HospitalInspections.org

Based on review of facility policy, medical records, and interview with staff (EMP), it was determined the facility failed to ensure that restraints were used in accordance with the patient's plan of care for three of three restraint medical records reviewed (MR1, MR2, and MR3).

Findings include:

A review of facility policy "Restraint and Seclusion" effective November 2017, revealed, "...2. Initiation...e. Place safety/restraint on the patient's Plan of Care. i. Plan of Care must reflect process of assessment, intervention, and evaluation.

1. A review of MR1 on February 8, 2018, revealed the patient was restrained daily from December 27, 2017, until January 4, 2018. The plan of care was not updated to reflect the use of restraints.

An interview conducted on February 8, 2018, at 11:15 AM with EMP5 confirmed the patient had been restrained and that the care plan was not updated.

2. A review of MR2 on February 8, 2018, revealed the patient was restrained on January 16, 2018. The plan of care was not updated to reflect the use of restraints.

An interview conducted on February 8, 2018, at 9:45 AM with EMP6 confirmed the patient had been restrained and that the care plan was not updated.

3. A review of MR3 on February 8, 2018, revealed the patient was restrained daily from January 3, 2018, until January 9, 2018. The plan of care was not updated to reflect the use of restraints.

An interview conducted on February 8, 2018, at 10:50 AM with EMP7 confirmed the patient had been restrained and that the care plan was not updated.