HospitalInspections.org

Based on medical record review, staff interview, and facility policy, facility staff failed to retain a physician's order for patient restraints as per facility policy for one (1) of three (3) medical records reviewed.

The findings included:

On 9/26/23, at 2:00 p.m., the surveyor reviewed with assistance of Staff Member #3 (SM3) Patient #6's (P6) medical record. During review, it was discovered that P6 was placed in non-violent restraints by the assigned Registered Nurse (RN) on 9/21/23 at 8:00 a.m. The physician's order for P6's restraints was created on 9/21/23 at 3:22 p.m. SM3 confirmed through the review that there was no other documentation in P6's medical record to indicate that a physician gave verbal order for P6's restraint prior to 9/21/23 3:22 p.m. During the review SM3 confirmed that according to the facility policy the nurse was supposed to obtain a physician order for the non-violent restraint prior to restraining P6.

A review of the facility's policy "IHS Restraints and Restraint Alternatives Policy", last revised 5/23/23, stated in part: "...Non-Violent or Non-Self-Destructive Reasons..Orders for Restraint or Seclusion...Physician/APP order required prior to application except in an emergency, in which trained personnel can apply prior but must obtain an order as soon as possible...".

The findings were discussed with Staff Members #1, #2, #10 and #11 at the exit conference on 9/27/23 at 1:20 p.m.