HospitalInspections.org

Based on record review and staff interview, six of nine Patient records( #1, #2, #3, #4, #5 and #6) reviewed lacked documentation that the least restrictive interventions were determined to be ineffective prior to implementation of restraint.

The findings are as follow:

PATIENT # I:

Review of the medical record indicated Patient #1 was scheduled for inpatient hemodialysis on 04/26/11.

Review of the Restraint Order for Non-Violent Behaviors dated 04/26/11 at 11 AM indicated the physician ordered the application of limb/wrist restraints to be applied to Patient# I during hemodialysis secondary to a risk for removing critical medical devices. The physician's order was written six and one half hours prior to Patient #1 being taken for hemodialysis. The order was written in advance of a nursing assessment for the need of the restraints. It was not clear if Patient #1 required restraints during hemodialysis on 04/26/11.

The Senior Director of Nursing was interviewed on the first day of survey. The Senior Director of Nursing said the restraint order should not have been obtained prior to the assessment of Patient #1on 04/26/11.

Review of the Dialysis Record dated 04/26/11 indicated Patient #1 was in dialysis from 5:30 PM to 9:15 PM.

Review of the Non-Violent Restraint Order dated 04/27/11 at 1 AM indicated the physician ordered the application of both a vest restraint and wrist restraint for Patient #1 for confusion, removing critical medical devices, agitation and impulsiveness.

Review of the Non-Violent Restraint Plan of Care for Patient #1 lacked a specific time the Posey vest was applied. There was no documentation the wrist restraints were applied between the hours of 1 AM to 7 AM on 04/27/11 on the Non-Violent Restraint Plan of Care.

Review of the Nurses Notes dated 04/27/11 indicated at 3:42 AM, Patient #1 pulled out an intravenous line.

Continued review of the Non-Violent Restraint Plan of Care dated 04/27/11 between the hours of 7 AM to 3 PM indicated Patient #1 had a vest restraint for pulling at tubes and devices and interfering with personal care. There was no documentation wrist restraints had been continued for pulling at tubes and devices. Licensed Practical Nurse(LPN) #1 documented Patient #1 remained in a vest restraint for pulling on tubes and devices. The documentation for the nursing assessment was contradictory to the behavior of pulling at the tubes and devices.

During the 3 PM to 7 PM shift on 04/27/11, LPN #1 documented on the Non-Violent Restraint Plan of Care and (untimed) Nurses Note that Patient #1 continued with the vest restraint. However, an identified entry on the Non-Violent Plan of Care indicated the vest restraint had been removed on 04/27/11 at 12 PM. LPN #1 continued the Non-Violent Restraint Plan of Care during the hours of 3 PM to 7 PM and documented Patient #1 was restrained despite that fact Patient #1 was off of the inpatient unit at dialysis between the hours of 2:52 PM to 6:35 PM.

LPN #1 was interviewed in person on 05/04/11 at 2 PM. LPN #1 said Patient #1 was placed in restraints during the early morning hours on 04/27/11 for pulling out an intravenous line as per protocol and as the least restrictive devices had been exhausted. LPN #1 did not assume the care of Patient #1 until 7 AM on 04/27/11.

There was no clear documentation of a nursing reassessment after the multiple applications of physical restraint.

PATIENT #2:

Review of the Non-Violent Restraint Order dated 03/12/11 at 10 PM indicated a waist restraint was ordered by a physician for Patient #2. The behavior documented for the need for the restraint was Patient #2 was at risk for removing critical medical devices due to inability to follow directions.

There was no documentation the ordering physician was contacted regarding the incorrect order for restraint.

Review of the Non-Violent Plan of Care Restraint Form for Patient #2 dated 03/13/11 indicated soft wrist restraints were applied to Patient #2 . There was no specific time documented for the application of restraint.


PATIENT #3:

Review of the Medical-Surgical Physician Restraint Order dated 01/29/11 at 8:00 AM, indicated a vest restraint was ordered secondary to cognitive impairment and attempting to get out of bed without assistance.

There was no Non-Violent Plan of Care or Restraint Flowsheet documented in Patient #3's medical record.


PATIENT #4:

Review of the Medical-Surgical Restraint Order for Patient #4dated 12/20/10 at 5 PM indicated the physician ordered soft wrist restraints for pulling at medical devices, tubes and dressings

The Restraint Flow Sheet dated 12/20/10 between the hours of 12 PM and 10 PM was labeled with another patients name. There was no Restraint Flow Sheet maintained for Patient in the medical record.

PATIENT #5:

Patient #5 was non-English speaking and had resided in a long-term care facility.

Review of the Nurses Notes dated 02/15/11 between 7 AM to 9 AM indicated Patient #5 had been confused and agitated with periods of lethargy. Patient #5 had occasionally picked at an intravenous site which had been wrapped in Kerlix. The specific location of the peripheral line was not well documented. Between 9 AM and 10 AM, the Nurses Note indicated the right groin dressing had been saturated with sanguinous drainage and the old dressing at the site where the right femoral line had been was oozing . A physician had been in to examine Patient #5 and a Surgicel dressing was applied for pressure.

Review of the Medical-Surgical Restraint Order Sheet dated 02/15/10 at 10:40 AM indicated bilateral soft wrist restraints and a vest restraint were ordered by the physician. In addition, to the vest and wrist restraints, there was a third order dated 02/15/10 at 10:40 AM on the Physician Order Sheet for bilateral arm splints. It was not specifically clear as to why the physician ordered the additional bilateral arm splint restraints.

The Nurses Notes indicated between 12 PM to 2 PM, Patient #5 was transferred to a chair. Patient #5 was agitated and calling out and pulling at the intravenous site and cardiac leads. The Posey vest and bilateral wrist restraints, and bilateral arm immobilizers were on. The Nurses Notes indicated hand mittens were also applied. The Nurses Notes indicated Patient #5 pulled (the mitts off). The Nurses Notes indicated Patient #5 remained agitated and Haldol 2 milligrams was administered by intramuscular injection at 2:30 PM.

Review of the Medical-Surgical Restraint Flowsheet indicated bilateral soft wrist, mittens and a vest restraint were applied and the bed was positioned in the low position. There was no documentation the bilateral arm immobilizers used as a restraint on the Medical-Surgical Restraint Flowsheet.

Patient #5 was excessively restrained with the application of bilateral arm immobilizer,bilateral wrist restraints, hand mittens and a vest restraint. Patient #5 was additionally administered the medication Haldol.

On 02/15/11 at 11:15 PM, Patient #5 was transferred into CCU.


PATIENT #6:

Review of the Medical-Surgical Physician Restraint Order dated 11/23/10 at 8:30 AM and 11/24/10 at 8:30 AM and signed by a physician lacked a specific restraint order for the application of restraints, type or the behavior to justify the need for restraints. In addition, there was one blank Medical-Surgical Physician Order Sheet, labeled for Patient #6 in the medical record.

There was no physician justification for the need nor order for a specific type of restraint on 11/23/10 or 11/24/11.

Review of the Medical -Surgical Restraint Flowsheet for Patient #6 between the dates of 11/24/10 to 11/27/10 were inconsistently signed and filled out by the nursing staff for the application of bilateral wrist restraints.

Based on record review and staff interview, six of nine Patient records( #1, #2, #3, #4, #5 and #6) reviewed lacked documentation that the least restrictive interventions were determined to be ineffective prior to implementation of restraint or the type of physical restraint was applied without a proper nursing assessment to justify the use of the physical restraint.

The findings are as follow:

PATIENT # I:

Review of the medical record indicated Patient #1 was scheduled for inpatient hemodialysis on 04/26/11.

Review of the Restraint Order for Non-Violent Behaviors dated 04/26/11 at 11 AM indicated the physician ordered the application of limb/wrist restraints to be applied to Patient# I during hemodialysis secondary to a risk for removing critical medical devices. The physician's order was written six and one half hours prior to Patient #1 being taken for hemodialysis. The order was written in advance of a nursing assessment for the need of the restraints. It was not clear if Patient #1 required restraints during hemodialysis on 04/26/11.

The Senior Director of Nursing was interviewed on the first day of survey. The Senior Director of Nursing said the restraint order should not have been obtained prior to the assessment of Patient #1on 04/26/11.

Review of the Non-Violent Restraint Order dated 04/27/11 at 1 AM indicated the physician ordered the application of both a vest restraint and wrist restraint for Patient #1 for confusion, removing critical medical devices, agitation and impulsiveness.

Review of the Non-Violent Restraint Plan of Care for Patient #1 lacked a specific time the Posey vest was applied. There was no documentation the wrist restraints were applied between the hours of 1 AM to 7 AM on 04/27/11.

Review of the Nurses Notes dated 04/27/11 indicated at 3:42 AM, Patient #1 pulled out an intravenous line.

Continued review of the Non-Violent Restraint Plan of Care dated 04/27/11 between the hours of 7 AM to 3 PM indicated Patient #1 had a vest restraint for pulling at tubes and devices and interfering with personal care. There was no documentation wrist restraints had been continued for pulling at tubes and devices. Licensed Practical Nurse(LPN) #1 documented Patient #1 remained in a vest restraint for pulling on tubes and devices. The documentation for the nursing assessment was contradictory to the behavior of pulling at the tubes and devices.

During the 3 PM to 7 PM shift on 04/27/11, LPN #1 documented on the Non-Violent Restraint Plan of Care and (untimed) Nurses Note that Patient #1 continued with the vest restraint. However, an identified entry on the Non-Violent Plan of Care indicated the vest restraint had been removed on 04/27/11 at 12 PM. LPN #1 continued the Non-Violent Restraint Plan of Care that Patient #1 was restrained while Patient #1 was off of the inpatient unit at dialysis between the hours of 2:52 PM to 6:35 PM.

LPN #! was interviewed in person on 05/04/11 at 2 PM. LPN #1 said Patient #1 was placed in restraints during the early morning hours on 04/27/11 for pulling out an intravenous line as per protocol and as the least restrictive devices had been exhausted. LPN #1 did not assume the care of Patient #1 until 7 AM on 04/27/11.

PATIENT #2:

Review of the Non-Violent Restraint Order dated 03/12/11 at 10 PM indicated a waist restraint was ordered by a physician. The behavior documented for the need for the restraint was Patient #2 was at risk for removing critical medical devices due to inability to follow directions.

There was no documentation the ordering physician was notified of the incorrect order for restraint.

Review of the Non-Violent Plan of Care Restraint Form for Patient #2 dated 03/13/11 indicated soft wrist restraints were applied to Patient #2 . There was no specific time documented for the application of restraint.


PATIENT #3:

Review of the Medical-Surgical Physician Restraint Order dated 01/29/11 at 8:00 AM, indicated a vest restraint was ordered secondary to cognitive impairment and attempting to get out of bed without assistance.

There was no Non-Violent Plan of Care or Restraint FLowsheet documented in Patient #3's medical record.


PATIENT #4:

Review of the Medical-Surgical Restraint Order for Patient #4dated 12/20/10 at 5 PM indicated the physician ordered soft wrist restraints for pulling at medical devices, tubes and dressings

The Restraint Flow Sheet dated 12/20/10 between the hours of 12 PM and 10 PM was labeled with another patients name. There was no Restraint Flow Sheet maintained for Patient

PATIENT #5:

Patient #5 was non-English speaking and had resided in a long-term care facility.

Review of the Nurses Noes dated 02/15/11 between 7 AM to 9 AM indicated Patient #5 had been confused and agitated with periods of lethargy. Patient #5 had occasionally picked at an intravenous site which had been wrapped in Kerlix. The specific site of the peripheral intavenous line was not well documented. Between 9 AM and 10 Am, the Nurses Note indicated the right groin sanguinous dressing had been saturated with sanguinous drainage and the old dressing at the site where the right femoral line had been was oozing. A physician had been in and a Surgicel dressing was applied for pressure.

Review of the Medical-Surgical Restraint Order Sheet dated 02/15/10 at 10:40 AM indicated bilateral soft restraints and a vest restraint were ordered by the physician. In addition, to the vest and wrist restraints, there was a third order dated 02/15/10 at 10:40 AM on the Physician Order Sheet for bilateral arm splints. It was not specifically clear why the physician ordered the addition of bilateral arm splints.

The Nurses Notes indicated between 12 PM to 2 PM, indicated Patient #5 was transferred to a chair. Patient #5 was agitated and calling out and pulling at the intravenous site and cardiac leads. The Posey vest and bilateral wrist restraints, and bilateral arm immobilizers were on. The Nurses Notes indicated hand mittens were also applied. The Nurses Notes indicated Patient #5 pulled (the mitts off). The Nurses Notes indicated Patient #5 remained agitated and Haldol 2 milligrams was administered by intramuscular injection at 2:30 PM.

Review of the Medical-Surgical Restraint Flowsheet indicated bilateral soft wrist, mittens and a vest restraint were applied and the bed was positioned in the low position. There was no documentation for the bilateral arm immobilizers used as a restraint on the Medical-Surgical Restraint Flowsheet.

Patient #5 was excessively restrained with the application of bilateral arm immobilizer,bilateral wrist restraints, hand mittens and a vest restraint. Patient #5 was additionally administered the medication Haldol.

On 02/15/11 at 11:15 PM, Patient #5 was transferred into CCU.


PATIENT #6:

Review of the Medical-Surgical Physician Restraint Order dated 11/23/10 at 8:30 AM and 11/24/10 at 8:30 AM and signed by a physician lacked an specific order for the restraint application and the behavior to justify the need for restraints. In addition, there was blank Medical Surgical Physician Order Sheet labeled for Patient #6 in the medical record.

There was no physician justification for the need nor order for a specific type of restraint on 11/23/10 ro 11/24/10.

Review of the Medical -Surgical Restraint Flowsheet for Patient #6 between the dates of 11/24/10 to 11/27/10 were inconsistently signed and filled out by the nursing staff for the application of bilateral wrist restraints.

Based on record review one of one applicable medical record for Patient #6 indicated there was a signed Restraint Order Form by a physician. However, there restraint order lacked a specific order for the type of restraint and justification for the application of a physical restraints for two dates in November 2010.

The findings are as follow:

PATIENT #6:

Review of the Medical-Surgical Physician Restraint Order dated 11/23/10 at 8:30 AM and 11/24/10 at 8:30 AM and signed by a physician lacked an specific order for the type of restraint application lacked a written entry for the behavior to justify the need for restraints. In addition, there was blank Medical Surgical Physician Order Sheet for Patient #6 in the medical record.

There was no physician justification for the need nor order for a specific type of restraint on 11/23/10 ro 11/24/10.

Review of the Medical -Surgical Restraint Flowsheet for Patient #6 between the dates of 11/24/10 to 11/27/10 were inconsistently signed and filled out by the nursing staff for the application of bilateral wrist restraints.