HospitalInspections.org

Based on document review and interview, it was determined, for 3 of 3 patients in restraints (Pt's. #5, 6, & 9), the Hospital failed to ensure restrained patients were monitored and care provided every 2 hours, as required by policy.

Findings include:

1. On 4/21/15 at 9:00 AM, Hospital policy #987558, titled, "Restraint and Seclusion Management", effective 7/5/11, was reviewed. The policy required, "Process... 7. Nursing monitors and documents the following: Non-Violent / Non-Self-Destructive Behavior - Every 2 hours or more often as needed - Visual check of patient... circulation and skin integrity... range of motion to extremities in restraints...fluids and foods...elimination needs."

2. On 4/20/15 at 1:10 PM, Pt. #5's clinical record was reviewed. Pt. #5 was a 95 year old female, admitted on 4/16/15, with diagnoses of closed C2 (cervical) vertebra fracture and dementia. Physician orders dated 4/17/15 at 12:32 AM and 4/18/15 at 10:14 AM, included non-violent soft bilateral wrist restraints to prevent medical equipment removal. Pt. #5's restraint monitoring flow sheet lacked documentation of range of motion exercise from 4/17/15 at 8:00 PM to 4/18/15 at 8:00 AM, for 12 hours, instead of every 2 hours, as required. Pt. #5 was released from restraints on 4/18/15 at 8:00 AM.
3. On 4/20/15 at 1:50 PM, Pt. #6's clinical record was reviewed. Pt. #6 was a 91 year old female, admitted on 4/12/15, with diagnoses of right hip fracture, breast cancer, and dementia. Physician orders dated 4/14/15 at 8:45 AM and 4/15/15 at 5:57 PM, included non-violent soft bilateral wrist restraints to prevent medical equipment removal. Pt. #6's restraint monitoring flow sheet included monitoring and care on 4/14/15 at 8:45 AM and 10:45 AM, but lacked subsequent documentation on 4/14/15 or 4/15/15. There was no documentation when Pt. #6's was released from restraints.
4. On 4/21/15 at 8:30 AM, Pt. #9's clinical record was reviewed. Pt. #9 was a 34 year old male, admitted on 3/31/15, with a diagnosis of intractable pain. Physician orders dated 4/4/15 at 8:53 AM, included non-violent soft bilateral wrist restraints to prevent medical equipment removal. Pt. #9's restraint monitoring flow sheet lacked monitoring and care offered between 4/4/15 at 8:52 AM to 12:45 PM, for almost 4 hours, instead of every 2 hours as required. Pt. #9 was released from restraints on 4/4/15 at 2:00 PM.
5. On 4/21/15 at 8:45 AM, an interview was conducted with the Accreditation Coordinator/ Risk Management (E #3). E#3 stated she did not know why the 2 hour documentation was not done.