HospitalInspections.org

Based upon a review of facility policy and medical records (MR) and staff interview (EMP), it was determined that the facility failed to monitor the condition of restrained patients in 3 of 9 medical records reviewed (MR1, MR2, MR3).

Findings include:

A review of facility Policy HS-NA0416, Section VIII, A. Order states the following, "A physician order, order of a CRNP or order of a PA is required for restraints use."Section VIII, D- On Going Patient Assessment and Care Interventions Number 4 (a) requires documentation of reassessment of "Non Violent/Non Self-Destructive behavior-every 2 hours."

1. A review of MR1 on February 8, 2022 (Admission date: 1/15/2022; Discharge date: 01/25/2022) for physician and nursing restraint documentation revealed the following deficiencies:
Missing physician order: 01/19/2022
Missing Restraint Initiation Form: 01/25/2022
Missing two hour nursing assessment: 01/23/2022 at 0400 and 0600.
2. A review of MR2 on February 8, 2022 (Admission date: 12/27/2021; Discharge date: 01/04/2022) for physician and nursing restraint documentation revealed missing two hour nursing assessments: 12/19/2021 at 0600; 01/03/2022 at1000; and 01/04/2022 at 0000, 0200,0400, and 0600.
3. A review of MR3 on February 8, 2022 (Admission date: 12/28/2022; Discharge date: 1/15/2022) for physician and nursing restraint documentation revealed the following:
Missing physician order: 01/10/2022
Missing Restraint Initiation Form: 01/15/2022
The above findings were reviewed and confirmed by EMP5 on Feb. 8, 2022 at 1330.

Based upon a review of facility documents and medical records (MR) and staff interview (EMP), it was determined that the facility failed to accurately complete a Report of a Hospital Dealth Associated with Restraint form (CMS 10455) in 2 of 2 medical records reviewed (MR1 and MR3).

Findings:

1. A review of MR 1 on February 8, 2022 determined that the patient expired on 01/25/2022, while in both a vest and bilateral soft wrist restraints. Review of CMS 10455 indicates that the patient expired "Within 24 hours of removal of restraint, seclusion or both;" instead of, "While in restraint, seclusion, or both."
On February 8, 2022, at approximately 12:30 PM, EMP5 indicated that the CMS 10455 for MR1 was not completed accurately.
2. A review of MR3 on February 8, 2022 revealed that the patient expired on 01/15/2022 while in both a vest and bilateral soft wrist restraints. Review of CMS 10455 indicates that the patient expired "Within 24 hours of removal of restraint, seclusion or both.;" instead of, "While in restraint, seclusion, or both."
On February 8, 2022, at aproximately 11:00 AM, EMP5 indicated that the CMS 10455 for MR3 was not completed accurately. EMP5 stated that addtional information was needed by the assigned registered nurse (RN) in this case and the RN was not available.