and documented on the entity based downtime form or appropriate electronic documentation, and will include: a. Fluid/nutritional needs b. toileting needs c. Circulation of the restrained limb (s) d. Range of motion and positioning e. Behavior..."

Review of MR15 on March 7, 2024 revealed, physician order for a non-violent restraint placed on December 28, 2023 at 18:10 and discontinued on December 30, 2023 at 19:42. Further review revealed, documentation for the non-violent restrain on December 30, 2023 as follows: 0200, 0400, 0800, 1000, 1200, 1355... no documentation of patient monitoring at 0600.

Interview with EMP1 on March 7, 2024 at 2:35 PM confirmed the above findings.