HospitalInspections.org

Based on clinical record review and interview, it was determined the facility failed to ensure three (#1, #2, and #3) of ten (#1-#10) patients in restraints had daily orders for those restraints. The failed practice created the potential for unnecessary restraint use and could affect any patient admitted to the facility. Findings follow.

A. Clinical record review for Patient #1 revealed the patient was in restraints without an order for 6 of 11 days (10/18/12, 10/19/12, 10/20/12, 10/21/12, 10/25/12 and 10/28/12). Findings were confirmed by the Unit 3B Supervisor on 11/13/12 at 1315.

B. Clinical record review for Patient #2 revealed the patient was in restraints without an order for four of seven days (10/25/12, 10/28/12, 10/29/12 and 10/30/12). Findings were confirmed by the Director of Nursing on 11/13/12 at 1420.

C. Clinical record review for Patient #3 revealed the patient was in restraints without an order for four of 12 days (10/28/12, 10/29/12, 10/30/12, and 11/02/12). Findings were confirmed by the Director of Nursing on 11/13/12 at 1425.

Based on review of policy and procedures, interview and clinical record review, it was determined the facility failed to ensure five (#1, #2, #3, #4 and #10) of 10 (#1-#10) patients in restraints were monitored every two hours according to facility policy. The failed practice created the potential for patient injury or death and did not allow the patient to be assessed and released from restraints as early as safely possible and could affect any patient in restraints. Findings follow:

A. Review of policy titled "Restraints/Seclusion" stated, "6.1. Observe the patient's physical and mental status a minimum of every two (2) hours and more frequently as condition warrants. 6.2. Offer fluids and toileting at least every two (2) hours while awake. 6.3. Release restraints, perform range of motion for any restrained joints and physical assessment at least every two (2) hours."

B. Review of Patient #1's clinical record revealed restraint monitoring was not documented on the following:
10/19/12 from 0300 through 2000;
10/20/12 from 0400 through 0715, from 1100 through 1500;
from 1700 on 10/20/12 through 0745 on 10/21/12;
from 1800 on 10/21/12 through 0900 on 10/22/12;
10/23/12 from 0400 through 1413, from 1413 through 1900;
from 2300 on 10/23/12 through 1800 on 10/24/12; and
from 1518 through 1800 on 10/27/12.
Findings were confirmed by the Unit 3B Supervisor on 11/13/12 at 1315.

C. Review of Patient #2's clinical record revealed restraint monitoring was not documented on the following:
10/25/12 from 0600 through 2000;
10/26/12 from 1000 through 1300;
10/28/12 from 1400 through 1800; and
10/29/12 from 0400 through 0800 and 1400 through 1800.
Findings were confirmed by the Director of Nursing on 11/13/12 at 1420.

D. Review of Patient #3's clinical record revealed restraint monitoring was not documented on the following:
10/27/12 from 1000 through 1800, from 1800 on 10/27/12 through 0700 on 10/28/12;
10/29/12 from 0300 through 0830, from 0830 through 1700, from 1700 on 10/29/12 through 1930 on 10/30/12;
10/31/12 from 0300 through 0700, 2100 on 10/31/12 through 0800 on 11/01/12; and
11/05/12 from 0306 through 0700.
Findings were confirmed by the Director of Nursing on 11/13/12 at 1425.

E. Review of Patient #4's clinical record revealed restraint monitoring was not documented on the following:
11/11/12 from 0600 through 0900 and 2100 through 0000 on 11/12/12.
Findings were confirmed by the Unit 3B Supervisor on 11/13/12 at 1100.

F. Review of Patient #10's clinical record revealed restraint monitoring was not documented on the following:
11/12/12 from 1500 through 1800; and
11/13/12 from 0000 through 0300.
Findings were confirmed by the Unit 3B Supervisor on 11/13/12 at 1110.