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Based on clinical record review and interview, it was determined the facility failed to ensure the restraint application, assessment and monitoring was reflected on the patient's care plan for one (#4) of three (#4, #21 and #22) patients in restraints. This failed practice had the potential for lack of communication of nursing personnel regarding the patient's care needs. The failed practice had the potential to affect all patients in restraints.

A. Review of the care plan for patient #4 revealed a lack of reference to time the restraint was initiated, the reason for restraint use, or assessment and monitoring of the patient while in restraints.

B. Interview with the Director of Medical Review at 0830 on 01/19/11 confirmed the failure to care plan Patient #4's restraints.

Based on policy review, clinical record review and interview, it was determined the facility failed to ensure a physician's order for three (#4, #21 and #22) of three patients reviewed in restraints, during the entire time the patient was in restraints. The failed practice had the potential to restrain patients without a medical need. This failed practice had the potential to affect all patients in restraints. Evidence follows:

A. Review of the Medical Restraint Policy, revised 12/07, revealed a physician's order was required when a patient was restrained.

B Review of the clinical record for Patient #4 revealed the following:
1) Physician's Orders lacked an order for restraints.
2) Review of the Narrative Nurse's Notes at 0500 on 12/07/10, revealed soft wrist restraints were applied. At 0655 on 12/07/10, the restraints were released for five minutes and reapplied.
3) Review of all nursing documentation in the clinical record failed to reveal any other reference to the restraints, including any documentation the restraints were discontinued.

C. Interview with the Director of Medical Review at 0830 on 01/19/11 confirmed the physician did not order restraints and the clinical record revealed the patient was in restraints from 0500 on 12/07/10 and there was no documentation in the clinical record that the restraints were discontinued after application at 0655 on 12/07/10.

D. Review of the clinical record for Patient #21 revealed the following:
1) Physician's Orders contained a 24-hour time limited order for bilateral soft wrist restraints signed by the physician at 1700 on 01/15/11. The next two 24-hour time limited orders were for bilateral soft wrist restraints and side rails up x 4, and both were signed by the physician at the same time at 0800 on 01/18/11. The final restraint order in the clinical record was a 24-hour time limited order for bilateral soft wrist restraints and was not signed by the physician as of 1100 on 01/19/11.
2) Review of the Treatment Documentation on the Nursing Flow Sheets for 01/15 through 01/19/11 revealed the patient was in restraints from 2400 on 01/14/11 through 0800 on 01/19/11. The patient was in restraints from 2400 on 01/14/11 through 1659 on 01/15/11 without a physician's order and from 1659 on 01/16/11 through 0800 on 01/19/11 without a physician's order.

E. Review of the clinical record for Patient #22 revealed the following:
1) Physician's Orders lacked a signed physician's order for restraints until 0800 on 01/18/11. At that time, the physician ordered soft bilateral wrist restraints for 24 hours. The Physician's Orders contained a 24-hour time limited order for bilateral soft wrist restraints on 01/19/11, but there was no time documented, so it could not be determined when the physician wrote the order.
2) Review of the Treatment Documentation on the Nursing Flow Sheets for 01/17 through 01/19/11 revealed the patient was in restraints from 1400 on 01/17/11 through 2300 on 01/17/11; from 0000 on 01/18/11 through 0800 on 01/19/11. The patient was in restraints without a physician's order from 1400 on 01/17/10 until 0800 on 01/18/11.

F. The Director of Medical Review during interview at 1135 on 01/19/11 confirmed the above (D and E).

Based on clinical record review, policy review and interview, it was determined the facility failed to ensure one (#4) of three patients (#4, #21 and #22) in restraints was monitored and assessed per facility policy while in restraints. This failed practice had the potential for the patient's needs not to be met while in restraints. The failed practice had the potential to affect all patients in restraints. Evidence follows:

A. Review of the Medical Restraint Policy, revised 12/07, revealed documentation must show evidence visual observation of the patient at least every hour with positioning for comfort and proper application of restraint. The policy required evidence of physical assessment of the patient at least every two hours. The observations and assessments
were to be documented on the Non-Violent/Non-Self Destructive Restraint Assessment and Documentation Form.

B. Review of the Non-Violent/Non-Self Destructive Restraint Assessment and Documentation Form in the clinical record for Patient #4 revealed a failure to observe and reposition the patient for comfort every hour and failure to asses the patient every two hours.

C. Interview with the Director of Medical Review at 0830 on 01/19/11 confirmed hourly monitoring and every two hour interventions were not documented as required by facility policy for Patient #4.

D. Review of the clinical record for Patient #21 revealed the following:
1) Review of the Treatment Documentation on the Nursing Flow Sheets for 01/15 through 01/19/11 revealed the patient was in restraints from 2400 on 01/14/11 through 0800 on 01/19/11.
2) Review of patient monitoring on the Non-Violent/Non-Self Destructive Restraint Assessment and Documentation Form in the clinical record revealed a lack of evidence the patient was monitored while in restraints from 0700 on 01/15/11 through 1915 on 01/17/11 and from 0000 on 01/19/11 until the restraints were discontinued at 0800 on 01/19/11.

E. Interview with the Director of Medical Review at 1135 on 01/19/11 confirmed hourly monitoring and every two hour interventions were not documented as required by facility policy for Patient #21.

Based on policy review, clinical record review and interview, it was determined the facility failed to ensure, per their policy, restraints were used only after less effective measures had failed for one patient (#4) of three patients (#4, #21 and #22) reviewed in restraints. This failed practice had the potential for patients that did not require restraints to be restrained. The failed practice had the potential to affect all patients in restraints. Evidence follows:

A. Review of the Medical Restraint Policy, revised 12/07, revealed a Registered Nurse (RN) was to determine that alternative measures did not successfully modify the reasons for which the restraint was applied.

B. Review of the clinical record for Patient #4 revealed a lack of documentation to show that alternative methods were unsuccessful to prevent the need for restraint.

C. The Director of Medical Review confirmed the above during interview at 0830 on 01/19/11.