HospitalInspections.org

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined that UPMC Altoona failed to document the discontinuation of restraints at the earliest time possible, based on documented reassessments for two of four medical records reviewed (MR2, MR4), and failed to document every two hour reassessments as described in their adopted restraint policy for one of four medical records reviewed. (MR4)

Findings include:

A review of UPMC Policy and Procedure Manual Policy: HS-NA0416. Tittle: Nursing Subject: Restraint and Seclusion. Date: February 27, 2015 "... V III, Use of Restraint for Non Violent/Non Self-Destructive Behavior. A. Order (Written/Computerized Provider Order Entry or CPOE) A physician order, order of a CRNP or order of a PA is required for restraint use. 1. The order will include: a. type of restraint ... b. reason for use or continuation c. date and time of order 2. Restraint use is to be discontinued at the earliest possible time, based on individualized assessment that the individuals needs can be addressed using less restrictive methods, regardless of the length of time identified in the order ... B. Initial Patient Assessment. 1. An assessment of the patient at the initiation of restraint is required and will include the following and be documented in the medical record: b. Concrete, objective observations of the patient's behavior. c. The reason for the use of restraint. d. Any alternative methods employed to avoid restraint use and the effectiveness of those methods. e. Physical limitations that would preclude the use of a particular restraint. f. Discussion with the patient and/or family when feasible. g. Type of restraint, reason, time and date of application. ... D. Ongoing Patient Assessment and Care Interventions ... 4. The continued need for the use of restraint for Non Violent/Non Self-Destructive behavior will be reassessed and documented in the medical record at the following frequencies or more often as the patient condition requires. a. Non Violent/Non Self-Destructive behavior - every 2 hours ... E. Discontinuation of Restraint 1. The RN or physician, CRNP, or PA may discontinue the restraint if the criteria for discontinuation have been met. 2. The time and criteria for release will be documented when the restraints are removed ... ."

1. MR2 revealed that the patient was ordered soft bilateral wrist restraints on September 6, 2015, at 6:50AM. Subsequent assessment documentation dated September 7, 2015, beginning at 8:00AM, revealed that the patient was quiet, calm, no longer attempting to discontinue therapeutic interventions and was no longer demonstrating actions that could impede recovery/healing. However, during the same period,documentation indicated that the patient remained restrained.

2. MR4 revealed at least two restraint episodes in which the patient was ordered soft bilateral wrist restraints on September 12, 2015, at 9:24 AM, and September 12, 2015, at 11:47 PM. Reassessment documentation dated September 12, 2015, from 10:00AM to 10:00 PM, and September 13, 2015, at 8:00AM, 10:00AM, and 12:00 PM, revealed the patient was quiet, calm, no longer attempting to discontinue therapeutic interventions and was no longer demonstrating actions that could impede recovery/healing. However, during the same period, documentation indicated that the patient remained restrained.

3. Continued review of MR4 revealed no restraint reassessment documentation on September 13, 2015, from 2:00AM through 6:00AM.

4. An interview was conducted with EMP6, on October 7, 2015 at 2:00 PM. EMP6 confirmed the above finding and agreed that the medical records contained no documentation for the continued use of restraints in MR2 & MR4.