HospitalInspections.org

Based on interview and record review the nursing staff failed to keep a care plan current in
1 of 3 patients reviewed. (Patient ID# 1)

Findings include:

Interview 10/3/11 at 8:15 a.m. with Patient ID# 1's daughter revealed her 85 year-old father had back surgery at St. Luke's Hospital in June 2011. The daughter stated the family visited her father on the morning of June 12th, 2011 and noticed a strap had been placed across the patient's waist and connected to the sides of the bed. The nursing staff explained to the daughter that the strap was referred to as a "Gentle Reminder." The daughter was upset because her father was not confused and the device resembled a restraint limiting the patient's movement.

Record review of a nursing " patient care flow sheet " dated 6/12/11 at 7:30 a.m. stated " gentle reminder on. " The nursing care plan identified the patient as a fall risk but the interventions did not include the use a "Gentle Reminder" strap across his waist. The nursing notes failed to document why it became necessary to use a "Gentle Reminder."

The Risk Manager (ID# 50) acknowledged 10/3/11 at 11:15 a.m. that a "Gentle Reminder" is a seatbelt with a quick release snap. The staff member further stated the "Gentle Reminder" is not classified as a restraint and that the hospital does not have a specific policy regarding the use of this device.

Record review of a policy titled " Restraint " dated June 2011 stated the Purpose:
" Promote a safe, consistent, patient-oriented approach to the use of restraints that preserves the patient's rights, dignity and well-being during restraint use; ...." The restraint policy also provided a list of exclusions for devices that were not classified as a restraint. A "Gentle Reminder" was not classified as an exclusion to a restraint.