HospitalInspections.org

Based on record review and interview the facility failed to monitor a patient who is restrained according to hospital policy for 2 of 2 behavioral management restrained patients (#18, #30). Findings include:

The hospital policy, titled "Behavioral Health Services Restraint Policy", states in Section 3.1, "A patient in restraint must be personally checked and have the circulation of each extremity checked by nursing staff every 15 minutes. Documentation of the patient's behavior and responses to restraint and the circulation status of each extremity will be recorded on the Seclusion/Restraint Record every 15 minutes."

In Section 3.2 of the same policy, it states, "A registered nurse (RN) shall assess the mental/physical state of the restrained patient at least two times during an eight hour shift. This assessment includes an evaluation of the patient's response to restraint and readiness for release."
On 9/7/10 at approximately 1150 during a tour of the Psychiatric Unit on Campus A, staff #A stated that they are reporting a death that occurred earlier this morning (9/7/10) of patient #30. Patient #30 had been in behavioral management restraints a couple days prior to death. Upon review of the restraint order and monitoring, it was noted that on 9/4/10 while the patient was in 2 point leather restraints, there was no monitoring of the patient documented for the time 0200 to 0246, 0300 to 0400, 0400 to 0500, 0500 to 0600, and from 0600 to 0700.

On 9/8/10 at approximately 1500 during a tour of the Psychiatric Unit on Campus B, staff #U when queried regarding the frequency of assessment of a patient in 4-point leather restraints replied " it once a shift, what the doctor ordered on admission " then Staff #U was queried about what the restraint policy had written and replied " The restraint policy does not mention any timeframes. " Upon review of patient #30 ' s medical record at approximately 1500 due to presently being in 4-point leather restraints, one set of vital signs had been taken on the patient and that was at 0600. No other assessment regarding the mental/physical state of the patient by a registered nurse was documented in the medical record. In addition, the only time the patient ' s circulation was assessed between 0600 and 1400 was documented at 1215.