HospitalInspections.org

Based on review of hospital policy, staff interview and review of 11 medical records, it was determined that the nursing care plan was not updated to include the use of restraint for patient #5.

Patient #5 was placed in non-violent 2 point wrist restraints on 6/2/15 at 0430. Review of the patient's care plan on 6/4/15 revealed the care plan had not be modified to include the recent restraint use and a plan of care including least restrictive interventions.

Based on review of hospital policy, staff interview and review of 11 medical records, it was determined that the hospital failed to obtain an order for non-violent restraint for patient #6.


Patient #6 was 76 years old, admitted from an Assisted Living Home to the hospital on 4/23/15 with medical conditions that included dementia with a behavior disturbance. The purpose of the admission to the hospital was to stabilize the patient's aggressive, agitated, and combative behavior (in spite of being on multiple antipsychotic medications prior to admission).

On 6/4/15 at 0700 the nursing staff noted that mittens had to be re-applied because when mittens were removed , the patient reached for his catheter. An order was not obtained by the nursing staff from the physician to apply the mittens even though the nursing staff determined that this was a necessary measure in order to keep the patient's urinary catheter in place. The mittens remained applied to the patient's hands for a period of 8 hours until they were discontinued at 1500 the same day.

Based on review of 11 medical records, policy and procedure, and staff interviews, it was determined that there was no documentation for restraint termination in the medical records of Patients #5, #8 and #9.


Patient #5 was admitted on 5/27/15 for rehabilitation services. The patient was restless and was provided a sitter but continued to pull at tubes including her trach. Patient #5 was placed in two point soft wrist restraints at 0430 on 6/2/15. Review of the medical record revealed a blank space for the two hour assessment and no notation regarding when the restraint was discontinued. The only note referencing the restraint removal was written on 6/2/15 at 1715 by the nurse stating "resumed care of patient at 0745 with sitter at bedside and bilateral wrist restraints off."


Patient #8's medical record review revealed that the patient required the use of non-violent restraints (waist belt) intermittently due to the patient's inability to remember safety precautions. The patient was a high falls risk due to an unsteady gait and recent history of falls. The patient had attempted to stand and walk unattended. The restraint (waist belt) was applied intermittently from 4/24/15 through discharge on 6/4/15 for safety measures. The medical record consistently revealed the staff's failure to perform and document 2 hour assessments when the restraint was in place. In addition, no documentation could be found in the medical record of when the restraint was removed.


Patient #9 required the use of restraints (waist belt) due to the inability to remember safety precautions. This patient was a high fall risk and was unable to retain education about safety precautions due to advanced dementia. The restraint was ordered and had been applied intermittently starting on 5/28/15 at 2358 through 6/5/15. Staff failed to document assessments every 2 hours while the restraint was in place. In addition, no documentation could be found in the medical record of when the restraint was removed.


In the cases of patients #5, #8, and #9, the failure of the nursing staff to document date and time the restraints were discontinued and their failure to document assessment of the patient's behaviors on the every two hour monitoring flow-sheet prevented determination of whether the restraints were discontinued at the earliest possible time.

Based on review of 11 medical records, policy and procedure, and staff interview, it was determined that the every two hour monitoring and assessment was incomplete for patients #5, #6, #8 and #9.

Patient #5 was admitted on 5/27/15 for rehabilitation services. The patient was restless and was provided a sitter but continued to pull at tubes including her trach. Patient #5 was placed in two point soft wrist restraints at 0430 on 6/2/15. Review of the restraint/seclusion flow-sheet revealed no two hour assessment performed from 0430 until 0800. The documentation included a note written at 1715 by the nurse stating "resumed care of patient at 0745 with sitter at bedside and bilateral wrist restraints off. "


Patient #6 was admitted to the hospital on 4/23/15 to the Behavioral Health Unit (BHU) for management and stabilization of aggressive behavior. The medical record review revealed that the patient required the use of mittens on the following dates: 5/22/15, 5/23/15, 6/1/15, 6/2/15 and 6/3/15. An interview of the Chief Nursing Officer on 6/5/15 at 0800 revealed that the policy for non-violent restraint use is hourly rounding and every 2 hour assessment of the patient's condition by the nursing staff while the patient is in restraints. A review of the nursing staff restraint assessments indicated that staff did not perform and document the every 2 hour assessments for the following dates: 5/23/15, 6/1/15, 6/2/15 and 6/3/15.


Patient #8's medical record review revealed that the patient required the use of non-violent restraints (waist belt) intermittently due to the patient's inability to remember safety precautions. The patient was a high falls risk due to an unsteady gait and a recent history of falls. The patient had attempted to stand and walk unattended. The restraint (waist belt) was applied intermittently from 4/24/15 through discharge on 6/4/15 for safety measures. When the restraint was in place staff failed to perform and document 2 hour assessments.


Patient #9 required the use of restraints (waist belt) due to the inability to remember safety precautions. This patient was a high fall risk and was unable to retain education about safety precautions due to advanced dementia. The restraint was ordered and had been applied intermittently starting on 5/28/15 at 2358 through 6/5/15. Staff failed to document assessments every 2 hours while the restraint was in place.


An interview with the BHU manager on 6/4/15 at 1400 revealed that the facility did have a policy regarding documentation of assessment while a patient is in restraints and that all employees are annually provided education about the use and documentation of restraints. The manager reviewed the medical records of patient #8 and patient #9 with the surveyor on 6/4/15 and on 6/5/15. The lack of 2 hour assessment documentation for restraints was confirmed.

Based on the review of 11 medical records and interview of hospital staff, it was determined that the hospital failed to plan and anticipate care needs for patient #6.

Patient #6 was 76 years old, admitted from an Assisted Living Home to the hospital on 4/23/15 with medical conditions that included dementia with a behavior disturbance. The purpose of the admission to the hospital was to stabilize the patient's aggressive, agitated and combative behavior (in spite of being on multiple antipsychotic medications prior to admission).

A review of the patient's medical record gero-psychiatric progress notes revealed that the patient presented with behaviors such as refusal of a blood draw, choking a Geriatric Nursing Assistant (GNA), increased agitation and combativeness, knocking medications out of the nurse's hand, refusal of medications, kicking, spitting , hitting, grabbing at nursing staff, taking off clothes or undressing, and required the use of non-violent bilateral mittens (untied) to prevent picking and pulling at tubes (indwelling urinary catheter for a sacral pressure ulcer Stage III-IV) and intravenous lines. The patient was also assessed for having poor safety awareness and was unable to follow directions.

On 5/27/15 the patient had a peripheral inserted central (PICC) line placed for hydration. The patient was medicated prior to the line insertion/placement with an antipsychotic agent (Haldol 0.5 milligrams intramuscularly). By 5/28/15 at 0404 the patient pulled out the central line. There was no indication that the nursing staff anticipated the use of mittens as a protective measure based on the potentiality of the patient pulling the PICC Line out and the patient's prior unpredictable behaviors even though the patient was noted by the staff as refusing medications, agitated, and combative requiring an injection of Haldol on 5/26/15.