HospitalInspections.org

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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that patient care staff members monitored patients restrained for violent/self-destructive behavior every 15 minutes as directed by hospital policy, as demonstrated by 4 of 5 patients reviewed (Patients #1, #2, #3, #4).

Failure to follow approved policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Review of the hospital's policy and procedure titled, "Restraint - Seclusion Policy," Policy #6516441 revised 06/11/19, showed when patients were placed in restraints and/or seclusion due to violent/self-destructive behavior, staff would monitor and document the patient's condition every 15 minutes in the patient's medical record. The documentation was to include signs of injury from application of the restraint or seclusion; appropriate placement of restraint devices; the patient's physical and psychological status and comfort; and the patient's readiness for discontinuation of the restraints.

2. On 10/01/19, the investigator reviewed the medical records of five patients who had been restrained due to violent/self-destructive behavior during their hospital stay. The review showed that patient care staff members did not document the condition of Patients #1, #2, #3, and #4 every 15 minutes while the patients were in restraints according to hospital policy.

3. On 10/01/19 at 4:00 PM during an interview with the investigator, the hospital's Accreditation Manager (Staff #1) nurse manager confirmed that staff had not followed the hospital's restraint policy and procedure while caring for the patients above.
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