HospitalInspections.org

The facility failed to promote and protect each patient's rights relative to the ordering and application of restraints. This Condition remains uncorrected. See A0168.

This standard remains uncorrected as evidenced by the following:

********************************************************************************
Based on record review and interview on 1/26/10, the facility failed to obtain a completed order for restraints for 4 of 8(#28, #41, #43, #44) patients restrained. Findings include:

Record review of patient #28's closed chart revealed that there was an order for restraints dated 1/13/10 at 5:45pm for "soft limb restraints" . The physician marked that the "upper left" and "upper right" extremities were to be restrained. There was a restraint order dated 1/14/10 with incomplete orders. There was no time and no type of restraints to be used. On the last order the physician failed to complete the order.

Record review of patient #41's closed chart revealed that on 1/11/10 the physician ordered soft limb restraints on the "upper right" and "lower right" extremities. Nursing documentation revealed that the patient had "soft bilateral upper extremities"restrained.

Record review of patient #43's closed chart revealed that on 1/18/10 at 8am the physician did not complete the restraint order form completely. The physician failed to document which extremity was to be restrained.

Record review of patient #44's closed chart revealed that on 12/31/09, 1/2/10, and 1/3/10 the physician ordered restraints for the "upper right" and" upper left" extremity. The order was changed to the "upper left" extremity on 1/4/10 and continued until 1/9/10. Nursing documentation supported the physicians order. On 1/9/10 and 1/10/10, the physician order was for "all Extremities" . The nursing documentation supported that only the "upper left" extremity was restrained.


Policy labeled PCS G-02 titled Restraint Policy and Procedure states:

"Restraints may be used only by physician order".

"As needed and /or PRN orders are not acceptable for ....or for devices used by physical restraints " .

" The physician must conduct a face-to-face reassessment of the patient to determine whether continued restraint is appropriate and complete physician restraint order (every calendar day). "

" Continued use must be re-ordered every calendar day" .

Interview with the Vice President of Quality and Safety on 1/26/10 at 2:00pm, confirmed that the form titled " Restraint Orders for Non-Aggressiv/Non-Assultive Actions " were incomplete for patient ' s #28, #41, #43, #44.