HospitalInspections.org

Based on medical record review the hospital failed, for one (Patient #5) of ten patients sampled, to perform and/or appropriately document two restraint assessments while Patient #5 was in active 2-point soft restraints, in accordance with hospital policy.

Findings include:

The hospital policy titled "CO 9.805 - Medical Surgical Use of Restraints," under section IIIC. Care of Restrained Patients, Assessment, "Application and monitoring of the restraint will be conducted by trained personnel. The nurse will conduct the assessment of ongoing need for and response to the restraint. The ongoing assessment includes the following:

1. Patient's need for nutrition, fluids, toileting, mobility, skin care and comfort every 2 hours.
2. Circulation to the restrained limb every 2 hours.
3. Complications of immobility and cardio-pulmonary system every 2 hours.
4. Patient's response to restraints every 2 hours.
5. Need for continued restraint every 2 hours."

Medical record review of Patient #5 indicated that there were two missing restraint assessments during Patient #5's active 2-point soft restraint period. The medical record indicated that an 11/02/2023 @12:00 A.M. restraint assessment was missed and an 11/03/2023 @6:00 A.M. restraint assessment was missed.