HospitalInspections.org

Based on staff interview and medical record review, the hospital failed to ensure nursing staff provided a comprehensive documentation of events that led to the placement of restraints on 2 of 4 sample patients (#11, #14) who had physical restraints applied. The findings were:

1. Review of the medical record for patient #11 showed s/he required the application of a Posey restraint on 7/25/10 at 12:38 AM. Review of the medical-surgical mechanical restraint form showed the patient was pulling at his/her Foley and nasal tubes, trying to remove them. Review of the nursing notes showed no description of the events that led up to the need for restraint application.

2. Review of the medical record for patient #14 showed s/he was intubated at 12:45 PM on 10/5/10. Review of the medical-surgical mechanical restraint form showed soft wrist restraints were applied on 10/5/10 at 3 PM because the patient was unable to follow instructions and was attempting to dislodge the ventilator tube. Review of the nursing notes failed to describe the events that led to the patient's need for restraints.

3. Interview with the vice president of nursing and the vice president of quality improvement on 10/21/10 at 2 PM revealed the practice was for nursing to document restraint information only on the medical-surgical mechanical restraint form, not in the nursing notes. The documentation on the restraint form was a checklist without comprehensive description of the events that led up to the need for restraints.