HospitalInspections.org

Based on medical record reviews, interviews and document review, it was determined the facility failed to document the notification to the family concerning the application of restraints in one (1) out of five (5) medical records reviewed for the usage of restraints. Specifically, there was no documentation that the family of MR2 was notified of the usage of restraints.

The findings:

A review of the facility's policy entitled, "Restraints for Nonviolent, Non-Self-Destructive Patient Situations: Medical Use of Restraints," effective date February 10, 2025, reads, in part:
... "G. Plan of Care/Patient Education....
... 3. The patient/family will be educated on the use of restraints, on an individual basis while their preferences and insights related to prevention and alternatives will be incorporated into the plan of care, whenever possible. All education is documented in the medical record."

A review of the medical record of MR2 revealed the usage of nonviolent restraints documented in the flowsheet on February 13, 2025, at 8:24 P.M. There is no documentation on the flowsheet that the family was notified. There is no documentation in the plan of care that MR2's family was notified of the usage of restraints.

During an interview on June 2, 2025, Employee (EMP) 1 indicated that there should have been a notation in the medical record, on the flowsheet and in the plan of care, that MR2's family was notified of the usage of restraints.

During an interview on June 2, 2025, at 12:15 P.M., EMP3 confirmed documentation of notification to MR2's family was absent from MR2's flowsheet and the plan of care.

Based on medical record reviews, interviews and document reviews, it was determined the facility failed to obtain an order for a restraint in one (1) out of five (5) medical records reviewed for the usage of restraints. Specifically, there was no order for a hold involving Patient (MR) 6.

The findings:

The facility's policy entitled, "Restraints or Seclusion for Violent, Self-Destructive Patient Situations," effective date April 29, 2025, reads, in part:
... "D. Restraint or Seclusion Order (to manage violent or self-destructive behavior)
1. Any type of violent restraint including, but not limited to, 4-point restraints, chemical restraints, physical hold, or use of force in order to medicate a patient, seclusion, etc. requires a provider order."

A review of the medical record for MR6 on June 2, 2025, revealed an entry on the flowsheet of a physical hold on June 4, 2024, at 4:10 P.M. The medical record did not contain documentation of a physician order for the physical hold.

During an interview on June 3, 2025, EMP1 confirmed the lack of an order for a physical hold in the medical record of MR6.

During an interview on June 3, 2025, at 11:20 A.M., EMP5 confirmed an physician order was required for the physical hold of MR6 that occurred on June 4, 2024.

Based on medical record reviews, interviews and document review, it was determined the facility failed to document the less restrictive interventions employed prior to the usage of a restraint in one (1) out of five (5) medical records reviewed. Specifically, there was no documentation that less restrictive interventions were attempted prior to using a restraint on Patient (MR) 2.

The findings:

A review of the facility's policy entitled, "Restraints for Nonviolent, Non-Self Destructive Patient Situations: Medical Use of Restraints," effective date February 10, 2025, reads, in part:
... "C. Alternatives - Least Restrictive
1. The organization's culture promotes a physical and social environment that minimizes the use of restraint through preventive or alternative strategies. The use of restraint occurs when other less-restrictive interventions have been attempted but found ineffective for providing a safe and therapeutic environment for the patient, staff, and others."

A review of the medical record for MR2 revealed there was no documentation on the flowsheet of less restrictive alternatives to a restraint on February 13, 2025, at 8:24 P.M., prior to the initiation of a restraint on MR2. There is no documentation in the medical record that less restrictive alternatives to restraint were attempted prior to the initiation of the restraint.

During an interview on June 2, 2025, Employee (EMP) 1 indicated that there should have been a notation in MR2's medical record and on the flowsheet that less restrictive alternatives were attempted prior to the usage of a restraint.

During an interview on June 3, 2025, at 11:20 A.M., EMP5 indicated that less restrictive alternatives should be attempted prior to initiating restraints on a patient. EMP5 further indicated that those attempts should be documented on the flowsheet and noted in the patient's medical record.