HospitalInspections.org

Based on review of facility documents, medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to monitor and assess a patient during the use of physical restraints for one of three medical records reviewed (MR1).

Findings include:

A review on December 10, 2012, of facility policy "Restraints and Seclusion," dated April 2010, revealed "... Definitions; Physical Restraints: The application of any manual method that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. ... 12.0 Nursing standards during the use of restraints and/or seclusion ... 12.4 The patient shall be assessed every 15 minutes while in restraints by a Registered Nurse or Psych Technician ..."

A review of facility policy "Use of Restraints When Taking Patients To Off-Site Civil Commitment Hearings ("Mental Health Court")," dated January 2012, revealed " ... Nursing Standards During the use of Restraints for Mental Health Court ... 3.0 Continuous patient observation will be documented by the psychiatric technician no less than every 15 minutes. An RN or physician must assess the patient no less than once an hour for physical and psychological status and any signs of injury ... "

A review of MR1 revealed a physician order for full leather restraints dated November 28, 2012, at 9:45 AM, which were released at 12:05 PM. Further review of MR1 "Seclusion / Restraint Observation Record" revealed no documented evidence that the patient's "Circulation," "Hygiene," and "Comfort" were assessed.

An interview with EMP2 on December 10, 2012, at approximately 1:50 PM confirmed that there was no documented evidence that MR1's "Circulation," "Hygiene," and "Comfort" were assessed in accordance with protocol revealed on the patient's "Seclusion/Restraint Observation Record."

A review of MR1 revealed a physician order for wrist restraints on November 30, 2012, at 9:00 AM related to the patient going to court. The order was discontinued on November 30, 2012, at 3:30 PM. Further review of MR1 revealed no documented evidence that a registered nurse or physician assessed the patient no less than once an hour for physical and psychological status and any signs of injury.

An interview with EMP2 on December 10, 2012, at approximately 1:45 PM confirmed that MR1 revealed no documented evidence that a registered nurse or physician assessed the patient no less than once an hour for physical and psychological status and any signs of injury.