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Based on a review of clinical records, review of facility policies, hospital documentation, and interviews, the hospital failed to protect and promote the rights of eight (8) of ten (10) patients reviewed for restraints.


The facility failed to ensure that restraints were least restrictive, that the patients plan of care was modified to include restraint use, restraints were instituted based on a physician's order, restraints were removed at the earliest possible time, and failed to monitor patients in restraints in accordance with hospital policies.


Cross Reference to A 165, 166, 168, 174, and 175.

Based on a review of clinical records with Nurse Manager #1, interview and policy review for six of ten patients (Patient #1, 2, 3, 4, 7 & 8) reviewed for restraint usage, the hospital failed to ensure that least restrictive restraints were utilized. The findings include the following:

a. Patient #1 presented to the Emergency Department (ED) after falling at home. The ED orders dated 6/25/13 at 11:13 PM directed the use of a sitter secondary to the patient pulling at lines and change of mental status. An untimed physician's order dated 6/26/13 directed the use of bilateral wrist restraints secondary to patient pulling at lines and Foley catheter. Documentation failed to identify less restrictive interventions attempted or rationale for not using alternative measures prior to the application of a bilateral wrist restraints.


b. Patient #2 was admitted on 6/1/13 with Delirium Tremens (DT's). Review of a physician's order dated 12:00 AM indicated the patient was placed in bilateral wrist restraints to prevent the removal of medical device. The record dated 6/1/13 at 4:00 AM identified the patient was placed in a vest restraint due to attempting unsafe ambulation and fall risk. Documentation failed to identify less restrictive interventions attempted or rationale for not using alternative measures prior to the application of a vest restraints.

The restraint monitoring flow sheet dated 6/1/13 at 2:00 PM reflected the patient was in four-point soft restraints and a vest restraint for "agitation". Documentation failed to reflect that less restrictive measures were tried and determined to be ineffective prior to the implementation of double restraints.

c. Patient #3 was admitted on 6/5/13 with respiratory failure and pneumonitis requiring mechanical ventilation. A physician's order dated 6/5/13 directed the use of bilateral wrist restraints to maintain endotracheal tube (ET) placement. The flow sheets dated 6/9/13 at 4:00 AM indicated that the patient was placed in four-point restraints and a vest restraint due to attempting to remove devices and Foley, absent documentation that supported rationale for the double restraints and/or alternative approaches determined to be ineffective to maintain the patient's safety.

Review of the restraint monitoring flow sheets for the period of 6/9/13 at 4:00 AM through 8:00 AM indicated that four point restraints and a vest restraint were in use for "restraints maintained for safety".

d. Patient #4 was admitted on 6/22/13 with hematemesis, DT's and respiratory failure. Review of the physician's orders dated 6/22/13 at 12:00 PM directed a vest restraint be applied to prevent the patient from climbing out of bed. Documentation failed to identify less restrictive interventions attempted or rationale for not using alternative measures prior to the application of a vest restraint.

The record indicated that at 2:00 PM, bilateral wrist restraints were applied due to agitation and to prevent the patient from pulling out lines/catheter. At 6:00 PM the record reflected that the patient was in a vest restraint and four-point soft restraints to prevent the patient from climbing out of bed and pulling out lines. Documentation failed to reflect that less restrictive measures were tried and determined to be ineffective prior to the implementation of double restraints.

Review of the restraint monitoring flow sheets dated 6/22/13 at 6:00 PM through 6/23/13 at 8:00 AM identified the patient was maintained in a vest restraint and four point restraints to "maintain patient safety".

e. Patient #7 was admitted on 7/1/13 with atrial fibrillation. A physician's order dated 7/1/13 directed the use of bilateral wrist restraints secondary to confusion and combative behaviors. Documentation failed to reflect that less restrictive measures were tried and determined to be ineffective prior to the implementation of wrist restraints.

A physician's order dated 7/6/13 at 7:05 PM directed a vest and bilateral wrist restraints secondary to trying to get out of bed unsafely and removing nasal cannula. The patient remained in bilateral wrist restraints and a vest restraint through 7/7/13 at 2:00 PM to "maintain patient safety". Documentation failed to reflect that less restrictive measures were tried and determined to be ineffective prior to the implementation of double restraints.


f. Patient #8 was admitted on 6/12/13 for drug induced delirium. Review of a physician's order dated 6/12/13 directed bilateral wrist restraints and a vest restraint during the period of 6/12/13 at 4:00 PM through 6/13/13 at 11:00 AM for "unsafe ambulation". Documentation failed to reflect that less restrictive measures were tried and determined to be ineffective prior to the implementation of double restraints. Review of the RN reassessment dated 6/13/13 at 8:00 AM and 10:00 AM indicated that the patient required restraints "tries to get out of bed inappropriately". Documentation failed to reflect that less restrictive measures were tried and determined to be ineffective prior to the implementation of double restraints.

Review of the clinical records of Patient # 1, 2, 3, 4, 7 & 8 and interview with Nurse Manager #1 on 7/16/13 at 10:00 AM indicated that the nurse's notes should reflect the interventions attempted and rationale for the restraint usage.

Review of the facility Restraint Policy indicated that the clinical record should reflect a clear progression of the less restrictive interventions attempted.

Based on a review of clinical records, interviews and policy review for eight of ten records reviewed for restraint usage (Patient #1, 2, 3, 4, 5, 7, 8, and 9), the hospital failed to modify the plan of care when restraints were implemented. The findings include the following:


a. Patient #1 was admitted on 6/26/13 after falling at home. Review of a physician's order dated 6/26/13 directed the use of bilateral wrist restraints for pulling at lines and change of mental status. The record reflected that the patient arrived to the ICU at 4:00 AM with restraints in place. Review of the restraint monitoring flow sheets dated 6/26/13 through 6/28/13 indicated that the patient remained in bilateral wrist restraints. Review of the plan of care dated 6/26/13 and 6/27/13 included active problems related to multi-system failure, pain, fall risk, anxiety, knowledge and nutrition.

The clinical record failed to identify that a care plan was developed to address the use of restraints.


b. Patient #2 was admitted on 6/1/13 with Delirium Tremens (DT's). A physician's order dated 6/1/13 at 12:00 AM directed bilateral wrist restraints secondary to device removal. A physician's order dated 6/1/13 at 4:29 AM directed the use of a vest restraint for attempting unsafe ambulation and fall risk. Restraint monitoring flow sheets dated 6/1/13 at 2:00 PM identfied the patient was in four-point soft restraints, absent a physician's order, and a vest restraint.

The clinical record failed to identify that a care plan was developed to address the use of restraints.

c. Patient #3 was admitted on 6/5/13 with respiratory failure and pneumonitis requiring mechanical ventilation. A physician's order dated 6/3/13 directed the use of bilateral wrist restraints to maintain ET tube placement. A physician's order dated 6/9/13 directed the use of four-point restraints and a posey. Review of the restraint monitoring flow sheets for the period of 6/9/13 at 4:00 AM through 8:00 AM indicated that the patient remained in four-point restraints and a vest restraint for "safety".


The clinical record failed to identify that a care plan was developed to address the use of restraints.


d. Patient #4 was admitted on 6/22/13 with hematemesis, DT's and respiratory failure. Review of the physician's orders dated 6/22/13 at 12:00 PM directed a vest restraint be applied to prevent the patient from climbing out of bed. The record indicated that at 2:00 PM, bilateral wrist restraints were applied due to agitation and to prevent the patient from pulling out lines/catheter. At 6:00 PM the record noted the patient remained in a vest restraint and four-point soft restraints to prevent the patient from climbing out of bed and pulling out lines.

The clinical record failed to identify that a care plan was developed to address the use of restraints.

e. Patient #5 was admitted on 6/30/13 for respiratory failure secondary to anoxic brain injury and required mechanical ventilation. Review of the clinical record indicated that the patient had bilateral wrist restraints in place during the period of 6/30/13 through 7/14/13 while being mechanically ventilated to maintain ET tube placement in accordance with physician's orders. The clinical record indicated that bilateral wrist restraints were discontinued on 7/14/13. On 7/15/13 at 10:40 AM, Patient #5 was observed in bilateral wrist restraints. Interview with the RN #3 on 7/16/13 at 11:45 AM indicated that the patient had been placed in restraints on 7/15/13 at 2:00 PM.

The clinical record failed to identify that a care plan was developed to address the use of restraints.

f. Patient #7 was admitted on 7/1/13 with atrial fibrillation. A physicians order dated 7/6/13 directed bilateral wrist restraints secondary to confused and combative behaviors. The restraint monitoring flow sheet dated 7/6/13 at 7:05 PM indicated that the patient remained in bilateral wrist restraints and a vest restraint secondary to trying to get out of bed unsafely and removing nasal cannula.

The clinical record failed to identify that a care plan was developed to address the use of restraints.

g. Patient #8 was admitted on 6/12/13 for drug induced delirium. A physician's order dated 6/12/13 at 4:00 PM directed a vest restraint and bilateral wrist restraints for unsafe ambulation. The monitoring flowsheets reflected the patient remained in bilateral wrist restraints and a vest restraint during the period of 6/12/13 at 4:00 PM through 6/13/13 at 11:00 AM when the restraints were discontinued.


The clinical record failed to identify that a care plan was developed to address the use of restraints.

h. Patient #9 was admitted on 6/24/13 with gastroenteritis and respiratory failure. A physician's order 6/24/13 at 4:00 AM directed the use of bilateral wrist restraints for restlessness and pulling at lines. The restraint monitoring flow sheets indicated that Patient #9 remained in bilateral restraints through 6/27/13 at 2:00 PM.

The clinical record failed to identify that a care plan was developed to address the use of restraints.


Interview with Vice President of Patient Care Services on 7/16/13 at 1:00 PM stated s/he was unable to locate careplan's related to restraint use for Patient #1, 2, 3, 4, 5, 7, 8, and 9. Interview with the VP of Patient Care Services on 7/16/13 at 2:00 PM indicated that the electronic record does not have an option to generate a plan of care for restraints. Subsequent to inquiry the Information Technology (IT) department was contacted to make adjustments to the care plan options.

Review of the Restraint policy indicated under the documentation guidelines there should be a modification of the plan of care.

Based on a review of clinical records, interview and policy review for three of ten patients (Patients #2, 3, and 9) reviewed for restraint usage, the hospital failed to ensure restraints were applied based on a physician's order. The findings include the following:

a. Patient #2 was admitted on 6/1/13 with Delirium Tremens. Review of a physician's order dated 6/1/13 at 12:00 AM indicated the patient was placed in bilateral wrist restraints to prevent the removal of medical device. At 4:00 AM, the patient was placed in a vest restraint due to attempting unsafe ambulation and fall risk. Review of the restraint monitoring flow sheets indicated that on 6/1/13 at 12:00 PM the patient was in four-point soft restraints and a vest restraint. The record failed to identify an order for the use of four point restraints.

b. Patient #3 was admitted on 6/5/13 with respiratory failure and pneumonitis requiring mechanical ventilation. The clinical record indicated that the patient was placed in bilateral wrist restraints to maintain ET tube placement. Review of the restraint monitoring flow sheets indicated that the patient remained in bilateral wrist restraints thru 6/13/13, absent a physician's order for continued restraints.

c. Patient #9 was admitted on 6/24/13 with gastroenteritis and respiratory failure. A physician's order dated 6/24/13 directed bilateral wrist restraints secondary to restless behaviors. The restraint monitoring flow sheets indicated that Patient #9 remained in bilateral restraints through 6/27/13 at 2:00 PM. Review of the record failed to reflect an order for the bilateral wrist restraints on 6/27/13.

Interview with Nurse Manager #1 on 7/16/13 at 10:00 AM identified that a physician's order should be obtained for restraints.

Review of the restraint policy directed that there must be an order for restraints and should be renewed every 24 hours based on the physician/LIP evaluation.

Based on a review of clinical records, interview and policy review for seven of ten patients (Patient #1, 2, 3, 4, 7, 8 & 9) reviewed for restraint usage, the hospital failed to ensure restraints were discontinued at the earliest possible time. The findings include the following:

a. Patient #1 presented to the Emergency Department (ED) on 6/25/13 after falling at home. The ED orders dated 6/25/13 at 11:13 PM directed the use of a sitter secondary to the patient pulling at lines and change of mental status. An untimed physician's order dated 6/26/13 directed the use of bilateral wrist restraints secondary to patient pulling out lines. Review of the flow sheets dated 6/27/13 at 8:00 AM through 6/28/13 8:00 AM identified the patient remained in bilateral wrist restraints with behaviors documented as "calm" for the 24 hour period. The record failed to reflect attempted reduction in the use of restraints based on observation of the patients behaviors.

b. Patient #2 was admitted on 6/1/13 with Delirium Tremens (DT's). Review of the clinical record indicated that on 6/1/13 at 10:00 PM the patient was placed in a SOMA bed. A physician's order dated 6/1/13 at 11:12 PM directed the use of a SOMA bed unsafe ambulation and fall risk. The restraint monitoring flow sheets indicated that for the period of 12:00 AM on 6/2/13 through 6:00 AM the patient was identified as sleeping however remained restrained. Documentation failed to support the rationale why Patient #2 continued to be restrained when s/he was sleeping.



c. Patient #3 was admitted on 6/5/13 with respiratory failure and pneumonitis requiring mechanical ventilation. A physician's order dated 6/5/13 directed the use of bilateral wrist restraints to maintain endotracheal tube (ET) placement. The flow sheets dated 6/9/13 at 4:00 AM indicated that the patient was placed in four-point restraints and a vest restraint due to attempting to remove medical devices. Review of the restraint monitoring flow sheets for the period of 6/9/13 at 4:00 AM through 8:00 AM indicated that four point restraints and a vest restraint remained in use for "safety". Behaviors exhibited by the patient during this time were described as quiet and/or anxious. Documentation failed to reflect attempted reduction in the use of restraints based on observation of the patients behaviors.


In addition, review of the restraint monitoring flow sheets for the period of 6/9/13 at 12:00 PM through 6/12/13 at 2:00 AM indicated that the patient remained in four-point restraints for behaviors described as "anxious", protect ET tube, restless, sleeping, and agitated. Documentation failed to reflect attempted reduction in the use of restraints based on observation of the patients behaviors.

d. Patient #4 was admitted on 6/22/13 with hematemesis, DT's and respiratory failure. A physician's order dated 6/22/13 at 2:00 PM directed the use of a vest restraint and four-points restraints for agitated behaviors and to prevent the patient from climbing out of bed. Review of the restraint monitoring flow sheets dated 6/23/13 during the period of 6:00 AM through 2:00 PM described the patient as "calm", however the patient remained in a vest restraint and four point restraints. Documentation failed to reflect attempted reduction in the use of restraints based on observation of the patients behaviors.

e. Patient #7 was admitted on 7/1/13 with atrial fibrillation. The record reflected that the patient remained in bilateral wrist restraints and a vest restraint through 7/7/13 at 2:00 PM to "maintain patient safety" in accordance with the physician's order. The restraint flow sheet dated 7/6/13 at 8:00 AM and 10:00 AM identfied that although the patient was "sleeping", the patient remained in bilateral wrist restraints and a vest restraint. Documentation failed to reflect attempted reduction in the use of restraints based on observation of the patients behaviors.

f. Patient #8 was admitted on 6/12/13 for drug induced delirium. A physician's order dated 6/12/13 directed the use of bilateral wrist restraints and a vest restraint for unsafe ambulation. Review of the record reflected that during the period of 6/13/13 from 2:00 AM through 11:00 AM, the patient was "calm", although remained in bilateral wrist restraints and a vest restraints. Documentation failed to reflect attempted reduction in the use of restraints based on observation of the patients behaviors.

g. Patient #9 was admitted on 6/24/13 with gastroenteritis and respiratory failure. A physician's order 6/24/13 at 4:00 AM directed the use of bilateral wrist restraints for restlessness and pulling at lines. During this period of 12:00 PM through 6:00 PM on 6/24/13, the patient remained in bilateral wrist restraints while asleep. The monitoring flow sheets indicated the patient remained in bilateral wrist restraints on 6/26/13 at 8:00 PM through 6/27/13 at 2:00 PM with the behaviors identified as suspicious or anxious. Documentation failed to reflect attempted reduction in the use of restraints based on observation of the patients behaviors.

Interview with Nurse Manager #1 on 7/16/13 at 10:00 AM indicated that s/he acknowledged that the clinical records failed to reflect attempts to decrease the use of restraints.

Review of the restraint policy directed that restraints and seclusion should be discontinued at the earliest possible time regardless of the length of time ordered.

Based on a review of clinical records, interview and policy review for four of ten (Patients #1, 2, 5, and 7) patients reviewed for restraint usage, the hospital failed to ensure patients were monitored in accordance with hospital policy. The findings include the following:


a. Patient #1 presented to the Emergency Department (ED) after falling at home. The ED orders dated 6/25/13 at 11:13 PM directed the use of a sitter secondary to the patient pulling at lines and change of mental status. Review of the electronic medical record indicated that on 6/26/13 at 1:32 AM, the patient was trying to get out of bed and had pulled out his/her IV line. A nurse's note dated 6/26/13 at 4:02 AM indicated that Patient #1 arrived to the nursing unit from the ED with bilateral wrist restraints in place. Review of the ED record and interview with Nurse Manager #2 on 7/16/13 at 11:00 AM indicated that the ED record failed to identify that the patient had been placed in restraints and/or any monitoring of the patient while in restraints was completed. The Manager stated that although ED staff had the ability to document restraint monitoring of the behavioral health patient in the electronic medical record, staff did not have access to a monitoring flow sheet for medical restraints. Subsequent to inquiry, IT added access for ED staff to document monitoring checks for medical restraints in the electronic record.

b. Patient #2 was admitted on 6/1/13 with Delirium Tremens (DT's). Review of a physician's order dated 12:00 AM indicated the patient was placed in bilateral wrist restraints to prevent the removal of medical device. The record dated 6/1/13 at 4:00 AM identified the patient was placed in a vest restraint while remaining in bilateral wrist restraints due to attempting unsafe ambulation and fall risk. The clinical record failed to identify that the patient's every two hour monitoring check was completed on 6/1/13 at 8:00 AM in accordance with hospital policy.

c. Patient #5 was admitted on 6/30/13 for respiratory failure secondary to anoxic brain injury and required mechanical ventilation. Review of the clinical record indicated that the patient had bilateral wrist restraints in place during the period of 6/30/13 through 7/14/13 while being mechanically ventilated to maintain ET tube placement in accordance with physician's orders. The clinical record indicated that bilateral wrist restraints were discontinued on 7/14/13. On 7/15/13 at 10:40 AM, Patient #5 was observed to be restrained in bed with bilateral wrist restraints. Interview with the RN #3 on 7/16/13 at 11:45 AM indicated that the patient had been placed in restraints on 7/15/13 at 2:00 PM. Review of the clinical record with Nurse Manager #1 lacked documentation that the patient was monitored every two-hours during the period of 7/15/13 at 2:00 PM through 7/16/13 at 10:45 AM.

d. Patient #7 was admitted on 7/1/13 with atrial fibrillation. The clinical record indicated that the patient was placed in bilateral wrist restraints secondary to confused and combative behaviors and remained in bilateral wrist restraints through 7/3/13 at 10:00 PM. Review of the restraint flow sheets failed to identify that the patient was monitored on 7/3/13 at 8:00 AM and 10:00 AM.

In addition, the restraint monitoring flow sheets dated 7/6/13 at 8:30 AM identified the patient was placed in bilateral wrist restraints to prevent removal of medical devices. The clinical record failed to reflect restraint monitoring was completed on 7/6/13 at 12:00 PM.


Review of the restraint policy directed care and range of motion should be provided every two hours.