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ST MARY'S REGIONAL MEDICAL CENTER
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0208
Based on document reviews and interviews, the hospital failed to ensure staff completed restraint training and the documentation was contained in the staff member's personnel record for two (2) of eleven (11) staff reviewed who had been involved in a patient restraint (Registered Nurse #1 and Medical Doctor #1).
Findings:
The hospitals "Restraint and Seclusion" policy, last revised 10/2021, states in part, "Physicians and other LIP's authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint and seclusion...Staff providing care for patients in restraints must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion before performing any of the actions specified in this paragraph; as part of orientation; and subsequently on an annual basis".
1. Registered Nurse ("RN") #1 was involved in the care of the following patient who was restrained:
- Patient 2R was in restraints on 7/19/2022 from 10:33 PM through 2:00 AM and on 7/20/2022 at 9:34 PM through 7/22/2022 at 9:25 PM.
The surveyor requested to review RN #1's training records.
As of 8/12/2022, there was no evidence provided to the surveyor that indicated RN #1 had completed training on restraints that is required per hospital policy.
2. Medical Doctor ("MD") #1 was involved in the care of the following patient who was restrained:
- Patient 2R had orders to be in restraints on 7/18/2022 from 3:45 AM through 9:45 AM; 7/19/2022 from 10:33 PM through 2:00 AM; and on 7/20/2022 at 9:34 PM through 7/22/2022 at 9:25 PM.
The surveyor requested to review MD #1's training records.
As of 8/12/2022, there was no evidence provided to the surveyor that indicated MD #1 had completed any training on restraints.
On 8/12/2022 at 10:07 AM, the Director of Quality confirmed that MD #1 did not have the training on restraints, per hospital policy.
On 8/12/2022 at 11:30 AM, the Vice President of Patient Care Services/Chief Nursing Officer was asked to confirm that RN #1 had not completed training on restraints that is required per hospital policy, but she declined.