HospitalInspections.org

Based on review of two of two applicable medical records the Hospital failed to 1.) ensure a restraint ordered for Patient #1 on 4/15/10 was used to ensure the immediate physical safety and the restraints used for Patient #1 on 4/21/10 and on 4/22/10 were discontinued at the earliest possible time.

Findings include:

1.) Documentation in Patient #1's record dated 4/15/10 at 10:00 PM indicated a verbal order was taken for soft wrist restraints for 24 hours. However, nursing documentation dated 4/15/10 indicated the restraint was ordered if the Patient's aggression continued and not for an immediate physical safety.


2.) Review of Nursing documentation on 4/21/10 and on 4/22/10 indicated soft wrist restraints were used, however, the documentation failed to indicate the specific time when the restraints were removed.

3.) Review of Patient #2's medical record dated 4/27/10 at 12:10 AM indicated Haldol was ordered to be administered when necessary for anxiety. However documentation indicated the Patient became combative and aggressive


Review of Hospital policies and procedures related to restraints indicated the following:

i) the use of restraint is to be limited to emergencies in which there is imminent risk of the patient harming themselves, staff or others, and non physical interventions would not be effective

ii) a restraint and/or seclusion must be discontinued at the earliest possible time

iii) no standing order for a restraint is permitted

Based on review of one of two medical records reviewed it was determined the Hospital failed to ensure that when Haldol was used as a restratint to manage Patient #2's behavior, restraint policies and procedures were followed.

Findings include:

1.) Review of Hospital policies and procedures related to restraints indicated the following:

i) that orders for a chemical restraint must be written on the restraint order sheet.

ii) as with any use of restraint or seclusion, staff must conduct a comprehensive patient assessment to determine the need for other types of interventions before using a drug or medication as a restraint.

2.) Review of Patient's #2's medical record indicated on 4/27/10 the order written for Ativan 1 milligram (mg) intravenous (IV) every three hours was written to be administered as necessary. Nursing documentation indicated 3 mg of Haldol was administered at 12:10 AM and at 7:30 AM. However, the order was no documented on the restraint order sheet as required by Hospital policies and procedures.

Based on documentation review of one of two applicable medical records the hospital failed to ensure less restrictive measures had been found to be ineffective before restraints were used for Patient #1 and Patient #2.

Findings include:

Review of Patient #1's medical record indicated alternatives to the restraint were attempted but the documentation failed to evidence the interventions tried were ineffective.

Based on review of one of two medical record the hospital failed to ensure the use of the restraint for Patient #1 was documented in the Patient's plan of care.

Findings include:

Review of Patient #1's plan of care dated 4/15/10 #1 indicated the use of the wrist restraint 4/21/10 and 4/22/10 was not documented in the plan of care.

Based on interview and documentation review of Patient #1's medical record the hospital failed to ensure there was a physician's order for the utilization of a wrist restraint on 4/22/10 at 10:45 AM.

Findings included:

Review of the Patient #1's medical record indicated there was no physician order for the restraint used when she became combative at 10:45 AM and was placed in soft wrist restraints.

Based on review of one of one applicable record it was determined the hospital failed to ensure that an order for a wrist restraint must never to written as on an as needed basis (and staff can not discontinue a restraint intervention, and then re-start it under the same order. This would constitute a prn order and no authority has been given to reinstituted the intervention without a new order.

Findings include:

See Tag A-0168

Based on interviews and documentation review it was determined the Hospital failed ensure documentation indicated that the Patient restraints were documented at the earliest possible time.

See Tag A 154

Based on review of one of two applicable medical records the hospital failed to ensure the Patient was monitored while in wrist restraint according to hospital policy.

Findings include:

Review of the Hospital's policy titled Restraint Management indicated that an observation assistant or nursing assistant must be assigned for 1:1 constant observation if the patient is a suicide risk and/or violent/self-destructive and the Observation Assistant Handoff Communication Form must be utilized.

Review of the the Observation Assistant Hand Off Communication Tool Forms in Patient #1's medical record indicated there were no Forms were utilized on 4/22/10 at 12:00 AM and 10:45 AM when wrist restraints were utilized.

Based on documentation review of two of two applicable medical records indicated that one hour after restraints were either applied or administered a face to face evaluation was not documented by an appropriately trained staff member as required.

Findings include:

Review of hospital policy titled Restraint Management indicated the requirement that the patient be seen face to face within 1 hour after the initiation of the restraint was not incorporated into the Restraint Management policy.

Based on review of the Hospital's policy titled Restraint Management indicated the policy and procedure did not include the CMS Death Reporting Requirements.

Findings include:

1.) Review of the Hospital's policy titled Restraint Management indicated there was no instruction for the Hospital to report the following to CMS:

(i) that each death that occurs while a patient is in restraint or seclusion.
(ii) each death that occurs within 24 hours after the patient has been removed from restraint or seclusion
(iii) each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that the use of restraint or placement in seclusion contributed directly or indirectly to a patient's death. Reasonable to assume in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation.

(2) Each death referenced in this paragraph must be reported to CMS by telephone no later than the close of business the next business day following knowledge of the patient ' s death.

(3) Staff must document in the patient's medical record the date and time the death was reported to CMS.

Based on review of two of two applicable medical records the Hospital failed to 1.) ensure a restraint ordered for Patient #1 on 4/15/10 was used to ensure the immediate physical safety and the restraints used for Patient #1 on 4/21/10 and on 4/22/10 were discontinued at the earliest possible time.

Findings include:

1.) Documentation in Patient #1's record dated 4/15/10 at 10:00 PM indicated a verbal order was taken for soft wrist restraints for 24 hours. However, nursing documentation dated 4/15/10 indicated the restraint was ordered if the Patient's aggression continued and not for an immediate physical safety.


2.) Review of Nursing documentation on 4/21/10 and on 4/22/10 indicated soft wrist restraints were used, however, the documentation failed to indicate the specific time when the restraints were removed.

3.) Review of Patient #2's medical record dated 4/27/10 at 12:10 AM indicated Haldol was ordered to be administered when necessary for anxiety. However documentation indicated the Patient became combative and aggressive


Review of Hospital policies and procedures related to restraints indicated the following:

i) the use of restraint is to be limited to emergencies in which there is imminent risk of the patient harming themselves, staff or others, and non physical interventions would not be effective

ii) a restraint and/or seclusion must be discontinued at the earliest possible time

iii) no standing order for a restraint is permitted

Based on review of one of two medical records reviewed it was determined the Hospital failed to ensure that when Haldol was used as a restratint to manage Patient #2's behavior, restraint policies and procedures were followed.

Findings include:

1.) Review of Hospital policies and procedures related to restraints indicated the following:

i) that orders for a chemical restraint must be written on the restraint order sheet.

ii) as with any use of restraint or seclusion, staff must conduct a comprehensive patient assessment to determine the need for other types of interventions before using a drug or medication as a restraint.

2.) Review of Patient's #2's medical record indicated on 4/27/10 the order written for Ativan 1 milligram (mg) intravenous (IV) every three hours was written to be administered as necessary. Nursing documentation indicated 3 mg of Haldol was administered at 12:10 AM and at 7:30 AM. However, the order was no documented on the restraint order sheet as required by Hospital policies and procedures.

Based on documentation review of one of two applicable medical records the hospital failed to ensure less restrictive measures had been found to be ineffective before restraints were used for Patient #1 and Patient #2.

Findings include:

Review of Patient #1's medical record indicated alternatives to the restraint were attempted but the documentation failed to evidence the interventions tried were ineffective.

Based on review of one of two medical record the hospital failed to ensure the use of the restraint for Patient #1 was documented in the Patient's plan of care.

Findings include:

Review of Patient #1's plan of care dated 4/15/10 #1 indicated the use of the wrist restraint 4/21/10 and 4/22/10 was not documented in the plan of care.

Based on interview and documentation review of Patient #1's medical record the hospital failed to ensure there was a physician's order for the utilization of a wrist restraint on 4/22/10 at 10:45 AM.

Findings included:

Review of the Patient #1's medical record indicated there was no physician order for the restraint used when she became combative at 10:45 AM and was placed in soft wrist restraints.

Based on review of one of one applicable record it was determined the hospital failed to ensure that an order for a wrist restraint must never to written as on an as needed basis (and staff can not discontinue a restraint intervention, and then re-start it under the same order. This would constitute a prn order and no authority has been given to reinstituted the intervention without a new order.

Findings include:

See Tag A-0168

Based on interviews and documentation review it was determined the Hospital failed ensure documentation indicated that the Patient restraints were documented at the earliest possible time.

See Tag A 154

Based on review of one of two applicable medical records the hospital failed to ensure the Patient was monitored while in wrist restraint according to hospital policy.

Findings include:

Review of the Hospital's policy titled Restraint Management indicated that an observation assistant or nursing assistant must be assigned for 1:1 constant observation if the patient is a suicide risk and/or violent/self-destructive and the Observation Assistant Handoff Communication Form must be utilized.

Review of the the Observation Assistant Hand Off Communication Tool Forms in Patient #1's medical record indicated there were no Forms were utilized on 4/22/10 at 12:00 AM and 10:45 AM when wrist restraints were utilized.

Based on documentation review of two of two applicable medical records indicated that one hour after restraints were either applied or administered a face to face evaluation was not documented by an appropriately trained staff member as required.

Findings include:

Review of hospital policy titled Restraint Management indicated the requirement that the patient be seen face to face within 1 hour after the initiation of the restraint was not incorporated into the Restraint Management policy.

Based on review of the Hospital's policy titled Restraint Management indicated the policy and procedure did not include the CMS Death Reporting Requirements.

Findings include:

1.) Review of the Hospital's policy titled Restraint Management indicated there was no instruction for the Hospital to report the following to CMS:

(i) that each death that occurs while a patient is in restraint or seclusion.
(ii) each death that occurs within 24 hours after the patient has been removed from restraint or seclusion
(iii) each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that the use of restraint or placement in seclusion contributed directly or indirectly to a patient's death. Reasonable to assume in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation.

(2) Each death referenced in this paragraph must be reported to CMS by telephone no later than the close of business the next business day following knowledge of the patient ' s death.

(3) Staff must document in the patient's medical record the date and time the death was reported to CMS.