HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 5 (Pt #8) clinical records reviewed for restraints, the Hospital failed to ensure restraints were removed within 4 hours of application or a new order placed for restraints.

Findings include:

1. On 8/18/2021, the Hospital's policy titled, "Restraints and Seclusion Policy," (revised 8/2012) was reviewed and required, " ...Restraint and Seclusion for Violent, self-destructive patients who are a threat to themselves or others ...II. Orders for Restraint or Seclusion ... 3. Orders are limited in time. Orders for the use of Restraint or Seclusion must never be written as a standing order or on an as needed basis (PRN). Each order for Restraint or Seclusion may only last for the following amount of time: (A) 4 hours for adults 18 years of age or older..."

2. On 8/18/2021, Pt#8's clinical record was reviewed. Pt#8 presented to the Emergency Department on 7/15/2021 with a diagnosis of intentional overdose. Pt#8's restraint documentation, dated 7/16/2021, included a physician's order, dated 7/16/2021 at 9:41 AM, for soft restraints to all extremities for 4 hours. Pt#8's restraint flowsheet indicated that Pt#8 remained in restraints, applied to bilateral wrists and bilateral ankles, when a new physician's order for restraints was written on 7/16/2021 at 3:27 PM (greater than the 4 hours.)

3. On 8/18/2021, approximately 1:20 PM, an interview was conducted with the Manager of Regulatory Compliance (E#9). E#9 stated that if a restraint is ordered for a patient for a timeframe of 4 hours and the 4 hours has elapsed, but the patient still needs the restraint; a new restraint order should be written.

Based on document review and interview, it was determined that for 1 of 5 (Pt #10) clinical records reviewed for restraints, the Hospital failed to ensure documentation of a one-hour face to face evaluation was completed.

Findings include:

1. On 8/18/2021, the Hospital's policy titled, "Restraints and Seclusion Policy," (revised 8/2012) was reviewed and required, " ...Restraint and Seclusion for Violent, self-destructive patients who are a threat to themselves or others ... II. Documentation of Restraint and Seclusion ... The time and results of every patient evaluation, monitoring, and reassessment, including but not limited to the 1-hour face-to-face medical and behavioral evaluation and continuous monitoring, as required below ... III. Monitor, Assess, and Evaluate ... 3. A LIP [licensed independent practitioner] pursuant to this policy must see the patient face-to-face within 1 hour after the initiation of Restraint or Seclusion to evaluate the patient ..."

2. On 8/18/2021, Pt#10's clinical record was reviewed. Pt#10 presented to the Emergency Department on 7/12/2021 with a diagnosis of psychosis. Pt#10's restraint documentation included a physician's order, dated 7/12/2021 at 4:20 PM, for locked restraints to all extremities for 4 hours. Pt#10's restraint flowsheet indicated that Pt #10 was in restraints to all extremities from 4:00 PM until 5:15 PM. Pt#10's record did not include a face-to-face evaluation within 1 hour of the initiation of restraints.

3. On 8/18/2021, at approximately 1:40 PM, an interview was conducted with the Director of Regulatory Compliance (E#1). E#1 stated that when a physician orders restraints for a patient, they should perform a face to face with the patient, within 1 hour of the restraints being applied.