HospitalInspections.org

Based on review of medical records, policies and procedures and interview with staff, it was determined the hospital failed to require orders for restraints were not written on an as needed (prn) basis for one (1) of three (3) patients with restraint orders reviewed (Patient # 2).

Findings include:

The hospital's policy titled Restraints & Seclusion in the Acute Care Setting required: "...A restraint order must never be written as a standing or PRN order...."

Pt #2 was admitted on 06/11/10, for sepsis and subsequently alcohol withdrawal symptom management.

The patient was first restrained on 06/13/10 at 0315 hours, for agitation and pulling out a Foley catheter.

A physician's telephone order was written by nursing on 06/14/10 at 0320 hours, which read: "...May continue soft restraints X 24 (hours) as needed...."

The medical / surgical clinical coordinator reviewed the medical record on 08/05/10 with the Surveyor, and confirmed the medical record contained a PRN order for restraints and verified this is not according to hospital policy.