HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 4 (Pt #10) clinical records reviewed for restraints, the Hospital failed to ensure that the use of a restraint was in accordance with the order of a physician.

Findings include:

1. The Hospital's policy titled, "Utilization of Restraints and Seclusion" (revised 4/11/19) was reviewed on 7/28/2020, and required, "...C. Medical Surgical Restraints-means Restraints used when a non-Violent, non-Self Destructive patient's actions or potential actions may endanger themselves or compromise their care and do not involve a patient with decisional capacity refusing treatment...Medical Surgical Restraint: 2. The Attending Physician or LIP [Licensed Independent Practitioner] must provide an order within 12 hours of initiation of the restraint..."

2. The clinical record for Pt #10 was reviewed on 7/28/2020. Pt #10 presented to the Emergency Department for poisoning by a Calcium Channel Blocker (blood pressure medication) on 9/30/19. Pt #10's restraint documentation, dated 9/30/19 at 4:50 AM, included, "Reason for Restraint/Seclusion: Pulling at lines/tubes. Soft limb. Bilateral UE [upper extremity], Bilateral LE [lower extremity]. Disoriented..."

- Pt #10's record indicated that the patient was in restraints from on 9/30/19, from 4:50 AM-2:43 PM (for 9 hours and 53 minutes). However, the Physician's order for restraints was not provided until 9/30/19 at 11:16 PM (18 hours and 26 minutes after the application of restraints).

3. On 7/28/2020 at approximately 11:15 AM, an interview was conducted with the Medical/Surgical/ICU Manager (E #6). E #6 stated that there should be an order for non-violent restraints within 12 hours of applying them.

Based on document review and interview, it was determined that for 1 of 4 (Pt #10) clinical records reviewed for restraints, the Hospital failed to ensure that trained staff monitored a restrained patient every two hours, as required.

Findings include:

1. The Hospital's policy titled, "Utilization of Restraints and Seclusion", (revised 4/11/19), was reviewed on 7/28/2020, and required, "...E. Medical Surgical Restraint. 5. Monitoring Frequency and Documentation. a. Patients will be monitored/assessed by trained associates. c. Every 30 minutes for the first hour. d. Then every two hours or per physician order with documentation in the appropriate intervention..."

2. The clinical record for Pt #10 was reviewed on 7/28/2020. Pt #10 presented to the Emergency Department (ED) for poisoning by a Calcium Channel Blocker (blood pressure medication) on 9/30/19. Pt #10's restraint documentation, dated 9/30/19 at 4:50 AM, included, "Reason for Restraint/Seclusion: Pulling at lines/tubes. Soft limb. Bilateral UE [both sides/upper extremity], Bilateral LE [lower extremity]. Disoriented...."

- Pt #10 was transferred from the ED to the Intensive Care Unit (ICU), on 9/30/19 at 8:45 AM. The "Alternatives Assessment" Note, documented by the ED nurse at the time of transfer (8:45 AM) included, "...pt [patient] does not display readiness to discontinue restraints r/t [related to] intubation and central line placement."

- The Nurse's Note (dated 9/30/19 at 2:23 PM), documented by the ICU Nurse, included, "Patient noted to have bilateral wrist restraints...Bilateral lower extremity soft restraints also noted...which were still attached to ED bed..." Pt #10's clinical record lacked documentation of restraint monitoring/assessment every two hours, from 8:45 AM through 2:23 PM.

5. On 7/28/2020 at approximately 10:30 AM, an interview was conducted with the Medical/Surgical/ICU Manager (E #6). E #6 stated that patients that are in non-violent restraints should be monitored every 30 minutes for an hour and then every 2 hours. E #6 reviewed Pt #10's clinical record and confirmed that there was no documentation of restraint monitoring from 8:45 AM on 9/30/19.