HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the use of restraints for the management of violent or self-destructive behaviors was renewed within two hours for one of three sampled patients (Patient 1). This failure posed the risk of unnecessary restraint use and substandard outcomes for the patient.

Findings:

Review of the hospital's P&P titled Restraints dated June 2024 showed each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be obtained and renewed in accordance with the following limits for up to a total of 24 hours:

- Up to two hours for children and adolescents ages 9-17.

On 3/19/25 at 1530 hours, review of Patient 1's closed medical record was initiated.

Patient 1's closed medical record showed the patient came to the emergency department on 2/17/25. The initial physician's order for restraints to manage the violent behaviors was issued on 2/17/25 at 1755 hours.

Review of Patient 1's Restraint Documentation dated 2/17/25, showed the hard restraints were applied to Patient 1's bilateral wrists and ankles on 2/17/25 at 1755 hours, and discontinued on 2/17/25 at 2018 hours, for a total duration of 143 minutes (2 hours and 23 minutes).

On 3/20/25 at 1005 hours, a concurrent interview and record review was conducted with Director of Emergency Department. The Director of Emergency Department was unable to locate an order renewing the violent restraints for Patient 1 after two hours from the initial order time. The Director of Emergency Department acknowledged an additional order to renew the violent restraints for Patient 1 should have been obtained after two hours.

On 3/20/25 at 1420 hours, the Chief Executive Officer, Chief Nursing Officer, and Chief Quality and Patient Safety Officer were notified of the above findings.

Based on interview and record review, the hospital failed to ensure the staff reassessed and monitored one of three sampled patients (Patient 2) as per the hospital's P&P while Patient 2 was restrained. This failure had the potential to result in unsafe care for the patient.

Findings:

Review of the hospital's P&P titled Restraints dated June 2024 showed under the section for Ongoing Assessment of a Patient Placed in Restraint or Seclusion, the ongoing assessment means the patient will be evaluated to determine the patient's response to the restraint or seclusion and if the patient has any care needs. This assessment shall include checking the patient vital signs, hydration and circulation, the patient's level of distress and agitation, or skin integrity; and may also provide for general care needs (e.g., eating, hydration, toileting, and range of motion exercises). This assessment shall also determine if the patient continues to require restraint or seclusion. Patients placed in restraint for safety, non-violent, and non-destructive behavior should be assessed at least every two hours.

On 3/20/25 at 1330 hours, an interview and concurrent review of Patient 2's medical record was conducted with the Director of ICU.

Patient 2's medical record showed the patient was admitted to the hospital on 2/28/25.

Review of Patient 2's Order Requisition dated 3/18/25 at 0800 hours, showed an order for the non-violent soft restraints to be applied to Patient 2's bilateral wrists. The order also showed the patients in non-violent restraints shall be observed at intervals not greater than two hours and documented every two hours.

Review of Patient 2's Restraint Flowsheet dated 3/18/25, showed no restraint monitoring documentation on 3/18/25 from 1000 to 1800 hours (eight hours).

During a concurrent interview and record review, the Director of ICU was unable to locate any restraint monitoring documentation for Patient 2 on 3/18/25 from 1000 to 1800 hours. The Director of ICU acknowledged the restraint monitoring documentation for the patients in non-violent restraints should be completed every two hours.

On 3/20/25 at 1420 hours, the Chief Executive Officer, Chief Nursing Officer, and Chief Quality and Patient Safety Officer were notified and acknowledged the above findings.