HospitalInspections.org

I. Based on document review and staff interview, the hospital's administrative staff failed to ensure a Licensed Independent Practitioner (LIP) wrote an order prior to the nursing staff initiating restraints for non-violent or non self-destructive behavior for 1 of 2 patients (Patient #2) reviewed. Failure to ensure the LIP wrote an order prior to the nursing staff initiating restraints may result in patients being restrained unnecessarily which could potentially put them at risk for injury. The hospital identified a census of 173 medical/surgical patients on entrance.

Findings include:

1. Review of the policy "Restraint/Seclusion Management," effective November 2019, revealed in part, "An order must be obtained within 8 hours for all restraints [non-violent or non self-destructive.]"

2. Review of Patient #2's medical record revealed the hospital staff admitted Patient #2 on 12/07/19 with a diagnosis of hemorrhagic cystitis (inflammation of the bladder that can cause bleeding). On 12/07/19 at 8:15 AM, RN C initiated soft upper extremity restraints for interference with medical treatment/devices. On 12/09/19 at 10:40 AM, RN C documented a verbal order for initiating the restraints on 12/7/19 from Physician D (almost two days after RN C initiated the restraints on Patient #2).

3. During an interview on 12/19/19 at 1:25 PM, the Director of Clinical Informatics confirmed the nursing staff did not document the order for restraints for over 2 days, while the nursing staff had Patient #2 in soft upper extremity restraints for non-violent or non self-destructive behavior.




II. Based on document review and staff interview the hospital's administrative staff failed to ensure a Licensed Independent Practitioner (LIP) signed a verbal order within 24 hours for 2 of 2 patients (Patient #1 and Patient #2) who were placed in a restraints due to non-violent or non-self destructive behavior. Failure to ensure a LIP signed a verbal order for patients requiring restraints may result in patients being restrained unnecessarily which could potentially put them at risk for injury. The hospital identified a census of 173 medical/surgical patients on entrance.

Findings include:

1. Review of the policy "Restraint/Seclusion Management," effective November 2019, revealed in part, "In emergencies, a telephone order may be obtained and is entered into the patient's medical records ... and must be signed within 24 hours."

2. Review of Patient #1's medical record revealed Patient #1 was admitted on 12/15/19 with a diagnosis of pneumonia. On 12/15/19 at 12:45 PM, RN A documented a verbal order from Physician B for mitten restraints for Patient #1 due to interference with medical treatments/devices. Review of medical record on 12/19/19 at 1:25 PM (over 4 days later) revealed Physician B had not signed the verbal order.

3. Review of Patient #2's medical record revealed Patient #2 was admitted on 12/07/19 with a diagnosis of hemorrhagic cystitis (inflammation of the bladder that can cause bleeding). On 12/09/19 at 10:40 AM, RN C documented a verbal order from Physician D for soft upper extremity restraints due to interference with medical treatments/devices. On 12/14/19 at 7:12 AM, approximately five days later, Physician E signed the verbal order.

4. During an interview on 12/19/19 at 1:25 PM, the Director of Clinical Informatics confirmed the verbal orders for restraints due to non-violent or non self-destructive behavior had not been signed within 24 hours as required by policy.

Based on document review and staff interview, the hospital's administrative staff failed to ensure the attending physician (Physician I) was notified when an order was written by another Licensed Independent Practitioner (LIP) to place 1 of 1 patients, attended by Physician I, in restraints (Patient #3). Failure to ensure the attending physician was notified may result in patients being restrained unnecessarily or inappropriately because the physician primarily responsible for the patient's care may have information regarding the patient's history that may have a significant impact on the selection of a restraint or alternative interventions. The hospital identified a census of 173 medical/surgical patients on entrance.

Findings include:

1. Review of the policy "Restraint/Seclusion Management," effective November 2019, revealed in part, "All orders must be given by a Licensed Independent Practitioner (LIP) ... If the restraint order is given by a physician other than the attending, the attending physician must be consulted as soon as possible."

2. Review of Patient #3's medical record revealed Patient #3 was admitted on 11/22/19 with a diagnosis of C. difficile colitis (an infection of the bowel.) On 11/24/19 at 12:11 AM Advanced Registered Nurse Practitioner (ARNP) F wrote an order for soft lower extremity restraints for Patient #3 due to Patient #3's inability to follow directions and assist with care. Review of the medical record on 12/19/19 revealed the documentation lacked any evidence the nursing staff or ARNP F notified Physician I that the nursing staff placed Patient #3 in restraints.

3. During an interview on 12/19/19 at 1:25 PM, the Director of Clinical Informatics confirmed the medical record did not contain documentation that ARNP F or the nursing staff had notified Patient #3's attending physician, Physician I, of the need for restraints.

Based on document review and staff interview, the hospital's administrative staff failed to ensure an order was written by a Licensed Independent Practitioner (LIP) every 24 hours for 2 of 2 patients (Patient #2 and Patient #4) placed in restraints for non-violent or non-self-destructive behavior. Failure to ensure that an order was written every 24 hours may result in patients being restrained unnecessarily which could potentially put them at risk for injury. The hospital identified a census of 173 medical/surgical patients on entrance.

Findings include:

1. Review of the policy "Restraint/Seclusion Management," effective November 2019, revealed in part, "Continued use of restraint beyond the first 24 hours is authorized by a licensed independent practitioner renewing the original order or issuing a new order if restraint use continues to be clinically justified. Such renewal or new order is issued every 24 hours ..."

2. Review of Patient #2's medical record revealed Patient #2 was admitted on 12/07/19 with a diagnosis of hemorrhagic cystitis (inflammation of the bladder that can cause bleeding.) On 12/07/19 at 8:15 AM, RN C initiated soft upper extremity restraints for Patient #2 due to interference with medical treatment/devices. On 12/09/19 at 10:40 AM, RN C documented a verbal order for restraints from Physician D. The medical record lacked documentation of restraints orders on 12/07/19 or 12/08/19.

3. Review of Patient #4's medical record revealed Patient #4 was admitted on 11/24/19 for increasing confusion. On 11/27/19 at 7:40 AM, RN H documented a verbal order from Physician G to apply soft upper extremity restraints to Patient #4 due to interference with medical treatment/devices. On 11/28/19 at 8:04 PM (more than 24 hours later) Physician G wrote an order to continue the restraints.

4. During an interview on 12/19/19 at 1:25 PM, the Director of Clinical Informatics confirmed the medical records for Patient #2 and Patient #4 lacked orders every 24 hours for restraints due to non-violent or non self-destructive behavior.