HospitalInspections.org

Based on document review and staff interview, it was determined for 2 of 8 (Pt #1, Pt #7) patients with non-violent restraints, the staff failed to obtain an order for the restraints. This has the potential to affect all patients requiring non-violent restraints.


Findings include:

1. A review of the hospital policy titled Non-Violent Restraints and Restraint Alternative (revision date by the facility, 2/22/2021) was completed on 5/2/22 at 3:00 PM. The policy under "V. Authorization and Ordering Non-Violent Restraints: A. After restraint alternatives have been determined to be ineffective... the physician (or an Advanced Practice (APN), Advanced Practice Registered Nurse (APRN)... will be contacted for an order to restrain the patient and the patient will then be placed in restraints. 1. Restraints may be utilized and applied in an emergent situation with an order obtained immediately after application. D. Orders for restraints must be renewed before noon the following day."

2. The medical record of Pt #1 was reviewed on 5/2/22-5/4/22. Pt #1 was admitted from the emergency department (ED) on 9/4/21 at 6:32 PM with chief complaint of shortness of breath (SOB). Pt #1 reported being diagnosed with COVID-19 on 8/29/21. Pt #1 was admitted to the COVID unit on 9/4/21 at 1:28 AM. Documentation in the nursing flow sheets indicated on 9/7/21 at 3:46 AM, non-violent soft right and left wrist restraints were applied. The justification was due to Pt #1 "Pulling tubes; Removal of equipment; Prevention of significant harm". The physician was notified of restraint order on 9/7/21 at 4:18 AM and the restraints were verified per physicians order. On 9/7/21 at 8:10 AM, documentation indicated bilateral soft wrist and ankle restraints were applied. On 9/8/21 at 10:00 AM, bilateral soft wrist restraint is documented. On 9/8/21 at 11:00 AM, bilateral wrist ankle restraints were continued, bilateral ankle restraints were discontinued. On 9/8/21 at 8:23 PM, the ankle restraints were reapplied. Pt #1 continued to require restraints until 9/11/21 at 12:15 AM. On 9/16/21 at 9:00 PM, soft bilateral wrist and ankle restraints were reapplied. On 9/17/21 at 12:00 AM, the restraints were removed. There was no documentation of physician orders for soft bilateral ankle restraints. The last physician order documented was on 9/10/21 at 12:38 PM for soft bilateral wrist restraints.

3. The medical record of Pt #7 was reviewed on 5/3/22. Pt #7 was received on 3/7/22 at 1:15 AM from an outside hospital with diagnoses of pneumonia, congestive heart failure and respiratory failure. Documentation on the nursing flowsheets for "non violent restraints" indicated "bilateral soft wrist restrains" were applied to Pt #7 on 3/7/22 at 6:00 PM. Documentation in the physician progress notes indicated Pt #7 had a second cardiac arrest at approximately 12:00 midnight on 3/8/22 and after this family changed Pt #7's code status to Do Not Resuscitate (DNR). The restraint flowsheet indicates restraints were continued until Pt #7 expired on 3/8/22 at 1:58 am. There were no orders for the bilateral soft wrist restraints.

4. On 5/4/22 at 3:00 PM, an interview was conducted with the regulatory specialist (E#1). E#1 reviewed Pt #1 and Pt #7's medical records. E#1 reviewed Pt #1 and confirmed there was no physician order for soft bilateral wrist restraints after 9/10/21. E#1 also confirmed there was no physician order for ankle restraints for Pt #1. E#1 also confirmed there were no restraint orders written for Pt #7.