HospitalInspections.org

Based on record review and interview patient care staff placed the index patient in restraints without an order from medical staff.

Findings:

-Review of the medical record completed on 8/8/2020 revealed that staff placed the index patient in four- point restraints on 2/24/2020 sometime after 0730. An additional episode of agitation occurred at 1739; the patient was again placed in four- point restraints. There were no orders in the medical record from a physician or other medical provider for the application of restraints during these episodes.



-Review of the facility policy entitled "Patient Restraints Medical Violent and Seclusion" dated October 2019 indicates in Section ll "Restraints for Violent Behavior", that a physician's order is required for restraint (Form #E0574) and will include the following information:
-Time Limitations
-Goals of restraint/seclusion
-Conditions for release
-Types of restraint used
-Signatures, dates, and times of order


-The hospital's Director of Patient Safety confirmed on interview on 6/17/2020 at 1100
that a physician/provider order for four point restraints was not obtained for the index patient.

Based on medical record review and interview patient care staff failed to document on going assessment and monitoring of the index patient during the time periods the patient was in restraints (episodically between 2/24/2020 and 3/4/2020)

-Review of the patient's medical record conducted on 6/17/2020 indicate that Nursing Assessment and Documentation were not completed per policy during two episodes of restraint on 2/25/2020. (approximately 0730 and 1946). There were similar findings on 2/25, 2/27, 2/28, 2/29, 3/1, 3/2 & 3/4.

-Review of the facility policy entitled "Patient Restraints Medical Violent and Seclusion" dated October 2019, Section B "Nursing Assessment and Documentation" indicates minimal timeframes for assessment and monitoring of the patient be conducted and documented on the Restraint Flow Sheet-Violent. The following content is to be included in the assessment and monitoring:
-Behavioral Observation
-Restraint Device
-Limb Restraint
-Range of Motion for limb restraint
-Restraint Release
-Position/Comfort of patient
-Offer food/fluids
-Offer toileting
-Provide hygiene
-Assess respiratory effort
-Assess need to continue restraint
-Document comment as to behavior that justifies continuation of restraint on tool
-Reason Restraint discontinued
-Debriefing form
-Restraint Log

-The Director of Patient Safety stated on interview on 6/17/2020 at 1100 that there was no patient restraint flowsheet in the medical record and could not verify that one was completed.