HospitalInspections.org

Based on review of facility policies and documents, review of medical records (MR), and interviews with staff, it was determined the hospital failed to properly monitor the condition of restrained patients for 1 of 2 patients (Patient # 1) sampled that were restrained. Findings include:

Review of facility policy "Seclusion and Restraint" effective January 2018 and reviewed March 2024, revealed, "Assessment and monitoring...The RN [registered nurse] is responsible for assessment of the individual in restraint or seclusion...The RN or LVN/LPN [licensed vocational/practical nurse] will document...behavior and physical status of patient every (5) minutes..."

A review of "Seclusion & Restraint/Emergency Medication Documentation" in the MR of Patient #1, dated 8/25/2024, revealed the patient was restrained with a physical hold on 8/25/24 from 8:00 PM to 8:36 PM. The document stated, "...Documentation must occur every 5 minutes, or more frequently as appropriate to the patient's physical, emotional, and safety needs; or as the patient condition changes ..." There was no evidence that the patient's behavior or physical status or that the patient's physical, emotional, and safety needs were assessed during the entire length of the restraint period.

During an interview on 8/30/24 at 1:41 PM, Employee # 1 confirmed there was no evidence that the patient's behavior or physical status or that the patient's physical, emotional, and safety needs were assessed during the entire length of the restraint period.