HospitalInspections.org

Based on hospital policy review, open and closed restraint medical record reviews, and staff interviews, nursing staff failed to monitor a patient restrained per the hospital policy, in 2 of 2 restrained patient records reviewed (#1, #8).

The findings included:

Review of hospital policy "Restrictive Interventions" revised April 2017, revealed "...VII. INTERVENTION...E. Monitor patient response to the restraint; assist patients to meet the criteria for discontinuation of restraint. F. Assessment/monitoring/patient care: non-violent non-self destructive restraint utilization 1. Assess and document safety, circulatory status, affect/behavior, and correct device application at initiation. 2. Assess and document the following every 2 hours: a. Safety, circulatory status, affect, behavior and correct device application b. Strategies to reduce or remove restrictive intervention c. Whether less restrictive methods or alternative strategies are now possible d. Does patient continue to meet criteria for restraint use e. Skin care, range of motion, assistance with food, hydration and elimination. i. Remove restraint device every 2 hours to provide skin care and ROM (range of motion) as indicated. ii. Provide toileting, nutrition, hydration every 2 hours while awake as indicated. iii. Temporarily release or take restraints off to care for patient's needs such as feeding, toileting, ambulation, out of bed, interaction with staff, etc. 3. Record patient assessment, including response/behavior while in restrictive interventions as part of on-going monitoring of the patient...H. Assess patient and discontinue restraint at the earliest possible time regardless of the length of the order...VIII. DOCUMENTATION...B. Document assessments and interventions on Restraint Order Form/Restraint Documentation Form..."

1. Open medical record review on 07/09-10/2019 of Patient # 1, revealed a 68 year old patient admitted 06/11/2019 with a diagnosis of altered mental status and confusion. Record review revealed the patient was ordered to be restrained with bilateral soft wrist restraints on 07/04/2019. Review of restraint documentation dated 07/04/2019 revealed documentation of restraint monitoring at 1600 and 2000 (4 hours between monitoring). Record review revealed the patient was ordered to be restrained with bilateral soft wrists restraints on 07/08/2019. Review of restraint documentation dated 07/08/2019 revealed documentation of restraint monitoring at 0500 and 2000 (15 hours between monitoring). Record review revealed the patient was ordered to be restrained with bilateral soft wrist restraints on 07/09/2019. Review of restraint documentation dated 07/09/2019 revealed documentation of restraint monitoring at 0400 and 0800 (4 hours between monitoring).

Interview on 07/11/2019 at 1030 with RN #1 (Registered Nurse), revealed restraint monitoring should be done every two hours. Interview revealed RN #1 thought she correctly documented Patient #1's restraint monitoring. Interview revealed RN #1 did not see the task list alert for restraint documentation for Patient #1 and that was why she did not document on it.

Interview on 07/10/2019 at 1525 with Nurse Educator #1 revealed non-violent restraint monitoring should be done every two hours. Interview confirmed nursing staff failed to follow hospital policy to assess and monitor patients every two hours while in restraints.

2. Closed medical record review on 07/10/2019 of Patient #8, revealed a 23 year old patient admitted on 03/17/2019 with a diagnosis of trauma after a dirt bike accident. Record review revealed the patient was ordered to be restrained with non-violent bilateral soft wrists, bilateral soft ankle, and bilateral tied down mitts on 04/05/2019. Review of restraint documentation dated 04/05/2019, revealed documentation of restraint monitoring at 1200 and 1600 (4 hours between monitoring).

Interview on 07/11/2019 at 1200 with RN #2, revealed restraint monitoring should be done every two hours. Interview revealed RN #1 was unsure why there was not restraint monitoring on Patient #8 on 04/05/2019 between 1200 and 1600.

Interview on 07/10/2019 at 1525 with Nurse Educator #1 revealed non-violent restraint monitoring should be done every two hours. Interview confirmed nursing staff failed to follow hospital policy to assess and monitor patients every two hours while in restraints.

NC00152795, NC00151454