HospitalInspections.org

Based on clinical record review and interview for 1 (P#4) of 11 patients reviewed for the use of restraints the facility failed to ensure the patient was assessed according to the frequency identified in the facility policy. The findings include:

Patient #5 was admitted on 1/23/19 for treatment of acute encephalopathy likely to recent surgery and narcotic use, in addition to major depressive disorder. According to the medical record on 1/24/19 at 4:53 PM an order was entered into the medical record for an enclosure/canopy bed for behaviors exhibited by P#5 such as confusion, agitation and restlessness. Alternatives such as 1:1 sitters, bed alarms and redirection were not successful in maintaining a safe environment for P#5.

According to nursing documentation the canopy/enclosure bed arrived and was initiated on 1/24/19 at 9:00 PM as evidenced by a nursing assessment that identified an assessment of exhibited behaviors, circulation, respiratory status, range of motion and the evaluation of needs such as hygiene, fluid, meals/food and elimination.

Although the medical record identified on 1/25/19 at 4:55 AM P#5 remains in the canopy/enclosure bed with frequent checks per protocol nursing documentation lacked evidence that P#5 was assessed for exhibited behaviors, circulation, respiratory status, range of motion and the evaluation of needs such as hygiene, fluid, meals/food and elimination on 1/24/19 at 11:00 PM and 1/ 25/19 at 1:00 AM, 3:00 AM and 5:00 AM.

During an interview and review of the medical record with the Unit Manager and Charge Nurse on 1/29/19 at 9:00 AM they indicated P#5 should have been assessed every 2 hours while in the canopy/enclosure bed and the medical record lacked those assessments as identified.

Hospital Restraint/Seclusion policy indicated for the use of non-violent or non-self-destructive restraints a nursing assessment is to be completed and documented every 2 hours. The assessment should include proper application of the restraint, signs of injury, physical and psychological status, hygiene, food and fluid needs, adequate circulation, range of motion, movement feeling of touch and skin integrity.