HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 5 patients (Pt. #7) in the Emergency Department (ED) in restraints, the Hospital failed to ensure restraints were removed at the earliest possible time.

Findings include:

1. On 8/24/2021, the Hospital's policy tiled, "Restraint Usage for Non-Behavioral Inpatient Units," effective March 2019, was reviewed. The policy required, "III. Procedure/ Process...A. Orders for all restraint(s) whether non-violent or violent use should be as follows... j. Restraints must be discontinued at the earliest possible time, regardless of the length of time in the order..."

2. On 8/24/2021, Pt. #7's clinical record was reviwed. Pt. #7 was examined in the ED on 8/7/2021 with a complaint of "bizarre behavior". A nursing note on 8/7/2021 at 1:42 PM, included that Pt. #7 attempted elopement, was fighting with security resulting in a security guard receiving a "blunt head injury". A Physician's order for violent restraints (bilateral arms and legs) for 4 hours was written at 1:34 PM. Fifteen minute checks of Pt. #7 between 2:20 PM and release from restraints at 5:00 PM, over 2 1/2 hours, indicated Pt. #7 was "asleep" not requiring restraints.

3. On 8/25/2021 at 8:30 AM, an interview was conduced with the Chief Nursing Officer (E #1). E #1 stated that Pt. #7's record did not indicate that Pt. #7 needed restraints between 2:20 PM and 5:00 PM, and this finding was an "opportunity for improvement".