HospitalInspections.org

Based on a review of medical records, hospital policies, and staff interviews, the hospital failed to ensure that restraint orders were signed by a physician and that restraints did not exceed 15 minutes.

Findings included:

Review of the Restraint and Seclusion Order for 1/16/2015 revealed that Patient #2 was restrained at 1905 and the time out of restraint was 1923. The order was not signed by the physician as of 3/11/15. The restraint lasted longer than 15 minutes.

Review of the Restraint and Seclusion Order for 1/16/15 at 1925 revealed that Patient #2 was placed in seclusion at 1925 and released at 1935 for continued previous behaviors, aggression towards staff, verbal threats. The order was not signed by the physician as of 3/11/15.


Review of facility policy, Seclusion and Restraint stated, in part, "General Principles ...16. A physician must order each use of restraint or seclusion ...19. Staff members must avoid causing undue physical discomfort and must not cause harm or pain to the individual when initiating or using restraint or seclusion ...
Initiation ...6. If restraint or seclusion was ordered by telephone, the ordering physician must personally sign, time, and date the telephone order within 24 hours of the time the order was originally issued ...
Physician Orders. 1. Original orders - A physician may order restraint or seclusion for a period of time not to exceed: a. 15 minutes for personal restraint; ...
Release. 1. When the individual has exhibited the release behaviors described in the physician's order, the staff member must notify the RN. 2. The RN must evaluate the individual for release based on the individual's current behavior."

The above findings were confirmed in an interview with Staff #2, Risk Manager, the afternoon of 3/11/15 in the facility conference room.

Based on a review of nurse staffing schedules, staffing grid, and staff interview, the facility failed to ensure that there were adequate numbers of nursing staff on the Child/Adolescent Unit.

Findings included:

The nurse staffing for 1/16/15 was reviewed with Staff #3, Director of Nursing the morning of 3/11/15 in the facility conference room. Review of the nurse staffing for the Child/Adolescent Unit for 1/16/15 revealed that the unit was not staff according to the staffing matrix. There were 23 patients on the unit. On the day shift, there was one RN and one LVN and 5 MHTs working. On the night shift, there was one RN and one LVN and 3 MHTs working. The staffing grid for requires two RNs for census greater than 17 patients. This was confirmed in interview with Staff #3, the Director of Nursing during the interview.