HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the nursing staff monitored and assessed the patient's status and response to restraints for one of six sampled patients (Patient 3) as per the hospital's P&P. This failure posed the risk of substandard outcomes for the patient.

Findings:

Review of the hospital's document titled Restraints and Seclusion; Policy and Nursing Documentation Changes and Updates, undated showed under frequency, complete documentation under "Restraint Placement/Monitoring" and "Restraint Patient Assessment," to be done at the beginning and end of the shift or with any changes in the patient's condition or restraints.

On 6/30/25, Patient 3's medical record was reviewed with the Director of Quality.

Review of Patient 3's medical record showed Patient 3 was admitted to the hospital on 6/25/25.

Review of the Restraint Initiation Non Violent order dated 6/26/25 at 2200 hours, showed the soft limb restraints were to be applied to Patient 3's bilateral upper extremities. An additional review of Patient 3's physician's orders showed the order for restraints was renewed on 6/27/25 and 6/28/25.

Review of the Restraint Placement Flowsheet dated 6/28/25, showed the restraint monitoring was completed for Patient 3 at 0700 hours (start of day shift). The Director of Quality was unable to locate documentation showing the restraint monitoring was completed at the end of the day shift on 6/28/25.

On 7/1/25 at 1330 hours, the Director of Quality acknowledged and verified the above findings.