HospitalInspections.org

Based on findings from document review, medical record (MR) review and interview, in 1 of 5 MRs reviewed (Patient B), staff did not document discontinuation of a patient's wrist restraints as required by hospital policy and procedure (P&P).

Findings included:

-- The facility's P&P titled "Restraints, Physical & Chemical, Safety, Suicide (Suicidal) Risk and Prevention Adult," last revised 12/2014, indicated Registered Nurse (RN) staff are to document the date and time restraints or seclusions are removed, reason for discontinuation, any injury, and if injury, a description of injury.

-- Review of Patient B's MR identified a physician order for bilateral soft wrist restraints for 24 hours to prevent dislodging/pulling medical equipment (i.e., endotracheal tube). MR documentation did not describe when the restraints were discontinued or the reason the restraints were discontinued.

-- During interview of Staff #1, Nurse Manager of the Intensive Care Unit (ICU), on 7/28/15 at 10:45 am, he/she confirmed the above findings.
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Based on findings from document review and interview, the hospital's policy and procedure (P&P) regarding emergency restraint application in the absence of a physician, for a violent or self destructive patient, lacked a provision for immediate (within a few minutes) physician notification as required by this regulation.

Findings include:

--The facility's P&P titled "Restraints, Physical & Chemical, Safety, Suicide (Suicidal) Risk and Prevention Adult," last revised 12/2014, indicated that if restraints are applied in an emergency, in the absence of physician presence, the Registered Nurse (RN) should notify the physician/affliate within 30 minutes. The policy does not include to notify the physician/affliate immediately (within a few minutes) after the restraint is applied.

--During interview of Staff #3, Administrator Maternal Child, In-patient Psychiatry, & Oncology, on 7/29/15 at 12:25 pm, he/she acknowledged the above finding.
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Based on medical record (MR) review, interview and document review in 2 of 5 MR's (Patients B & C) nursing staff did not notify the attending physician that a restraint had been applied. Also, the facility's policy and procedure (P&P) did not include attending physician notification of restraint application to nonviolent patients.

Findings included:

-- Review of Patient B's MR identified a physician order by the physician assistant (PA) for bilateral soft wrist restraints for 24 hours. There was no documentation that the attending physician was notified of the patient's restraint order.

-- During interview of Staff #1, on 7/28/15 at 10:45 am, he/she confirmed this finding.

-- Review of Patient C's MR identified a physician telephone order for bilateral soft wrist restraints on 7/27/15 at 7:41 pm by the physician on call. The MR lacked documentation that the attending physician was notified of the patient's restraint order.

-- During interview of Staff #5 on 7/28/15 at 1:10 pm, he/she confirmed this finding.

-- The facility's P&P titled "Restraints, Physical & Chemical, Safety, Suicide (Suicidal) Risk and Prevention Adult," last revised 12/2014, indicated attending/covering physician notification for restraint application for nonviolent patients is not required.
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Based on findings from medical record (MR) review, document review and interview, in 1 of 1 emergency department (ED) MR reviewed regarding restraint use (Patient A), documentation describing use of a restraint intervention was lacking.

Findings include:

-- Per MR review, Patient A presented to the emergency department (ED) on 5/10/15 at 4:10 pm escorted by police with paranoia and suicidal ideations. While in the ED the patient became confused, removed his/her intravenous (IV) and patient gown, and attempted to leave the exam room/hospital. The patient was assisted back to the stretcher by three security staff. The patient was medicated with Ativan 1 mg intramuscular (IM) at 5:17 pm in the left deltoid and again at 6:35 pm in the right deltoid.

-- Per review of a Security Supervisors Daily Activity Report dated and timed 5/10/15 at 6:30 pm, three security staff helped medicate Patient A. The Security Supervisors Daily Activity Report is not part of the MR.

The MR lacked documentation of the type of intervention performed by security staff.

-- During interview of Staff #4, Nurse Manager ED, on 7/28/15 at 11:15 am, he/she acknowledged the above findings.
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