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SENTARA NORFOLK GENERAL HOSPITAL
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0175
Based on document review and interview, it was determined that the facility failed to ensure ongoing monitoring, assessment and documentation for patients in restraints to include circulation, range of motion, fluids, food/meal, and elimination at least every 1.5 - 2.5 hours for one (1) of two (2) Patients (P), P # 4.
The findings include:
On August 27, 2024, clinical record reviews revealed the following:
P # 4 was placed in soft restraints on bilateral wrists due to pulling at lines, tubing and drains based on an order dated August 26, 2024 at 6:59 AM.
There was no documentation from 12:00 AM through 9:29 AM on August 27, 2024, of ongoing patient monitoring and assessment.
On August 27, 2024 at 1:00 PM an interview with Staff Member (SM) # 6 revealed the restraints were "not removed" between 12:00 AM and 9:29 AM on August 27, 2024.
On August 27, 2024 at 2:00 PM, a review of the facility policy titled "Restraint and Seclusion Management: Least Restrictive" reads in part "Restraint monitoring and documentation of basic patient care needs shall include circulation, range of motion, fluids, food/meal, and elimination and shall be documented at least every 1.5 - 2.5 hours."