HospitalInspections.org

Based on interview and document review, it was determined the facility staff failed to obtain a physician's order for restraints for one (1) of five (5) restrained patients included in the survey sample. (Patient #7)

The findings included:

On January 30, 2019 review of Patient #7's electronic medical record (EMR) with Staff Member #10 documented the patient was admitted to the facility on January 24, 2019. Staff Member #10 and the surveyor reviewed Patient #7's restraint orders, care plans and monitoring from January 25 through January 30, 2019.

Nursing staff documented the need for restraining Patient #7 related to the patient's behavior of attempting to remove life-sustaining equipment. Patient #7's EMR contained only one (1) Physician's order for soft limb bilateral wrist restraints on January 28, 2019. The physician timed the January 28, 2019 order at 9:23 a.m.

A review of the nursing staff's assessment and monitoring documented discontinuing Patient #7's soft limb bilateral wrist restraints at 2:00 p.m. on January 28, 2019. The review revealed the reapplication of Patient #7's soft limb bilateral wrist restraints at 10:00 p.m. on January 28, 2019 related to increased agitation.

Staff Member #10 navigated Patient #7's EMR with the surveyor and verified the record contained only one (1) restraint order for January 28, 2019. Staff Member #10 verified the next physician's order for Patient #7's soft limb bilateral wrist restraints was dated January 29, 2019 at 4:26 p.m.

Nursing documentation at 9:45 p.m. on January 28, 2019 revealed a call was placed to Staff Member #15, related to Patient #7's increased agitation. A review of Staff Member #15's entry included a documented assessment of Patient #7 and the plan to initiate the administration of medication and soft limb bilateral wrist restraints. Staff Member #15 failed to order soft limb bilateral wrist restraints for Patient #7. Staff Member #10, in the presence of Staff Member #3, verified Staff Member #15 failed to write an order for Patient #7's soft limb bilateral wrist restraints.

A review of nursing documentation included monitoring Patient #7, who remained in soft limb bilateral wrist restraints, from 10:00 p.m. on January 28, 2019 through 4:26 p.m. on January 29, 2019. Patient #7 remained in soft limb bilateral wrist restraints for eighteen (18) hours and twenty-five (25) minutes without a documented physician's order for restraints.

Staff Member #3 and the surveyor reviewed the facility's policy titled "Restraints and Restraint Alternatives" revised "11/2018." The policy read in part: "B. Orders [:] The use of restraints must be ordered by a Licensed Independent Practitioner (LIP), unless the patient's RN [Registered Nurse] determines that the need to restrain the patient is critically justified and the LIP is not immediately available, in which case restraint procedures may be initiated. NOTE: In this instance, the LIP must be notified and a telephone or written order must be obtained within 4 hours ... 6. When restraint and/or seclusion is terminated and the behavior recurs, a new order must be obtained to reapply the restraints and/or seclusion ..."

During the end of the day briefing on January 30, 2019 at 4:05 p.m., the surveyor informed facility staff of the finding.

During an interview conducted on January 31, 2019 at 10:12 a.m., Staff Member #3 verified Patient #7's EMR did not contain a physician's order to reapply the soft limb bilateral wrist restraints on January 28, 2019.

Based on interview and document review, it was determined the facility staff failed to perform every two (2) hour monitoring for one (1) of five (5) restrained patients included in the survey sample. (Patient #8)

The finding included:

On January 31, 2019 a review of Patient #8's electronic medical record (EMR) with Staff Member #10 documented the patient was admitted to the facility on January 18, 2019. Staff Member #10 and the surveyor reviewed Patient #8's restraint orders, care plans and monitoring from January 25 through 31, 2019. The physicians' ordered soft limb bilateral wrist restraints for Patient #8 to deter the patient's removal of life-sustaining equipment.

A review of the nursing every two (2) hour restraint assessment and monitoring for Patient #8 did not reveal monitoring for:
January 27, 2019 for six (6) hours from 2:00 a.m. until 8:00 a.m.
January 27, 2019 for twelve (12) hours from 8:00 a.m. through 8:00 p.m. and
January 28, 2019 for four (4) hours from 4:00 a.m. through 8:00 a.m.

Staff Member #10 navigated Patient #8's EMR in order to determine the reasons why the nursing staff did not document every two (2) hours. Staff Member #10 verified Patient #8's EMR did not contain documentation the patient was off the unit for a procedure nor evidence the patient's restraints had been discontinued during the gaps of assessment/monitoring.

In the presence of Staff Member #10, the surveyor informed Staff Member #10 of the findings at 8:51 a.m., on January 31, 2019.

Staff Member #3 and the surveyor reviewed the facility's policy titled "Restraints and Restraint Alternatives" revised "11/2018." The policy read in part: "Medical Restraint: Non-Violent and/or Non-Self Destructive Behavior and Behavior and Behavioral Restraints: Violent and/or Self-Destructive Behavior [:] Documentation 1. The following must be documented in the EMR: ...e. Monitoring of the patient in restraints and seclusion: i. performed every 2 hours for medical restraints ..."

An interview conducted approximately at 11:38 a.m. on January 30 2019, Staff Member #3 verified the findings that nursing staff had failed to document the required every two (2) hour monitoring on January 27 and January, 28 2019.