HospitalInspections.org

A. Based on review of Hospital policy, clinical record review and staff interview, it was determined that in 1 of 1 (Pt #3) clinical record reviewed of a patient with restraint devise, , the Hospital failed to ensure all patients had their care plan updated to include utilization of restraint devices.

Findings include:

1. Hospital policy # 15.05.01 entitled, "Restraints or Seclusion,"reviewed on 12/14/10 at approximately 10:00 AM required, "...1.4 The use of restraints or seclusion must be: a. in accordance with a written modification to the patient's plan of care."

2. The clinical record of Pt #3 was reviewed on survey date 12/14/10 at approximately 10:00 AM. Pt #3 was a 76 year old female admitted on 10/21/10 with a diagnosis of Lung Carcinoma. The clinical record indicated that Pt #3 had bilateral soft wrist restraints applied from 10/23/10 to 10/28/10 and 11/1/10 to 11/3/10. The patient's plan of care was not updated to include the use of the restraint devices.

3. The findings were verified by the Nurse Manager of Critical Care during an interview on 12/14/10 at approximately 10:15 AM.