HospitalInspections.org

Based on record review and interview the facility failed to ensure the use of a physical restraint was in accordance with the patient's plan of care.

Findings include:

Patient #1
Review of nurses notes dated 11/22/10 at 05:57 revealed "Pt has been pleasant and co-operative. Confussed[sic] and delutional[sic] at times... Pt has a posey[sic] and bed alarm on for safety...". Nurses notes dated 11/30/10 at 20:56 revealed "...Bed alarm on for safety. Security vest on, pt stated she did not want vest on. Will continue to monitor this shift." Review of patient's plan of care for Patient #1 did not include any documented evidence for the use of physical restraints.

Review of consultation note from neurology and psychiatry on 11/18/10 revealed "The patient lacks capacity to make decisions related to medical issues and disposition. Starting the process for appropriate guardianship is recommended." Physician note from Staff C (Medical Doctor) responsible for care of patient acknowledges assessment of neurologist and psychiatrist regarding medical issues process for guardianship will commence...."

Review of facility policy titled "Restraint and Seclusion" revealed "Use of restraint or seclusion is based on patient needs and plan of care." Plan of care for admission date 11/13/10 through discharge date 12/2/2010 does not include goals or interventions for the use of physical restraints.

Interview on 1/25/12 at 4 pm with Staff A (Unit Director) and Staff B (Clinical Manager) confirmed the absence of a physician order for use of physical restraints for Patient #1.

Based on record review and interviews the facility failed to ensure the use of a restraint was in accordance with a physician's order and facility policy for 1 patient in an investigation sample of 1. (Patient identifier is #1.)

Findings include:

Patient #1
Review of nurses notes dated 11/22/10 at 05:57 revealed "Pt has been pleasant and co-operative. Confussed[sic] and delutional[sic] at times... Pt has a posey[sic] and bed alarm on for safety...". Nurses notes dated 11/30/10 at 20:56 revealed "...Bed alarm on for safety. Security vest on, pt stated she did not want vest on. Will continue to monitor this shift." Review of patient's plan of care for admission did not include any documented evidence for use of restraints.

Review of physician orders for hospital stay admission date 11/13/10 through discharge date 12/2/2010 revealed the absence of an order for the use a vest restraint.

Review of physician progress notes for the aforementioned admission revealed the absence of documented evidence the physician acknowledged the use of a vest restraint.

Review of consultation note from neurology and psychiatry on 11/18/10 revealed "The patient lacks capacity to make decisions related to medical issues and disposition. Starting the process for appropriate guardianship is recommended." Physician note from Staff C (Medical Doctor) responsible for care of patient acknowledges assessment of neurologist and psychiatrist regarding medical issues process for guardianship will commence...."

Review of facility policy titled "Restraint and Seclusion" subtitle "Non-Violent Non Self Destructive Restraint Guidelines (Medical-Surgical Restraint Guidelines)" revealed "Except in emergency situations the provider is notified in advance by the nurse or access clinician of the need for restraint; a telephone order is obtained and entered into the patient's medical record" Documented evidence of a Physician order for use of restraint was not found.

Interview on 1/25/12 at 4 pm with Staff A (Unit Director) and Staff B (Clinical Manager) confirmed the absence of a physician order for use of physical restraints for Patient #1.