HospitalInspections.org

Based on review of facility policy, medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to provide adequate justification for the application of physical restraints for one of six medical records reviewed (MR1).

Findings include:

Review on February 28, 2014, of policy "Restraint and Seclusion," dated February 2013, revealed " ... AMH provides resources and guidance to create an environment that will assist in developing systems and processes that attempt to eliminate the inappropriate use of restraint or seclusion. ... Restraint or seclusion will not be used as a means of coercion, discipline, convenience or retaliation by staff or be based on a patient's history of restraint use or dangerous behavior. Restraint or seclusion protects the immediate physical safety of the patient, a staff member, or others and is discontinued at the earliest possible time. ... Restraint or seclusion is only used after alternatives have been considered and/or determined to be ineffective. Staff uses the least restrictive form of restraint or seclusion necessary to protect the patient, staff, or others. Reassessment and reevaluation of patients for the use of alternatives to restraints will be made with a goal of discontinuation. ..."

Review of MR1 revealed that the patient was 91 years old and admitted to the facilty on January 17, 2014. A review of MR1 revealed a "Restraint Plan Of Care Violent/Self Destructive" initial assessment, dated January 19, 2014, that indicated that the patient was identified with Dementia and was "verbally abusive towards staff, refusing to return to ... room after wandering into hall, grabbed a telephone receiver and swung at nursing staff with receiver in ... hand. Restraints initiated at 1630 (4:30 PM). "

Review of a physician's order, dated January 19, 2014 timed 17:00 (5:00 PM), revealed "Soft Limb Restraints, Both Ankles/Both wrists, Stop After: 24 Hours, Indications: Patient persists in attempt to get OOB/transfer/ambulate unassisted and is at risk for injury."

Interview on February 28, 2014, at 3:15 PM, with EMP1, confirmed that there was not adequate justification to initiate and apply physical restraints on this patient.

Based on review of facility policy, medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to discontinue the use of physical restraints at the earliest possible time and failed to provide adequate documentation regarding the continued use of physical restraints for one of six medical records reviewed (MR1).

Findings include:

Review on February 28, 2014, of policy "Restraint and Seclusion," dated February 2013, revealed " ... AMH provides resources and guidance to create an environment that will assist in developing systems and processes that attempt to eliminate the inappropriate use of restraint or seclusion. ... Restraint or seclusion will not be used as a means of coercion, discipline, convenience or retaliation by staff or be based on a patient's history of restraint use or dangerous behavior. Restraint or seclusion protects the immediate physical safety of the patient, a staff member, or others and is discontinued at the earliest possible time. ... Restraint or seclusion is only used after alternatives have been considered and/or determined to be ineffective. Staff uses the least restrictive form of restraint or seclusion necessary to protect the patient, staff, or others. Reassessment and reevaluation of patients for the use of alternatives to restraints will be made with a goal of discontinuation. ..."

Review of MR1 revealed that the patient was 91 years old and admitted to the facilty on January 17, 2014. A review of MR1 revealed a "Restraint Plan Of Care Violent/Self Destructive" initial assessment, dated January 19, 2014, that indicated that the patient was identified with Dementia and was "verbally abusive towards staff, refusing to return to ... room after wandering into hall, grabbed a telephone receiver and swung at nursing staff with receiver in ... hand. Restraints initiated at 1630 (4:30 PM). "

Review of a physician's order, dated January 19, 2014 timed 17:00 (5:00 PM), revealed "Soft Limb Restraints, Both Ankles/Both wrists, Stop After: 24 Hours, Indications: Patient persists in attempt to get OOB/transfer/ambulate unassisted and is at risk for injury."

Review of a physician's order, dated January 19, 2014 timed 21:30 (9:30 PM), revealed "Soft Limb Restraints, Both Ankles/Both wrists, Stop After: 24 Hours, Indications: Patient persists in attempt to get OOB/transfer/ambulate unassisted and is at risk for injury."

Review of a physician's order, dated January 20, 2014 timed 01:01, revealed "For sudden aggressive or destructive behavior that puts patient or others in imminent danger. Restraint Type: 2 point locked restraint, diagonal, Left Ankle, Right Wrist, Initial restraint order, Stop After: 4 Hours, Indications: Patient demonstrates behavior which has potential to harm self or others."

Review of MR1 documentation, dated January 20, 2014 timed 5:30 AM, revealed that the patient "has been calm for a few hours. No aggressive behaviors observed so far. Took off 2 point restraints."

Interview on February 28, 2014, at 3:15 PM, with EMP1 confirmed that a "Restraint Plan Of Care Violent/Self Destructive" packet was missing from MR1 and that there was not adequate documentation regarding justification for the continued use of physical restraints on this patient.

Based on review of facility policy, medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to provide adequate justification for the application of physical restraints for one of six medical records reviewed (MR1).

Findings include:

Review on February 28, 2014, of policy "Restraint and Seclusion," dated February 2013, revealed " ... AMH provides resources and guidance to create an environment that will assist in developing systems and processes that attempt to eliminate the inappropriate use of restraint or seclusion. ... Restraint or seclusion will not be used as a means of coercion, discipline, convenience or retaliation by staff or be based on a patient's history of restraint use or dangerous behavior. Restraint or seclusion protects the immediate physical safety of the patient, a staff member, or others and is discontinued at the earliest possible time. ... Restraint or seclusion is only used after alternatives have been considered and/or determined to be ineffective. Staff uses the least restrictive form of restraint or seclusion necessary to protect the patient, staff, or others. Reassessment and reevaluation of patients for the use of alternatives to restraints will be made with a goal of discontinuation. ..."

Review of MR1 revealed that the patient was 91 years old and admitted to the facilty on January 17, 2014. A review of MR1 revealed a "Restraint Plan Of Care Violent/Self Destructive" initial assessment, dated January 19, 2014, that indicated that the patient was identified with Dementia and was "verbally abusive towards staff, refusing to return to ... room after wandering into hall, grabbed a telephone receiver and swung at nursing staff with receiver in ... hand. Restraints initiated at 1630 (4:30 PM). "

Review of a physician's order, dated January 19, 2014 timed 17:00 (5:00 PM), revealed "Soft Limb Restraints, Both Ankles/Both wrists, Stop After: 24 Hours, Indications: Patient persists in attempt to get OOB/transfer/ambulate unassisted and is at risk for injury."

Interview on February 28, 2014, at 3:15 PM, with EMP1, confirmed that there was not adequate justification to initiate and apply physical restraints on this patient.

Based on review of facility policy, medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to discontinue the use of physical restraints at the earliest possible time and failed to provide adequate documentation regarding the continued use of physical restraints for one of six medical records reviewed (MR1).

Findings include:

Review on February 28, 2014, of policy "Restraint and Seclusion," dated February 2013, revealed " ... AMH provides resources and guidance to create an environment that will assist in developing systems and processes that attempt to eliminate the inappropriate use of restraint or seclusion. ... Restraint or seclusion will not be used as a means of coercion, discipline, convenience or retaliation by staff or be based on a patient's history of restraint use or dangerous behavior. Restraint or seclusion protects the immediate physical safety of the patient, a staff member, or others and is discontinued at the earliest possible time. ... Restraint or seclusion is only used after alternatives have been considered and/or determined to be ineffective. Staff uses the least restrictive form of restraint or seclusion necessary to protect the patient, staff, or others. Reassessment and reevaluation of patients for the use of alternatives to restraints will be made with a goal of discontinuation. ..."

Review of MR1 revealed that the patient was 91 years old and admitted to the facilty on January 17, 2014. A review of MR1 revealed a "Restraint Plan Of Care Violent/Self Destructive" initial assessment, dated January 19, 2014, that indicated that the patient was identified with Dementia and was "verbally abusive towards staff, refusing to return to ... room after wandering into hall, grabbed a telephone receiver and swung at nursing staff with receiver in ... hand. Restraints initiated at 1630 (4:30 PM). "

Review of a physician's order, dated January 19, 2014 timed 17:00 (5:00 PM), revealed "Soft Limb Restraints, Both Ankles/Both wrists, Stop After: 24 Hours, Indications: Patient persists in attempt to get OOB/transfer/ambulate unassisted and is at risk for injury."

Review of a physician's order, dated January 19, 2014 timed 21:30 (9:30 PM), revealed "Soft Limb Restraints, Both Ankles/Both wrists, Stop After: 24 Hours, Indications: Patient persists in attempt to get OOB/transfer/ambulate unassisted and is at risk for injury."

Review of a physician's order, dated January 20, 2014 timed 01:01, revealed "For sudden aggressive or destructive behavior that puts patient or others in imminent danger. Restraint Type: 2 point locked restraint, diagonal, Left Ankle, Right Wrist, Initial restraint order, Stop After: 4 Hours, Indications: Patient demonstrates behavior which has potential to harm self or others."

Review of MR1 documentation, dated January 20, 2014 timed 5:30 AM, revealed that the patient "has been calm for a few hours. No aggressive behaviors observed so far. Took off 2 point restraints."

Interview on February 28, 2014, at 3:15 PM, with EMP1 confirmed that a "Restraint Plan Of Care Violent/Self Destructive" packet was missing from MR1 and that there was not adequate documentation regarding justification for the continued use of physical restraints on this patient.