HospitalInspections.org

Based on observation, interview, review of Hospital documentation, and review of Hospital policy for 5 of 11 patients (Patients #1, #2, #3, #7, and #10) sampled for restraints, the Hospital failed to identify specific behaviors in the physician's order to necessitate the use of restraints. The findings include:


a. Patient #1 was admitted on 1/25/20 with diagnoses that included schizophrenia and atrial fibrillation. Review of the clinical record identified Patient #1 had a pacemaker implanted on 2/6/20 and had noted delirium.

The nurse's note dated 2/9/20 at 11:03 AM identified Patient #1 was very impulsive, did not retain information, and needed constant reorientation. The nurse's note identified attempts to redirect Patient #1 were unsuccessful and Patient #1 had made multiple attempts to get out of bed and was extremely unsteady and weak.

The physician's order dated 2/9/20 at 2:17 PM directed to place patient in a SOMA bed (an enclosed bed) because the patient is unwilling/unable to follow commands. The physician's order failed to identify behaviors requiring use of a restraint.

Review of the clinical record identified the SOMA bed was discontinued on 2/13/20.

The physician's order dated 2/14/20 at 9:15 AM directed to place Patient #1 in a SOMA bed for delirium. The physician's order failed to identify specific patient behaviors that would require the patient to be restrained in a SOMA bed.

The nurses note dated 2/14/20 at 5:52 PM identified Patient #1 was attempting to get out of bed multiples times and unable to redirect.

Interview with PA #1 on 3/3/20 at 10:20 AM identified on 2/14/19 Patient #1 was experiencing delirium and she observed Patient #1 climbing out of bed that morning, was unable to redirect Patient #1, and ordered a SOMA bed for patient safety.

Interview with Manager #1 on 3/4/20 at 1:00 PM identified it was unsafe for Patient #1 to get out of bed because he/she recently had surgery, IV lines, telemetry wires, an indwelling catheter, was very unsteady on his/her feet, impulsive and made frequent attempts to get out of bed. Manager #1 identified attempts to redirect Patient #1 to stay in bed were unsuccessful, and attempts to increase supervision were not effective. Manager #1 identified when Patient #1 did get out of bed he/she was very difficult to redirect back into bed, and at times would require multiple staff to direct back into bed.

The Restraint and Seclusion Policy dated 3/14/18 identified restraints are driven by patient behaviors. The policy directed that documentation in the medical record for restraint orders included the rationale for the restraint, the type of restraint, the extremity or body parts to be restrained and the duration for restraint application.



b. Patient #2 was admitted on 2/27/20 with diagnosis that included encephalopathy and alcohol withdrawal.

The physician's order dated 3/1/20 at 8:00 AM directed to place Patient #2 in a SOMA bed because Patient #2 was unwilling/unable to follow commands and was at serious risk for injury. The physician's order failed to identify behaviors requiring use of a restraint.

The nurse's note dated 3/1/20 at 12:56 PM identified Patient #2 made frequent attempts to climb out of bed and was unable to be redirected, bed alarm on.



c. Patient #3 was admitted on 3/1/20 with hypoxemic respiratory failure and required intubation and mechanical ventilation. The nurses note dated 3/2/20 at 4:00 AM identified the patient was lethargic, with bilateral wrist restraints on for safety.

The physician's order dated 3/2/20 at 4:05 AM directed to apply right and left wrist restraints because Patient #3 was unwilling/unable to follow commands and life preserving equipment was being protected. The physician's order failed to identify behaviors requiring use of a restraint.

Review of the restraint flowsheet dated 3/2/20 at 4:00 AM identified the clinical justification for restraints was at risk for injury. The flowsheet failed to identify specific behaviors that required the use of bilateral wrist restraints.

Interview with Assistant Manager #1 on 3/3/20 at 1:15 PM identified Patient #3 had multiple IV's, was intubated, on a ventilator, was no longer on sedation, and had attempted to pull at lines and equipment.

Interview with Manager #2 on 3/3/20 at 1:15 PM identified the clinical justification (behaviors) of the patient necessitating the use of medical restraints should be documented on the restraint flowsheet upon initiation of the restraint and every 4 hours while the restraint is in use.

The Restraint and Seclusion Policy dated 3/14/18 directed that monitoring, assessment and reassessment of the patient are to be documented in the medical record including criteria used for continuation and discontinuation of the restraint.



d. Patient #7 was admitted on 3/2/20 with diagnosis that included dementia and angioedema.

The physician's order dated 3/2/20 at 6:21 PM directed to restrain Patient #7 with roll belt (waist restraint that allows for greater movement in the bed) because Patient #7 is unwilling/unable to follow commands and is at serious risk for injury. The physician's order did not identify specific behaviors requiring the use of a restraint.

The nurse's note dated 3/2/20 identified the patient was in roll belt for safety as Patient #7 was impulsive when he/she wakes and attempts to get out of bed. Observation on 3/3/20 at 11:30 AM identified Patient #7 was out of bed to a chair in his/her room.

Interview with RN #1 on 3/3/20 at the time of the observation (11:30 AM) identified Patient #7 made multiple attempts to get out of bed overnight and the roll belt was in place to prevent Patient #7 from getting out of bed. RN #1 identified Patient #7 had not made any recent attempts to get out of bed, so after morning care they put Patient #7 in the recliner chair and he/she had not made any further attempts to get out of bed.



e. Patient #10 was admitted on 1/3/20 with diagnosis that included Parkinson's disease and colitis.

The physician's order dated 1/5/20 at 6:40 PM directed to place Patient #10 in a SOMA bed because Patient #10 was unwilling/unable to follow commands and Patient #10 was at risk for injury. The physician's order did not identify specific behaviors requiring the use of a restraint.

The nurse's note dated 1/5/20 at 7:47 PM identified Patient #10 was given Xanax and it had caused increased confusion, and Patient #10 was jumping out of bed and a SOMA bed was ordered for safety.

Interview with Quality Manager #1 on 3/4/20 at 11:00 AM identified the use of restraints is based on patient behaviors. He identified when physician orders for restraints are entered into the computer there is a drop down box with limited options for behaviors without the ability to free text specific behaviors.

Based on observation, review of Hospital documentation, interview, review of Hospital policy for 1 of 11 patients (Patient #3) sampled for restraints, the Hospital failed to document patient behaviors for the clinical justification of restraint use per facility policy. The finding includes:


a. Patient #3 was admitted on 3/1/20 with hypoxemic respiratory failure and required intubation and mechanical ventilation. The nurses note dated 3/2/20 at 4:00 AM identified the patient was lethargic, with bilateral wrist restraints on for safety.

The physician's order dated 3/2/20 at 4:05 AM directed to apply right and left wrist restraints because Patient #3 was unwilling/unable to follow commands and life preserving equipment was being protected.

Review of the restraint flowsheet dated 3/2/20 at 4:00 AM identified the clinical justification for restraints was at risk for injury. The flowsheet failed to identify specific behaviors that required the use of bilateral wrist restraints.

Interview with Assistant Manager #1 on 3/3/20 at 1:15 PM identified Patient #3 had multiple IV's, was intubated, on a ventilator, was no longer on sedation, and had attempted to pull at lines and equipment.

Interview with Manager #2 on 3/3/20 at 1:15 PM identified the clinical justification (behaviors) of the patient necessitating the use of medical restraints should be documented on the restraint flowsheet upon initiation of the restraint and every 4 hours while the restraint is in use.

The Restraint and Seclusion Policy dated 3/14/18 identified restraints are driven by patient behaviors. The policy directed that monitoring, assessment and reassessment of the patient are to be documented in the medical record including criteria used for continuation and discontinuation of the restraint.