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NORTHWESTERN MEDICINE MCHENRY HOSPITAL
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0175
Based on document review and interview, it was determined that for 1 of 3 (Pt. #9) patients reviewed for violent restraints, the Hospital failed to ensure that patients in violent restraints were monitored every 15 minutes, as required.
Findings included:
1. The Hospital's policy titled, "Restraints and Seclusion" (12/06/2023) was reviewed on 7/24/2024 and required, "Individuals in violent restraints/seclusion are monitored ... Every 15 minutes for psychological/Behavioral status of the patient, Restraint status."
2. The clinical record for Pt. #9 was reviewed on 7/24/2024. Pt. #9 was admitted on 5/12/2024 with the diagnoses of COVID and dementia.
- An order, dated 5/14/2024 at 10:08 PM included, "Restraint type - Four Way Locking , reason - Danger to self and others."
- The restraint flow sheet included the restraints were applied on 5/14/2024 at 9:55 PM. The following assessments were completed: 5/14/2024 at 10:55 PM (60 minutes later), and 5/15/2024 at 1:32 AM (157 minutes later). The restraints were removed on 5/15/2024 at 1:54 AM.
3. During an interview on 7/24/2024 at 12:00 PM, the Nursing Director (E# 8) stated that there should be documentation of the every 15 minute monitoring for all violent restraint usage.