HospitalInspections.org

Based on interview and record review the facility failed to ensure restraint orders are reordered daily per facility policy for 1 of 10 medical records reviewed of patients who had restraints (Patient #3) in a total universe of 10.

Findings include:

Review of facility policy titled, "Restraints Policy" last revised 9/2020 revealed under "III. Orders f. Medical management restraint orders are placed every calendar day."

Review of Patient #3's medical record revealed restraint flowsheet documentation on 10/14/2020, "soft restraints left and right wrist continued" Restraint documentation for 10/20/2020 revealed "soft restraints left and right wrist continued." There were no physician orders for restraints found from 10/14/2020 or 10/20/2020.

Interview on 11/16/2020 at 2:18 PM, Staff D stated, "Restraint orders are only good for one calendar day, after that if there is not a renewed order, the order expires."

Interview on 11/16/2020 at 4:14 PM with Staff A stated, "The restraint orders (for Patient #3) are missing for 10/14/2020 and 10/19/2020."