HospitalInspections.org

Based on record review and staff interview, the facility failed to ensure education and working knowledge of the facility restraint process (in accordance with the hospital policy) for all practitioners credentialed and approved to order restraints. Ten patients were identified by facility quality staff as needing medical restraint use in the preceding quarter and two of those patients were placed on the sample.

FINDINGS ARE:

A. A review of the facility restraint re-training policy #4517843 for practitioners ordering restraints revealed that the facility plan was to provide practitioner renewal of restraint knowledge at the facility Medical Staff annual meeting which was held yearly in February. However, interview with the Chief Medical Officer (CMO), Chief Nursing Officer (CNO) and the Medical Staff Coordinator (MSC) on 4/2/18 at 10:50am revealed this practice had not been completed and no records were available in the minutes or newsletters from the preceding year. CNO further stated "we do not have a current process in place for the "Physician attestation of restraints."

B. At 11:43am on 4/2/18 a copy of the updated Restraint policy (4517843 effective January 2018) was sent by the MSC to all credentialed practitioners in an email on 3/9/18. This email was noted as "high importance" titled "Restraint Management in Acute Care". THE CNO stated "we identified this omission during our mock survey and we sent out this email with the new policy attached but we do not have a confirmation of receipt or verification by each practitioner at this time."

C. Practitioners A, B and C were identified by facility CNO as ordering restraints for sampled patients in the preceding month, however no confirmation of provider restraint training was available/attested to for Practitioners A, B and C.

D. An Interview on 4/2/18 at 2:10 pm with THE MSC noted the facility has over 800 credentialed medical practitioners including Active, Courtesy and Consulting categories. Per the MSC interview "Moving forward the facility plan would be to complete an Attestation of Restraint Education during the Credentialing process every two years".

E. A Review of Hospital Policy #4517843- Restraint Usage: Paragraph G stated: "appropriately credentialed practitioners i.e., Physicians and APRNs (Advance Practice Registered Nurse) who are educated and have a working knowledge of the hospital policy regarding the use of restraint and seclusion may order restraints and they must sign an attestation on initial appointment and every two years at reappointment."