HospitalInspections.org

Based on a medical record review and interview, it was determined that facility staff failed to ensure that restraints were documented in the plan of care for four (4) of five (5) patients sampled (Patient #1, 5, 7, 15).

Findings included:

A surveyor review of clinical records was conducted on 3/26/19 with the assistance of Staff Members (SM's) #3 and #35, navigators provided by the hospital.

A record review was conducted for Patient #1, admitted as a transfer from another acute care hospital on 3/24/19, with diagnoses including but not limited to, mucosal bleeding, Systemic lupus erythematosus (SLE), pancytopenia, chronic kidney disease (CKD), and platelet count less than three (3).

A physician order dated 3/25/19 at 4:00 p.m. for non-violent restraints, "Mitts" to "both wrists" for "pulling out/at lines or tubes" was noted in the record. The plan of care included "Impaired gas exchange" and "Impaired Patient/Family Coping"; however, restraints were not included on the plan of care for Patient #1.

A discussion was held with Staff Member (SM) #3, chart navigator, on 3/26/19 at 10:00 a.m. related to restraints not included in the plan of care documentation. SM #3 stated "Our health system policy on plan of care is that we look at the entire health record as the plan of care. Restraints are documented in the record. They (staff) do a hand off to pass along information so that oncoming staff don't have to review the entire record. Information like restraints is passed on during the hand off report".

SM #38, the Nursing Director of Patient Safety, was interviewed on 3/27/19 at 2:40 p.m. related to restraint documentation on the plan of care, and the entire medical record as used as a plan of care. SM #38 stated: "The whole record is the plan of care, but in response to restraints, they should be included on the plan of care. Restraints should be on the electronic plan of care, that's where I should expect to see it-specifically from restraint point of view; it (restraint) should be included in the electronic plan of care. We have had issues with what the plan of care is, we don't want staff to say the plan was only in the plan of care".

A review of the medical record was conducted for Patient #7, admitted to the facility 1/27/19, with diagnoses including but not limited to, shortness of breath, weakness, swelling for one (1) week, diabetes, cardiomyopathy, bundle branch block, pacemaker, and history of lunch cancer.

The record review revealed an order for non-violent restraint "Mitts" "both wrists" due to "pulling out/at lines or tubes" dated 2/4/19 at 9:34 a.m. The plan of care documented problems of "Discharge planning care, Self-Care deficit, impaired mobility, and altered metal status"; however, restraints were not included on the plan of care.
A review of the medical record for Patient #5 provided evidence of the application of non-violent bilateral upper extremity restraints on 3/25/19 at 5:24 p.m.. Patient #5 remained in bilateral restraints at the time of the survey. A review of the clinical record for Patient #5 failed to provide evidence of restraint use included in the plan of care.

A review of the medical record for Patient #15 provided evidence of the application of mitten restraints on 3/25/19 at 8:38 a.m. Patient #15 remained in mitten restraints at the time of the survey. A review of the plan of care for Patient #15 failed to provide evidence of a modification to the plan of care related to the use of restraints.

Hospital Policy "Restraint and Seclusion" effective date: 2/5/2018 read in part the following: "Policy E. Restraints and seclusion are only used in accordance with written modifications to the patient's plan of care." "9.1. The use of restraints is documented in the medical record and includes the following information: ...8. Revisions to the plan of care".

Discussions related to restraint documentation on the plan of care were discussed as noted above, and again with members of management on 3/27/19 between 3:30 p.m. and 4:00 p.m. prior to exit. No further evidence was provided to the survey team.