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ADVOCATE SHERMAN HOSPITAL
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0168
Based on document review and interview, it was determined for 1 of 5 (Pt. #6) clinical records reviewed for restraint usage, the Hospital failed to ensure an order for restraints was written as required.
Findings include:
1. The Hospital policy titled, "Utilization of Restraint and Seclusion (reviewed on 5/5/15)" was reviewed on 1/21/16. The policy required, "Use of restraint and seclusion is based upon the order of a physician."
2. The clinical record of Pt. #6 was reviewed on 1/21/16. Pt. #6 was a 20 year old male who presented to the emergency department on 11/29/15 with an eye contusion after an altercation. Pt. #6 was placed in leather restraints on 11/29/15 at 3:30 AM. The restraints were removed on 11/29/15 at 10:00 AM. Pt. #6 was discharged from the ED on 11/29/15 at 10:50 AM. The order for restraints was written on 12/1/15 at 6:48 AM (after discharge).
3. During an interview on 1/21/16 at 11:00 AM, the Clinical Informatics Coordinator stated, that was the only order available in the computer system.
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0175
Based on document review and interview, it was determined for 1 of 5 (Pt. #5), clinical records reviewed for restraint usage, the Hospital failed to ensure the patient was monitored as per policy.
Findings include:
1. The Hospital policy titled, "Utilization of Restraint and Seclusion (reviewed on 5/5/15)" was reviewed on 1/21/16. The policy required, "RN assessment of the patient will occur no less often than every 2 hours..."
2. The clinical record of Pt. #5 was reviewed on 1/21/16. Pt. #4 was an 84 year old female admitted on 10/8/15 with the diagnosis of fractured hip. An order for restraints was written on 10/11/15 at 1:33 AM due to cognitive impairment interfering with care. Pt. #5 remained in restraints until 10/13/15 at 3:00 PM. The clinical record lacked documentation of every 2 hour restraint monitoring for the following times: 10/12/15 - 2:00 AM, 12:00 PM, 2:00 PM and 8:00 PM.
3. During an interview on 1/21/16 at 11:00 AM, the Clinical Informatics Coordinator stated the restraint monitoring was not documented as per policy.