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M HEALTH FAIRVIEW SOUTHDALE HOSPITAL
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0167
Based on documentation review and interviews, the hospital failed to follow the hospital policy for two of four patients (Patient #1 and Patient #2) who had medical restraints when they did not obtain physician orders within accepted time frames.
Findings include:
Patient #1 was admitted on 5/18/2011 with a subarachnoid hemorrhage. A review of his medical record established that a medical restraint for bilateral upper extremities was initiated on 5/19/2011. Patient #1's physician orders were reviewed and established that a physician order for the bilateral upper extremity restraint was not obtained until 5/26/2011, 8 days later.
Patient #2 was admitted on 5/24/2011 due to cardiac arrest. A review of his medical record established that a medical restraint for bilateral upper extremities was initiated on 5/24/2011. Patient #2's physicians orders were reviewed and established that a physician order for the bilateral upper extremity restraint was not obtained until 5/26/2011, 2 days later.
Employee (D)/nurse was interviewed on 5/27/2011 at 11:30 a.m. and confirmed that Patient #1 had a restraint started on 5/19/2011 but no order was in the medical record until 5/26/2011. Employee (D) confirmed that Patient #2 had a restraint started on 5/24/2011 but no order was in the medical record until 5/26/2011.
Employee (E)/administrative nurse was interviewed on 5/27/2011 at 11:30 a.m. and confirmed that Patient #1 had a restraint started on 5/19/2011 but no order was in the medical record until 5/26/2011. Employee (E) confirmed that Patient #2 had a restraint started on 5/24/2011 but no order was in the medical record until 5/26/2011.
According to the hospitals Restraint or Seclusion policy and procedure, dated January 2010, initiation of a restraint for medical healing may be initiated by a Registered Nurse (RN) if a licensed independent practitioner (LIP) is not immediately available. The policy directs that the RN must notify the LIP of the change in patient status and obtain an order as soon as possible but no later than 12 hours of initiation of the restraint.