HospitalInspections.org

Based on medical record review, policy review, and staff interview; the facility failed to ensure each order for restraint use to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy for one of one patient reviewed with restraints (Patient #2). The total sample was ten patients. The facility's census was 177.

Findings include:

Review of the policy titled, "Use of Restraints for Nonviolent, Non-Self-Destructive Patient Situations: Medical Use of Restraints," effective 10/06/22, revealed restraint orders must be time limited and may extend only to midnight of the day after the order is written (every calendar day).

Review of the medical record for Patient #2 revealed bilateral soft wrist restraints were applied on 10/04/23 at 5:34 PM and remained in place until removed on 10/06/23 at 7:30 PM. The medical record contained an order dated 10/04/23 at 5:34 PM for bilateral soft wrist restraints with a frequency of routine continuous until 11:59 PM of the next calendar day 10/04/23 5:45 PM - one day. A second order for bilateral soft wrist restraints was dated 10/06/23 at 7:40 AM with a frequency of routine continuous until 11:59 PM of the next calendar day 10/05/23 9:00 AM - one day.

The facility policy indicated restraint orders must be time limited and may extend only to midnight of the day after the order is written. It was not clear if the order written on 10/04/23 at 5:34 PM was good through 11:59 PM on 10/05/23. It was also not clear if there should have been an order for the restraints from 12:00 AM on 10/06/23 through 7:40 AM on 10/06/23 since the order was written on 10/06/23 at 7:40 AM. The facility policy also gave the time frame of every calendar day, so it could not be determined if there should have been a restraint order written for 10/05/23.

The findings were verified in an interview on 10/10/23 at 3:50 PM by Staff A and B.