HospitalInspections.org

Based on review of facility policy and procedures, facility documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to use restraints in accordance with physician or other licensed independent practitioners' (LIP) orders by failing to obtain orders for restraints in two MR (MR5 and MR6) reviewed.

Findings include:

Review of policy entitled "Use of Restraint for Non-violent/Non-self-destructive Behavior," effective date: 6/1/18, revealed "Procedures: Orders: Start & end-time up to a maximum of twenty-four (24) hours...Physician order required for renewal within the twenty-four hour window."

Review of MR5 revealed the patient was placed in bilateral soft wrist restraints from 01:53 to 07:00 on December 11, 2018 with no physician order for the restraints. Additional review of MR5 revealed the patient was again placed in bilateral wrist restraints from 06:59 on December 12, 2018, to 07:00 on December 13, 2018, with no physician order for the restraints.

Review of MR6 revealed the patient was placed in bilateral soft wrist restraints from 03:00 to 07:00 on December 25, 2018 and again from 06:59 to 10:00 on December 26, 2018, with no physician order for the restraints.

Interview with EMP4 confirmed that no physician order was documented for the indicated dates and times for these two medical records.