HospitalInspections.org

Based on interview and document review, it was determined that hospital staff failed to modify a patient's plan of care to reflect the use of restraints in one (1) out of three (3) medical records.

The findings include:

Three (3) medical records of patients listed as having restraints from May 1,2024 to July 1, 2024 were reviewed on 07/01/2024 at 12:37 p.m. with the assistance of Staff Member #10, acting as a navigator for the electronic medical records.

Patient #4 had three (3) orders for soft bilateral upper extremity non-violent restraints noted in the record. The orders were dated 02/01/2024, 02/09/2024 and 02/10/2024. The usage of restraints was documented on 02/01/2024 in the plan of care. There was no modification present in the medical record to indicate usage of restraints in the plan of care for the 02/09/2024 order, nor the 02/10/2024.

The other two (2) medical records indicated changes had been made to the plan of care.

In interviews with Staff Members #4, 5 and 10 on 07/01/2024, there was agreement that the plan of care needs to be modified with each new order for restraints.

A review of the facility's policy entitled, "Seclusion, Restraints and Restraint Alternatives," ID #15758361, last revised 05/2024, reads, in part:
... "Procedure:
... 10. Care of the Patient/Plan of Care:
a. The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications.
... 12. Documentation Requirements
... n. Modifications of the plan of care"

The above findings were discussed at the exit interview on 07/01/2024.