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Based on staff interview and document review, it was determined the facility failed to ensure it modified each patient's plan of care when using restraints in two (2) of two (2) medical records reviewed of patients in restraints in the survey sample Patient # 1 and 2).

Findings:

Two (2) medical record of patients in restraints were reviewed. The medical record for Patient #1 contained documentation that the patient was placed in bilateral soft wrist restraints on November 02, 2024 at 3:09 PM for pulling at medical devices. The patient continued in restraints November 03, 04, and 05, 2024. The patient's plan of care was not updated to include the use of restraints until November 04, 2024 (two days after restraints were initiated).

The medical record for Patient #2 contained documentation that the patient was placed in bilateral soft upper wrist restraints around midnight on November 10, 2024 for pulling at medical devices. The patient's care plan was not modified to include the use of restraints until 5:11 PM on November 10, 2024.

The hospital's policy, Restraints and Seclusion was reviewed and reads in part: Documentation 1. Each episode of restraint or seclusion use is documented in the patient's medical record. 2. The use of restraint or seclusion must be in accordance with a written modification to the patient's plan of care following the initiation of restraints.

An interview with Staff Member #1 on December 12, 2024 revealed the patient's plan of care should be updated when restraints were initiated and reviewed and updated each calendar day.

Based on staff interview and document review, it was determined the hospital failed to ensure each patient in restraints was monitored according to hospital policy in one (1) of two (2) medical records reviewed of patients who were in restraints in the survey sample (Patient #2).

Findings:

The hospital's policy, Restraints and Seclusion was reviewed and reads in part: "Monitoring...The following will be monitored and documented every 2 hours (within 15 minutes before or after) or more often as indicated by patient condition: a. respiratory and circulatory status; b. skin condition; c. correct application of restraint; d. restraint release/repositioning and range of motion; e. nutrition (at meal time or when snacks are offered between meals); f, hydration (when offered); g. elimination needs; h. psychological well-being; i. vital signs as indicated; j. readiness for discontinuation of restraint."

The medical record for Patient #2 contained documentation that the patient was placed in bilateral soft upper wrist restraints around midnight on November 10, 2024 for pulling at medical devices. From 8:00 AM to 8:00 PM on November 10, 2024 the medical record contained documentation that the patient was monitored every three (3) hours instead of every two (2) hours as required by hospital policy.

An interview was conducted with Staff Member #1 on November 12, 2024 who confirmed monitoring of restraints should occur every two (2) hours.