HospitalInspections.org

Based on document review and interview, it was determined for 1 of 5 (Pt #2) records reviewed for the use of non-violent restraints, the Hospital failed to ensure patients were appropriately monitored per policy. This has the potential to affect all patients requiring restraint usage.

Findings include:

1. The policy titled "Restraint Utilization" (approved 2/26/21) was reviewed on 2/18/22. The policy noted "Restraint for NON-VIOLENT Behavior...Assessment and Monitoring...RN reassessment of the patient will occur no less often than every 2 hours..."

2. The clinical record of Pt #2 was reviewed on 2/17/22 at approximately 1:00 PM. Pt #2 presented to the ED 1/31/22 with tachycardia (increased heart rate) and tachypnea (increased respirations). Pt #2 was admitted to the Surgical/Ortho floor on 1/31/22. Non-violent bilateral wrist restraints were placed on 2/7/22 related to Pt #2 pulling at lines. The record lacked every 2 hour documentation of the RN (Registered Nurse) reassessment of the patient from 2/8/22 at 8:00 PM to 2/9/22 at 8:00 AM.

3. An interview was conducted on 2/18/22 at approximately 11:00 AM with the Manager of Quality/Regulatory (E #9). E #9 agreed the record lacked documentation of the RN assessment every 2 hours for patients in non-violent restraints.