HospitalInspections.org

Based on review of facility documentation, medical records (MR), and staff interview (EMP)it was determined the facility failed to use restraints in accordance with the order of a physician for MR1 and failed to identify the type of restraint ordered for MR14 out of seven restraint records reviewed.

Findings include:

A review on August 16, 2016, of Holy Spirit Hospital policy entitled, "Violent/Self-Destructive Restraint Use" last reviewed, June 2016 revealed, " ... The provider ... must give authorization to initiate seclusion or restraint ... as soon as possible following the restraint ... "

A review on August 16, 2016, of the Holy Spirit Hospital policy entitled "Non Violent/ Non Self-Destructive restraint Use" last reviewed, June 2016 revealed, " ... Physician order 1. Type of restraint ( i.e. soft, locked) ... "

1) A review on August 16, 2016 of MR1 revealed the patient was admitted to the emergency department on June 29, 2016, had self-inflicted neck and right and left wrist wounds and was placed in four point restraint. The last order for four point restraint use was June 29, 2016, at 9:43 AM. MR1 was transferred to the Surgical Care Intensive Unit (SICU) on June 29, 2016, at 12:30 PM. Review of nursing documentation revealed the patient remained in four point restraint from 5:35 AM while in the emergency department, was transported to the SICU in restraint and remained in restraint until June 30, 2016, at 6:00 AM. The order for four point restraint expired on June 29, 2016, at 13:43 PM and was not renewed until 18:44 PM.

An interview conducted on August 17, 2016, at 8:45 AM with EMP1 confirmed that there were no orders for restraint use for MR1 while on the SICU on June 29, 2016, at 12:30 PM until 18:44 PM.

2) A review on August 17, 2016, of MR14 revealed "ED Initial Violent Restraints/Seclusion Order Sheet" form, dated June 27, 2016, had no check mark for the "Type of restriction..."." There was no documentation in the order to indicate if restraints or seclusion were to be used. Further review of MR14 revealed the patient was placed in seclusion at 7:08 AM until 11:08 when the order was renewed.

An interview conducted on August 17, 2016, at 8:55 AM with EMP1 confirmed that there was no check mark for the "Type of restriction" for MR14 and the order did not indicate if restraints or seclusion was to be used.