HospitalInspections.org

Based on medical record review, hospital policy and an interview the hospital failed to assure less restrictive interventions were attempted or not appropriate to protect the patient. This affected 1 of 3 medical records reviewed and had the potential to affect all patients served.

Findings include:

Hospital Policy: Use of Restraints and Seclusion
General guidelines for restraint and seclusion

3. Less restrictive measures should be documented in the medical record prior to the use of restraints or seclusion.

Medical Record Review:

1. Medical Record (MR) # 1 was admitted to the hospital on 8/22/11 with a diagnosis of perforated viscous.

A review of the medical record on 8/30/11 revealed a Physician's Restraint Order sheet dated 8/24/11. There were no alternatives documented to the application of soft bilateral wrist restraints.

The Chief Clinical Officer, Employee Identifier (EI) # 1, was interviewed on 8/30/11 at 4:15 PM and verified the alternatives were not documented.

Based on medical record review, hospital policy and an interview the hospital failed to assure a completed physician order was obtained and documented prior to the use of restraints. This affected Medical Record # 2 and # 3, 2 of 3 records reviewed for restraints. This had the potential to affect all patients served.

Findings include:

Hospital Policy: Use of Restraints and Seclusion
General Guidelines for restraint and seclusion

6. A physician's written/verbal/e-order should be obtained for restraint or seclusion. The order should be renewed according to the reason for restraint, medical/surgical or behavioral/emergency.
8. Restraint orders must include the reason for restraint, restraint type, and duration.

Medical Record Review:

1. Medical Record (MR) # 2 was admitted on 8/23/11 with a diagnoses of Aspiration Respiratory Failure, Renal Failure and Hypotension.

A review of the medical record on 8/30/11 revealed a Physician's Restraint Order form completed by a registered nurse dated 8/23/11 at 6:00 PM. The Physician's Order section of the form only contained a physician signature. There was no clinical justification, type of restraint (soft wrist, soft ankle or other), and no time frame for the use of the restraint documented.

On 8/30/11 at 3:30 PM, in an interview with the Chief Clinical Officer, Employee Identifier (EI) # 1, confirmed the order was not complete.

2. Medical Record # 3 was admitted on 8/16/11 with a diagnosis of, Unresponsive.

A review of the medical record on 8/30/11 revealed a Physician's Restraint Order form dated 8/17/11. There was no time frame for restraints documented on the order sheet.

On 8/30/11 at 3:35 PM, in an interview with EI # 1 it was confirmed the order was not complete.



Carter Sims, RN