HospitalInspections.org

Based on document reviews and interviews, the hospital failed to ensure that restraint orders were renewed, or that restraints were removed upon the expiration of the restraint order for one (1) out of five (5) restrained patients reviewed (Patient #1R).

Findings:

1. Patient #1R's medical record was reviewed and revealed that Physician #1 ordered the patient be placed in soft restraints at 9:03 AM on 09/05/2023. The order reads in part:

" ...Order Details: Restraint Type: 4 Point Soft, Orders May NOT Exceed 4 Hours. MD Must see patient within 1 hour and minimally every 4 hours ..."

2. Patient #1R's medical record contains an entry by RN #1 dated 09/05/2023 at 2:45 PM which stated that the physical restraints were discontinued at 14:45 (2:45 PM) on 09/05/2023. RN #1's documentation reads in part:

" ...Restraint Activity Physical Restraint Discontinued
Restraint Discontinue Time 9/5/2023 14:45 EDT ..."

3. At 9:06 AM on 02/07/2024 RN #2 reviewed Patient #1R's medical record and provided the following information:

RN #2 confirmed at 9:06 AM on 02/07/2024 that Patient #1R was placed in restraints on 09/05/2023.

RN #2 confirmed that the restraints were ordered for a duration of 4 hours beginning at 9:03 AM.

RN #2 confirmed that the restraint order was not renewed.

RN #2 confirmed that either the restraints should have been discontinued at 1:03 PM on 09/05/2023 per the order, or the order should have been renewed.

RN#2 confirmed that according to the medical record, the restraints were not removed until 2:45 PM on 09/05/2023.

4. At 10:32 AM on 02/07/2024 an in-person interview was conducted with Accreditation Coordinator which revealed the following information:

Accreditation Coordinator confirmed at 10:33 AM on 02/07/2024, that the 09/05/2023 restraint order for Patient #1R should have been renewed.