HospitalInspections.org

Based on interviews and document review, it was determined the facility staff failed to monitor the non-violent restrained patient by not documenting the required two-hour assessment criteria for one (1) out of three (3) patients. The required two-hour assessment criteria for nonviolent restraints include, clinical justification for the restraint, performing visual and safety checks, circulation and skin integrity assessments, performing range of motion exercises, and offering fluids, meals, and elimination services.


The findings include:

The surveyor reviewed the restraint documentation record of Patient #4 on 08/17/21 at 1:45 pm. Record review revealed Patient #4 was ordered non-violent, soft bilateral wrist restraints for interference with medical treatment by pulling out lines, tubes, dressings, and other equipment. The initial order was placed by the physician (Staff Member #32) on 08/15/21 at 7:45 pm. The order was then renewed by another provider (Staff Member #33) the following day on 08/16/21 at 8:00 pm.

The surveyor observed that the required two (2)-hour restraint monitoring section of Patient #4's medical record was entirely incomplete. The surveyor questioned Staff Member #1 and Staff Member #5 on the afternoon of 08/17/21 where the restraint documentation that showed the clinical justification, visual/safety check, circulation/skin integrity, range of motion, fluids, food and meal, elimination were offered to Patient #4 while in restraints. Both staff members later confirmed that the two (2) hour restraint monitoring documentation was not done on Patient #4.

The surveyor received facility policy titled, "Use of Restraints for Nonviolent, Non-Self-Destructive Patient Situations: Medical Use of Restraints" (with last effective date of 06/16/21) on 08/17/21 at 10:00 am by Staff Member #5. Under "B. Monitoring/Documentation" section of Page 4, the policy states, "Monitoring is required at a minimum of every 2 hours to include: clinical justification criteria (RN only), visual/safety check, circulation/skin integrity, range of motion, fluids, food and meal, elimination".