HospitalInspections.org

Based on a review of the Hospital Policy for Restraint Use - Chronic Hospital Only (revised 7/13), and the medical records of patients #4, #11, and #13, it was revealed that the hospital allows Licensed Practical Nurses (LPN) to conduct initial, ongoing and discontinuation assessments of patients placed in non-violent restraints.
Hospital Policy for Restraint Use revealed in part under " Assessment and Reassessment, b. Prior to restraint use, the nurse assesses patient behaviors every shift and documents in the progress notes the alternative methods used to address those behaviors. c. When a restraint is applied, the nurse immediately initiates the 24-hour Restraint Monitoring Flow Sheet. Either RN or LPN may reassess the patient ... " These policy statements authorize LPN's to reassess patients in restraint which would include assessing for the discontinuation of restraints. However, in practice, LPN's are also initiating restraints.

Patient #4, was female in her nineties who in the second week of August 2016 became agitated. A " Restraint Nonviolent Form " revealed that an LPN initiated the waist restraint and conducted assessments for the next 3.5 hours. Additionally, multiple other reassessments of the waist restraint were conducted by an LPN over the course of two days.


Patient #11 was an elder female who at the beginning of October from 0136 to 0710 was restrained in a waist belt. The initiation of the restraint as well as reassessments were conducted by an LPN.

Patient #13 was an adult male who in late September 2016 was restrained in a waist belt at 1000. An LPN note indicated that the patient was unable to follow direction, and continued to push himself out of the chair. An LPN initiated the restraint, and made continuing assessments on patient #13.


Based the review of these records , the hospital failed to provide a safe, appropriate restraint process when it failed to utilize an RN for the initiation and ongoing restraint assessments, to monitor care and assess for the discontinuation of restraint.

Based on a review of hospital policy, The Code of Maryland Regulations 10.21.12.09 and patient #13 ' s record, it is revealed that for a non-violent restraint episode, an order to continue the restraint was not renewed per policy or regulation for a 24-hour order limitation.

Review of Hospital policy " Restraint Use - Chronic Hospital Only " (revised 7/13) revealed in part, " ...orders are reviewed at least every 24-hours. "

The Code of Maryland Regulations 10.21.12.09 Limitations on Restraint and Continuous Restraint, revealed in part, " B. A physician may write an order for restraint for a period of up to, but not more than, 24 hours. "

Patient #13 was an elder male admitted to the hospital in late September 2016 with an altered mental status. Patient #13 had periods of agitation and on day 7 of admission, was placed in a chair with a waist restraint at 10am. An order of 0954 appears in the record.

A new order to continue the waist belt for patient #13 was received the following day at 1157 which was approximately two hours after the 24-hour limitation of the initial order. Therefore, the hospital failed to follow policy and regulation for restraint orders limited to 24-hours.

Based on a review of, 11 open and 2 closed records, it was determined that 1) for patients #4, #5, #6, #11 and #14, who required two physician incapacity statements signed within two hours, no times of the evaluations were documented; 2) and for patient #13, incapacity statements by two physicians were signed two days apart, on 9/17 and 9/19/2016.
Review of patients #4, #5, #6, #11 and #14, who all required two physician ' s incapacity statements signed within two hours of examination, found no times entered on the capacity statements.
Review of patient #13's capacity statements who required two physician incapacity statements signed within two hours of examination, found signatures two days apart on 9/17 and 9/19/2016. Based on this the hospital failed to meet requirements for the patient right to make informed decisions regarding care.