HospitalInspections.org

Based on policy and procedure review, closed medical record review, and staff interviews, the nursing staff failed to obtain a physician order for 1 of 5 patients restrained (Patient #3).

The findings include:

Review of the hospital's "Restraints, Seclusion and Safety Devices" revised effective date 9/23/13 revealed, "5. APPLICABILITY STATEMENT:...Continuation of restraint use requires a physician order at least every calendar day...8. TIME LIMITED ORDERS: A verbal or telephone order is required from the physician within 30 minutes of the placement of the restraints...If restraints or seclusion are discontinued prior to the expiration of the original order, a new order is obtained prior to reinitiating seclusion or reapplying the restraints and the requirements restart..."

Review of the medical record for Patient #3 revealed a 93 year old female admitted to the hospital on 12/19/2013 for "chemical pneumoritis versus aspiration pneumonoritis." Record review revealed a "Restraint/Seclusion" continuation order for 12/29/13 at 1135. Review of "Restraint/Seclusion Assessment & Monitoring Flowsheet" revealed documentation of restraint placement at "1135, 1335, 1535, 1735, 1935, 2135, 2355, 0135 (new day: 12/30/2013), 0335, 0535, 0735, 0933, 1135, 1335, 1535, 1735, 1935, 2135, 2335, 0135 (new day: 12/31/2013), 0335, 0535, and 0735." Further review of the flowsheet revealed at 0735, "restraint status n.o.(no order)." Review of medical record revealed documentation of a restraint initiation order dated 12/31/13 at 0815. Review of medical record revealed no documentation of a restraint order for 12/30/2013. Further review of the medical record revealed documentation on 12/30/2013 at 731PM, "new order set on chart (restraint order) needs MD signature MD comes later in night XXX made aware." Record review on 12/31/13 at 0700 revealed, "made aware about no order for restraints. RN YYY removed the mitts from patient..."

Interview on 02/26/2014 at 1030 with RN#1 revealed no documentation of a restraint order on 12/30/2013 was available.

Interview on 02/27/2014 at 1300 with Administrative staff #1, revealed "There is not an order for the 30th. A new order should have been obtained verbally with a telephone call."