HospitalInspections.org

Based on medical record review, policy review and interview, the facility failed to ensure the use of restraints was in accordance with a physician's order for one of four medical records reviewed for restraints (Patient #2). The facility's census was 1098.

Findings include:

Review of the facility policy titled, Restraint Use Procedure for Non-Violent/Non-Self-Destructive Behavior (NVNSD) (Version 5, Effective 11/01/22) revealed if alternatives are unsuccessful, immediately notify the physician/licensed independent practitioner (LIP) who is primarily responsible for the patient and obtain and enter a verbal order, or the physician/LIP will enter the order for the restraint. Apply the least restrictive restraint. In an emergent situation, apply the least restrictive restraint. Immediately notify the physician/LIP who is primarily responsible for the patient and enter a verbal order. The need for restraint intervention may occur so quickly that an order cannot be obtained prior to the application of restraints. In these emergency application situations, the order must be obtained either during the emergency application of the restraint, or immediately after the restraint is applied.

Review of Patient #2's medical record revealed the patient was placed in restraints on 01/11/24 at 8:00 PM. The medical record for Patient #2 did not contain an order for restraints until 01/12/24 at 2:22 AM.

The findings were shared with Staff A in an interview on 02/05/24 at 9:46 AM and confirmed.