HospitalInspections.org

Based on staff interview and review of medical record, it was determined the hospital failed to ensure patient #1, who had behavioral restraints applied and whose record was reviewed, was seen face to face within 1 hour after initiation of the intervention by a person authorized to conduct restraint evaluations. This resulted in the inability of the hospital to adequately assess patient for causes of behaviors and treatment alternatives.
Findings include:
Patient ' s medical record documented 67 year old female underwent posterior lumbar decompression and fusion. On 05/10/11 at 02:15 patient had pulled her IV out was yelling and screaming; would not let nursing staff assessed her and aggressive towards staff. Patient has a telephone order from her attending physician for 24 hour restraints, written at 02:31 on 05/11/11. After patient was placed in restraints, she was not seen face to face by a physician or LIP in order to assess the need for restraint and possible alternative interventions. The earliest documented physician visit is on 05/11/11 at 08:05.

The hospital ' s Vice President Risk Management was interviewed on 09/21/11 at 2:30 PM. She had reviewed patient #1 record. She indicated a face to face reassessment of patient #1 was not completed within 1 hour of the use of restraints.