HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 3 (Pt. #12) clinical records reviewed for non-violent restraints, the Hospital failed to ensure the restraints order was renewed as required by Hospital policy.

Findings include:

1. The Hospital's policy titled, "Restraints and/or Seclusion Use and Indications in the Acute Care Setting" dated 09/14/2020, was reviewed and included, "...11..If restraint or seclusion needs to continue beyond the expiration of the time ...obtain a new order from the licensed independent practitioner ...6. ...Nonviolent/Non self-destructive restraint orders are renewed daily... by a physician..."

2. On 04/14/2021 at approximately 1:00 PM, the clinical record of Pt. #12 was reviewed. Pt. #12 was admitted to the Hospital on 01/14/2021 with a diagnosis of Cerebral Vascular Accident (CVA/Stroke). Pt. #12's clinical record included a physician's order dated 01/16/2021 at 5:10 PM, for soft wrist restraints to both left and right wrists. Pt. #12 was placed in restraints from 01/16/2021 at 5:10 PM through 01/18/2021 at 12:06 AM. The physician's order for restraints expired on 01/17/2021 at 5:10 PM.

3. Pt. #12's clinical record lacked the documentation indicating the renewal of the patient restraints on 01/17/2021 at 5:10 PM. The total time lapsed while Pt. #12 remained on restraints without a physician's order was approximately seven (7) hours.

4. On 04/14/2021 at approximately 2:00 PM, the Clinical Practice Specialist (E #14) was interviewed. E #14 stated that, the physician's order for restraints should be renewed daily every 24 hours. The primary nurse failed to renew the restraints orders for Pt. #12. E #14 continued that there was no documentation indicating the order was renewed.