HospitalInspections.org
Bringing transparency to federal inspections
ASCENSION COLUMBIA ST MARY'S HOSPITAL MILWAUKEE CA
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0168
Based on record review and interview, the facility failed to ensure restraints were ordered by a physician according to the facilities policy in 2 of 3 patients in restraints (Patient #1 and #3) in a total of 10 medical records reviewed.
Findings include:
Review of policy titled "Restraint and Seclusion" #6979831, last revised 1/2020, page 4, #4 revealed "All restraints require a provider order." Under Procedure, Page 6, Reassessment of Continued Use or Discontinuation of Restraint #1 revealed "Continued use of restraints beyond the first 24 hours must be authorized by a provider. If the restraints are clinically justified, a new restraint order must be written by the provider... each calendar day."
Review of Patient #1's medical record revealed Patient #1 was in restraints 3/26/20 thru 4/05/20. Review of physician orders revealed no physician order for restraints on 3/28/20 and 4/01/20.
Review of Patient #3's medical record revealed Patient #3 was in restraints 7/26/20 thru 7/30/20. Review of physician orders revealed no physician order for restraints on 7/27/20, 7/29/20 and 7/30/20.
On 8/11/20 at 10:35 AM during interview with Quality Management Director B, Director B stated an "order is needed daily for restraints."
On 8/12/20 at 7:25 AM during interview with Quality Coordinator C, Coordinator C confirmed physician orders were missing in Patient #1 and #3's medical records.
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0187
Based on record review and interview, the facility failed to assess the patient's condition while in restraints according to their policy and procedures in 2 of 3 patient's in restraints (Patient #1 and Patient #3) in a total of 10 medical records reviewed.
Findings include:
Review of policy titled "Restraint and Seclusion" #6979831, last revised 1/2020, page 6 under Procedure revealed "Assessment and documentation of the patient's condition will occur at least every two (2) hours."
Review of Patient #1's medical record revealed Patient #1 was in restraints 3/26/20 thru 4/05/20. Review of medical record documentation titled "Medical Restraints" revealed missing documentation of patient assessments between 3/27/20 at 6 AM thru 3/27/20 at 8 PM, 3/29 20 at 4 PM thru 3/29/20 at 8 PM, 3/30/20 at 2 PM thru 3/30/20 at 5:44 PM, 3/31/20 at 6 AM thru 3/31/20 at 8 PM, 4/03/20 at 4 PM to 4/03/20 at 7 PM, 4/04/20 at 6 AM to 10 AM, 10 AM to 2 PM, 2 PM to 6 PM, and 4/05/20 at 3:30 AM thru 9 AM, 9 AM to 1 PM, and 1 PM to 5 PM.
Review of Patient #3's medical record revealed Patient #3 was in restraints 7/26/20 thru 7/30/20. Review of medical record documentation titled "Medical Restraints" revealed missing documentation of patient assessments between 7/27/20 at 11 PM thru 7/28/20 at 8 AM and 7/30/20 at 4 AM thru 7/30/20 at 8 AM.
On 8/12/20 at 7:25 AM 8:49 AM during interview with Quality Coordinator C, Coordinator C confirmed there was no further restraint documentation in Patient #1 and #3's medical records.