HospitalInspections.org

Based on interview and record review, the hospital failed to obtain an order for the use of restraints (any manual method or device that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) for one of four patients (Patient 5) when Patient 5 was placed in bilateral (both sides) ankle restraints without a physician order. This failure had the potential to result in an inappropriate and prolonged use of restraints.

Findings:

Review of Patient 5's medical record, he was admitted to the facility on 8/9/24 with diagnoses including sepsis (a life-threatening condition caused by the body's reaction to an infection) and urinary tract infection (UTI, infection in the urinary system).

Review of Patient 5's Emergency Department (ED) nursing notes, dated 8/10/24 indicated, "Patient is highly confused, [MD] notified. He will not follow directions. Soft restraints applied at this time on all 4 limbs to protect patient during care."

Review of Patient 5's restraints flowsheet, dated 8/10/24 to 8/13/24 indicated the patient had soft restraints on the right wrist, left wrist, right ankle, and left ankle starting on 8/10/24 at 12 a.m. The flowsheet indicated the soft restraints on the right wrist, left wrist, right ankle, and left ankle were discontinued on 8/10/24 at 5:27 a.m.

Review of Patient 5's Order History, dated 8/9/24 to 8/12/24 indicated the patient had an order, dated 8/10/24 for restraints for both wrists. There was no order for restraints for both ankles.

During an interview on 8/13/24 at 12 p.m., the Clinical Director Quality Services (CDQS) confirmed there was no order for bilateral ankle restraints.

Review of the hospital's policy, "Restraints," revised 7/2/17 indicated, "Restraint may only be initiated or continued upon the order of a physician or authorized licensed independent practitioner (LIP) primaryly responsible for the patient's ongoing care ... In a situation requiring the emergency application of restraint, a registered nurse may initiate restraint use ... An order for restraint must be obtained from the physician/LIP either during the emergency application of the restraint, or immediately (within a few minutes) after the restraint has been applied. If an order is not obtained immediately, it would be considered application of restraint without an order."

Based on interview and record review, the hospital failed to document a clear description of the behavior of one of four patients (Patient 5) that warranted the use of restraints (any manual method or device that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely). This failure had the potential to result in patients being unnecessarily restrained.

Findings:

Review of Patient 5's medical record, he was admitted to the facility on 8/9/24 with diagnoses including sepsis (a life-threatening condition caused by the body's reaction to an infection) and urinary tract infection (UTI, infection in the urinary system).

Review of Patient 5's Emergency Department (ED) nursing notes, dated 8/10/24 indicated, "Patient is highly confused, [MD] notified. He will not follow directions. Soft restraints applied at this time on all 4 limbs to protect patient during care."

Review of Patient 5's restraints flowsheet, dated 8/10/24 to 8/13/24 indicated the patient had soft restraints on the right wrist, left wrist, right ankle, and left ankle starting on 8/10/24 at 12 a.m. The flowsheet indicated the clinical justification for the restraints was the patient was pulling at lines, tubes, and removing equipment. The flowsheet had no documentation that indicated the clinical justification for ankle restraints.

Review of Patient 5's Order History, dated 8/9/24 to 8/12/24 indicated the patient had an order, dated 8/10/24 for restraints for both wrists for pulling out lines/dressings. There was no order for restraints for both ankles. There was no documentation that indicated the clinical reason for ankle restraints.

During an interview on 8/13/24 at 2:50 p.m. the Clinical Director Quality Services (CDQS) confirmed there should be documentation that indicated the reason Patient 5 required ankle restraints.

Review of the hospital's policy, "Restraints," revised 7/2/17 indicated, "The order for restraint shall be based on the specific behaviors that indicate the need for restraint."