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Based on interview and record review, the hospital failed to ensure the nursing staff monitored one of four sampled patients (Patient 1) every two hours for the use of non violent behavior restraint as per the hospital's P&P. This failure posed the risk of injury and inappropriate care and treatment for the patient.

Findings:

Review of the hospital's P&P titled Restraints: Non Violent Behavior dated March 2023 showed the following:

* A patient in restraints is monitored at least every two hours or more often as applicable to the patient.

* Monitoring is accomplished by observation, interaction with the patient, or related direct examination of the patient by qualified staff.

* Monitoring includes:
- Assessing the patient's physical and emotional well-being.
- Maintaining the patient's rights, dignity, and safety.
- Determining if less restrictive methods are possible.
- Assessing for changes in the patient's behavior or clinical condition needed to initiate the removal of restraint
- Confirming the proper restraint application, remove and reapplication.

* Care includes toileting, positioning, circulation checks, range of motion, food/fluids offered.

On 9/11/24 at 1000 hours, an interview and concurrent review of Patient 1's medical record was conducted with the Director of Performance Improvement and Director of Medical Surgical and Telemetry.

Patient 1's medical record showed Patient 1 was admitted to the hospital on 9/5/24.

Review of the physician's order dated 9/10/24 at 1013 hours, showed the physician's order of soft restraint to bilateral wrists and the restraint reason was interference with medical treatment.

Review of the nursing flowsheet dated 9/10 and 9/11/24, failed to show documented evidence showing the nursing staff conducted the initial assessment applied the restraints on Patient 1; and monitored the patient every two hours on 9/10/24, from 1000 to 1800 hours as per the hospital's P&P.

When asked about the process of using restraint, the Director of Medical Surgical and Telemetry stated when the patient was danger to self or removed the lines used for medical interventions, the nurses provided the alternative interventions before applying restraints on the patient. If the alternative interventions were not effective, the nurse obtained the physician's order for restraint, applied the restraint on the patient, assessed the patient, documented the patient monitoring every two hours, and initiated the plan of care.

The Director of Performance Improvement and Director of Medical Surgical and Telemetry confirmed the above findings.

Based on interview and record review, the hospital failed to ensure the nursing staff developed the individualized nursing care plan to address the use of restraint for one of four sampled patients (Patient 1). This failure posed the risk of patient care and treatment were not being provided appropriate to the patient.

Findings:

Review of the hospital's P&P titled Restraints - Non Violent Behavior dated March 2023 showed to use Electronic Medical Record Restraint Flow Sheet, restraint order forms, and narrative notes to document all pertinent information in the medical record including but not limited to plan of care/ treatment plan, including criteria for discontinuation when applicable.

On 9/11/24 at 1000 hours, an interview and concurrent review of Patient 1's medical record was conducted with the Director of Performance Improvement and Director of Medical Surgical and Telemetry.

Patient 1's medical record showed Patient 1 was admitted to the hospital on 9/5/24.

Review of the physician's order dated 9/10/24 at 1013 hours, showed the physician's order of soft restraint to bilateral wrists and the restraint reason was interference with medical treatment.

Patient 1's medical record failed to show documented evidence the nursing staff developed the plan of care related to the use of restraints for Patient 1. The Director of Performance Improvement and Director of Medical Surgical and Telemetry confirmed the above findings.