HospitalInspections.org

Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to follow their approved policy for the use of restraints and failed to ensure only the less restrictive interventions were used for two of ten medical records reviewed (MR3 and MR5).

Review on June 3, 2024, of facility policy "Restraint" with a revision date of 11/2023, revealed "... General Points: A. Restraints are to be used as infrequent and/or temporary measure when an assessment determines it is clinically necessary to improve the patient's well-being and when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm ... Nonviolent/Non-Self-Destructive Restraint ... C. An order by a physician, or other LIP is required prior to the application of restraint ...Violent/Self Destructive Restraint ... C. An order by a physician, or other LIP is required prior to the application of restraint ... D. A physician, or other LIP must see the patient face to face (in person) and evaluate the need for restraint or seclusion within 1 hour after initiation of restraint ..."

Review of MR3 on June 3, 2024, revealed the patient was placed in upper extremity restraints on April 26, 2024, at 07:27 AM. There was no documentation of less restrictive interventions used prior to patient being placed in nonviolent restraints.

Review of MR5 on June 3, 2024, revealed the patient was placed in 4-point restraints on May 23, 2024, at 11:21 PM. There was no documentation of less restrictive interventions used prior to patient being placed in violent restraints.

Interview with EMP10 on June 3, 2024, confirmed the above finding for MR3 and MR5.

Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to follow their approved policy for the use of restraints and failed to use a restarint in accordance with the order of a physician for one of ten medical records reviewed (MR7).

Review on June 3, 2024, of facility policy "Restraint" with a revision date of 11/2023, revealed "... General Points: A. Restraints are to be used as infrequent and/or temporary measure when an assessment determines it is clinically necessary to improve the patient ' s well-being and when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm ... Nonviolent/Non-Self-Destructive Restraint ... C. An order by a physician, or other LIP is required prior to the application of restraint ...Violent/Self Destructive Restraint ... C. An order by a physician, or other LIP is required prior to the application of restraint ... D. A physician, or other LIP must see the patient face to face (in person) and evaluate the need for restraint or seclusion within 1 hour after initiation of restraint ..."

Review of MR7 on June 3, 2024, revealed the patient was placed in upper extremity soft wrist restraints. There was no documentation of a restraint order prior to the patient being placed in nonviolent restraints.

Interview with EMP11 on June 3, 2024, confirmed the above finding for MR7.

Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to follow their approved policy for the use of restraints and failed to ensure that a patient was seen face-to-face within 1 hour after the initiation of a restraint for one of ten medical records reviewed (MR1).

Review on June 3, 2024, of facility policy "Restraint" with a revision date of 11/2023, revealed "... General Points: A. Restraints are to be used as infrequent and/or temporary measure when an assessment determines it is clinically necessary to improve the patient ' s well-being and when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm ... Nonviolent/Non-Self-Destructive Restraint ... C. An order by a physician, or other LIP is required prior to the application of restraint ...Violent/Self Destructive Restraint ... C. An order by a physician, or other LIP is required prior to the application of restraint ... D. A physician, or other LIP must see the patient face to face (in person) and evaluate the need for restraint or seclusion within 1 hour after initiation of restraint ..."

Review of MR1 on June 3, 2024, revealed the patient was placed in 4-point violent restraints on May 18, 2024, at 10:11 PM. There was no documentation of the physician assessing the patient within 1 hour of being placed in violent restraints. MR1 was assessed on May 19, 2024, at 1:31 AM.

Interview with EMP10 on June 3, 2024, confirmed the above findings for MR1.