HospitalInspections.org

Based on medical record review, interview and policy review the facility failed to ensure that the patient's plan of care was changed and updated for 1 out of 4 (#8) restrained inpatients, resulting in the potential for an ineffective treatment plan for restrained patients. Findings include:

On 1/14/15 at 1000 during review of patient #8's medical record it was revealed that the patient was admitted on 12/13/14 and was still currently an inpatient at the facility. The patient was placed in restraints on admission per a physician's order. The patient's medical record showed that the patient has remained in restraints. During review of patient #8's medical record it was also revealed that there was no plan of care initiated on admission on 12/13/14 and for the dates of 12/14/14-12/19/14, 12/21/14-1/3/15, 1/5/15 and 1/6/15 there were no updates to the patient's plan of care per the facility's policy.

On 1/14/15 at 1015 during an interview with staff E when queried as to how often a restrained patient's care plan should be updated, she replied, "They should be updating the plan of care every shift." When asked if there were any care plans available for review for the dates listed above, to which she replied, "No."

On 1/14/15 at 1230 during policy review, it was revealed in the policy titled, "Restraint Use for Non-Violent/Non-Self Destructive Behavior in the Non-Psychiatric, Medical/Surgical Healthcare Setting," with an effective date of 1/22/13, stated under, "Appendix A: Non-Violent/Non-Self Destructive Behavior," under the section, "Monitoring of Continued Need: Documentation on the EMR (electronic medical record) Restraint Plan of Care (or appropriate downtime form) is required on initiation and q (every) shift throughout episode of restraint use."

Based on medical record review, interview and policy/procedure review the facility failed to ensure that restraint orders were renewed per facility policy for 2 out of 4 (#8 and #9) restrained inpatients, resulting in the potential for patients to be restrained without a physician order. Findings include:

On 1/14/15 at 1000 during review of patient #8's medical record it was revealed that the patient was admitted on 12/13/14 and was still currently an inpatient at the facility. The patient was placed in restraints on admission per a physician's order. The patient's medical record showed that the patient has remained in restraints and it was revealed that on 12/22/14, 12/23/14, 1/4/15, 1/7/15, 1/8/15, 1/9/15 and 1/12/15 there were no physician orders to renew restraints, per facility policy.

On 1/14/14 at 1015 during an interview with staff E, when asked if any physician orders were available for review for the dates listed above, she replied, "No, I don't see any."

On 1/14/15 at 1030 during review of patient #9's medical record it was revealed that the patient was admitted on 1/1/14 and was still currently an inpatient at the facility. The patient was placed in restraints on admission per a physician's order. The patient's medical record showed that the patient has remained in restraints and it was revealed that on 1/2/15, 1/3/15, 1/7/15 and 1/9/15 there were no physician orders to renew restraints, per facility policy.

On 1/14/15 at 1045 during an interview with staff E, when queried as to if there were any further restraint orders available for review for the dates listed above, she responded, "No, they aren't there."

On 1/14/15 at 1230 during policy review, it was revealed in the policy titled, "Restraint Use for Non-Violent/Non-Self Destructive Behavior in the Non-Psychiatric, Medical/Surgical Healthcare Setting," with an effective date of 1/22/13, stated under the section "Non-Violent/Non Self-Destructive Behavior Orders: ....4 A physician's/MLP (mid-level practitioner) designee's order is required to order, change, continue, and discontinue restraint... 5 A restraint order is good for a maximum of one calendar day... Continued use of restraint beyond the first day requires an order by the physician/MLP designee no less than once every calendar day based on his/her face-to-face assessment of the patient."

Based on medical record review, interview and policy/procedure review the facility failed to ensure that restrained patients were monitored and assessed per the facility policy for 2 out of 4 (#8 and #9) restrained inpatients. Resulting in the potential for harm to patients in restraints. Findings include:

On 1/14/15 at 1000 during review of patient #8's medical record it was revealed that the patient was admitted on 12/13/14 and was still currently an inpatient at the facility. The patient was placed in restraints on admission and has remained in restraints. It was revealed that there had been no documented two-hour assessment checks completed on the patient.

On 1/14/15 at 1030 during review of patient #9's medical record it was revealed that the patient was admitted on 1/1/14 and was still currently an inpatient at the facility. The patient was placed in restraints on admission and has remained in restraints. It was revealed that there had been no documented two-hour assessment checks done on the patient.

On 1/14/15 at 1045 during an interview with staff E, when queried if there was any documentation available for review in regards to the required two-hour assessments for the patient's aforementioned, she responded, "No, the restraint orders were not properly ordered and therefore the computer failed to initiate the required two-hour assessment check list."

On 1/14/15 at 1230 during policy review, it was revealed in the policy titled, "Restraint Use for Non-Violent/Non-Self Destructive Behavior in the Non-Psychiatric, Medical/Surgical Healthcare Setting," with an effective date of 1/22/13, stated under, "Patient Care During Restraint:.... 2 When the restraint is in place, the patient is assessed, monitored and re-evaluated based on the patient's care needs, at a minimum of every two (2) hours." Further review revealed, "Appendix A: Non-Violent/Non-Self Destructive Behavior," under the section, "Nursing Assessment and Documentation Required: On-going throughout the episode of restraint. Assessment required minimally q (every) 2 hrs. Includes assessment of continued need, comfort level, level of distress/agitation, mental status..."