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Based on record review, policy review and staff interview it was determine the nursing staff failed to ensure patients in restraints were monitored for safety and needs in accordance with facility policy for two (#1, #4) of ten sampled patients. This practice does not ensure patient safety and that the patient's needs are met.

Findings include:

1. Patient #1's nursing notes dated 1/2/13 at 11:30 p.m. indicated the physician was notified of the patient becoming agitated and pulling out the intravenous (IV). The physician ordered soft restraints to all four extremities.

Review of the Assessments Flow Sheet dated 1/11/13 at 2:00 a.m. revealed the patient was in restraints and was assessed. The record failed to reveal documentation of monitoring the patient while in restraints until 1/11/13 at 8:00 a.m., a period of approximately six hours.

The Assessments Flow Sheet dated 1/14/13 at 2:02 a.m. indicated the patient was in restraints and was assessed. The record failed to reveal documentation of monitoring the patient while in restraints until 1/14/13 at 8:00 a.m., a period of approximately six hours.

The Assessments Flow Sheet dated 1/16/13 at midnight noted the patient was in restraints and was assessed. The record failed to reveal documentation of monitoring the patient while in restraints until 1/16/13 at 8:00 a.m., a period of approximately eight hours.

The Assessments Flow Sheet dated 1/18/13 at 8:00 p.m. indicated the patient was in restraints and was assessed. The record failed to reveal documentation of monitoring the patient while in restraints until 1/18/13 at midnight, a period of approximately four hours.

The Assessments Flow Sheet dated 1/18/13 at 10:00 p.m. indicated the patient was in restraints and was assessed. The record failed to reveal documentation of monitoring the patient while in restraints until 1/18/13 at 8:00 a.m., a period of approximately ten hours.


2. Patient #4's Nurses Notes dated 1/7/13 (time not available) indicated the patient required soft restraints for non-violent behavior.

The Assessments Flow Sheet dated 1/8/13 at 12:00 p.m. indicated the patient was in restraints and was assessed. The record failed to reveal documentation of monitoring the patient while in restraints until 1/8/13 at 8:00 p.m., a period of approximately eight hours.

Review of policy and procedure "Restraint Use" #PC 519- C, effective date 5/12, page 4, section N, revealed ongoing assessment and monitoring of the patient in restraints should be documented throughout the duration of the restraint usage. The policy continued on page 5, Section N.b. indicated hospital staff provides for the physical needs of the patient to include, but not limited to, range of motion exercise, hygiene and elimination needs, nutrition and hydration needs and skin reassessment every two hours. Section N.c. stated monitoring occurs every two hours.

An interview was conducted on 1/23/13 at approximately 3:00 p.m. with the Nurse Manager of the Stroke Unit. She confirmed the findings that Patient #1 and Patient #4 did not contain documentation of assessment, reassessment or monitoring of the patient while in restraints.