HospitalInspections.org

Based on policy review, medical record review and staff interview, the facility failed to assess and monitor a patient in non-violent restraints according to policy for 1 of 3 sampled patients who were restrained (Patient #3).

The findings included:

Review on 11/29/2017 of the hospital's policy "Restrictive Interventions" (Reviewed/Revised 5/17) revealed "...VII. Intervention... F. Assessment/monitoring/patient care: non-violent non self-destructive restraint utilization..., 2. Assess and document the following every 2 hours: a. Safety, circulatory status, affect behavior and correct device application ...3. Record patient assessment, including response/behavior while in restrictive interventions as part of on-going monitoring of the patient..."

Closed record review on 11/28/2017-11/30/2017 of Patient #3 revealed a 59 year old female admitted on 10/05/2017 to neurosurgical service for treatment of lumbar spondylosis and lumbar stenosis. Review of a nurse practitioner note dated 10/06/2017 at 1551 revealed "...status post L4-5 decompression and fusion ...yesterday (10/05/2017)." Review of a neurosurgery progress note dated 10/09/2017 stated that "...patient is agitated and still confused about the events that have transpired over the weekend (10/07/2017-10/08/2017)...escorted to her room by security...psych (psychiatrist) have (sic) been consulted for agitation ...and confusion." Review of "Physician Progress Notes" electronically signed 10/09/2017 at 1148 revealed that "Patient has been very agitated, confused, not able to make safe and good medical decisions...Impression and Plan...Anxiety with agitation, confusion, questionable delirium versus psychotic break." Review of physician's orders revealed a verbal order for nonviolent/non self destructive restrictive intervention dated 10/08/2017 at 1627 for a "Restrictive Intervention Device - Vest and Side Rail Protectors, frequency q2hour (every 2 hours)" entered by RN #3 (registered nurse). Continued review revealed the order was electronically signed by the ordering provider on 10/09/2017 at 0745. Review of the flow sheet "restrictive intervention view" revealed the following: 10/08/2017 at 1620 restrictive intervention initiated; 10/08/2017 at 1900 restraint reassessment documented (2 hours and 40 minutes after initiation); 10/08/2017 1900 to 2300 no documented restraint reassessment (4 hours); 10/09/2017 0300 to 0900 no documented restraint reassessment (6 hours). Review revealed the restraint remained on through 10/09/2017 at 1500. Review revealed after 1500 on 10/09/2017 no further restraint reassessment/monitoring or discontinuation of restraints was documented. Review revealed that Patient #3 was not monitored and assessed while in a restrictive intervention every two hours per policy.

Request for interview on 10/29/2017 of RN #10 who took care of Patient #3 while in restraints revealed nurse not available for interview.

Interview with RN #3 on 11/30/2017 at 0925 revealed that nurse had been charge nurse on unit taking care of Patient #3 while in restraints. Interview revealed "we tried to avoid" restraints ...patient safety attendant (sitter)" was in place and (patient) "kept pushing past ...(patient safety attendant)." Interview revealed MD (medical doctor) ordered restraints to keep patient" (safe) "in room until psych (psychiatrist)" evaluation.

Staff interview with AS #7 (administrative staff) on 11/29/2017 at 1624 revealed that she received a call from the charge nurse related to concern for Patient #3 safety. Continued interview revealed that at 1800 on 10/08/2017 MD (medical doctor) was called because Patient #3 wanted to leave AMA (against medical advice). Interview revealed a telephone order (verbal order) was obtained on 10/08/2017 at 1627 for nonviolent restraints.

Staff interview with RN #6 on 11/29/2017 at 1515 revealed that she was a restraint trainer. Interview revealed restraint assessment and monitoring should be documented every two hours after initiation on the restraint flow sheet. Continued interview revealed RN#6 could not locate every two hour documentation on Patient#3's medical record and there was no nurse's note related to the discontinuation of restraints. Interview revealed that facility policy was not followed for 1 of 3 patients in nonviolent/non self destructive restrictive interventions.