HospitalInspections.org

Based on document review and staff interview, the acute care hospital's administration failed to ensure the nursing staff documented the ongoing assessment of the patient's response to restraints for 1 of 1 patient (Patient #1) which the nursing staff placed in restraints for non-violent or non-self-destructive behavior. Failure to document the ongoing assessment of a patient in restraints for non-violent or non-self-destructive behavior could potentially result in the nursing staff failing to detect changes in the patient's medical condition indicating the patient was experiencing life-threatening distress from the nursing staff applying restraints, potentially resulting in the nursing staff failing to provide life-saving care to the patients. The hospital identified on entrance the daily census of 556 patients.

1. Review of the policy, "Restraint/Seclusion Management", dated November 2019, and review of the "Restraint Management Nursing Practice Guidelines", revised 01/2020, revealed in part, "Use of restraint for the management of Non-Violent or Non-Self-Destructive Behavior ... Assessment: Monitor patient ... every 2 hours while in restraints ... Document restraint monitoring in EMR (Electronic Medical Records) ... Once, prior to restraint initiation, every 2 hours ..."

2. Review of Patient #1's medical record revealed, in part:

--03/08/2020 12:27 AM, RN A contacted PA C to get the restraint order for Patient #1, verbal order for non-violent/non-self-destructive restraints was obtained at that time. The restraint initiation documentation was started with a completed initial assessment on Patient #1.

--03/08/2019 at 4:00 AM, RN A made their first documented assessment of Patient #1 into "Restraint/Assessment Monitoring." RN A documented " ...Type of Restraint-Soft upper extremity (UE) ...UE Restraint Location-Bilateral wrist ...Will continue to monitor [Patient #1]".

--03/08/2020 at 5:29 AM, RN A electronically entered and signed the non-violent/non-self-destructive restraint order from PA C for soft restraints (soft cloth restraints which allow patients more freedom of movement) on Patient #1.

--03/08/2020 at 6:00 AM, RN A documented "Restraint Assessment Monitoring" on Patient #1 with all required documentation and will continue to monitor Patient #1.

--03/08/2020 at 8:00 AM, RN B documented "Restraint Assessment Monitoring" on Patient #1 with all required documentation and will continue to monitor Patient #1.

3. During an interview on 03/16/2020 at 2:00 PM, the Director of Accreditatian and Regulatory Service confirmed the hospital's policy required the nursing staff to assess patients in restraints for non-violent or non-self-destructive behavior every 2 hours after the initial assessment. Director of Accreditation and Regulatory Service also confirmed Patient #1's medical record lacked documentation the nursing staff documented performing an assessment for almost 3 1/2 hours, from the initial documented assessment at 12:27 AM, until 4:00 AM