HospitalInspections.org

Based on documentation review, the facility failed to ensure that restraint orders indicated time to end use of restraint for 1 of 10 medical records (MR) reviewed (patient #1).

Findings included:

1. Review of policy/procedure provided CLN 2010, Restraints, Nonviolent for Protection of Bodily Injury, last updated 4/16/2015, indicated the following:
(2). A physician order is required to use nonviolent restraint. A new physician order must be obtained for each restraint episode. This policy prohibits use of any standing or PRN nonviolent restraint orders.

2. Review of patient #1's MR indicated the following restraint orders were written.

a. On 5/01/2016, physician #7's order indicated: Restraints non-violent or non-self destructive Side Rails up x4, Soft-Restraint-wrist (Comment: Left, Right, Bilateral); Interference with medical treatment, Other (comment)--Bilateral wrist restraints and side rails x4. Patient attempting to get ou (sic). Duration Until Specified.
b. On 5/8/2016 physician #8's order indicated: Restraints non-violent or non-self destructive Side Rails up x4, Soft-Restraint-wrist (Comment: Left, Right, Bilateral); Interference with medical treatment, Other (comment)--Bilateral wrist restraints, L ankle. Duration: Until specified.
c. On 5/10/2016 by physician #9's order indicated Restraints non-violent or non-self destructive Soft-Ankle (Comment: Left, Right, Bilateral); Soft Restraint-wrist (Comment Left, Right, Bilateral); Interference with medical treatment, Other (comment)-- Duration- Until Specified.
d. On 6/17/2016 physician #11's order indicated: Restraints non-violent or-non-self destructive Lap Belt; Interference with medical treatment. End time-Until Specified.
e. On 7/7/2016 physician #12's order indicated: Restraints non-violent or non self destructive Lap Belt; Interference with Medical treatment. End date/time-until specified.