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SPRING VALLEY HOSPITAL MEDICAL CENTER
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0194
Based on observation, interview and record review, the facility failed to ensure safe implementation of a restraint by misapplying a lap belt for 1 of 10 patients observed (Patient #4).
Findings include:
Patient #4
On 8/9/2023, the facility admitted Patient #4 with coronary artery disease.
On 8/15/2023 at 3:30 PM, Patient #4 was observed with a self-releasing foam belt misapplied. The misapplication was evidenced by the belt observed tautly applied over the patient's sequential compression devices across both legs (over the calves) and below the knees. The belt was looped around underneath the lower bed frame and fastened back to itself. The patient was lying prone with both upper limbs restrained with soft cuffs.
The assigned Registered Nurse explained the patient presented with the lap belt in place as observed at the start of shift. The Registered Nurse indicated the order was modified to reflect the use of the lap belt earlier in the day. The Registered Nurse had not seen the lap belt used in the manner observed before but did not question it.
On 8/15/2023 at 11:22 AM, the medical record revealed documented evidence the restraint order was modified to include the lap belt with soft upper left and right extremity restraints and full siderails x 4.
The medical record lacked documented evidence an assessment was performed to either add the lap belt or discontinue its use.
On 8/15/2023 at 3:57 PM, the medical record revealed documented evidence the restraint order was modified to exclude the lap belt.
On 8/15/2023 at 4:30 PM, Patient #4 was observed with soft upper left and right extremity restraints and full siderails x 4.
On 8/15/2023 in the late afternoon, a Medical/Surgical Manager had the ascribed role of restraint representative. The Manager indicated the lap belt was used across the patient's lap, so it could be self-released.
The manufacturer's instructions for the lap belt revealed the patient should be sitting up while the lapbelt was applied. The lap belt was wrapped around the portion of the bed frame that moved with the patient (the upper half) and brought forward in front of the patient.
Section IV.D. of the Restraint and Seclusion policy revealed assessment of the patient determined that the benefits associated with the use of restraints outweighed the risk of not restraining the patient. The assessment was documented in the patient's medical record.