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Based on the hospital's policy review, medical record review, patient observation and staff interview, the hospital staff failed to document restraint use in the patient's plan of care in 6 of 6 sampled restrained patients with physical non-violent restraints (Patient's #18, # 1, #2, #6, #8, #20).

The findings include:

Review on 07/26/2017 of the hospital's policy and procedure "Restraint and Seclusion" (Current Revision Date: 07/2014), revealed "E. RN (Registered Nurse) Documentation for Restraints or Seclusion...4. Use of restraints or seclusion is included in the patient's Plan of Care in the safety section. The Plan is updated as the patient's condition warrants and no less than daily."

1. An open medical record review on 07/26/2017 for patient #18 revealed the patient was a 76 year-old patient who was admitted to the hospital on 07/17/2017 with a diagnosis of "Altered Mental Status." Review of the patient's medical orders revealed a physician order for use of "Bilateral Hand Mittens" (Considered Restraint-Non-Violent) dated 07/22/2017 to prevent the patient from pulling out or dislodging his tubes and lines. The review revealed no documentation in the patient's plan of care or treatment plan reference the patient's restraint use for bilateral hand mittens.

Observation on 07/26/2017 at 1622 on the hospital's "General Medicine" unit revealed that patient #18 was in his room and had bilateral hand mittens on his hands. The observation revealed the patient was not able to remove the mittens as they were secured on both of his hands.

Interview during the observation period on 07/26/2017 at 1625 with the unit manager (RN #1) revealed no documentation was found in the medical record's Plan of Care reference the patient's restraint interventions. The interview revealed "You will not find any documentation in the plan of care."




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2. A closed medical record review on 07/26/2017 for patient #1 revealed the patient was a 43 year-old patient male who was admitted to the hospital on 06/20/2017 with a diagnosis of "Alcohol Withdraw Seizure." Review of the patient's medical orders revealed a physician order for use of "Bilateral Hand Mittens, Bilateral Soft Wrist, Bilateral Soft Ankles and Vest Restraint (Considered Restraint-Violent) dated 06/20/2017 to 06/23/2017 for combative/aggressive behavior. Continued review revealed the use of "Bilateral Wrist Restraints" from 06/24/2017 to 07/15/2017 (Considered Restraint-Non Violent). The review revealed no documentation in the patient's Plan of Care or treatment plan in reference to the need for the use of restraints on Patient #1.

Interview during the observation period on 07/26/2017 at 1625 with the unit manager (RN #1) revealed no documentation was found in the medical record's Plan of Care reference the patient's restraint interventions. The interview revealed "You will not find any documentation in the plan of care."

Interview with RN #2 on 07/27/2017 at 1045 revealed restraints were used as a last resort. Documented education should have been provided to the patient and family. In addition, the restraint intervention should was documented on the Plan of Care.

3. A closed medical record review on 07/26/2017 for patient #8 revealed the patient was a 72 year-old patient male who was admitted to the hospital on 06/27/2017 with a diagnosis of "Acute Kidney Injury and Altered Mental Status." Review of the patient's medical orders revealed a physician order for use of "Bilateral Wrist Restraints" (Considered Restraint-Non-Violent) dated 06/29/2017 to 07/04/2017 to prevent the patient from pulling out or dislodging his tubes and lines. The review revealed no documentation in the patient's Plan of Care or treatment plan in reference to the use of bilateral wrist restraints on Patient #8.

Interview during the observation period on 07/26/2017 at 1625 with the unit manager (RN #1) revealed no documentation was found in the medical record's Plan of Care reference the patient's restraint interventions. The interview revealed "You will not find any documentation in the plan of care."

Interview with RN #2 on 07/27/17 at 1045 revealed restraints were used as a last resort. Documented education should have been provided to the patient and family. In addition, the restraint intervention should was documented on the Plan of Care.






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4. An open medical record review on 07/26/2017 for patient #20 revealed the patient was a 71 year-old male who was admitted to the hospital on 05/28/2017 with a diagnosis of "Abdominal Pain." Review of the patient's medical orders revealed a physician order for use of "Bilateral Wrist Restraints" (Considered Restraint-Non-Violent) dated 05/29/2017 to maintain therapeutic interventions. The review revealed no documentation in the patient's plan of care or treatment plan reference the patient's restraint use for bilateral wrist restraints.

Interview on 07/26/2017 at 1622 with the patient's family revealed the patient was in bilateral wrist restraints on and off since admission to prevent the patient from pulling out his tubes and lines.

Interview on 07/27/2017 at 1010 with RN #4 revealed the use of restraints should be reflected on the patient's plan of care.

5. A closed medical record review on 07/26/2017 for patient #6 revealed the patient was a 55 year-old male who was admitted to the hospital on 06/03/2017 with the diagnosis of "Overdose, Acute Respiratory Failure, Chronic Pain and COPD (Chronic Obstructive Pulmonary Disease)." Review of the patient's medical orders revealed a physician order for use of "Bilateral Wrist Restraints" (Considered Restraint-Non-Violent) dated 06/03/2017 to prevent the patient from self-extubated. The review revealed no documentation in the patient's plan of care or treatment plan reference the patient's restraint use.

Observation on 07/27/2017 at 0848 of the EEG monitor video revealed that patient #6 was placed in 4-point restraints (Considered Restraint-Violent) to prevent the patient from harming himself and others. The observation revealed the patient was not able to remove the restraints.

Interview on 07/27/2017 at 1010 with RN #4 revealed the use of restraints should be reflected on the patient's plan of care.

6. An open medical record review on 07/26/2017 for patient #2 revealed the patient was a 74-year-old female who was admitted to the hospital with "Chest Paint and SOB (Shortness of Breath)." Review of the patient's medical orders revealed a physician order for use of "Bilateral Wrist Restraints" (Considered Restraint-Non-Violent) dated 07/23/2017 to prevent the patient from dislodging her lines and tubes. The review revealed no documentation in the patient's plan of care or treatment plan reference the patient's restraint use.

Observation on 07/26/2017 at 1430 on the hospital's "Medical Intensive Care Unit" revealed that patient #2 was in her room and had bilateral wrist restraints. The observation revealed the patient was not able to remove the wrist restraints as they were secured on both sides of the bed.

Interview on 07/27/2017 at 1010 with RN #4 revealed the use of restraints should be reflected on the patient's plan of care.

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