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Based on record review and interview, the facility failed to assure a physician order was in place for use of behavioral restraints in one of one restrained patient.


Findings include:

Review of policy F80.0, " Use of Restraints, " revealed the following: " Upon notification, the primary physician or licensed independent practitioner reviews with the RN (Registered Nurse) the physical and psychological status of the patient. Together they determine whether restraints are required and the physician supplies the order, verbal or written. " (page 9, paragraph 1)

Review of patient #1 ' s medical record revealed the patient was placed in behavioral restraints 10:00pm on 3/22/11 until 1:00am on 3/23/11. Restraints were in place for a total of three hours, while the patient was in the Emergency Department. No physician order for restraints was documented.

During an interview on 5/3/11 at 11:45am in the Quality Office, staff #1 confirmed that patient #1 was restrained, that a physician order was required for initiation of restraints, and that there was no documented physician order on patient #1 ' s chart.

During an interview on 5/3/11 at 12:00 noon in the Quality Office, staff #2 confirmed that patient #1 was restrained, that a physician order was required for initiation of restraints, and that there was no documented physician order on patient #1 ' s chart.

Based on record review and interview, the facility failed to assure one of one patient in behavioral restraints was monitored according to hospital policy.


Findings include:

Review of policy F80.0, " Use of Restraints, " revealed the following: " Licensed nursing staff will re-assess the patient and every 15 minutes thereafter. Assessment and re-assessment findings will be documented. The assessment and re-assessment includes: signs of injury associated with application of restraint, circulation, ROM (range of motion) of extremities, vital signs, nutrition/hydration, hygiene/elimination, physical and psychological status and comfort, readiness for discontinuation of restraint. " (page 9, paragraph 4)

Review of patient #1 ' s medical record revealed the patient was placed in behavioral restraints 10:00pm on 3/22/11 until 1:00am on 3/23/11. Restraints were in place for a total of three hours, while the patient was in the Emergency Department. Restraint re-assessments were not documented per facility policy

During an interview on 5/3/11 at 11:45am in the Quality Office, staff #1 confirmed that patient #1 was restrained. Staff #1 also confirmed restraint re-assessments were not documented per facility policy.

During an interview on 5/3/11 at 12:00 noon in the Quality Office, staff #2 confirmed that patient #1 was restrained. Staff #2 also confirmed restraint re-assessments were not documented per facility policy.