HospitalInspections.org

Based on document review and interview, it was determined that hospital staff failed to ensure orders to restrain were secured for one (1) of three (3) patients included in the survey sample for review of restraints. (Patient #8)

The findings include:

A review of clinical record for Patient #8 revealed the following in part: Patient #8 was transported to the Emergency Department (ED) on 6/3/19 by emergency medical services (EMS) after being found unresponsive in the street. EMS documents upon their arrival the patient was not responsive and was noted to have pinpoint pupils. Patient #8 was given 2 mg of Narcan after which they became combative. After becoming combative, Patient #8 was given 5 mg of versed. ED triage documents Patient #8 arrived to the ED at 10:31 AM. Nursing documentation on 6/3/19 at 7:16 PM reads in part "assumed care of patient. Patient is in stretcher in ED, with one to one. Patient is 8 pouint (sic) restraints". At 7:39 PM nursing documentation reads "patient biting off restraints. Attempting to get up, striking at nursing staff.". At 8:52 PM nursing documentation reads " [Physician name] at bedside. PAtient (sic) is to be changed to icu admission. continue with restraints". On 6/4/19 at 2:03 AM nursing documentation reads in part "patient is one to one in 4 point restraints".

A review of the clinical record found Patient #8 was restrained as early as 7:16 PM on 6/3/19, the clinical record failed to provide clear evidence of when restraints were applied and failed to provide evidence of a provider order for restraints during the time Patient #8 was in the ED.

A review of hospital policy "Restraint and Seclusion" revision date 1/23/19 found the following in part: "VI. Procedures E. Orders for Restraint Violent or Self Destructive Restraint or Seclusion Orders: When a restraint or seclusion is used for the management of violent and/or self-destructive behavior that jeopardized safety, the registered nurse immediately notifies the physician to obtain an order."

The failure to obtain an order for restraints to be applied to Patient #8 while in the ED was discussed with SM #6 at the time of discovery on 12/18/19 and with the management team prior to exit on 12/19/19. No further information was provided to the surveyor.